Peter Herzen

Origins and education

Peter Alexandrovich Herzen was born on (1871-05-08)May 8, 1871 in Florence, Kingdom of Italy, into the family of the Swiss physiologist of Russian origin Alexander Alexandrovich Herzen^[6] and the daughter of a peasant, the Italian Thérèse (Toreze^[7]) Félici (Thérèse Félici,^[8] 1851–1927).^[9] Besides Peter, the family had nine more children: three girls and six boys.^[10][11] He was the grandson of the Russian publicist, writer, and philosopher Alexander Ivanovich Herzen.^[3][4]

In 1896, Peter Alexandrovich graduated from the medical faculty of the University of Lausanne, where he attended lectures by professors such as Kaufmann, Heinrich Stilling, Roth, Bumm, after which he worked for one year as an unsalaried assistant^[12] in the clinic of the Swiss surgeon César Roux.^[13][14] At the same time, he conducted researhes in his father's physiological laboratory at the University of Lausanne.^[15] Just one year after graduating from university, Herzen successfully defended his dissertation in Lausanne for the degree of Doctor of Medicine titled On the Causes of Death after Bilateral Vagotomy in Their Relation to Survival Conditions,^{[16][17][18][19]} based on extensive experimental material^[20] and receiving positive reviews in the specialized literature.^[15][21][22]

After moving to the Russian Empire

In 1897, after declining César Roux's offer of a staff assistant position in the clinic,^[12] Herzen moved to Russia, as his grandfather had willed.^{[Notes 1][23][21][24][25]} Quickly learning Russian (that he did not know),^{[Notes 2]} he enrolled as an auditor in the fifth year of the medical faculty of Moscow University. In December 1898, P. A. Herzen received his Russian diploma as a physician with honors, having passed state examinations for the entire university course.^[2] That same year, Peter Alexandrovich began working as an extern physician^{[Notes 3][26]} at the Old Catherine's Hospital^[27] under the guidance of the Moscow surgeon and experienced educator I. D. Sarychev, a student of N. V. Sklifosovsky. He worked in this clinic first as an extern physician (until 1900), then as a resident of the surgical department (until 1920) for 22 years (with interruptions for military service as a military surgeon), acquiring vast practical experience and surgical skill here. At the same time as Herzen, talented surgeons such as V. N. Rozanov and V. M. Mints studied and worked at Old Catherine's Hospital.^[28] During 1904–1905, in the Russo-Japanese War, as a military surgeon with the Moscow detachment,^[12] he spent 14 months on the Manchurian front. In 1909, Herzen defended his second doctoral dissertation^[14] Experimental Study on the Effect on the Kidneys of Substances Arising in the Blood during Immunization of Animals with Renal Tissue or Damage to One Kidney,^[29] and in 1910 he was elected privatdozent^[14] of the faculty surgical clinic of Moscow University, headed by Professor I. K. Spizharny.^[15][30][31] During World War I, he served as a surgeon in the active army.^[19][32]

After the October Revolution

After the October Revolution, Peter Alexandrovich's wife left for Italy with their three children, but he did not follow them. In 1919, P. A. Herzen was elected as the head of the Department of Operative Surgery at the 1st Moscow State University, which became vacant after the departure of Professor F. A. Rein.^[33][34] There, he revised the operative surgery program, basing it on the physiological justification of applied surgical treatment methods.^[35] Since 1920, he simultaneously lectured on operative surgery at the 2nd Moscow State University, heading that department from 1920 to 1922.^[36] During the Russian Civil War, P. A. Herzen served as a consultant to the 151st military hospital (1920–1921).^[15] In 1921, he was elected head of the Department of General Surgery at the 1st Moscow State University,^[37] which in 1922 was transferred to the base of the Institute for the Treatment of Tumors (now the Moscow Research Institute of Oncology named after P. A. Herzen). Since that moment, Peter Alexandrovich headed both the department and the institute, remaining its director until 1934.^[38] Despite his high position, Herzen personally consulted a large number of outpatients daily at the institute's polyclinic, performed many complex operations, and conducted detailed clinical rounds; he could spend hours working at the microscope, studying blood pictures in patients with systemic diseases of the hematopoietic organs. In 1926, Herzen was first elected chairman of the Moscow Surgical Society, and in 1929 — chairman of the XXI Congress of Russian Surgeons.^[37] After the death of Professor A. V. Martynov in 1934, Herzen became head of the Department of Hospital Surgery at the 1st Moscow Medical Institute^[39] (now the First Moscow State Medical University), which he led until the end of his life. In 1934, he was awarded the honorary title of Honoured Scientist of the RSFSR,^[29][40] and on January 29, 1939, he was elected a corresponding member of the Academy of Sciences of the Soviet Union in the Department of Mathematical and Natural Sciences, specialty "Surgery".^{[12][21][41][42]}

