Russian Surgery in the Crimean War:
NIKOLAy PIROGOV and the first anesthesia
“Stretcher
parties were constantly arriving with casualties, setting them down one beside
the other on the floor – which was already so packed that the wretched men were
jostling one another and smearing one another with their blood – and then
leaving to fetch more… Gloomy-faced surgeons in their rolled up shirtsleeves
knelt beside wounded men while an apothecary assistant held up the candle,
pushing their fingers into bullet wounds and searching them or turning over
severed limbs that still hung by a thread…” . Thus described an eyewitness, Leo Tostoy, the main hospital in his Sebastopol Sketches about the Crimean War. The hospital was
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| Siege of Sebastopol by Franz Roubaud (from Wikipedia)
set up in the large “Noble’s
Club”, where the billiard room morphed into the operating room and the
ballroom into an open ward for the wounded. Moving within this grim scene was an eminent surgeon who greatly advanced the knowledge of
battle surgery: Nikolay Pirogov.
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Pirogov was born in 1810, the thirteenth child of a Moscow
family whose
house perished when Napoleon set fire to the city in 1812. His father died
early, but being a quick learner Nikolay raced through school and was admitted
to Moscow University at age 14 to study medicine. He found the curriculum
inadequate but won a scholarship for further training at Dorpat University (now
in Estonia) under a German faculty. There he learned experimental
physiology,
did numerous anatomy dissections, and rose to become Professor of Surgery,
publishing an atlas of surgical anatomy shortly thereafter (see illustration below). He studied briefly in Paris
and Germany. At the age of 30 he won the Chair of Surgery at St. Petersburg’s
Medico-Surgical Academy and directorship of the Surgical Department at the Army
Hospital. During 14 years there he performed about 12,000 autopsies and,
utilizing the cold weather, made frozen sections of the human body at various
levels to produce a 5 volume Anatomia
Topographica, a highly praised work. “Pirogov’s triangle” (the
hypoglossohyoid triangle in the neck) is described there. The young and
restless surgeon, as one might expect, battled an entrenched and reactionary
medical staff jealous of his growing fame.
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| Nikolay Pirogov by Ilya Repin (from Wikipedia) |
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| From: Chirurgische Anatomie der Arterienstämme und Fascien,2nd ed, orig pub'd 1840 (from Internet Archives) |
In 1846 ether was first demonstrated at the Massachusetts General
Hospital and only a few months later Pirogov published a manuscript describing
his own research on both animals and humans (himself first). He tested ether
by inhalation, intravenously, and by enema, realizing its wonderful potential. In
the spring of 1847 he was appointed by the Tsar to provide ether anesthesia for
the Army fighting in the Caucasus, both to relieve suffering and to boost the
morale of men terrified of painful surgery if wounded. Pirogov designed a
tight-fitting inhalation mask employing a valve to regulate the ether-air mix,
and did not hesitate to perform amputations in the presence of other soldiers,
who indeed were relieved to witness the painless surgery. This was the first
use of anesthesia in wartime.
On return Pirogov experimented with chloroform, finding it easier to
transport and store, and safe if used properly. The supreme test came in the
Crimean War, in which the Russians lost over 250,000 men during the
eleven-month siege of Sebastopol alone. Pirogov volunteered his services and
with the influence of Grand Duchess Elena Pavlovna was appointed chief surgeon.
Pavlovna
was the originator of the Russian nursing service, called the “Holy
Cross Community”, whose volunteers worked tirelessly under Pirogov’s direction in the besieged city (Florence Nightingale’s nurses were far away from
fighting). At Sebastopol Pirogov instituted a system of triage still used
today. He freely gave anesthesia (the British used it sparingly), mainly
chloroform, used plaster casts frequently for severe fractures (avoiding
amputations), and was a believer in the transmission of sepsis, requiring hand
washing by his surgeons and limited wound probing for bullets. He advised
prompt treatment in the field whenever possible, an innovation still observed.
He also invented an amputation of the foot that saved higher leg amputations. His
experience was distilled into the monumental, Principles of War Surgery (available in German), a work studied
until WW II.
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| Grand Duchess Elena Pavlovna, by Karl Briullov (from Wikipedia) |
(Little known is that 36 American
surgeons worked under Pirogov and in the Caucasus during the siege. They were
volunteers, though paid, and at their request the American representative in
the Tsar’s court, an ex-Governor of Connecticut, arranged the details. About
half of them died of typhus or cholera, but lessons learned were later helpful
in the American Civil War.)
After the war, as educational reforms were introduced by Tsar Alexander II,
Pirogov resigned from the Medico-Surgical Academy and became an education
advisor, working in Odessa, Kiev, and later as advisor to Russians studying in
Germany. While in
Heidelberg he consulted on a bullet wound in Garibaldi’s
ankle. In 1870 he was invited by the Red Cross to inspect the military
hospitals in the Franco-Prussian War, and found that most of his
recommendations from the Crimean War were being observed. A similar evaluation
was performed in 1877 in the Russo-Turkish War, at which he now emphasized even
more the importance of antisepsis.
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| Memorial statue of Pirogov, Moscow (from Himetop, creative commons license) |
Between these assignments and in his waning days Pirogov retired to an
estate near Vinnytsia (now in Ukraine) where he was a country doctor and
farmer. There he composed, but did not finish, his memoirs, a mix of diary,
autobiography, and reflective philosophy.
He died in 1881, and was mourned
as a hero throughout Russia. The Society of Russian Physicians, formed in 1884
in Pirogov’s
honor, was influential in Russian medicine until abolished in
1918 by personal order of Lenin. The same fate met the Russian Red Cross, a
direct descendent of the innovative use of wartime
volunteer nurses organized
by Grand Duchess Pavlovna. Pirogov’s reputation was revived under the later Soviets.
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| Entrance to Pirogov Estate and Museum, Vinnystia, Ukraine (from Wikipedia) |
Nikolay Pirogov is an underappreciated pioneer in anesthesia and battle
surgery, a gifted anatomist and educator, and a humanitarian supporting the
highest ideals of his profession. Sadly, few of the works by or about him are
available in English.
SOURCES:
Pirogov N: Questions of Life:
Diary of an Old Physician. 1991 (orig. in 1885)
Tolstoy L: Sebastopol Sketches.
1986 (orig 1855-6)
Raymond E A: “American Doctors in the Crimean War”. 1974. Connecticut Medicine, 38: 373-6.
Hendriks IF, Bovil JG, Boer F, Houwaart ES, Hogendoom PCW: “Nikolay
Ivanovich Pirogov: A Surgeon’s Contribution to Military and Civilian
Anaesthesia". 2015. Anaesthesia 70:
219-27.
Pirogov, N: Recherches Partiques et Physiologiques sur l’Etherisation. 1847
Sorokina, T: “The Great Russian Surgeon Nikolay Ivanovich Pirogov
(1810-1881)”. 2011. Vesalius 17:
10-15.
Halperin G. “Nikolai Ivanovich Pirogov – Surgeon, Anatomist, Educator”.
1956. Bull Hist Med 30: 347-55.
Fried BM. “Pirogoff in the Crimean Campaign, 1854-55” 1955. Bull NY Acad Med 31: 519-36.
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