Surgery

SURGERY (from Greek cheir - hand, and ergon - action). The original meaning of the word surgery, "handicraft," indicated that surgery was understood as a purely practical branch of healing, the therapeutic methods of which were performed by hands or instruments. From this original content of surgery, dating back to ancient times, modern surgery has advanced far ahead and developed into an independent, leading medical discipline. At present, the surgeon is required to have a profound knowledge of the biological disciplines upon which all modern medicine is built. Thus, surgery is simultaneously both a science and an art. Insofar as it bases its investigations and practical activities primarily on biology, biochemistry, physiology, and normal and pathological anatomy, it is a science. Insofar as surgery requires mastery of technical methods for its main goal—assisting the patient—regardless of whether the intervention is bloody or bloodless, it is an art. But while pursuing predominantly practical goals, surgery cannot carry them out without theoretical foundations, the development of which must stand in the first place. The view of surgery as a purely practical discipline is profoundly erroneous and leads back to those times when it stood outside the system of medical knowledge, occupying the place of an applied craft in the healing business. In the modern understanding of surgery, the principle of the synthesis of theory and practice is most fruitfully realized. Utilizing in its daily work the ideas of theoretical disciplines, surgery in turn enriches the latter with its observations and facts obtained during operations, which are a kind of experiment on a living human being. Moreover, surgical observations very often pose new problems for theoretical sciences, which may receive one resolution or another in animal experiments. This interaction between the clinic and experiment is not revealed with such clarity in any other medical discipline as in surgery. Many examples could be given to confirm this proposition, but it is sufficient to limit oneself to a few. The work of the school of Academician I. P. Pavlov on the physiology of the digestive tract organs provided a series of ideas valuable for the surgical clinic (the reaction of gastric glands to food in operated subjects with a gastric fistula, the influence of the vagus nerve and its transection on gastric juice secretion, changes in the bone system during a long-standing gallbladder fistula, etc.). It is further sufficient to point out, for example, the diseases of an organ such as the thyroid gland, the surgical treatment of which brought to the fore the question of the function of this gland. This in turn called to life a whole series of experimental, biochemical, morphological, and other works. In this same field of endemic endocrinopathies (endemic goiter, Kashin-Beck disease), the fight against them goes hand in hand with the study of domestic, social, sanitary-epidemiological, and hygienic factors. If thus the connection of surgery with the theoretical disciplines of medicine and biology cannot be subjected to any doubt, its close relations to practical medicine are no less obvious. In essence, there is no clinical discipline in which the influence of surgery is not felt to one degree or another. Here we do not mean internal medicine, from which entire departments have passed into the domain of surgery (many diseases of the gastrointestinal tract, the thoracic cavity, the vascular system, etc.). It is sufficient to recall ophthalmology, gynecology, otorhinolaryngology, orthopedics, and urology, which, having separated from surgery, developed into independent clinical disciplines. Having developed their own principles of diagnostics, they retained a connection with surgery by utilizing its methods of practical intervention, i.e., operative technique. A trained orthopedist, urologist, or other specialist can only be one who has passed through the surgical school to one degree or another. Before our very eyes, neurosurgery and traumatology are separating from surgery. The former, constituting simultaneously a part of neuropathology, utilizes its diagnostic methods, which naturally require special knowledge. Therefore, neurosurgery is most successfully carried out in close contact between the surgeon and the neuropathologist. Traumatology as a doctrine constitutes an integral part of surgery, and wherever it is placed in an independent position, this is caused by motives of an organizational rather than a principled character. One of the main methods of traumatology—primary wound toilet—is based on the solid foundations of surgical pathology. We see that surgery constitutes one of the main links of medical knowledge. And although historically it developed largely independently of internal medicine, at present, in the light of the synthetic understanding of medicine, surgery cannot stand isolated from other disciplines. It is therefore natural that acquaintance with the basics of surgery is necessary for any physician, even one not dedicating themselves to this specialty. History dates back to the distant times of human life. In essence, surgery is as old as humanity itself, since the need to stop bleeding, get rid of pain, and remove a foreign body from tissues forced primitive man in all difficult situations accompanying him in his fierce struggle for existence to resort to simple and at the same time reliable means of mutual aid or self-help: thus arose the primitive methods of dressing wounds with leaves, extracting foreign bodies (fragments of stone, wood, etc.), and later—fixing broken bones. Finds in caves of various continents of skulls with trepanation openings, dating back to the later period of the Stone Age, with traces of healed defects indicate that this operation was already undertaken at that time, mainly for injuries. In historical times, we find numerous traces testifying that many operative techniques were already in use then. These sources relate both to material culture objects and to literary and artistic monuments. Surgical instruments found during excavations, depictions on bas-reliefs, and surviving treatises leave no doubt that long before our era, the surgical art was already known. In the Code of Hammurabi (2000 BCE), among other clauses, there are provisions concerning the liability of the physician in case of an unsuccessful outcome of an operation performed by him. The severe punishments and risks to which the physician was exposed in these cases could hardly contribute to the development of surgical knowledge. In Egypt, approximately at the same time, medicine, including surgery, was almost exclusively in the hands of priests. In the Edwin Smith Papyrus, we find descriptions of injuries to various body regions and surgical interventions for them. Various surgical instruments have been preserved in tombs, including stone knives, which served, among other things, for the circumcision operation, which, as established, was practiced in Egypt 5000 years BCE. Healed bone fractures on skeletons of approximately the same antiquity with applied splints indicate the high technique of fracture treatment possessed by the Egyptians of this period. Later, medicine in Egypt, like all its culture, became stagnant. Among the Indians, in the book written by Sushruta, as now assumed, in the first centuries CE, is contained everything valuable that their medicine possessed, including surgery; by this time, surgical diagnostics and technique were already quite high. Wounds were sutured; linen threads and hair served as suture material. To close intestinal wounds, red ants were applied, which grabbed the adjusted edges of the wound with their pincers, after which the insect's body was cut off. Bougienage of the urethra for its strictures was already applied. Sushruta particularly detailed numerous surgical instruments made of good steel. One of the oldest operations of Indian surgery is rhinoplasty, the flap for which was taken from the cheek, later from the forehead. Given their custom of cutting off the nose, ear, or upper lip as punishment, there was no shortage of operative material. In the ancient Greek epic—Homer's Iliad and Odyssey—there are many indications that during the time of the Trojan War in the Greek army, surgical aid was rendered to the wounded partly by fighting heroes, partly by professional physicians. The followers of the semi-legendary Asclepius (Aesculapius), the so-called Asclepiads, forming a closed association of physicians, upon entering the alliance, took an oath containing an indication of lithotomy of the urinary bladder—an operation which they bound themselves not to perform, but to leave its execution to special practitioners. Of particular interest from Hippocrates' writings for surgeons are treatises on wounds, bone fractures, skull injuries, and dislocations. He elevates cleanliness in the treatment of wounds to a rule: the physician is required to wash hands thoroughly, care for nails, and wear clean clothing. Wounds must be given rest as far as possible; a dry, clean bandage is applied to a fresh wound. For bleeding, elevation of the bleeding organ, cold, a pressure bandage, and the cautery iron are applied. Wounds can heal by primary intention and through granulation, following preliminary suppuration.

