History of Medicine

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

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.

     Pirogov was born in 1810, the thirteenth child of a Moscow

Nikolay Pirogov by Ilya Repin (from
Wikipedia)

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.    

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

Grand Duchess Elena Pavlovna, by
Karl Briullov (from Wikipedia)

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.

     (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

Memorial statue of Pirogov, Moscow
(from Himetop, creative commons license)

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.

     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

Entrance to Pirogov Estate and Museum, Vinnystia,
Ukraine (from Wikipedia)

volunteer nurses organized by Grand Duchess Pavlovna. Pirogov’s reputation was revived under the later Soviets.

     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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