Br. J. Surg. Vol. 68 (1981) 678-679 Printed in Great Britain

Biographical note on Theodor Billroth M. ALLGOWER A N D U. T R t ) H L E R *

IN 1981, it is fitting to remind ourselves of Theodor Billroth as the greatest surgeon, teacher, scientist and humanist among many excellent nineteenth century German sur eons. It was on 29 January 1881 that Billroth perkrrned if not the first at least the first successful resection of a cancerous pylorus. This caused a great sensation in medical circles comparable to the first successful heart transplantation some 80 years later. Yet it was already the third hazardous operation successfully introduced by Billroth. In 1872, he had been the first to resect the oesophagus and in 1873 to perform a total laryngectomy.

Who was this man? He was by no means just a technically skilled surgeon. Billroth was born at Bergen, on the island of Riigen, Germany, in 1829. His father, a clergyman. died when Theodor was 5 years old and his mother then moved to the old University town of Greifswald. He was musically inclined (a family characteristic) and, maybe for that reason, was not an exceptional pupil. He seemed unable to master languages and mathematics (yet later made reasonable use of both). He started studying music but was induced by his mother and two Greifswald professors to become a doctor for financial reasons. He remained, nevertheless, an artist throughout his life: intuitive, sensitive, humane and inventive. His home in Vienna later became a musical centre where he played second violin, viola or the piano and became friendly with Johannes Brahms. Two of Brahms’ string quartets are dedicated to Billroth, and during his last illness Billroth was working on the physico-psychological book Who is Musical?, published posthumously by Hanslick in 1896.

During his studies at Gottingen in 1851, Billroth established a lasting friendship with Georg Meissner (who discovered the tactile nerve endings in 1852, the ‘Meissner bodies’). Together they travelled to Trieste to study the origin and insertion of the nerves of the torpedo fish: this interest in natural sciences remained life long. In Berlin, his teachers constitute a catalogue of medical eponyms: B. von Langenbeck, Schonlein, Romberg, Traube. Traube motivated Billroth’s interest in the autonomous nervous system, the regulatory role of which was in the foreground at a time when the come t of endocrine secretion had not yet been ac- cepte8. Thus, Billroth wrote his MD thesis (in Latin) on the nature and cause of pneumonia caused by cervical vagotomy (1852).

Billroth then became attached to the famous surgeon von Langenbeck and started publishing also on patho- logical anatomy and embryology. He was, of course, a contemporary of Rudolf Virchow (1821-1902), who was then working at his ‘cellular pathology’ (1 858). Indeed, in 1858 Billroth was offered a Professorship of Pathology at Greifswald which he declined. He wanted to be a surgeon. This story shows the extent of Billroth’s training. After 2 years, in 1860, at the age of 30, he was nominated Professor of Surgery at Zurich, where he directed the clinic for 7 years.

Modem surgery (after the introduction of anaesthesia around 1850) was in its infancy and Billroth became

especially interested in the causes of ‘wound fever’, the most dreaded surgical complication. It was then considered a ‘stimulus-fever’ (Reizfieber) transmitted by the nervous system. Billroth, the clinician, insisted on regular temperature taking, and Billroth, the microscopist, found ‘microbes’ in septic patients. How- ever, in the absence of staining technique and of Robert Koch’s specific culture techniques, he considered the different types of microbes he saw to be various forms of the same basic bacterial type. He termed them ‘coccobacteriae septicae’. (Darwinism influenced him in this view, as he said.) These coccobacteriae he thought to be a byproduct of inflammation and septicaemia rather than their cause.

During his Zurich years, Billroth published his classic textbook on surgical pathology and therapy and started editing the Handbuch der Chirurgie (1865-68). But his most remarkable work of these 7 years is the statistical account of his experience, Chirurgische Klinik Zurich, 186047. He fully realized the importance of the statistical method for the evaluation of surgical versus conservative treatment and introduced the com- prehensive reports of results-failures and successes alike-as a ‘must’ into the German hospital world. ‘That is how we ought to work-if clinical experience is to add to medical knowledge’, Billroth exclaimed, ’if only we were not so hopelessly lazy’. He himself continued his reports for another 10 years from the Vienna surgical clinic until 1876.

Indeed, having declined positions in Rostock and Heidelber , he accepted the Chair in Vienna in 1867, at the age o f 3 8 . That was the year when Joseph Lister published his first paper on the antiseptic principle in surgery in The Lancet. Billroth’s attitude towards ‘Listerism’, which was rapidly introduced into German and Swiss clinics, was at first rather reserved. He felt that his ‘open wound management’ had given him excellent and statistically documented results but that a strictly scientific basis to the excessive antiseptic pre- scriptions was lacking, particularly since his own attempts in this direction had given him only inconclusive results. Some years later, convinced by comparative statistics from various clinics and by the works of Pasteur and Robert Koch (after 1878), Billroth became one of the foremost promoters of antisepsis and asepsis on the Continent. As had many others, Billroth had largely ignored Sernmelweis’ work! One work accomplished in Vienna was his Historical Study on the Nature and Treatment of Gunshot Wounds from the 15th Century to the Present Time, which was still deemed worthy a translation into English by C. P. Rhoads in 1933. Further examples are his books and monographs on the teaching and learning of the medical sciences (1 876, 1886).