In Hippocrates' doctrine on fractures and dislocations, one sees fine observation combined with vast experience. The timely reposition of bone fragments, their fixation using bandages and splints, was developed by him very thoroughly, and the Hippocratic cap—a bandage for the head—has remained in use to the present time. The instruments he used for surgical purposes are notable for their simplicity and are made of iron and bronze; many of them were found on the island of Kos, the birthplace of Hippocrates. Since Alexandrian times, the ligation of vessels during hemorrhages began to be used, which proved to be a great conquest for surgery: it is known that in Hippocrates' time, amputation was performed at the border or even within the affected tissues, because physicians did not possess a method for stopping hemorrhage. No less important an acquisition was the use of narcotizing liquids containing mandrake extracts, which were given internally to induce sleep during operations. The effect of mandrake probably became known to Alexandrian physicians through Egypt, where this remedy was used for the same purpose much earlier. Many prominent surgeons of the Alexandrian Academy continued to develop surgical operations. One of them, Ammonius, in treating stone disease, was the first to begin crushing large stones in the urinary bladder, for which he received the nickname of lithotomist. The doctrine of dislocations left by Hippocrates was significantly expanded in Alexandria. The cult of the body in ancient Greece brought to life special practitioners—teachers of sports and gymnastics, who conducted their classes and at the same time practiced massage in gymnasiums and public baths. Having the opportunity for daily observation of the human body, they acquired some knowledge of anatomy and physiology and frequently provided first aid for various injuries. Thus, gradually alongside educated physicians, a class of craftsmen was formed who also claimed the right to medical practice; the field of their activity was mainly the surgery of bones and joints. Later they penetrated ancient Rome as Greek slaves and under the name of servi medici (medical slaves) were the first Roman physicians. Celsus in his encyclopedia, of which almost half is devoted to surgery, gives an exhaustive overview of the state of all branches of medical knowledge of that time. All departments of surgery that were known at the time found a place in his books. In one of them, he expresses his opinion on what physical and moral qualities a surgeon should possess. This reflected a desire, which was repeated more than once and even in our time, to find a certain formula defining the qualities of a surgeon and the requirements presented to surgery itself. Thus, among other qualities, Celsus demands that the surgeon be young or at an age close to youth, possess a steady, reliable hand, equally fast as the right or the left, with a sharp, clear gaze, fearless, ruthless (the latter in view of the fact that operations were performed without anesthesia). Some methods or operations known previously were first described by Celsus. For example, the description of the ligation of vessels introduced into practice by Alexandrian physicians is given for the first time by Celsus. From that time on, it was applied in such a way that the ends of the threads remained in the wound and hung from it until they separated on their own. This method lasted in surgery for centuries until asepsis put an end to it: sterilized threads began to be left in the sutured wound with impunity. Also for the first time, we have an exact description of the operation of lithotomy, which had been in use since ancient times (it must be noted that then and for many years thereafter, until modern times, it was exclusively a question of perineal lithotomy). Celsus devoted much attention to the chapter on military surgery and the doctrine of plastic operations. Surgical instruments in use at his time and subsequently found during the excavations of Pompeii testify to a high degree of perfection and suitability. Many modern instruments differ little from them in idea and design. In the later Roman era, surgery was also enriched by certain conquests of no small importance. Among the physicians of this time, Antyllus (in the first half of the 2nd century) should be mentioned, to whom surgery owes not only the well-known operation for aneurysms, but also works in the field of treating fistulas, bloodletting, and lithotomy. Aneurysms at that time were not uncommon and arose as a result of the favorite operation of bloodletting in the elbow bend, during which vessels were wounded. Galen showed himself much less in the field of surgery than in internal medicine. In any case, Galen was not only at the height of the surgical knowledge of the time, but he himself was not averse to engaging in surgery. By Galen's time, the stratification of medicine into internal and surgical begins to outline itself, and philosophically educated physicians more and more gave their attention and time to internal medicine, paying little attention to surgical practice. The latter is concentrated in the hands of specialist surgeons, and partly enters the duties of military and naval physicians. The frequent wars that Rome was then waging, having already its permanent army with a military-medical organization, could not fail to affect the development of military surgery: its foundations were laid back in the time of Celsus. Surgery is fragmented into a number of specialties. Physicians serving places such as circuses, gymnastics schools, and gladiators perfected themselves mainly in the treatment of wounds. Specialists in herniotomy, lithotomy, the operative treatment of cataracts, and so on appear. Finally, this business is engaged in by a vast army of craftsmen—barbers, bathhouse keepers, gymnasts, masseurs; their activity can be traced right up to modern times. Subsequently, for several centuries, we see complete stagnation in medicine, including surgery. The Arabs, who at the beginning of the Middle Ages were the keepers and conductors of Greek and Roman wisdom, introduced little new to surgery, but on the other hand, carefully and lovingly preserving everything that remained from ancient times, managed to pass it on through Spain to Europe. If we recall that autopsies and studies on corpses were forbidden by the Mohammedan religion, it will become clear that knowledge of anatomy among the Arabs could not stand at a high level. Likewise, the development of surgery was subjected to a certain limit due to their aversion to blood. Any bloody intervention was preferred to be bloodless in the form of the hot iron. Thus, for example, the treatment of hernia consisted in the fact that after the reduction of its contents, all tissues were cauterized right down to the bone, and subsequently, with a prolonged resting position of the patient, the process of scarring took place. If the Arabs, who devoted themselves mainly to the study of former classics and works on their translations, did not show special creativity, nevertheless, extensive experience at the patient's bedside gave them much material for the development of clinical thinking. Symptomatology and surgical diagnostics in their writings are developed rather thoroughly. Among the Arabian physicians whose names have survived in the history of medicine, Rhazes (850–923), Abulcasis (10th century to the beginning of the 11th century), and Avenzoar (1113–1162) left a mark on surgery. Abulcasis has something original in the technique of certain operations; he described new types of sutures, and for complicated fractures, he proposed a fenestrated fixing bandage. In Italy, surgery found favorable conditions for development in the famous medical school in Salerno, which arose in the 9th century. A monument of this epoch remained a work on surgery compiled from the lectures of the famous Salernitan physician Roger in the middle of the 12th century. This book was subsequently supplemented many times and served as a guide for physicians for many years. Another famous medical school was in Bologna, in Northern Italy, in the 13th century. To this time (12th–13th centuries) belong the first legislative acts in some southern countries regarding the right of medical practice. Thus, according to a law issued in 1224 by Emperor Frederick II, to obtain the right to practice, physicians had to study logic for 3 years, medicine and surgery for 5 years, and practice for 1 year under the supervision of an experienced physician. For those dedicating themselves exclusively to surgery, the requirements were not so strict. For several centuries, surgery in Italy stood higher than in other countries, then in the 14th century the palm of victory gradually passed to the French, although the latter often still continued to receive their education in Italian universities and medical schools. Among the physicians of the late Middle Ages to whom surgery owes its successes are Ugo da Lucca (Hugoc> de Lucca, 13th century), Bruno da Longoburgo (Bruno de Longoburgo), Lanfranc (Lanfranco), Henri de Mondeville (Henri de Mondeville), and Guy de Chauliac (Guy de Chauliac). Lucca was mainly a specialist in the treatment of wounds. He participated in the crusade, made many observations, and on the basis of them rebelled against the doctrine that wounds can heal only by suppuration. With the help of alcohol, he achieved first-intention healing of the wound. When treating the wounded, he demanded cleanliness, advised avoiding polypharmacy, especially probing. He also proposed anew in 1200 to use anesthetic sponges impregnated with a mixture of sleep-inducing substances, known since the time of Alexandria. Bruno da Longoburgo, who released a work on surgery in 1252, despite his scholastic direction, also encounters something valuable.

