Christian Albert Theodor Billroth

Christian Albert Theodor Billroth is considered the founder of modern abdominal surgery. Billroth introduced epoch-making treatments which for subsequent decades constituted a pattern for surgical operations of the stomach, bile and female genitalia. For many years he was the Vienna school of surgery; because of his own work and that of his many eminent pupils, he must probably be considered the most single influence on the development of modern surgical knowledge. His operational methods or modifications of these are still in use. "Billroth" is a household word.

Music or medicine?
Christian Albert Theodor Billroth was the first of five sons born to Carl Theodor Billroth, a priest – Diaconus – in the Lutheran church and his wife Johanna Christina, born Nagel, the daughter of a Berlin Kammerrat (counsellor of the exchequer). The family lived in Klosterstrasse, later renamed Billrothstraße. A plaque on the house reads:

"Am 26. April 1829 wurde hier Theodor Billroth geboren; nachmals Professor der Chirurgie in Zürich und Wien, einer der hervorragendsten Chirurgen seiner Zeit", erinnert an den großen Sohn unserer Stadt.

Three years after Billroth's birth the family moved from the fishing village Bergen on the Baltic coast, to Reinberg. His father died when Theodor was five, and his mother then moved to his grandfather in Greifswald, where Billroth attended the Gymnasium. He was musically inclined – a family characteristic – and probably for that reason was not an exceptional pupil, even needing tutoring at home. He seemed unable to master languages and mathematics, was not quick-witted, and spoke slowly. However, in 1848 he passed the Abitur.

Into medicine
His mother and two professors of medicine in Greifswald, Wilhelm Baum (1799-1883) and Philipp Magnus Seifert (1800-1845), induced Billroth to become a doctor for financial reasons. Billroth was a nephew of the medical officer in Stettin, Wilhelm Friedrich Billroth, who distinguished himself during the cholera period.

During his first semester as a medical student in Greifswald, Billroth studied natural sciences and began the multifaceted activity and careful use of his time that characterised his later years. He followed Baum to the University of Göttingen, where he established a lasting friendship with Georg Meissner (1829-1905). Like Billroth, Meissner was interested in music and a pupil of the physiologist Rudolph Wagner (1805-1864), who taught Billroth microscopy.

With Wagner and Meissner, Billroth went to Trieste to study the origin and insertion of the nerves of the torpedo fish. In 1851 he continued his studies at Berlin with Bernhard Rudolf Konrad von Langenbeck (1810-1887), Johann Lukas Schönlein (1793-1864), Moritz Heinrich Romberg (1795-1873), and Ludwig Traube (1818-1876). Traube taught him experimental pathology and encouraged him to write the thesis De natura et causa pulmonum affectionis quae nerve utroque vago dissectro exoritur. On September 30, 1852, Billroth received his doctorate in Berlin, and that winter he passed the state medical examination, after which he worked in the ophthalmological clinic of Albrecht von Graefe (1828-1870).

The young surgeon
In order to take courses in dermatology with Ferdinand von Hebra (1816-1880), in pathology with August Wilhelm Eduard Theodor Henschel (1790-1856) and in internal medicine with Johann von Oppolzer (1808-1871), Billroth went to Vienna in the spring of 1853. That fall he tried in vain to establish himself as a general practitioner in Berlin, but after a few months he was appointed assistant to Bernhard von Langenbeck - the man who developed 21 surgical methods – in the surgical clinic at the Berlin University (1853-1860).

He published on pathological histology and in 1856 became Privatdozent in surgery and pathological anatomy. Later he lectures on surgery and gave practical demonstrations. In 1855 he produced his first monograph on polyps and concluded that benign and malign polypoid tumours of the colon were related and suggested early treatment. He published numerous works on pathology of cystoid tumours in the testis, blood vessel development and comparative anatomy of the spleen.

Competing with Virchow
On the death of Heinrich Meckel von Helmsbach (1822-1856) from intestinal tuberculosis, Billroth was short-listed for the Chair of Pathologic anatomy in Berlin with Robert Remak (1815-1865) and Virchow (1821-1902). The former had lost support because he had made application before Meckel's death and was Jewish, and Virchow had publicly expressed strong political views favouring democracy and freedom. Following Virchow's monograph in 1848/49, Die medizinische Reform which set out his strong opposition to unproven hypotheses laid down by authoritarian professors, he was dismissed from Berlin where he was a prosector. In the end Virchow was appointed with Billroth being the second candidate.

