Dr. Will’s musings on German surgical centers
To the American traveling in Germany for the purpose of visiting surgical clinics some of the smaller cities offer superior advantages. The large clinics of Berlin and Vienna are well known, and so largely attended that personal observation is difficult, and one is debarred from that close contact with the operator and the observation of operating-room and patients which are of such great value.
Langenbeck was the first truly great German surgeon: he was the Gross of his time. Langenbeck brought from Paris, then the surgical center, to Berlin new methods and ideas which revolutionized German surgery. Billroth became Langenbeck’s disciple, and when he was called to Vienna, those two cities, Berlin and Vienna, at once rivaled and eventually eclipsed Paris in the surgical world.
Contemporaneous with Billroth another great surgeon appeared in Germany: Volkmann, of Halle, also a former assistant of Langenbeck’s. Volkmann applied his knowledge and skill especially to surgical tuberculosis and disease of the osseous system. He may be said to have originated modern surgery of the bones and joints.
Billroth and Volkmann were not only great surgeons, but they were inspiring teachers, shown by the fact that so many of their assistants are in active work, having hospitals in the smaller German provinces which rival in character and extent hospitals in the great centers of Berlin and Vienna.
Czerny, once first assistant to Billroth, is at Heidelberg, and Schede, a former assistant of Volkmann, is in Bonn. Mikulicz, Wölfler, and many others were assistants to these two men—in fact, more than half the chairs of surgery in German universities were filled by former assistants of Billroth and Volkmann.
Kocher, of Berne, is the commanding figure in German surgery today (1900). He spent three years in London as Lister’s assistant, and in all respects is a product of the best German, French, and English thought.
The great German clinics are in the hands of keen, well-trained, and ambitious men, and there is a large output of new and good things. One has but to remember the recent contributions to surgery of the chest, head, abdomen, bones, and joints to recognize the great position of German surgery in this generation.
The German hospitals are large, well-organized, and efficient. Trained women nurses are now in charge of the nursing in all the hospitals of note.
To a certain extent the German surgeon is relieved of direct responsibility to the patients, and he concerns himself with the pathologic processes rather than with the patient’s likes and dislikes. This has its good features inasmuch as the surgeon’s hands are not tied by the prejudices of patients and their friends.
Berlin (1912): Prof. Bier is here, the leading spirit in surgical progress. He is intensely interested in his work, and his clinic is very popular, especially with the American student. Prof. Bier has the largest surgical clinic in Germany, and he is a worthy successor to Langenbeck, Deffenbach, and von Bergmann, who each in his time, were the leaders of German surgery.
Berlin (1913): Prof. Rotter at the Hedwig Hospital and Prof. Bumm of the University Clinic in Berlin are doing extraordinarily good work along special lines, that is, cancer of the rectum and cancer of the uterus, respectively. Rotter has contributed largely to our fund of knowledge concerning cancer of the rectum. Prof. Rotter is a surgeon of large experience. His aseptic technic, which is of the best, is carried out rigorously, and his results are good.
Prof. Bumm in the Universität Frauen Klinik, Berlin, has devoted much time and energy to the study of cancer of the uterus. Before visiting the clinic my interest in his work had been stimulated by the excellent review of it by Herman J. Boldt. For some years I have carefully observed the total abdominal hysterectomy for cancer as performed in various countries, and while I can agree with those surgeons who believe this method to be the best, inasmuch as it gives the highest percentage of cure, it undoubtedly is an operation which has a high operative mortality, and in from 4 to 7 per cent of cases accidents have occurred causing injury to the bladder, rectum, and especially to the uterus. We must, therefore, welcome any improvements in technic which retains the obvious advantages of the operation and removes the disadvantages to as great an extent as possible. I believe the Bumm method of procedure to have distinct advantages.
Körte of Berlin is a painstaking, conservative surgeon, who enjoys the respect and confidence of his confreres. He is one of the best general surgeons in Europe, and his material is good.
At the Charity Hospital, Franz is chief of the obstetric and the gynecologic clinic, and he has a large amount of work. I witnessed several of his operations and have never seen more skillful pelvic surgery. A complete abdominal hysterectomy for cancer of the cervix was a masterpiece. Franz makes the transverse abdominal incision of Phannenstiel, and uses spinal analgesia; this was the only clinic in which I saw it used.
Bern (1912): For thirty years the Kocher clinic at Bern has been one of the leading surgical clinics of the world and is still one of the leading clinics. More new and good ideas have come from this one clinic than from any other clinic of my acquaintance, all due to the genius of one man, Theodor Kocher, who is still vigorous with a seemingly perpetual youth. Kocher is constantly at work trying out new things and improving the old. He is an inspiration to surgeons the world over. The work in this clinic is marked by the extensive use of local anesthesia by painstaking care in handling the tissues and the exclusive use of silk for sutures and ligatures. I was greatly interested in his method of procedure for prolapse of the uterus, which he has practiced for many years.
Bonn (1900): Schede is the surgeon-in-chief at this hospital (University Hospital). As an operator, he is quick and sure, and while watching him one has a feeling of absolute confidence in his knowledge and judgment. We observed many interesting and instructive things in this clinic, and, as elsewhere in Germany, were treated with great courtesy.
Bonn (1912): The surgical clinic has always been under the directorship of a great surgeon. Trendelenbufg was here before he went to Leipzig; Max Schede came from Hamburg at the height of his justly earned reputation and died here. Bier was here right before he went to Berlin. Garre is now in Bonn and is in every sense a sound and forceful surgeon. The organization and discipline of his clinic is nowhere excelled. Garre is one of the best teachers of surgery to be found in Germany, and he operates, not only on patients at the clinic for his students but also on the cadaver.