He uses the term prima et secunda intentio for the first time and recommends dry wound dressing. Lanfranco, an Italian by origin, worked in Paris, where in 1296 he published his "Chirurgia magna"; this book was also translated into other languages and served as a guide for a long time. He sought to place surgery on a scientific foundation instead of empiricism and to connect it with other branches of medicine. As a subtle observer, he gives many rational pieces of advice concerning the treatment of wounds and other injuries. Henry Mondeville, a pupil of the Bologna school, transferred much of Italian surgery to his homeland, France. As a good practitioner, well acquainted with military surgery as well, he declared himself an exceptional proponent of antiseptic wound treatment, for which he used strong wine with great success. At the close of the Middle Ages stands the French surgeon Guy de Chauliac (1300-1368), a pupil of the Montpellier school. His work on surgery, thoroughly imbued with a healthy critique of what had been before him, served as a guide for physicians until the end of the 16th century. He was the first to propose continuous extension in the straightened position of the limb for the treatment of fractures. Despite the reaction and stagnation of thought that reigned in the Middle Ages, surgery was nevertheless enriched by certain achievements. Among these must be included the clarity that began to emerge in the question of wound treatment. Frequent wars and the Crusades could not fail to enrich the physicians who took part in them with a certain, albeit rather modest, experience: fenestrated bandages for open fractures, continuous extension, alcohol in wound treatment, and nerve suture began to be used at this time. The old operation known to the Hindus—rhinoplasty—was revived, owing to the fact that the cutting off of the nose as a punishment was brought back into life. At the close of the Middle Ages, in the era of the revival of sciences and arts, the invention of printing played a huge role in the progress of medicine as well. The 16th century passed for surgery, as for all of medicine, under the sign of the great anatomical discoveries of Vesalius (Vesalius, 1514-1564), Fallopius (Fallopius), and Eustachius (Eustachius, born in the early 16th century, died in 1574), prepared in part by predecessors. Among the latter is Leonardo da Vinci (1452-1519). A feature of these anatomical investigations was that they did not remain aloof from the needs of therapeutic medicine, as had been the case before. A new direction was created in medicine and in surgery—the anatomical one. This was largely facilitated by the circumstance that many anatomists, such as Vesalius and Fabricius of Acquapendente (Fabricius ab Aqua-pendente, 1537-1619), were at the same time surgeons. One of the most famous physicians of all times, Paracelsus (Paracelsus, 1493-1541), who lived in Switzerland, not being a practical surgeon himself, expresses surprisingly correct judgments for that time in his work on wound diseases, which bring us closer to the concept of wound infection; he saw the source of the harmful principle for wounds in the air. Italian surgery later continued to occupy a prominent position in Europe, mainly due to the fact that surgery was not separated from the rest of medicine. The operations of lithotomy and rhinoplasty especially flourished in Italy. Approximately from the 16th century, the leading role in surgery passed to France. This was largely facilitated by the guild structure of French surgery, free from the scholastic yoke and tangled philosophical systems of learned physicians. Pierre Franco (Pierre Franco; born in the early 16th century, died in the 70s of the same century) and Ambroise Paré (Ambroise Paré, 1510-1590), who left a great mark in the history of surgery, came from the milieu of barbers. Franco did much for the further improvement of hernia and lithotomy operations; he was the first to propose the high operation of the bladder in 1560. A. Paré, the "father of modern surgery," introduced a very important change in the treatment of wounds, namely, he brought the method of cauterizing them with boiling oil out of use. Vascular ligation in amputations was known earlier as well, but Paré was the first to persistently implement this method instead of the previously applied cauterization and vessel compression. German surgery of the 16th century lagged significantly behind the level at which science stood in France and Italy, and bore a more imitative character. The 17th century was not marked by major achievements for surgery. Despite Harvey's discovery of blood circulation (1628), Malpighi's capillaries and formed elements of the blood, and despite other discoveries in the anatomy of the lymphatic system, surgery with its purely practical direction, based on bare empiricism, turned out to be unprepared for the scientific conquests that fell to the lot of the century. In Europe, the institution of family secrets and talents was still preserved, according to which a certain operation, most often lithotomy, herniotomy, or rhinoplasty, was practiced by representatives of the same family from generation to generation. French surgeons continued to occupy a preeminent position. At the same time, an attempt at animal-to-human blood transfusion was made, which ended sadly. The rift between medicine and surgery remained, and along with it, the division of physicians into two categories, sharply differing in their social position, was also preserved. Guild barbers and wandering specialists as before remained the main actors of surgery. A turning point begins to emerge in the first half of the 18th century in France, a country in which surgery stood higher than anywhere else over the past two centuries. Despite the opposition that the Paris Faculty of Medicine continued to offer to the members of the College de St. Côme, many from the milieu of the latter managed to stand out as very capable specialists who brought much more benefit than the faculty professors of surgery. In its time (1554), the members of the brotherhood of St. Cosmos were so farsighted that they admitted the barber Ambroise Paré to their college, awarding him the title of maitre chirurgien du collège St. Côme. The merits of the college were finally recognized, and in 1731 it was transformed into the Académie royale de chirurgie, which was initially called the Société académique des chirurgiens de Paris. The founders of the surgical academy, which in 1731 [sic] was equalized with the faculty in all respects, were the famous French surgeon La Peyronie (La Peyronie, 1678-1747) and his teacher, the first surgeon of the king, Mareschal (Mareschal), and the first director was one of the greatest authorities of surgery in the 18th century, Jean Louis Petit (Jean Louis Petit, 1674-1750), as fine an anatomist as he was a bold surgeon. Even earlier, in 1725, the surgeons of the brotherhood of St. Cosmos broke ties with the barbers despite the protest of the faculty. In 1738, the École pratique de chirurgie was founded, the first teachers of which were Chopart (Chopart, 1743-1795) and Desault (Desault, 1744-1795). The foundation of the surgical academy is the beginning of a new era of French surgery. Until the end of its existence (in 1793 the academy was closed by order of the Convention), it was the highest scientific center for surgeons of all countries. In England during this era, surgeons occupied the same position as other physicians, and surgery achieved significant success there. Among English surgeons, the greatest merits belong to Pott (Pott) and especially John Hunter (John Hunter, 1729-1793); the latter's work on inflammation and wound treatment enjoyed universal recognition for a very long time; English surgery owes its development to his influence, and in the first half of the 19th century, bone and joint resection was introduced into practice mainly by English surgeons. Italian surgery was headed by Scarpa (Scarpa, 1752-1832), whose versatile activity as an anatomist and surgeon continued into the first half of the 18th century. In Germany, surgery in the 18th century still lagged behind both theoretically and practically, but one achievement can already be noted—this is the care taken to train educated physicians for the army, skilled mainly in wound treatment. Surgery was also taught in universities, but mostly only theoretically, and professors did not engage in practical activity. Despite the fact that surgery continued to occupy an isolated position even in the 18th century, its specific weight nevertheless rose, mainly due to the fact that this subject began to be taught in universities and surgical schools opened for the special purpose of giving education to field surgeons. Along with this, wandering operators and barbers were gradually forced to leave the field of activity. However, in the Prussian army, military physicians called feldshers (from German Feldscher—field barber) had to perform the functions of a barber as well, since their duties included shaving officers and soldiers. The 19th century brought with it a brilliant development of surgery. Two circumstances contributed to this: the introduction of anesthesia into surgical practice and asepsis. The huge shift that occurred in natural science in the 19th century was bound to affect medicine as well. The successes of anatomy, physiology, newly created pathological anatomy, bacteriology, and the doctrine of immunity forced surgery to rebuild on completely new rational principles. And from this point of view, the historical course of the development of 19th-century surgery can be divided into two periods, the boundary between which passes approximately at the middle of the century. Over the course of two decades, surgery was enriched by two conquests that created its modern character: in 1846 inhalation anesthesia became known, and in 1865.