During the Great Patriotic War, P. A. Herzen remained in Moscow throughout, operating on and treating the wounded, and was awarded the Medal "For Valiant Labour in the Great Patriotic War 1941–1945".^[37][43]

P. A. Herzen died on January 2, 1947, in Moscow after a serious illness. He is buried at Novodevichy Cemetery, plot No. 4.^[12][44][45]

In abdominal surgery

At the II Congress of Russian Surgeons in 1901, he reported on his modification of cholecystoenterostomy: after transecting the jejunum, its distal end was connected to the gallbladder, while the proximal end was sutured into the side of the jejunum below the anastomosis, which prevented the development of ascending cholangitis.^[41]

In 1913, P. A. Herzen was the first to perform omentorenopexy — a surgical operation consisting of wrapping the lower pole of the kidney with the omentum and suturing it to the renal capsule. This operation is used in ascites caused by portal hypertension.^[50]

In his dispute with the advocate of gastroenterostomy in the treatment of peptic ulcer of the stomach, V. V. Uspensky, Herzen argued for the advantages of gastrectomy.^[48]

The clinic of hospital surgery at the 1st Moscow Medical Institute, headed by P. A. Herzen, effectively developed issues in the surgical treatment of diseases of the biliary tract. At the 5th Regional Conference of Surgeons of the Moscow Region (1934), reporting on biliary duct surgery, Herzen advocated early cholecystectomy as the operation of choice, abandoning cholecystostomy, of which he had long been a proponent. In his article Surgery of the Biliary Tract, he detailed the pathology of the gallbladder and biliary ducts, thoroughly discussed various types of surgical interventions, and emphasized the need for early cholecystectomy before the development of severe complications. P. A. Herzen supplemented the classification of S. P. Fyodorov (in particular, dividing chronic recurrent cholecystitis into uncomplicated and complicated forms) with dyskinetic forms and proposed the term "initial forms of cholecystitis" instead of diagnoses such as "hydrops of the gallbladder" and "sclerosing cholecystitis".^[41][51]

Herzen spoke at surgical congresses of various levels on numerous occasions, and his reports were devoted to issues of surgical treatment of spleen diseases. In 1924, at the XVI Congress of Russian Surgeons, he delivered a report On the Surgical Treatment of Certain Forms of Splenomegaly; a similar report was made in 1925 at the XXXIV Congress of French Surgeons, and in 1926 at the XVIII Congress of Russian Surgeons (On Spleen Diseases in Connection with Indications for Splenectomy and Its Long-Term Results). In these presentations, he pointed to the hemolytic role of the spleen and its ability to accumulate "blood poisons". In many spleen diseases, the severity of which is determined by dysfunction or hyperfunction of this organ, the patient's condition can be alleviated by its removal. He was the first in the Soviet Union to perform splenectomy for hemorrhagic diathesis.^[41][52]

