Nikolai Ivanovich Pirogov

Nikolai Ivanovich Pirogov was the greatest of all Russian surgeons. He introduced the teaching of applied topographical anatomy in Russia, and was one of the first to use ether in Europe. He described ether anaesthesia per rectum in 1847. This had been suggested by Philibert Joseph Roux, (1780-1854) earlier in 1847. He is now mainly remembered for his introduction of an osteoplastic operation for amputation of the foot, in 1854. His great atlas, published 1852 to 1859, represents the first use on a grand scale of frozen sections in anatomical illustration, an idea first carried out by Pieter de Riemer (1760-1831). Ivan Petrovich Pavlov (1849–1936) credited him with placing surgery on a scientific basis.

Nikolai Ivanovich Pirogov was the son of a major in the commissary service. He learned to read early, and was fluent in foreign languages as a child. When his father died suddenly in 1824, leaving the family without means, Pirogov might have entered an education to become a civil servant. However, Efrem Mukhin (1766-1850), the family physician, arranged for him to be admitted to the Medical Faculty of Moscow in 1825, even though Pirogov was then only fourteen and the entrance age was sixteen. Efrem Mukhin was professor of anatomy and physiology at Moscow University,

From theory to surgery
Pirogov chose surgery as his specialty; but during his four years at the university he was present at only two operations and did not perform any himself. Nevertheless, he received a good general theoretical preparation and qualified as a physician in 1828, still only seventeen years old. How little he understood of medicine at that time, is revealed in his autobiography. He was, however, well aware of his shortcomings and, with Muhkin's advice and help, he undertook further studies at the so-called institute of professors, in which a number of young, ambitious and hard-working apprentices were educated to become professors. This institute sent him to Dorpat (now Tartu), where he practically started his studies all over again, under Johann F. (or Christian) Moier (1786-1858), with a predilection for surgery and anatomy.

In 1832 he defended his doctoral dissertation, on the ligation of the ventral aorta. In this important work, which was soon published in German translation, Pirogov tried not only to improve the technical procedure of the operation but also to explain how the body reacts to it. Pirogov now travelled extensively in Germany, visiting the Universities of Berlin and Göttingen to observe the state of surgery. He became convinced that without special study of anatomy and physiology, surgery – even with the most advanced technique – could never rise to the level of a science but would remain an art.

Professor at twenty-six
Learning that the chair of surgery had become vacant, Pirogov returned to Moscow, but the chair had then been given to Fedor Inosemzew (1802-1869). However, in 1836 Pirogov, only twenty-six, received the chair of surgery at the German University of Dorpat, where he worked from 1836 to 1840. His most important works, on arteries and fascies, were authored in this period and spread his repute in the medical world.

In 1840 the minister Kleinmichel invited Pirogov to assume the chair of hospital surgery at the 1,000-bed hospital and academy of military medicine in St. Petersburg. Besides this activity Pirogov founded an anatomical institute, reorganised the hospital system. Working in an unheated, poorly lit basement that was the anatomical theatre of the Academy, Pirogov lectured and performed countless operations and 12,000 dissections in anatomical pathology. During this time he spent about three years in military service, organizing and providing medical aid tot he wounded.

In 1847 he developed a theory of the action and use of anaesthetic and, before using it on a patient, tested it on himself. From July to November that year he was active as a surgeon in the field hospitals in Caucasus and introduced the use of anaesthetic through the rectum, as well as several improvements of the care of the wounded. He also originated the intravenous administration of anaesthetic ether. From 1848 he conducted an important investigation of cholera, based on almost 800 sections.

Crimea calling
In September 1854, when thousands of the wounded died in Sevastopol, Pirogov forwarded a petition to send him to the theatre of war. With the help of Grand Princess Yelena Pavlovna, a pioneer in organizing nurses for the war, his petition was accepted. Accompanied by several other doctors, Pirogov set of on November 9, 1854, arriving in Simferopol on December 11, 1854.

Pirogov's work during the Crimean War is of such importance that he may be considered the founder of field surgery. He devised the plaster cast, first used successfully in the Sevastopol campaign, and the Pirogov amputation. He conceived the technique of plaster casting in 1851 while observing the work of a sculptor. During the siege of Sevastopol, he introduced the mass use of anaesthetic in surgical operations at the front. His experiences in field surgery, published in German in 1864, became a standard reference. Besides his personal efforts for the wounded, Pirogov organised the training of nurses.

A man on his estate
In 1856 Pirogov returned to St. Petersburg. Irritated by conditions at the Medical-Surgical Academy, he retired permanently from teaching and hospital work. In the same year Pirogov published a paper on the problems of pedagogy, which produced a great impression. He condemned the restrictions on education for the poor and for non-Russians and supported education for women. He also came out against early specialization and advocated the development of secondary schools. After the death if Nicholas I, Pirogov was appointed director of school affairs for the south of Russia. He came into conflict with the governor-general of Odessa and in 1858 was transferred to the same post i Kiev. He was forced to retire three years later and settled on his estate in the southern Ukraine, where he volunteered as a peace judge.

The old man at war
In 1862 Pirogov was named director of a group of young Russians sent abroad to supervise Russian students training for å future as teachers in their own country. After Garibaldi had been severely wounded in the leg in August 1862 during the battle of Aspromonte, Pirogov attended him and recommended a successful method of cure. After his return to Russia in 1866, Pirogov lived almost exclusively on his estate, which he left for prolonged periods only twice: in 1870, when he travelled to the battlefields of the Franco-Prussian War as a representative of the Russian Red Cross to inspect the hospitals of the two adversaries; and in 1877, when he served as a surgeon in the Russian-Turkish War for the independence of Bulgaria.