Lister published his first work on a new method of treatment in complicated fractures, abscesses, etc., and in 1867 he spoke at the Congress of British Physicians in Dublin with a report on the antiseptic principle in surgical practice. In the first half of the century, surgery made its progressive movement, improving technique and diagnostics. French surgeons continued to dominate in Europe. Among them stand out the talented military surgeon, companion of Napoleon I in his wars, Larrey (Jean Dominique Larrey, 1766-1842) and the best clinical surgeon of his time Dupuytren (Dupuytren, 1778-1835). To the same epoch belong Lisfranc (Lisfranc), Delpech (Delpech, 1777-1832), Velpeau (Velpeau, 1795-1867), Nélaton (Nélaton, 1807-1873), Lembert (Lembert). The sero-serous suture, introduced by Lembert in 1826, to this day serves as the basis of surgery of the gastrointestinal tract. Among English surgeons who left a significant trace, one must name the Bell brothers (Bell), Astley Cooper (Astley Cooper, 1768-1841), Liston (Liston, 1794-1847), Syme (Syme), Fergusson (Fergusson, 1808-1877), Brodie (Brodie). English surgeons developed mainly the technique of ligation of large arterial trunks, operations on bones and joints; in them they achieved perfection. The most significant surgeon among them, who enjoyed extraordinary authority, was Astley Cooper. At the beginning of the 19th century we already meet active surgeons in North America, who are pupils and followers of the English school. The founder of American surgery Philip Syng Physick (Philip Syng Physick, 1786-1837) was a pupil of Hunter. Like their teachers, the Americans did much in the field of the vascular and skeletal system, first developing abdominal surgery in gynecology. Their unforgettable merit remains inhalation anesthesia, first proposed and applied in their country. German surgery in the first half of the century as if accumulates strength; translations of works by French and English authors still predominate. Science did not stand very high. But along with this, figures are already appearing among German surgeons who prepared the brilliant flourishing of German surgery in the second half of the century. Among them especially stand out Vincenz Kern in Vienna (Vincenz v. Kern, 1760-1829), Conrad Langenbeck (the Elder) in Göttingen (Conrad Langenbeck, 1766-1851), Karl von Graefe (Karl v. Graefe, 1787-1840), Dieffenbach (Dieffenbach, 1792-1847), Bernhard Heine (Bernhard Heine, 1800-1846), Stromeyer (Stromeyer, 1804-1876), Gustav Simon (Gustav Simon, 1824-1876), Bernhard Langenbeck (Bernhard Langenbeck, 1810-1887). Dieffenbach became famous as a master of plastic surgery, B. Heine developed questions of bone regeneration, Stromeyer laid the foundations of military surgery in Germany. B. Langenbeck was an unusually versatile surgeon, one of the leaders of German surgery; many operations bear his name. In 1861 he founded the Archiv für klinische Chirurgie, which exists to this day. At the end of that same 1847, when ether anesthesia became known in Europe, James Young Simpson (James Young Simpson), English surgeon and obstetrician in Edinburgh, proposed and began to use chloroform for sleep induction, which took a place in surgery along with ether. One of the greatest obstacles standing in the way of the further development of surgery was overcome. Like any discovery, inhalation anesthesia was prepared by earlier studies, thanks to which such anesthetic substances as laughing gas and ethyl chloride became known. In 1884 the Viennese physician Koller (Koller) introduced cocaine for local anesthesia, replaced at the beginning of the current century by the less poisonous novocaine. A new period of development of local anesthesia begins, the field of which expands more and more every year. Spinal anesthesia proposed in 1899 by Bier found a response in most countries, and the development of this method, as well as other methods of local anesthesia (conduction, sacral, paravertebral, parasacral, splanchnicus anesthesia, tight infiltration anesthesia according to Vishnevsky), continues to the present time. --Lister's ideas, which created a new era in surgery, serving as the foundation for its further development, were also prepared by the works of his predecessors, first of all Semmelweis (1847). Later, in the late 1850s and early 1860s, reports by Pasteur appeared, proving that fermentation and putrefaction are caused by the vital activity of microorganisms which are carried by dust through the air. Proceeding from this idea, Lister came to the conclusion that the cause of wound suppuration is a kind of putrefaction, at the base of which lies the infection of the wound by microorganisms. From here also followed Lister's first proposal - to spray carbolic acid in the air as an antiseptic agent to protect the wound from microbes. Even before this, in 1860, the Paris pharmacist Lemaire (Lemaire) proved that carbolic acid kills microorganisms and that in its presence they do not develop. Lister was not familiar either with Semmelweis's teaching or with Lemaire's investigations. Developing his views, Lister in 1867 proposed his famous antiseptic dressing, which was subsequently modified. The principle of antiseptic wound treatment gradually gained universal recognition, in some places earlier, in others later (see Antiseptics and Asepsis). Finally, as a natural completion of this harmonious system, asepsis appears, i.e., chemical antiseptic is replaced by physical (sterilization by high temperature under high pressure). In his own country, in England, Lister was not recognized immediately and far from by everyone. Not England, but Germany, where Thiersch in Leipzig and Volkmann in Halle first began to apply the antiseptic method, was the first to follow the path of recognizing Lister. In France it was introduced by Lucas-Championnière (Lucas-Championnière). Lister's discovery marks a revolution in surgery such as it had never experienced before. The field of application of surgical intervention expanded to limits of which pre-Listerian surgery could not even dream. In the post-Listerian period, the leading role in surgery passes to Germany. This coincided in time with the victoriously ended Franco-Prussian War of 1870-71, the unification of Germany and the beginning of the flourishing of its political power and economic expansion. In April 1872 B. Langenbeck together with Simon and Volkmann founded the German Surgical Society, the purpose of which included the unification on a scientific basis of all German surgeons and the convocation of annual congresses. The first congress took place in Berlin in the same year and from that time the brilliant activity of German surgical congresses has not been interrupted to our days. The conquests of surgery quickly become the property of all civilized nations, but along with this each country imprints its own stamp on it. Precision, methodicalness, enormous working capacity characterize the works of German surgeons who have placed surgery at an unattainable height in their country over the past 50-60 years. The number of schools is growing rapidly, the authority of which is recognized far beyond the borders of their own country. Among the prominent leaders of German surgery of this last period should be named Billroth (Billroth, 1829-1894), a pupil of B. Langenbeck, Volkmann (1830-1889), Thiersch (1822-1895), Esmarch (Esmarch, 1823-1908), Bruns Viktor and Paul (father and son, V. Bruns, 1812-1883, P. Bruns, 1846-1916), Bardeleben (Bardeleben, 1819-1895), Trendelenburg (Trendelenburg, 1844-1924), Bergmann (Bergmann, 1836-1907), Franz König (F. König, 1832-1910), Kehr (Kehr, 1862-1916), Kocher (in German Switzerland, Kocher, 1841-1917). This by no means exhausts the enormous galaxy of prominent German surgeons who have enriched surgery with their works. The most fruitful is Billroth's school, the head of which, an unusually talented and versatile surgeon and researcher, manifested himself in the most diverse fields of this specialty. To Billroth, among other merits, belongs the honor of pioneer in gastric surgery. He succeeded in the first resection of the stomach on 29/I 1881 for cancer, after Péan and Rydygier (Péan, Rydygier), who performed this operation earlier, lost their patients. In the same year his assistant Wölfler (Wölfler) performed the first gastroenterostomy. Bergmann's clinic rendered invaluable services to surgery by its systematic development of the aseptic method. The name of Kocher, a pupil of Langenbeck and Billroth, is forever associated with research and development of the operative treatment of thyroid diseases. There is one feature that distinguishes German surgery of the last period, - this is the continuity of their schools. Some of them already number 4 generations, thus e.g., from Langenbeck's school successively came Billroth, Eiselsberg (Eiselsberg), Haberer (Haberer), on the one hand, and Billroth, Mikulicz (Mikulicz, 1850-1905), Sauerbruch (Sauerbruch) - on the other hand; each of them is a pupil of the previous one; from Esmarch's school - Bier (Bier), a pupil of the latter - Schmieden (Schmieden). A number of special journals, a huge number of excellent manuals and separate monographs in German have secured for German surgical literature a central position among other literatures for a long time. In France, the development of surgery proceeded at a slower pace, but here too there are very many brilliant representatives of it.