In the late 1930s, Herzen wrote an extensive article on chronic appendicitis and pseudoappendicitis, noting the difficulty in diagnosing chronic appendicitis due to the fact that in practice surgeons often encounter not inflammation of the appendix itself, but inflammatory changes in the cecum (typhlitis, typhlocolitis) and spastic conditions of the ascending colon, ileocecal valve. Herzen expressed the opinion that as these diseases simulating appendicitis are properly studied, the term "pseudoappendicitis" should disappear from medical usage. He also drew attention to the fact that involvement of the appendix is often secondary, while the primary problem lies in changes in the cecum (its atony, dilatation, excessive mobility) with involvement of the sympathetic nervous system in the pathological process, and warned surgeons against narrow and one-sided interpretation of chronic pain in the right iliac region as a symptom complex of chronic appendicitis.^[53]

In thoracic surgery

At the VII Congress of Russian Surgeons (1907), P. A. Herzen reported on the operation for forming an artificial presternal esophagus in connection with its benign stricture. This operation was first proposed by the Swiss surgeon César Roux in 1906 to replace the natural esophagus. After performing the initial stages (forming a transplant from the small intestine and advancing it through a subcutaneous tunnel to the base of the neck), due to the patient's cachexia, Roux postponed connecting the transplant to the esophagus to a later time, bringing the upper end of the intestine out to the skin as a jejunostomy. However, this patient required several reconstructive operations to connect the transplant to the esophagus in the neck; only in 1911 was Roux able to complete the plasty.^[13][56] The world's first successful completed total subcutaneous small intestine esophageal plasty was performed in Moscow by César Roux's student P. A. Herzen in three stages in September–November 1907 on a 20-year-old patient with post-burn stenosis of the esophagus resulting from sulfuric acid poisoning 6 months before the operation.^{[Notes 4][57]} In his report to the Congress of Russian Surgeons, Herzen pointed out five difficult-to-resolve aspects of Roux's method and proposed ways to eliminate these drawbacks: first, divide the entire operation into 3 and not 2 stages: first advance the intestine to the neck, then suture it into the stomach, and finally connect it to the esophagus, significantly shortening the duration of the first stage performed on the most debilitated patients; second, pass the long upper segment of the mobilized intestine through a spacious opening created in the mesocolon and gastrocolic ligament into the upper floor of the abdominal cavity, and from there through a tunnel under the skin to the neck.^[54][58] This operation became known in domestic and foreign medical literature as the Roux—Herzen operation.^{[19][25][59][60][61][62][63][64][65][66]}

My dear colleague!

I've just seen your mother today and got your address, and I hasten to sincerely congratulate you on this splendid success.

I am very glad that students surpass their teachers and rejoice at the opportunity to tell you so: You know that all your successes will always find a sympathetic response in Lausanne...

(From a letter by César Roux to P. A. Herzen)^[57]

For many years afterward, attempts by other domestic and foreign surgeons to repeat the Roux—Herzen operation were mostly unsuccessful.^[56]

In 1925, P. A. Herzen performed the first thoracoscopy in the USSR for chronic empyema of the pleura.^[67][68]

In oncology

Upon assuming the position of director of the Institute for the Treatment of Tumors, P. A. Herzen carried out a significant reorganization, establishing major radium-X-ray and hematology departments, as well as experimental, clinical, and anatomical pathology laboratories, thereby elevating this medical institution — where patients with oncopathology received care in accordance with modern scientific standards — to a leading position in the USSR. The number of operations increased threefold, while mortality decreased from 45% to 10%.^[21] Under Herzen's leadership, large-scale research was conducted at the institute on transplantation of tumors, development of immunity to them, and other areas of experimental oncology. A series of Herzen's works were devoted to oncological problems, in which he examined theoretical and practical aspects of treating malignant tumors, emphasizing the role of precancerous diseases as well as exogenous and endogenous factors in their development,^[37] the dependence of the degree of malignancy on the patient's age and sex, and the nature of the neoplasm. Herzen's highly valuable works on lip cancer and tongue cancer stand out. In 1930, his scientific works Introduction to the Clinic of Surgical Forms of Cancer, Cancer of the Ampulla of Vater, and Breast Cancer were published. Breast cancer was the subject of a separate chapter in the 1937 book Malignant Neoplasms published in Kyiv, where Herzen presented his many years of experience in this field and proposed distinguishing 4 stages of breast cancer, based on which he substantiated a scheme for cancer prevention on a national scale.^[69] In his works on oncology, Herzen constantly emphasized the importance of early diagnosis of malignant neoplasms and timely surgical intervention.^[70] While an advocate of the surgical method for treating cancer patients, Herzen was at the same time opposed to expanding surgical operations in advanced tumor processes and believed that this issue should be resolved individually, taking into account the stage of the process, histological form and location of the tumor, patient's age, and peculiarities of the clinical course of the disease.^[37] During these years, P. A. Herzen and his institute staff intensively addressed issues of treating esophageal cancer, cervical cancer, colorectal cancer, introduced electrosurgery for tumor removal, investigated the effects of radiation therapy methods in treating malignant neoplasms of various localizations, and studied the lymphatic system of the stomach in health and cancer. Significant attention was paid to combined treatment of malignant tumors, prevention of cancer, and precancerous conditions.^{[1][42][71][72][73]}