Braunschwieg (1900): The surgical department (State Hospital) is under the charge of Sprengel, a former assistant of Volkmann’s. He is a most excellent surgeon. He operates four mornings and overlooks the dressings the other three mornings of the week. As would be expected in an assistant of Volkmann’s, his bone and joint work is especially fine. I was already familiar with Sprengel’s contributions to surgical literature, and very glad of an opportunity to visit his clinic. I can testify to the excellent management of a very large amount of material.
Cologne (1900): Bardenheuer is the chief surgeon (Cologne Hospital). He is a small, elderly man, but very active in his movements. He is an authority on fractures and dislocations, having at his disposal the largest number of this class of patients of any hospital in Germany. He advocates extension in all cases of fracture by means of weights and pulleys, applied in a manner to counteract muscular contraction. As shown my x-ray, the anatomic results are remarkably good. Gloves are seldom used in this clinic.
Erlangen (1913): My purpose in visiting Erlangen was to see the work of Prof. Graser, whom I had the pleasure of meeting when he was in America. Graser is a surgeon of the first rank and in the prime of life. He has 180 hospital beds and a large amount of surgical materials. He has taken a great interest in work on the stomach and has originated a method of resection for cancer which has not been excelled. He uses a clamp of his own device which permits suturing of the closed stomach through a slot in the clamp. Like all German surgeons, he is greatly interested in bone and joint work, and I examined many cases following operations for deformed and ununited fractures.
Hamburg (1912): Our visit to Prof. Kümmell (Ependorf Hospital) was most interesting. He allows his patients to get up the day following an operation and believes this hastens convalescence. Prof. Kümmell impresses one as being a lover of truth in science, is original in his methods, and is a splendid surgeon.
Heidelberg (1913): Prof. Wilms of Heidelberg is one of the most rapid operators in Germany and he has a large amount of material. Local anesthesia is used extensively, and methods of using Novocain for this purpose have been greatly extended in his clinic.
Jena (1913): Prof. Lexer of Jena has made bone and joint surgery famous in Germany by his transplantation of entire joints. He is a disciple of Bergmann, still adheres to Bergmann’s technic, and has the reputation of being a surgeon who can carry out a desperate operation with skill and courage. I was present when he grafted pieces of ox horns in place of bone.
Leipzig (1913): At the University of Leipzig, Prof. Payr occupies the chair of surgery which Trendenlenburg so worthily held for many years and from which he retired only a few years ago. Trendenlenbufg’s work was markedly of great worth up to the time of his retirement. The operative removal of emboli from the pulmonary arteries was his final contribution. The “Trendenlenburg position” revolutionized pelvic surgery. I had the great pleasure when in Berlin of driving out to Nickolasee, where Prof. Trendenlenburg is now living, to call on him and to convey expressions of esteem and affection from the surgeons of America.
Payr is comparatively a young man, and a prodigious worker. His clinic is most instructive. One feature of his many operating-room facilities was an idea that he had brought with him from Königsberg for cooling the room in hot weather. It is a sprinkling device that keeps the skylight and windows covered with water and by its evaporation maintains the room at a very comfortable temperature.
Türbingen (1912): The surgical clinic at Türbingen is under the direction of Prof. Perthes, a former assistant of Prof. Trendelenburg. The hospital is very well appointed, the operating-rooms are well equipped, and the organization for the surgical work is of the bet. He (Perthes) does considerable work in surgery of the lungs and demonstrated many interesting cases. I would advise all American surgeons visiting Germany to attend the clinics at this university. We saw in Türbingen much that was new and interesting, and I enjoyed my stay there very much.
There is a distinct school of German surgery, and so far as I know it is the only distinct national school, although we have a standardization of technic in America and a trend of surgical opinion which may be said to be American. The American school has been greatly influenced by German ideas and German methods. The American travels and learns, and America is the surgical clearing-house for international surgery. Germany surgery is forceful, thorough, and exact, but has not been influenced by foreign ideas to any extent. German surgery dominates the neighboring countries, and all the clinics I visited this year were distinctly German, whether in Germany, Austria, Switzerland, or Holland. The central idea in German surgery is based on the sense of sight. “To do your work well,” says the German, “you must see what you do”; hence large incisions. To the American these incisions may seem excessive, yet we all know the size of the incision does not often affect the end-results. Another important point in German surgery is to eradicate the disease, if possible. Operations are not, therefore, undertaken lightly; the punishment must fit the crime, and, with the exception of cancer, patients are operated upon in a more advanced stage than with us. German surgery deals with pure science; sentiment has no place in it. The directing surgeons of the clinics are responsible men, well-trained and effective. They have three missions to perform: (1) to advance surgical science, (2) to teach the next generation of surgeons, and (3) to conscientiously devote themselves to help their patients.
Sources: “Notes on a Visit to the Surgical Clinics of Germany and France, William J. Mayo, St. Paul Medical Journal, 1900; “A Short Visit to Some of the Hospitals in Germany, Austria, Switzerland, and Holland,” William J. Mayo, M.D., The Journal-Lancet, 1912; “Notes from Some of the Surgical Clinics in Germany, Belgium, and Great Britain, 1913,” William J. Mayo, M.D., The Journal-Lancet, 1913.