These include Verneuil (1823–1895), Péan (1839–1898), Lucas-Championnière (1843–1913), Ollier (1825–1900), Jaboulay, Lannelongue, Guyon (1831–1920), and Tuffier. Péan is known as a great master of abdominal surgery; together with Nélaton, he introduced ovariotomy to France. To Ollier, surgery owes a thorough development of the question of bone regeneration and fracture healing; Jaboulay was one of the first to devote himself to the surgery of the sympathetic nervous system; our contemporary Leriche is his pupil. Guyon was one of the founders of modern urology, in which his no less famous pupil Albarran (1860–1912) worked. In 1820, the Académie de médecine was founded, to which a large part of the functions of the surgical academy, which had ceased to exist at the end of the 18th century, was transferred. In 1843, La Société de chirurgie (surgical society) was founded, which exists to the present time under the name Société nationale de chirurgie. In 1890, the first congress of French surgeons (Congrès de l'association française de chirurgie) assembled; the last, the 43rd in number, took place in 1934. The French consider the continuity of the activity of their old Académie royale de chirurgie not to have been interrupted and in 1931 celebrated the bicentenary of its foundation, timing this celebration to coincide with the 40th congress of French surgeons. English surgery continued its further movement without slackening its pace. Bone surgery, orthopedics, and craniocerebral surgery received special development here. Paget (1814–1899), Thomas (1834–1891), MacEwen (1848–1924), and Horsley (1857–1916) worked in this field. Spencer Wells (1818–1897) and Lawson Tait (1845–1899) stand out for their successes in ovariotomy. Thanks to them, and chiefly to Moynihan, a brilliant surgeon of recent times, abdominal surgery in Great Britain has attained great perfection. The industrial growth of North America and its financial might caused an upsurge of scientific creativity and technical progress in medicine and especially in surgery. Figures of an earlier period already, such as Bigelow (1816–1900), Gross (1805–1884), Sayre (1820–1900), McBurney (1845–1913), and Senn (1844–1909), showed that they kept pace with European surgery. In the second half of the 19th century and in our time, American surgery counts names enjoying world renown. These include Halsted (1852–1922), a surgeon and experimenter who created his own school and proposed in 1890 to use rubber gloves during operations; Murphy (1857–1916), with whose name is connected the idea of joining the ends of the intestine using a special button; Crile, who did very much in the doctrine of shock; and the Mayo brothers. Brain surgery over the past 30 years has achieved unprecedented flourishing in North America thanks to the concentration of huge clinical material in the hands of a few surgeons, such as Cushing, Frazier, Dandy, and others. This, of course, by no means exhausts the list of countries and names of people who made their contribution to the rich treasury of modern surgery. There is not a single civilised country that has not taken part, and frequently with great success, in the development and further improvement of surgery to one degree or another. To those conquests of the 19th century that produced a complete revolution in it and widely extended the boundaries of its influence—anesthesia and antisepsis—there have been added in the last quarter of a century new achievements in the form of various types of endoscopy. Cystoscopy with catheterization of the ureters, esophagoscopy, rectoscopy, bronchoscopy, and thoracoscopy have made it possible to significantly refine the diagnostics of many diseases and at the same time make them accessible to surgical intervention. Finally, the discovery of X-rays in 1895 created a new form of medical diagnostics. In blood transfusion, which has achieved great success in recent years thanks to the fact that it has been provided with a scientific foundation in the form of biological reactions, surgery has received a huge aid. The progress of medicine in the 19th century called forth the need for communication between physicians of various countries; hence international medical congresses with various sections arose. In 1902, the International Society of Surgery was formed, having chosen Brussels as the permanent seat of its presidium. The society is headed by an international committee, which convenes congresses of all members of the society once every 3 years. The first 3 congresses—in 1905, 1908, and 1911—took place in Brussels; the 9th, in 1932, in Madrid; the last, the 10th, at the end of 1935, in Cairo. Russian surgery appeared in the historical arena considerably later than Western European surgery, and as a scientific discipline it barely numbers a century and begins with N. I. Pirogov. The first traces of surgery in Russia are to be sought in empirical medicine, and its bearers were quacks and bone-setters possessing primitive surgical skills. Later, in the 15th and 16th centuries, foreign physicians and surgeons, chiefly Germans, Dutchmen, and Englishmen, began to appear at the court of the Grand Dukes. In the 17th century, troops already had their own regimental physicians and barbers, whose duties included performing uncomplicated surgical manipulations, such as bloodletting and bandaging. They learned their art from senior medics, since there were neither medical schools nor hospitals. In 1706, Peter I opened the first hospital in Russia in Moscow beyond the Yauza River (now the Krasnoarmeisky Communist Hospital), which at the same time served as the first medico-surgical school for training future physicians. At the head of the hospital, as well as the medico-surgical school, was placed the Dutch physician Nikolaas Bidloo, a very zealous promoter of medical knowledge in Russia; he himself taught surgery and performed all surgical operations in the hospital. In 1733, similar medico-surgical schools were opened in St. Petersburg at the land and naval hospitals. In the early years, students of these schools were recruited almost exclusively from foreigners, chiefly from the sons of foreign physicians, but since the number of students did not satisfy the demand for physicians, from the middle of the 18th century Russians, predominantly students of theological seminaries, began to be attracted to the medico-surgical schools. Teaching was initially conducted in Latin and German, and from 1764 the first Russian privatdozent, K. I. Shchepin, began to teach anatomy and surgery in the Russian language at the St. Petersburg Medico-Surgical School. Ivan Schreiber was appointed the first professor of surgery in both St. Petersburg hospitals in 1742, remaining at his post until his death (1760). Like our other teachers of that time, he taught anatomy along with surgery. This had significance in that from the very beginning surgery acquired an anatomical direction with us. At the end of 1798, the Medico-Surgical Academy was established in St. Petersburg, subsequently transformed into the Military Medical Academy. The growth of the country and the frequent wars that Russia waged in the 18th century caused a great demand for physicians. It could be satisfied by the creation of new schools. Such schools were the Kronstadt Medico-Surgical School and the Medico-Surgical Institute opened in 1783 at the Kalinkin Hospital in St. Petersburg, which existed until 1802. From this institute emerged the first professor of surgery at the Medico-Surgical Academy, Ivan Fedorovich Bush, the founder of surgery among us. In 1807, he wrote the first textbook on surgery in the Russian language. To Bush belongs the credit of creating the first Russian surgical school, from which emerged professors of the same academy and other higher medical schools: Salomon, Savenko, Buyalsky, Vysotsky, Gaevsky, Pelikan. Two of the former, upon Bush's retirement, continued his work, dividing the teaching at the Medico-Surgical Academy into theoretical surgery and operative surgery with clinic. Buyalsky, a brilliant surgeon, received the chair of anatomy at the Medico-Surgical Academy in 1833. Gravitating more toward surgery, which he continued to practice, he also worked in anatomy. Besides a large number of surgical works, he authored a classic labor on operative surgery with artistic plates: "Anatomico-Surgical Tables Explaining the Performance of Operations for Ligating Large Arteries." In 1755, the first Russian university opened in Moscow, which also had a medical faculty, but there was no surgical clinic for a long time, and all teaching was conducted theoretically. Only at the beginning of the 19th century was a clinic for 15 beds opened, which in 1846 was expanded to 60 beds. Nikolai Ivanovich Pirogov (1810–1881), who graduated from Moscow University in 1827, according to his own assertion, received no knowledge of surgery whatsoever at the university—neither theoretical nor practical. After a two-year foreign assignment, during which he studied in Berlin, as well as in Göttingen under the then brilliant surgeon Conrad Langenbeck (the elder), Pirogov in 1836 received the chair of his teacher Moyer in Dorpat. Having stayed in Dorpat for 5 years, he moved in 1841 to a chair at the Medico-Surgical Academy in St. Petersburg, and by his project a hospital surgical clinic for the 5th year was established for the first time 210>; this clinic subsequently took root in medical faculties as well. Pirogov's significance in the history of world surgery is colossal. An experimenter and clinician who was the first to wage a struggle against wound infection in hospitals, and a military field surgeon, Pirogov is in the full sense of the word an innovator. Pirogov's merits are so great that they could not be appreciated all at once.