It was in Berlin that Billroth met his wife Christine, daughter of the court physician Heinrich Sabatier Michaelis (1791-1857) and of Karoline Eunike. They were married in 1858, and of their four daughters and one son, three daughters survived.

Professor in Zurich
Billroth next turned to teaching and writing on historical developments in surgery and was nominated professor of surgery and director of the well-known surgical hospital and clinic in Zurich in 1860, staying in this position until 1867, when he became professor at the University of Vienna and head of the 2nd Surgical Clinic at the General Hospital in Vienna.. During his seven year stay as director in Zurich he added greatly to the fame and growth of the surgical clinic.

Modern surgery was in its infancy, and Billroth was especially interested in the causes of wound fever. He insisted on regular temperature-taking and believed that wound fever was caused by a chemical poison produced by some living organism.

While at the University of Zurich (1860-1867) as professor and director of the surgical clinic, Billroth published his classic textbook Die allgemeine chirurgische Pathologie und Therapie (1863). In Zurich he introduced the concept of audits, publishing all results, good and bad, which automatically resulted in honest discussion on morbidity, mortality, and techniques - with resultant improvement in patient selection

The master of surgery
The peak of Billroth's career, however, began when he joined the faculty of the University of Vienna, where he worked from 1867 until his death in 1894. Here Billroth excelled as a surgeon, as a teacher, and as a scientist.

In 1870 he volunteered for the Franco-Prussian War, working in the field hospitals at Weissenburg and Mannheim.

He was a pioneer in the study of the bacterial causes of wound fever, as evidenced by Untersuchungen über die Vegetationsformen von Cocobacteria septica (1874). Billroth was quick to use antiseptic techniques in his surgical practice and performed many hazardous operations successfully because of his great ability and caution. With the threat of fatal surgical infections eradicated, Billroth proceeded to alter or remove organs that had hitherto been considered inaccessible. In 1872 he was the first to remove a section of the oesophagus, joining the remaining parts together, and in 1873 he performed the first complete excision of a larynx. He was the first surgeon to excise a rectal cancer and by 1876 he had performed 33 such operations.

By 1881 Billroth had made intestinal surgery seem almost commonplace and was ready to attempt what appeared in his time as the most formidable abdominal operation conceivable: excision of a cancerous pylorus (the lower end of the stomach). His successful execution of the operation caused a great sensation and initiated the modern era of surgery. His methods of resection, although modified, remained in use for many years. Plastic surgery, especially of the face, was another of his specialities.

He is regarded by many as the leading German surgeon of late 19th century. As well an outstanding surgical technician he was able to bring experimental medicine to clinical practice. He had radical ideas for the time on surgical training advocating a prolonged surgical apprenticeship on completion of medical studies consisting of preliminary work in hospitals followed by performing operations on cadavers and experimental animals. This would be followed by a 2-3 year assistantship in a surgical department with studies of the surgical literature and the acquisition of advanced practical skills. His ideas were taken up by many who visited him

Billroth founded the House of the Society of Physicians in Vienna - K. K. Haus der Gesellschaft der Ärzte - and it was due to his energetic efforts that the "Rudolfinerhaus", a teaching institution for "worldly" nurses, was established in Vienna. For this purpose he wrote the handbook Ueber die Krankenpflege im Hause und im Spitale (1881). On the other hand, he never succeeded in having a new surgical clinic built.

The man
Billroth was also a man of strong artistic bent, above all a great lover of music. He was an artist by nature: intuitive, humane, inventive. His home in Vienna became a musical centre where he played second violin and viola and became friends with Johannes Brahms and with the musical theorist and writer Eduard Hanslick (1825-1904). Two of Brahm's string quartets are dedicated to Billroth, and during his last illness Billroth was working on the physio-psychological book "Wer ist musikalisch?", published by Hanslick in 1896. In Zürich he was invited at times to be guest conductor of the Zurich ymphony Orchestra.