Whilst Billroth attracted innumerable foreign

* Department Chirurgie, Universitltskliniken, Kantonsspital, CH-4031 Basel, S italstrasse 21, Basel, Switzerland, and Department of the history of Medicine, University of Basel, Klingelbergstrasse 23, CH-403 1 Basel, Switzerland.

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carried on his spirit of technical innovation, clinical and basic research and occupied many chairs of surgery or chief hospital positions throughout Europe and overseas.

Billroth lived in times of transition. As a student he had had to learn 60 categories of ‘fevers’; when he died most of them had ceased to exist. The rest had been reduced to specific causing agents. Surgery had definitively reached scientific status and most organs were safely accessible when he died in 1894 in Abbazia (near Trieste). Yet despite his own technical achieve- ments (for which he undeniably would have received a Nobel Prize had it existed then), operations were not for him the ultimate goal of surgery, let alone of medicine, as they were for many of his contemporaries. In 1890, he saw the future for the advancement of both medicine and surgery (even in the field of cancer therapy) in the study of biology-true then as well as today.

postgraduate students, his Austrian undergraduates largely perferred to prepare for their examinations from cheap scripts. Billroth would hardly be popular today, for he thought the ‘rigorosi’ were not rigorous enough and that the egalitarian principles which had definitely won over the ancien rtgime of Metternich’s style in 1848 had had appalling consequences in lowering standards of medical education in Austria. This and his helplessness in many diseases saddened him more towards the end of his life than his successes and his international fame gave him cause for pleasure: he considered his pioneer operations just as ‘little pieces of virtuosity’ (‘Virtuosenstiicklein’) and his good results with standardized methods sim ly as normal. Should he not give it all up and cfevote his life entirely to art? It was his pupils in whom he finally saw the reason for continuing his work as a surgeon. He had always been able to establish generous and open- hearted relationships with them. They widened and

Br. J. Surg. VoI. 68 (1981) 679-681 Printed in Great Britain

Recurrent ulcer ERIK A M D R U P *

PEPTIC ulcer is a disease with recurring symptomatic periods. Intermissions with none or few complaints alternate with more or less severe attacks, often regularly, but sometimes longer symptom-free intervals may occur. Therefore, the patients have to be observed for many years before any treatment can be judged successful. This type of management has convincingly proved that we have to accept a certain recurrence rate following any type of ulcer operation. The only exception is total gastrectomy in patients with gastrinoma, a special and uncommon cause of ulcer which will not be commented upon in this paper.

Poor results are not surprising when omissions and errors in surgical technique as a result of inadequate knowledge lead to insufficient operation. In order to solve the problem of the recurrent ulcer it is important to record carefully the failure rate of surgeons with a reasonable training in gastric surgery. We should not hide or attempt to excuse our recurrences, but face them bravely and try to discover their cause.

Modern endoscopy has added considerably to the diagnosis of recurrent ulcer. It can be seen and photo- graphed, the exact location can be stated and biopsies taken, thus confirming an ‘ulcer dyspepsia with proved ulcer’. Sometimes an active ulcer is not found in patients who have no doubt that the well-known preoperative complaints have reappeared. These cases may be grouped as ‘ulcer dyspepsia without proved ulcer’, but it is unfortunate if they are not calculated as recurrences in the statistics. Finally, some patients present with quite ‘uncharacteristic symptoms’ in combination with healed ulcers. In an overall grading they have to be recorded as failures (l), but it is more confusing than instructive to include them in the recurrent ulcer group.

Prospective clinical trials have shown that ulcers can recur at any time during the first 5 years (2-4) and

Table I: SYEAR CUMULATIVE RECURRENCE RATE FOLLOWING VACOTOMY FOR DU Operation and Preoperative PA0 , (mmol/h) recurrence rate 0-24 25-34 39-44 >45

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perhaps even later. This fact is of importance when comparing studies with different observation periods, and it is suggested that the time factor is included in the calculations by using a life-table method (5 ,6) ex- pressing the cumulative recurrence rate.

Surgical treatment of ulcers aims to reduce gastric acid secretion. A logical deduction from this main principle would be that hypersecretory patients might have a higher recurrence risk and therefore should be treated with more extensive operations (7). This concept has been supported in follow-up studies of duodenal ulcer (DU) patients treated with truncal vagotomy and drainage (TV + D) (8), selective gastric vagotomy and drainage (SGV+D) (9) and parietal cell vagotomy (PVC) (10). However, recent results of a large prospective trial (3, 4, 6) show no relation between preoperative astric out ut and subsequent recurrence (Table I ) . T i e same lac! of relation betwecn several other preoperative gastric acid parameters and recurrence rate appears from recent studies on the same patient material (1 1).

Our studies of PCV and SGV+D for DU have shown a 5-year cumulative recurrence rate of 15 per cent and 9 per cent respectively, the difference being not significant and similar to other published reports (9, 10,12,13). Reviewing the literature, one gets an

* Surgical Gastroenterological Department L, Aarhus Kommunehospital, 8OOO Aarhus C, Denmark.