P. A. Herzen was convinced that effective treatment of oncology patients required widespread health education of the population and active participation of healthcare authorities. He initiated the establishment in Moscow in 1930 of a special committee to develop regulations for the Moscow Oncology Organization. Herzen delivered lectures in many cities, insisted on organizing 9 oncology stations in Moscow, obliging institute staff to serve as district oncologists, and achieved the opening of branches in Ryazan, Tula, Kolomna, and several other cities. At the same time, he initiated the holding of "Anti-Cancer Week" and the 1st Regional Oncology Conference. Peter Alexandrovich and his staff began delivering lectures on oncology issues for physicians of major preventive medical institutions in the Moscow Oblast.^[41][42][71] Herzen emphasized the importance of strict registration and statistics of oncological diseases, creation of specialized medical institutions (oncological dispensaries), training of oncologist physicians, and raising the qualifications of general practitioners in oncology.^[37]

In cardiovascular surgery

Drawing on his experience treating wounded patients with blood vessel injuries during the Russo-Japanese War of 1904–1905, P. A. Herzen wrote the monograph Surgical Treatment of Traumatic Aneurysms Based on Observations from the Russo-Japanese War and Subsequent Years (1911), which became the first Russian book to most comprehensively cover this problem. In this monograph, he most fully for his time described the symptomatology of aneurysms, disease course, possible complications, indications and contraindications for surgical operation, determining surgeons' tactics for vascular injuries in military field surgery conditions, and detailed methods of corresponding operative interventions. Herzen was one of the first to ligature not only the artery but also the accompanying vein during ligation to prevent gangrene of the limb. Among his scientific works, special attention is deserved by the monograph On Hemorrhages (1940), which presented the latest data of the time on hemostasis, the significance of heparin, thrombus formation, as well as described a number of technical features playing a major role in vessel ligation and proposed an original transperitoneal method of ligating renal vessels. During ligation of a large arterial trunk performed for its traumatic injury, Herzen recommended excising this trunk along the wounded segment or removing the corresponding sympathetic trunk ganglia along the spine, which significantly improves blood circulation and optimizes trophism of the affected limb. P. A. Herzen explained in detail to surgeons — readers of the monograph — what tactics to follow in injuries to large vessels of the skull, oral cavity, lungs, abdominal organs, and other localizations. In addition, the monograph focused surgeons' attention on secondary hemorrhages in severe putrefactive processes and provided recommendations on this issue, which proved invaluable during the Great Patriotic War, when military field surgeons encountered the problem of secondary hemorrhages in putrefactive inflammation of wounds.^[1][21][74]

Herzen also prepared works On Pericardiotomy and On the Casuistry of Heart Wounds. He was one of the first in Russia to suture the myocardium in heart wounds: two operations for heart wounds were performed by him in 1902. He published his experience in this field in 1904, thoroughly analyzing issues of diagnosing heart wounds and technical features of operative intervention. Among other recommendations, Herzen justified the possibility of luxating the heart into the wound and fixing it by the surgeon's hand. Herzen applied an active tactic in treating purulent pericarditis, which remained relevant for a long time after his works.^[49][75][76]