Billroth was a member of the Academy of Sciences in Vienna and honorary member of thirty-two scientific societies, and a member of the Austrian Herrenhaus from 1886. He was also honoured with sixteen high decorations. His bibliography contains some 150 items.

Until the spring of 1887 he was exceptionally robust and healthy, when he or the first time fell ill with a severe inflammation of the lungs, already then threatening to kill him, and suffered from cardiac weakness that increased during his last years. However, he lived to enjoy is sixtieth birthday as well as his 25th anniversary as professor in Vienna. Billroth died on February 6, 1894, and was buried with "princely" honours in Vienna.

A memorial of him was unveiled in the arcade square at the University of Vienna on November 7, 1897.

«The future of a school is based on the work of the pupils, as the future of a country on the work is its citizens.»
Inaugural lecture, Second Surgical Department, Vienna, October 11, 1867.

«Can there be a better preparatory school for the physician than the study of the natural sciences? I think not!»
The Medical Sciences in the German Universities, pt, II, Ch. 2.

«There is only one way to train capable university teachers - one way that has been practically testes - and that is to secure for the universities the services of the most distinguished men of science, and to furnish them with the necessary equipment for their teaching.»
The Medical Sciences in the German Universities, Pt. IV,
«The Teaching Staff.».

«It is not the men of formal medical pedagogy that attract students; contrariwise, scientists are the magnets for these school.»

"Only the man who is familiar with the art and science of the past is competent to aid in its progress in the future." Ca 1850.

«The greatest happiness of my life was founding a school that carries on my aims of scientific and humanitarian accomplishments.»
Letter to Wilhelm His, 1893.

«Taking care of such an unhappy patient, with so little prospect of any success, is one of the heaviest loads one can lay on a human being, which only women can carry for any length of time with never-ending patience.»
Letter to Johannes Brahms, January 7, 1874 (tr. by H. Barkan).

«Let what you observe penetrate your inmost soul, let it so warm and replenish you that your thoughts constantly refer to it, and then you will find true pleasure and delight in your intellectual labours.»
Lectures on Surgical Pathology and Therapeutics.

«A person may have learned a very great deal and still be an exceedingly unskilled physician, who awaken little confidence in his powers... The manner of dealing with patients’ of winning their confidence, the art of listening to them (the patient is always more anxious to talk than to listen), of soothing and consoling them or of drawing their attention to serious matters, - all this cannot be learned from books. The student can learn these things only from immediate contact with the teacher, whom he will unconsciously imitate ... The patient longs for the doctor’s daily visit; it is the event upon which all his thoughts and emotions turn. The physician can do all he hast to do with speed and precision, but he must never appear to be in a hurry, and never absent-minded.»
The Medical Sciences in the German Universities, Pt. III.

«He who combines the knowledge of physiology and surgery, in addition to the artistic side of his subject, reaches the highest ideal in medicine.»
Quoted in Surgery, 1961; 50: 697.

«The pleasure of a physician is little, the gratitude of patients is rare, and even rarer is material reward, but these things will never deter the student who feels the call with him.»

«Culture is always an aristocratic thing. The physician, the school teacher, the lawyer, the clergyman should be the best men of their village, of their city, of the circles in which they move. In order to be so they must have the super-power that comes with knowledge and skill, and this is acquired only through the hard work of study, and even more through the cultivation of the inner urge to study.
The Medical Sciences in the German Universities, pt. 2.

«The principle, method and the goal of investigations is recognition of truth, even though the truth may be in conflict with our social, ethical and political circumstances.»
The Medical Sciences in the German Universities.

«Solitary, meditative observation is the first step in the poetry of research, in the formation of scientific phantasies, the reality of which we then test with the tools of logic, mathematics, physics and chemistry.»
The Medical Sciences in the German Universities, pt. II.

«The cases of throat, lung, brain, spinal and nerve diseases must not be taken from the general medical clinics, in order to supply the special clinics. The student ought not to become accustomed to hearing the professor say every day «You are hoarse? Go to the throat clinic,» or You are coughing? Go to the ward for lung cases!» Such a scattering of medical thought and action is sure to make a very bad impression of the students. They will accustom themselves not to examine and treat every case to the best of their ability, but on the contrary, they will think, «Well, if even the professor can’t handle this case, what shall I do later on in my practice?»