Only later did its significance for Russian medicine in general and for surgery in particular become fully apparent. The conditions for work during Pirogov's time were extremely burdensome: despotism and administrative arbitrariness suppressed any initiatives. The scope of his activity was so broad and his plans so original that much of what Pirogov began could only be realized much later, under more favorable conditions. Pirogov's student and successor to the chair, Prof. Kiter, encouraged young doctors to improve their skills and managed to create a school that continued Pirogov's work. Kiter's clinic has one immense merit: thanks to P. P. Pelekhin, it was the first to introduce antisepsis. Two other students of Pirogov, Nemmert (1819–1858) and V. A. Karavaev (1811–1892), also became professors of surgery—the former directly took over his teacher's chair at the academy after his retirement in 1856, while Karavaev went to Kiev, where he worked until his death, enjoying great popularity. Kiter received Pirogov's clinic in 1858 and headed it for 12 years; during this time, a whole constellation of student-surgeons and anatomists who headed chairs in the academy and universities graduated from it. Among them, besides Pelekhin, were E. I. Bogdanovsky, who took his teacher's chair, S. P. Kolomnin, Rinek, E. V. Pavlov, L. L. Levshin, Geppener, P. F. Lesgaft, Ermolaev, and Lyantsert; the last three were professors of anatomy. Bogdanovsky (1833–1888), theoretically very well-educated, was conservative as a surgeon, perceived new ideas in the clinic reluctantly, treated Lister's antisepsis with restraint, but managed to elevate theory to the proper level, paying great attention to surgical pathology. Levshin (1842–1911) was a professor in Kazan, where V. I. Razumovsky was his student, and later in Moscow, where he headed the hospital surgical clinic. Pelekhin was the first to acquaint Russian surgeons with Lister's method. Even before his professorship, while in Kiter's clinic, he traveled to England and Scotland, visited Lister, and upon returning, published an article in 1868 in which he set forth his observations on the antiseptic method of treatment. However, this method was far from universally recognized. Only in 1877–1878, during the Russo-Turkish War, was antisepsis applied on a wide scale for the first time in the entire world. The main credit for this matter belongs to K. K. Reyer and his teacher, the famous Dorpat surgeon E. Bergmann, who moved from Dorpat to a chair in Germany. Meanwhile, the method was far from taking root everywhere in clinical institutions. Velyaminov, who graduated from Moscow University in 1877, left for the Caucasian front not being familiar, by his own admission, with the Listerian method of wound treatment. In the Moscow faculty surgical clinic, antisepsis was not used until the end of V. A. Basov's tenure as head. It was introduced by Sklifosovsky (1836–1904), who assumed the headship of the clinic after Basov in 1880. All the more interesting is that this method found application in district Zemsvo hospitals in the late 1870s. The report of Zemsvo physician I. P. Varavva of Dmitrov Uyezd, Moscow Governorate, for 1879 contains the first indication that in the uyezd Zemsvo hospital, the Listerian bandage in its latest modification with carbolic acid spray was used as a normal method of wound treatment. The closer to the end of the 19th century, the more independent Russian surgery became. Russian surgical societies, congresses, and the specialized surgical press played a major role in this. The first surgical society in Russia was founded in 1873 in Moscow under the name "Surgical Society in Moscow." Older than it in Europe was only the Société de chirurgie in Paris. In 1881, the "Russian Pirogov Surgical Society," the second oldest in Russia, was founded in Petersburg. In 1896, a second surgical society arose in Moscow—the "Society of Russian Surgeons in Moscow," more democratic in its structure, since its charter lacked the clause according to which only doctors holding the academic degree of Doctor of Medicine could be members of the society (such a clause existed in the charter of the first society). For many years, both societies existed in parallel, until in 1918 they merged into one under the name "Russian Surgical Society in Moscow." In 1923, it celebrated the 50th anniversary of its existence. Following the reorganization in 1930 and the significant expansion of the goals and tasks of the society, it currently exists as the "Surgical Society of Moscow and Region." In 1931, the "Pirogov Surgical Society" in Leningrad also celebrated 50 years. An equally major role in the development of surgery fell to the numerous surgical societies and surgical sections of medical societies that arose in connection with the revival of scientific and public life in the post-revolutionary time in all large or medium-sized places of our Union. This was facilitated to a great extent by the network of medical higher educational institutions, which had grown significantly during this time. Among the congresses of physicians in Russia, the Pirogov Congresses played the greatest role in the development of surgery; surgery enjoyed special attention at these congresses, standing out into a special section, as did the congresses of Russian surgeons. The first congress of Russian surgeons took place in 1900, and prior to this, for 15 years, surgical issues were raised and discussed at all 7 Pirogov Congresses that took place (from 1885 to 1899 inclusive). At the last pre-revolutionary extraordinary congress, convened in 1916 at an extraordinary time when the army was suffering defeats at the front and state power in the country revealed complete bankruptcy, all attention was devoted to issues of public medicine in connection with the ongoing colossal traumatic epidemic and, chiefly, the organization of assistance to the sick and wounded. The significance of the Pirogov Congresses for Russian surgery is not exhausted by the surgical sections alone. The very character of the structuring of the congresses, their large attendance, and the diversity of sections in both theoretical and clinical medicine as well as public medicine ensured a versatile coverage of many issues from fields bordering on surgery. Throughout all congresses, there is almost not a single section in whose work issues of interest to the surgeon, and sometimes of great importance for surgery, were not touched upon to one degree or another. Within the bosom of the Society of Russian Surgeons in Moscow in the late 1890s, upon the report of founding member A. P. Levitsky, the idea arose to establish a central medical library in Moscow accessible to all Russian physicians. A corresponding report on behalf of the society was presented by him at the 7th Pirogov Congress in Kazan in 1899. In the 1890s, the aspiration to organize surgical congresses had already arisen among Russian surgeons. This idea was first voiced by Sklifosovsky; later, in 1894, this issue was raised in the surgical society in Moscow by A. A. Bobrov, P. I. Dyakonov, and some others. After lengthy preparatory work, the First Congress of Russian Surgeons was convened in Moscow in late 1900. The last XXIII Congress of Surgeons of the USSR was held in Leningrad in 1935. The role of surgical congresses in the development of our surgery is enormous: there is not a single problem of modern surgery to which they did not respond. On the basis of scientific interests, in the aspiration for the development of surgery in our country, the congresses united all surgeons. Over the first 20 congresses, about 1,500 reports passed through them. The published proceedings are the best testimony to the work accomplished. After the revolution, against the background of a complete break in communication among Russian surgeons, a congress of surgeons of the Red Army of the Northern Front was convened in Vologda in October 1919. This was the first attempt after the so-called military congress of 1916 to exchange thoughts and discuss, if only in a limited circle, the issues of assistance to the wounded in the difficult conditions of the Civil War front. When later, in 1922, the congresses of Russian surgeons were revived, along with them a new, previously unknown form of scientific communication arose—regional congresses of physicians, including surgeons. One feature is inherent to these congresses and distinguishes them from all-Russian congresses: along with general surgical issues, they raise issues of local, frequently everyday significance. Such are the congresses of surgeons of the North Caucasian Krai in Rostov-on-Don (the first took place in September 1925), Transcaucasia (Baku, December 1925), Odessa Governorate (1923, 1924, 1925), and surgeons of Left-Bank Ukraine (Kharkov, 1925). At the latter, the idea of the systematic organization of congresses of surgeons of Ukraine was born and soon implemented. Thus, All-Ukrainian Congresses of Surgeons arose. Keeping primarily in mind the practical and scientific demands of the district doctor, regional congresses put forward as program themes issues close to life with which the rural doctor deals in daily work. For example, at the 1st Congress of Physicians of Eastern Siberia in Irkutsk in 1924, out of 25 reports of the surgical section, 7 were devoted exclusively to issues of local significance, such as Beck's disease in Transbaikalia and goiter in the Cis-Baikal region. At the congresses of surgeons of the North Caucasian Krai and Transcaucasia, such important issues for the local region as echinococcal diseases and urolithiasis were put forward. Meeting the ripened need, all-Union and local congresses included for the first time issues of orthopedics, traumatology, social surgery, and the organization of surgical assistance to the population.