At the IX Pirogov Congress in 1904, Herzen proposed completely removing the bony part of the chest wall in the precordial region during operations for heart wounds, viewing this as prevention of heart compression in case of possible development of adhesive pericarditis in the future.^[77]

In urology

In 1906, at the VI Congress of Russian Surgeons, Herzen reported on the technique of transvesical prostatectomy. In 1907, he published a clinical case of surgical treatment of gunshot injury to renal vessels and liver: surgical intervention on both organs achieved complete recovery of the patient. That same year, he performed a rare urological operation — pelvioureteral plasty for remitting hydronephrosis — with very good results (this operation by Herzen was the 14th in world literature). In his doctoral dissertation defended in 1909, Experimental Study on the Effect on the Kidneys of Substances Arising in the Blood during Immunization of Animals with Renal Tissue or Damage to One Kidney,^[31] Herzen pointed to the connection between his research and conclusions on nephrolysins and nephrotoxins with problems of renal surgery: he considered ligation of the ureter without simultaneous removal of the kidney unacceptable, as nephrotoxins formed in the atrophying kidney exert a toxic effect on the healthy kidney.^[21]

In surgery of the autonomic nervous and endocrine systems

In his dissertation defended in Lausanne in 1897 for the degree of Doctor of Medicine, On the Causes of Death after Bilateral Vagotomy in Their Relation to Survival Conditions, based on extensive experimental material, Herzen shed light on many unclear questions at the time regarding the role of sectioning the vagus nerves in their various divisions and the influence of sectioning on the functioning of the gastrointestinal tract, as well as the permissibility of such sectioning. P. A. Herzen clarified the consequences of vagotomy, among which he noted significant dilatation and atony of the stomach, leading animals to death without gastric lavage or imposition of a gastrostomy.^[65] Analyzing data from studies by Bernard (1858), Contejeon (1892), Krechl (1892), and his own observations, Herzen concluded that in addition to impaired gastric motility in vagotomized animals, their digestive activity is reduced. Vagotomy at the neck level has no direct effect on abdominal organs but noticeably influences heart and lung function. Sectioning of the vagus nerves at the level of the lower esophageal sphincter or within the thoracic cavity usually does not lead to death.^[78]

In nephroptosis, Herzen removed the aorto-renal sympathetic ganglion simultaneously with nephropexy, obtaining good treatment results; he performed removal of sympathetic nerves of the ileocolic artery for partial denervation of the cecum and elimination of pain associated with mobile cecum and primary chronic appendicitis. P. A. Herzen was the first in the Soviet Union to perform operations for heart failure and angina pectoris,^[79] performing subtotal thyroidectomy and removing sympathetic ganglia in the neck, which reduced the intensity of metabolic processes in the body and decreased oxygen consumption by the myocardium, thereby easing the work of the diseased heart. Herzen performed surgical interventions on the brain and spinal cord; in spontaneous gangrene, he performed epinephrectomy, ganglionectomy, and neurotomy. P. A. Herzen wrote the work On the Surgical Treatment of Acromegaly.^[80] In diffuse toxic goiter, Herzen performed removal of the stellate ganglion.^[79]

In anesthesiology

P. A. Herzen paid great attention to the development of issues in local anesthesia. In 1901, he conducted studies on the use of conduction anesthesia, and from that moment preferred the simultaneous application of conduction and infiltration anesthesia for local anesthesia of the traumatized focus to be operated on, which allowed better results. At the same time, Herzen was not an advocate of only one anesthesia method, believing that in more complex cases, when it is necessary to operate on several wounds of different localizations or perform a more complex operation, preference should be given to general anesthesia; moreover, narcosis eliminates the danger of developing secondary shock. In the work Narcosis and Anesthesia, he thoroughly expounds the advantages of intravenous narcosis using barbiturate preparations hexobarbital and pronarcon.^[81]