«One may perform surgical procedures only if there is little chance of success. To operate without having a chance means to prostitute the beautiful art and science of surgery.»

«It is a most gratifying sign of the rapid progress of our time that our best text-books become antiquated so quickly.»

«He who cannot quote his therapeutic experience in numbers is a charlatan; be truthful for clarity’s sake, do not hesitate to admit failures, as they must show the mode and place of improvement.»

«Become familiar not only with teaching but also with writing.»
Quoted by James B. Herrick in Memories of Eight Years.

• Carl Gussenbauer:
  Ueber die erste durch Th. Billroth am Menschen ausgeführte Kehlkopf-Exstirpation und die Anwendung eines künstlichen Kehlkopfes.
  Verhandlungen der Deutschen Gesellschaft für Chirurgie, Berlin, 1874, 3, Heft 2: 76-79.
  The first complete excision of the larynx for cancer, performed by Billroth on December 31, 1873 and reported by Gussenbauer. The patient left the Hospital in good state on March 3, 1874. Also published in Archiv für klinische Chirurgie, Berlin, 1874, 17: 343-356.
• Ernst Hauer:
  Darmresektion und Enteroraphien, 1878-83. Zeitschrift für Heilkunde, 1884, 5: 83-108.
  An account of many intestinal resections carried out by Billroth. Works by Billroth:
  In this very incomplete list of publications only few articles are included:
• De natura et causa pulmonum affectionis quae nervo utroque vago dissecto exoritur.
  Doctoral dissertation. Berlin, 1852.
• Über den Bau der Schleimpolypen. Berlin, 1855.
  On this monograph on colonic polyps Billroth recognised the relationship between adenomatous polyps and colorectal cancers.
• Untersuchungen über die Entwicklung der Blutgefässe, nebst Beobachtungen aus der Königl. chirurg. Universitäts-Klinik zu Berlin. Berlin, 1856.
• Beiträge zur pathologischen Histologie nach Beobachtungen aus der Königlichen chirurgischen Universitäts-Klinik zu Berlin. Berlin, 1858.
• Die Einteilung, Diagnostik und Prognostik der Geschwülste vom chirurgisxh-klinischen Standpunkte für praktische Aerzte kurz bearbeitet.
  Berlin, 1859. Offprint from Deutsche Klinik, Berlin.
• Historische Studien über die Beurtheilung und Behandlung der Schusswunden vom fünfzehnten Jahrhundert bis auf die neueste Zeit. Berlin, G. Reimer, 1859.
  English translation in The Yale Journal of Biology and Medicine, 1931, 4: 16-36, 119-148, 225-257. Reprinted in book form, New Haven, 1933.
• Beobachtungsstudien über Wundfieber und accidentelle Wundkrankheiten.
  Archiv für klinische Chirurgie, Berlin, 1861; 2.
  Archiv für klinische Chirurgie, Berlin, 1864; 6. 1866.
  Archiv für klinische Chirurgie, Berlin, 1872: 13.
  (Neue Beobachtungsstudien über Wundfieber)
• Die allgemeine chirurgische Pathologie und Therapie in fünfzig Vorlesungen: ein Handbuch für Studirende und Ärzte.
  Berlin, G. Reimer, 1863; 2nd edition, 1866, etc. 11th edition, 1884, 16th edition, 1906.
  9th and subsequent editions by Billroth and Alexander von Winiwarter.
  13th edition, 1887: einundfunfzig Vorlesungen :
  This book is a landmark in the development of modern surgery and was translated into ten languages: French, English, Italian, Spanish, Hungarian, Polish, Russian, Serbian, Croatian, and Japanese.
  English translation: General surgical pathology and therapeutics, in fifty lectures. A text-book for students and physicians. By Theodor Billroth with additions by Alexander von Winiwarter ; Tr. and rev. from the 10th ed. by Charles E. Hackley.