The 17th Congress in 1925 in Leningrad devoted an entire session to orthopedics, and this custom became part of the agenda for all subsequent All-Russian and All-Ukrainian surgical congresses. The question of bone and joint tuberculosis, closely related to orthopedics, was discussed as a programmatic topic at several congresses; similarly, traumatology issues were set as programmatic topics at some regional congresses where industrial traumatism occupied a prominent place in the occupational morbidity of the working population. Finally, at the 22nd All-Union Congress (in 1932), besides others, two topics were discussed: blood transfusion and anaerobic infection—issues of extremely important significance for the defense capability of the country. Regarding blood transfusion, this congress showed that we have significant achievements both in the organizational sense and even more so in the development of a new problem implemented for the first time in the Soviet Union—the transfusion of cadaveric blood. In recent years, local conferences convened in the inter-congress period and devoted to one or another burning issue of practical surgery have become customary. Thus, we see how our specialized congresses increasingly adopt a character that meets the needs of socialist construction and public health. In the very same year of 1885, when the first congress of Russian physicians took place, the first Russian surgical journal, Khirurgicheskiy Vestnik (Surgical Herald), was founded in St. Petersburg by Velyaminov; it lasted until the end of 1894. During 1895, the journal appeared in a somewhat reduced format, without the abstract section, under the title Russkiy khirurgicheskiy arkhiv (Russian Surgical Archive). From 1896 to 1901, the journal was published by Velyaminov jointly with Sklifosovsky and bore the title Letopis russkoy khirurgii (Chronicle of Russian Surgery). From 1910, marking the 25th anniversary of the existence of the first Russian surgical organ, the journal was named Velyaminov's Surgical Archive in recognition of the merits of its permanent editor and in his honor. Special mention should be made of the journal's sections on prominent figures in surgery, clinic descriptions, history of surgery, and reports. In 1875, the Surgical Society in Moscow began publishing a journal that survived under various names for 40 years. For several decades, the organ of the surgical society in Moscow reflected its life: it was, as it were, a written history of the society. In 1896, Dyakonov left the editorial board of the journal Khirurgicheskaya letopis (Surgical Chronicle) and from 1897 published the journal Khirurgiya (Surgery) in Moscow, which existed almost until the end of 1914, when it also had to close down due to military events. Finally, during 1903–1906, Russkoye khirurgicheskoye obozreniye (Russian Surgical Review) (totaling 3 volumes) was published in Moscow under the editorship of I. P. Aleksinsky and A. V. Martynov—an organ of the congresses of Russian surgeons which had one important goal: to be a bibliographical reference book on Russian surgery. Unfortunately, with the cessation of this journal, Russian surgeons again lost an important publication whose need had long been felt. Only in 1927 was the gap filled by E. R. Hesse, who, thanks to the editorial board of the journal Novaya khirurgiya (New Surgery), was able to issue, under his editorship and with the participation of a number of Leningrad surgeons, the Bibliography of Russian Surgery and Borderland Fields for 1914–1924. In subsequent issues, the bibliography, issued as a supplement to the journal Novaya khirurgiya and later Sovetskaya khirurgiya (Soviet Surgery), was brought up to 1933 inclusive. This work in every respect represents an outstanding phenomenon in our surgical life. In pre-revolutionary years, besides dissertations, there was another type of surgical literature—clinic proceedings, which often contained valuable works. Such proceedings were published by the clinics of Dyakonov, Fedorov, and Oppel. In 1921 in Tver, thanks to the tremendous energy of Ya. O. Galpern, the first post-revolutionary surgical journal, Novyy khirurgicheskiy arkhiv (New Surgical Archive), began to appear, which now numbers 34 volumes (136 books). A year later, in 1922, I. I. Grekov issued the first number of Vestnik khirurgii i pogranichnykh oblastey (Herald of Surgery and Borderland Fields) in Petrograd—a journal which by the end of 1934 under the title Grekov Herald of Surgery was issued as its one-hundredth book. The next two journals, Novaya khirurgiya and Zhurnal sovremennoy khirurgii (Journal of Modern Surgery), arose in Moscow—the first in 1925, the second in 1926. From mid-1931, both journals merged into the united journal Sovetskaya khirurgiya. Each of the three surgical journals existing at present has its own physiognomy, its own features, and its own thematic scope. But our current surgical literature is not exhausted by them. Institutes that arose in recent years (for emergency aid, blood transfusion, traumatology, research institutes, etc.) and the increased network of higher medical educational institutions called to life a series of new works, as a result of which we have monographs on the most diverse issues of clinical and theoretical surgery. Original textbooks on surgery and clinical lectures published by a number of authors, which pre-war Russian literature did not know, meet the increased needs of teaching as well as the demand from practical and scientifically working surgeons. At the end of the 19th and beginning of the 20th centuries, several surgical schools emerged in Russia; of these, the schools of Bobrov, Dyakonov, Razumovsky, and Velyaminov were of the greatest importance for the development of surgery. Even earlier, Sklifosovsky developed his brilliant activity, successively occupying chairs in Kiev, St. Petersburg, Moscow, and again in St. Petersburg. Practical surgeons (in Moscow: I. D. Sarychev, M. P. Yakovlev, A. P. Levitsky, and others) and several professors emerged from Sklifosovsky's school, among them Prof. Tauber of Warsaw University, the head of the Moscow faculty clinic I. K. Spizharny (1857–1924), and Zematsky. Bobrov's school (1850–1904) produced I. P. Aleksinsky and S. P. Fedorov, one of the most brilliant representatives and leaders of our surgery. During his more than 30-year leadership of the hospital surgical clinic of the Military Medical Academy, S. P. Fedorov produced a huge constellation of disciples: his school, the most numerous one, numbers not a few dozen professors currently occupying chairs in the USSR. A completely special place among others was occupied by the clinic of P. I. Dyakonov (1855–1908) in Moscow, which attracted a particularly large number of Zemsky doctors. Himself a Zemsky doctor by his past activity, Dyakonov was tied by many threads to public medicine. An excellent organizer, talented teacher, and clinic head, Dyakonov knew how to stimulate scientific work. More of an anatomomorphologist than a clinician, he steered the clinic in this direction, producing a large number of works. Dyakonov's school numbers very many disciples, among them V. L. Pokotilo, the early deceased head of the surgical clinic in Odessa; N. I. Napalkov, occupying a chair at the North Caucasian Medical Institute; F. A. Rein (1866–1925) is partly a disciple of Dyakonov, having served for many years as chairman of the Board of the Pirogov Society of Physicians and the Society of Russian Surgeons and serving as a kind of connecting link between Zemsky and academic surgery. V. I. Razumovsky (1857–1935) spent his entire activity in the provinces, first in Kazan, then in Saratov, Baku, and Tiflis. In the latter three cities, he was the founder and organizer of universities and along with them medical faculties. A number of surgeons came from Razumovsky's school, some of whom occupy chairs. Together with Levshin, Dyakonov, and Subbotin, he was the creator of the 7-volume collective textbook Russian Surgery, for which he wrote several chapters. N. A. Velyaminov (1855–1920) managed to establish himself as a talented clinician even before taking the chair at the Military Medical Academy, which he received in 1895. Professors Tiele, V. M. Mysh, Serapin, M. M. Dieterichs, and others came from Velyaminov's school. Surgery in Dorpat put down deep roots since the time of Pirogov. His successors were Bergmann and Wahl. To Wahl's school belongs Zoege-Manteuffel (1857–1926), an outstanding clinician and surgeon equally close to both Russian and German surgery. Zoege-Manteuffel had immense merits: a brilliant technician, he particularly distinguished himself in the field of heart and blood vessel surgery, abdominal surgery, and military surgery. From his school, among other disciples, chiefly practical surgeons, came N. N. Burdenko, a representative of a new branch of surgery—neurosurgery—a surgeon-biologist currently heading two clinics in Moscow. In the persons of V. A. Oppel (1872–1932) and A. V. Martynov (1868–1934), Soviet surgery lost two major surgeons, representatives of two different trends, each of whom created his own school. With the death of V. A. Oppel, I. I. Grekov, R. R. Vreden, and S. P. Fedorov, the next generation of surgeons—Hesse, Dzhanelidze, Schaak, and others—rose to the front ranks of leading surgery in Leningrad. One of the most prominent contemporary surgeons of the Leningrad school is N. N. Petrov, a major authority in oncology not only in our country but also abroad. In the history of our science and its social role as a practical specialty, a special place belongs to municipal and Zemsky medicine. An extremely limited number of university centers and an insignificant number of beds in clinics were the reason why, in the pre-revolutionary period, surgical clinics could not play any noticeable role in providing surgical care to the population.