Pirogov’s last public appearance was on May 24, 1881, the year he celebrated his fiftieth year of service. He died in December that year. The biggest centre for emergency Medicine in Bulgaria, in Sofia, is named after him. This is also a centre for postgraduate studies.

We thank Dr. Geedi Farah for information submitted.

• Num vinctura aortae abdominalis in aneurysmate inguinali adhibita facile ac tutum sit remedium. Doctoral thesis, Dorpat, 1832.
• Anatomia chrirugica truncorum arteriarum atque fasciarum fibrosarum.
  Dorpat and Reval, 1837-1840. Atlas with Latin and German text.
• Ueber die Durchschneidung der Achillessehne als operativ-orthopädisches Heilmittel. Dorpat, 1840, 1870.
• Nouveau procédé pour produire, au moyen de la vapeur d'éther, l'insensibilité chez les individus soumis à des opérations chirurgicales.
  Comptes rendus de l'Académie des Sciences, Paris, 1847, 24: 789.
• Recherches pratiques et physiologiques sur l’éthérisation.
  St. Petersburg, Imprimérie Française, 1847.
  With the Scottish surgeon James Syme (1799-1870), Pirogov was the first in Europe to adopt ether anaesthesia.
• On the use of ether in the performance of surgical operations.
  London and Edinburgh Monthly Journal of Medical Science, 1847-1848, 8: 73-76.
• Anatomie pathologique du choléra morbus.
  St. Petersburg, 1849. With Atlas.
• Rapport médical d’un voyage en Caucase contenant la statistique comparative des amputations. St. Petersburg, 1849.
• Klinische Chirurgie. Eine Sammlung von Monographien.
  3 parts. Leipzig, Breitkopf u. Härtel, 1851-1854.
  This edition in German predates the first edition in Russian.
• Der Gypsklebeverband bei einfachen und complicirten Knochenbrüchen und in seiner Anwendung beim Transport Verwundeter und auf dem Schlachtfelde.
  Leipzig, 1854.
• Osteoplastische Verlängerung der Unterschenkelknochen bei der Exarticulation des Fusses.
  Leipzig, 1854. In this book he mentions the exarticulatio pedis that bears his name.
• Betrachtungen über die Schwierigkeiten der chirurgischen Diagnose und über das Glück in der Chirurgie. Leipzig, 1854.
• Statistischer Bericht über alle meine im Verlaufe eines Jahres daselbst 1852-53 beobachteten Operationsfälle. Leipzig, 1854.
• Anatomia topographica sectionibus per corpus humanum congelatum triplici directione ductis illustrata.
  8 parts. 5 volumes. Petropoli, J. Trey, 1852-1859.
  First publication on the technique of frozen sections.
  This work on topographical anatomy laid a firm foundation for that field as a special area of science having great practical significance for surgery. Pirogov used the same freezing technique employed by Pieter de Riemer, but he was unaware of the latter's priority. Assuming that he was the innovator, he states in his introduction that, "Nobody before me, as far as I know, has ever proposed or employed a method by which the human body could be cut like wood into thin sections."
• Grundzüge der allgemeinen Kriegschirurgie. Leipzig, 1864.
  Translated into Russian as Nachala obshchey voennopolevoy khirurgii [The Principles of General Military Field Surgery].
  2 volumes. Dresden, 1865-1866.
• Bericht über die Besichtigung der Militär-Sanitätsanstalten in Deutschland, Lothringen-Elsass 1870. Leipzig, 1871.
• Izbrannye pedagogichsekie sochinenia [Selected Pedagogical Works].
  Moscow, 1953.
• Sobranie sochiney [Collected Works]. 8 volumes. Moscow, 1957-1962.
• Pieter de Riemer (1760-1831):
  Afbeeldingen van de juiste plaatsing de inwendige deelen van het menschelijk ligchaam.
  's-Gravenhage, J. Allart, 1818.
  First use of anatomical sections for anatomical illustration. De Riemer appears to have been the first to freeze tissues in order to permit fine sectioning.
• N. N. Burdenko:
  I. Pirogov - osnovopolozhnik voenno-polevoy khirurgii [N. I. Pirogov - Founder of Military Surgey].
  In Pirogov's Nachala obshchey voenno-polevoy khirurgii [Beginning of General Military Field Surgery]. I Moscow, 1941, pp 9-42.
• Y. I Smirnov:
  I. Pirogov. Moscow, 1960.
• N. Maksimenkov:
  I. Pirogov. Leningrad, 1961.
• G. Rufanov:
  I. Pirogov - veliky russky khirurg i ucheny [N. I. Pirogov - Great Russian Surgeon and Scientist"]. Moscow, 1956.
• S. R. Mikulinsky:
  Nikolay Ivanovich Pirogov. In: Charles Coulston Gillispie. Editor in chief: Dictionary of Scientific Biographies. Charles Scribner’s Sons. New York, 1970. Volume 10, pp. 619-621.
• Harish Kumar Vijra & SN Paranjape , RM Bakaya
  Diary of an Old Physician by Nikolai Ivanovich Pirogov.
  New Delhi: Amerind Publishing Co. 1991
• Questions of Life : Diary of an Old Physician (Resources in Medical History).
  Nikolai Ivanovich Pirogov. 1992.
• Harish Kumar Vijra
  Nikolai: Ivanovich Pirogov – The Poetry of a Surgeon. University News, 1996.
• J. G. McKinnon, A. Tinker:
  Nikolai Ivanovich Pirogov and the Crimean War.
  Clinical and Investigative Medicine, Toronto, August 1997, 20 (4): 35.