  11th edition for sale in 2002: SFr250.
• Chirurgische Klinik, Zürich 1860-1867. Erfahrungen auf dem Gebiete der praktischen Chirurgie. 4 volumes, Berlin, 1869-1879.
• Chirurgische Klinik, Wien 1868 u. s. w. Berlin, 1870.
• Chirurgische Klinik, Wien 1869-1870 u. s. w. Berlin, 1872.
• Über die Verbreitungswege der entzündlichen Processe.
  Sammlung klinischer Vorträge, Leipzig, 1870, 4.
• Chirurgische Briefe aus den Kriegslazarethen in Weissenburg und Mannheim 1870.
  Berlin, 1872. Offprint from Berliner klinische Wochenschrift, 1870-1871.
• Ueber die Resection des Oesophagus.
  Archiv für klinische Chirurgie, Berlin, 1872, 13: 65-69.
• Historische und kritische Studien über den Transport der im Felde Verwundeten und Kranken auf Eisenbahnen.
  Vienna, 1874. Translated into French.
• Kurzer Rückblick auf die neueren Phasen der Lehre von der Entzündung und der Regeneration der Gewebe.
  Wiener medizinische Wochenschrift, 1874, 24 (Sp 561-566 + Sp. 589-594.
• Ein Wort an seine Schüler. Klinischer Vortrag vom 19. Oktober 1874.
  Wiener medizinische Wochenschrift, 1874, 24 (Sp. 943-947).
• Untersuchungen über die Vegetationsformen von Coccobacteria septica und den Antheil, welchen sie and der Enstehung und Verbreitung der accidentellen Wundkrankheiten haben u.s.w. Berlin, 1874.
• Ueber das Lehren und Lernen der medicinischen Wissenschaften an den Universitäten der deutschen Nation nebst allgemeinen Bemerkungen über Universitäten. Vienna, 1876.
  English translation by William Henry Welch (1850-1934): The medical sciences in the German Universities: a study in the history of civilization. New York, Macmillan, 1924.
• Chirurgische Klinik, Wien 1871-1876; nebst einem Gesamtberichte über die chirurgischen Kliniken in Zürich und Wien . . . 1860 – 1876 u. s. w. Berlin, 1879.
• Die Krankheiten der Brustdrüsen. Stuttgart, F. Enke, 1880.
  Deutsche Chirurgie, Berlin, Lieferung 41, 1990. Translated into English.
• Offenes Schreiben an Herrn Dr. D. Wittelshöfer (Über eine am 29. Januar 1881 ausgeführte Magenresektion.
  Wiener medizinische Wochenschrift, 1881, 31: 161-166.
• Zur Resektion des carcinomatösen Magens.
  Wiener medizinische Wochenschrift, 1881; 31: 634-635.
• Ueber die Krankenpflege im Hause und im Hospitale, ein Handbuch für Familien und Krankenpflegerinnen. Vienna, 1881. Swedish translation by H. Hülphers; also translated into Danish, Russian, Rumanian, Serbian, Croatian, Polish, and Italian.
• Aphorismen. Vienna, 1886.
• Wer ist musikalisch? Published by Hanslick, Berlin, 1896.
• Handbuch der allgemeinen und spezielle Chirurgie. 1865.
  By Franz Freiherr von Pitha (1810-1875) and Theodor Billroth (1829-1894).
  Later edition: Erlangen and Stuttgart, 1874.
  Billroth contributed:
  Skrophulose und Tuberkulose. 2nd edition, volume III, 1865.
  Allgemeine Instrumenten- und Operationslehre. I, 2. B., 1867.
  Verbrennungen, Erfrierungen, Quetschungen, Schnitt-, Riss-. Bisswunden, vergiftede Wunden. I, 2. B., 1867. A complete list of Billroth’s scientific work is in Wiener medizinische Wochenschrift, 1881, page 225. His autobiography is in Wiener medizinische Blätter, 1894, 17: 91-95.
• Theodor Billroth und seine eitgenossen. In Briefen an Billroth. Aus dem Archiv d. Gesellschaft der Ärzte in Wien herausgegeben von I. Fischer.
  Berlin/Wien, 1929. VII + 87 pages.