Naturally, this task in cities fell to the share of city hospitals, and in the zemstvo areas to district hospitals, wherever the latter could provide the population with more or less qualified care. Thus, in the last quarter of the 19th century and the beginning of the current one, large hospitals emerged in cities, which gradually managed to create surgical centers within their walls that later grew into schools. St. Petersburg and Moscow take first place here. In St. Petersburg, the Obukhov Hospital acquired the greatest fame, where A. A. Troyanov, G. F. Tseydler, and A. A. Kadyan worked. I. I. Grekov, B. K. Finkelstein, B. N. Kholtzov, M. M. Kryukov, N. I. Gurevich, N. N. Polyarsky, L. G. Stukkey, E. R. Hesse, and many other surgeons came from this school. But it was not only the Obukhov Hospital that had such an honor. Even earlier, in the 1880s, the Mariinsky Hospital with K. K. Reyer (1846-1890) working there was one of those surgical centers that attracted physicians. In the Peter and Paul Hospital (now named after Erisman), M. K. Kitayevsky performed the first stomach resection here in 1881, 5½ months after Billroth successfully performed it. The first gastroenterostomy was also performed in the same Peter and Paul Hospital in 1882 by Kitayevsky's colleague, N. D. Monastyrsky, and also 5½ months after Belfleur first performed it. And later for several years St. Petersburg remained the only place where the operation of stomach resection was practiced, and the initiative came not from the academic, but from the municipal surgery. Approximately the same role, but to a lesser degree, fell in Moscow to the share of the Old Catherine Hospital (now named after Baburin), from the walls of which came V. M. Mints, P. A. Hertsen, a brilliant technician heading at present the hospital surgery clinic of the First Moscow Medical Institute after the death of Martynov. One of the pioneers of zemstvo surgery was A. T. Bogaevsky (1848-1930), who began his surgical activity in a rural hospital and developed it in the district town of Kremenchug, where he worked for many years. In his time, his services to Russian surgery were appreciated by the University of Kiev, which awarded him the degree of Doctor of Medicine honoris causa. In the early 1880s, Y. V. Zilberberg (1857-1934) began working in Odessa. Surgery at that time was represented there by city doctors (the medical faculty opened only in 1900) S. N. Kalachevsky, M. A. Yuzefovich, and several others. Some of them were at the height of the knowledge of the time. Thus, in 1888, Kalachevsky apparently for the first time in Russia performed a stomach resection not for cancer, but for a stenosing ulcer of the pylorus. But not only large cities, and in some places even rural hospitals played the role of surgical centers. Thus, in the 1890s, the activity of the hospital in the settlement of Smela, Kiev Governorate, with its talented surgeon B. S. Kozlovsky (1855-1919), began to stand out. Even earlier, in the 1870s and 1880s, the foundations of surgical care began to be laid in the east of Russia, in the Volga-Kama region, in the Urals, by zemstvo doctors, almost exclusively alumni of the University of Kazan, the only incubator of higher education in this part of Russia at that time. A brilliant page in the history of Russian surgery among them was written by P. V. Kuznetsky (the elder, 1845-1912), who developed a huge surgical activity in Nizhny Tagil, performing, according to his biographers' calculations, several tens of thousands of operations and, just like Bogaevsky, awarded the degree of Doctor of Medicine honoris causa by the University of Kazan; there in the Urals, A. A. Mislavsky (the grandfather), the well-known lithotomist E. P. Assendelft, who worked in the village of Vetoshkino, Nizhny Novgorod Governorate, and many others. To the earlier generation of zemstvo surgeons belong currently working K. V. Volkov (Yadrin, Chuvashia), V. V. Uspensky (Kalinin); to the surgeons of the later formation belongs S. S. Yudin, heading the largest department in the Institute of Emergency Care in Moscow. Many interesting works came from the pen of zemstvo surgeons, such as on urolithiasis, on goiter in the Urals, on hernias. Not a few teachers of surgery and scientific workers came from the milieu of zemstvo surgeons. Suffice it to point to Dyakonov, who began his medical activity as a district doctor in the Oryol zemstvo; N. A. Gerken (1863-1933), who also began his work in a rural zemstvo hospital of Spassk Uyezd, Kazan Governorate, subsequently a professor in Kazan; A. A. Kadyan (1859-1917), who managed the surgical department of the Simbirsk Governorate zemstvo hospital; A. A. Abrazhanov (1867-1931), who worked in the Urals as a factory and then a zemstvo doctor. Of those currently living, S. I. Spasokukotsky should be named, who spent over 10 years in the Smolensk Governorate zemstvo hospital; Y. O. Halpern, who learned surgery in the settlement of Smela from Kozlovsky, then in Smolensk from Spasokukotsky, and worked independently in the Tver Governorate zemstvo hospital; P. D. Solovov, who worked in a rural hospital of the Yekaterinoslav zemstvo; V. S. Levit in the Ardatov zemstvo hospital of Simbirsk Governorate. A powerful impetus to the further development of surgery was received in the years of restoration after the experienced hard years of the Civil War and its consequences. The revolution put forward new principles for the organization of surgical care and posed a number of new concrete questions subject to resolution. All this contributes to that flourishing of surgery among us which we are experiencing at the present time, in the era of socialism under construction. The surgical network in the country has grown greatly, the number of surgical beds has increased several times over, the qualification of surgeons has significantly risen, and their need for further improvement has intensified, which the newly created institutes meet. Along with this, the scientific and literary activity of surgeons has increased, interest has appeared in those issues that were not touched upon before: surgery begins to be studied in connection with social problems, with the conditions of everyday life and production, and the issues of organizing surgical care in both peacetime and wartime are widely posed. All these topics among Soviet surgeons have a single goal: to link their activities as fully as possible with the demands of socialist construction. The upswing characterizing Soviet surgery serves as the best proof that it has bypassed the crossroads, and the method with which it is to arm itself—dialectical materialism—is a reliable guarantee that it does not fear the crisis experienced by science in capitalist countries. Surgery makes great demands on the physicians who devote themselves to it; naturally, a surgeon must be a comprehensively educated physician. Since the main type of physician needed by our country remains the general practitioner with the profile of an "encyclopedist" who knows how to do everything, the question of his training in the field of surgery acquires immense importance. The medical education received by a student in an educational institution cannot make a finished surgeon out of him, but it must give him such development as would serve as a base for further improvement and deepening of special knowledge. After a series of reorganizations, the curriculum of surgery in medical higher education institutions is conceived by the surgical community of our country in the following form. Three separate surgical clinics are preserved: propedeutic, faculty, and hospital, which ensure the student's successive and systematic acquaintance with surgery, with teaching in the three courses conducted on the principle of continuity and proceeding from the general to the particular. Topographical anatomy, playing the role of a preparatory discipline in the 3rd year, is called upon to serve the clinic, and in this sense the content of the subject must fully correspond to clinical facts and operative procedures. Operative surgery must not only be preserved, but is extremely desirable to be supplemented by a course of vivisections with the mandatory performance of a number of typical operations on animals. In the 3rd year, where the foundations of surgical pathology are laid and the analysis of surgical diseases is given, the student must receive basic concepts of traumatology and military field surgery. The teaching of both should be conducted on the basis of emergency surgery material without separating them from the surgical departments. Other disciplines, such as oncology, surgical tuberculosis, urology, orthopedics, should find their place depending on the capacity of a given clinic and the available teaching staff in the 4th and 5th years. Along with clinical teaching, it is necessary starting from the 3rd year to create a polyclinic teaching with the active participation of students and their tutorship. Production practice should be concentrated within the walls of the higher education institution or in large medical institutions associated with the clinics. Of particular importance in the system of surgical education and the training of a full-fledged surgeon are postgraduate specialization courses for physicians, the number of which should be increased. The decree of the Soviet Government of September 4, 1934, meets these fully matured tasks. A physician's education will be incomplete if he is not acquainted with the history of his science. It was indicated above how, in the process of long centuries of searching, struggle of views and trends, those foundations upon which modern surgery rests as a science crystallized in the final analysis. The study of the history of surgery, enriching our knowledge, broadens the mental horizon and can safeguard against many methodological errors in our actions and scientific pursuits.