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MOST IMPORTANT SCIENTIFIC DISCOVERIES
Topographic anatomy. History and essence of scientific discovery
Directory / The most important scientific discoveries The great Russian surgeon and scientist Pirogov is considered to be the founder of topographic anatomy. Nikolai Ivanovich Pirogov (1810–1881) was born in Moscow. When Nikolai was fourteen years old, he entered the medical faculty of Moscow University. To do this, he had to add two years to himself, but he passed the exams no worse than his older comrades. After graduating from the university, Pirogov went to prepare for a professorship at the University of Dorpat. At that time, this university was considered the best in Russia. Here, in the surgical clinic, Pirogov worked for five years, brilliantly defended his doctoral dissertation, and at the age of twenty-six became a professor of surgery. The subject of his thesis, he chose the ligation of the abdominal aorta, performed until that time - and then with a fatal outcome - only once by the English surgeon Astley Cooper. The conclusions of the Pirogov dissertation were equally important for both theory and practice. When Pirogov, after five years in Dept, went to Berlin to study, the famous surgeons, to whom he went with a respectfully bowed head, read his dissertation, hastily translated into German. A teacher who, more than others, combined everything that Pirogov was looking for in a surgeon, he found in Göttingen, in the person of Professor Langenbeck. The Göttingen professor taught him the purity of surgical techniques. Returning home, Pirogov fell seriously ill and was left for treatment in Riga. As soon as Pirogov got up from the hospital bed, he undertook to operate. The city had heard rumors before about the promising young surgeon. Now it was necessary to confirm the good reputation that ran far ahead. He began with rhinoplasty: he carved out a new nose for a noseless barber. Then he recalled that it was the best nose he had ever made in his life. Plastic surgery was followed by the inevitable lithotomies, amputations, removal of tumors. In Riga, he operated for the first time as a teacher. From Riga, Pirogov went to a clinic in Dorpat. Here, in 1837, one of Pirogov's most significant works, Surgical Anatomy of Arterial Trunks and Fascia, was born. It was the result of eight years of work, a work of classical breadth and completeness. There may be a different approach to information about the structure of the human body, and Pirogov writes about this: “... A surgeon should study anatomy, but not in the same way as an anatomist ... The department of surgical anatomy should belong to a professor not of anatomy, but of surgery ... Only in the hands of a practical physician, applied anatomy can be instructive for the listeners.Let the anatomist examine the human corpse to the smallest detail, and yet he will never be able to draw the attention of students to those points of anatomy that are of the highest importance for the surgeon, but for him may not matter at all." The reason for the failure of most of the "anatomical and surgical treatises" compiled by Pirogov's predecessors is the underestimation of the applied value of anatomy, in avoiding the "private goal" - to serve as a guide for the surgeon. Meanwhile, everything must be subordinated to this "private goal", only to it. Pirogov, of course, was well acquainted with the works of his predecessors - the prominent French scientists Velpeau and Blandin. I carefully examined the famous atlas of Buyalsky. He asks himself the question: "Can a young surgeon be guided in his operational exercises on a corpse, not to mention operations on the living, by drawings of arterial trunks in the best works on surgical anatomy, what are the works of Velpo and Blunden?" And the answer is emphatically: no! "The usual method of preparation adopted by anatomists ... is not suitable for our applied purposes: a lot of connective tissue is removed that holds the various parts in their mutual position, as a result of which their normal relations change. Muscles, veins, nerves are removed in the drawings from each other and from arteries at a much greater distance than it actually exists. Pirogov criticized Buyalsky's atlas: "... You see, for example, that in one of the drawings depicting the ligation of the subclavian artery, the author removed the collarbone: thus, he deprived this area of \uXNUMXb\uXNUMXbthe main, natural border and completely confused the surgeon's idea of the relative position of the arteries and nerves to the clavicle, which serves as the main guiding thread during the operation, and about the distance of the parts located here from each other. Brilliant for their time, the attempts of Velpo and Buyalsky faded before the new word of Pirogov. In his essay, a whole science, surgical anatomy, Pirogov develops and approves on the basis of a very specific and at first glance not very voluminous doctrine of fascia. Before Pirogov, they almost did not deal with fascia. They knew that there were such membranes, plates, surrounding muscle groups or individual muscles, saw them on a corpse, stumbled upon them during operations, cut them - and did not attach importance to them, treated them as some kind of "anatomical inevitability". Pirogov's basic idea is quite specific: to study the course of fascial membranes. He gets to the smallest details and already here he finds a lot of new things. Having thoroughly studied the particular - the course of each fascia - he goes to the general: he deduces certain patterns of the relationship of fascial membranes with blood vessels and surrounding tissues. That is, it opens up new anatomical laws. But he needs all this not in itself, but in order to find rational methods for performing operations, "to find the right way to ligate this or that artery," as he himself says. “Finding a vessel is sometimes not easy,” V.I. Porudominsky writes in his book about Pirogov. “The human body is complex - much more difficult than it seems to a non-specialist who learned about it from posters-diagrams of a school anatomy course. In order not to get lost, you need to know the landmarks” . Pirogov again scolds (does not get tired!) "scientists who do not want to be convinced of the benefits of surgical anatomy", "famous professors" in "enlightened Germany", "who speak from the department about the uselessness of anatomical knowledge for the surgeon", professors whose "method of finding of this or that arterial trunk is reduced exclusively to touch: "one should feel the beating of the artery and bandage everything from where the blood spurts" - that's their teaching!!" If the head "does not balance" the hand with extensive anatomical knowledge, the surgeon's knife, even an experienced one, wanders like a child in the forest. The most experienced Grefe fiddled around for three quarters of an hour until he found the brachial artery. Pirogov explains: "The operation became difficult because Grefe did not get into the arterial vagina, but into a fibrous bag." Here, in order to prevent this from happening, Pirogov studied the fascia in detail, looking for their relationship to blood vessels and nearby tissues. He pointed out the most detailed landmarks to traveling surgeons, set milestones, - according to the apt definition of the professor of surgery Lev Levshin, he developed "excellent rules on how to go with a knife from the surface of the body to the depths in order to easily and quickly tie up the various arteries of the human body." In each section of his work, Pirogov, firstly, outlines the boundaries of the area within which the operation is performed; secondly, he lists the layers that the surgeon goes through, making his way deeper; thirdly, it gives the most precise operational remarks. "Surgical anatomy of the arterial trunks and fascia" is a text and over fifty tables. Pirogov has always been particularly meticulous about illustrations. He wrote that "a good anatomical and surgical drawing should serve the surgeon for what a guide map serves the traveler: it should represent the topography of the area somewhat differently than an ordinary geographical map, which can be compared with a purely anatomical drawing." Pirogov illustrated each operation mentioned in the book with two or three drawings. No discounts, the greatest subtlety and accuracy of drawings, reflecting the subtlety and accuracy of Pirogov preparations - the proportions are not violated, every branch, every knot, jumper is preserved and reproduced. According to such a map, the surgeon will go unmistakably. Among those who admired the "Surgical Anatomy of the Arterial Trunks and Fascia" was the famous Parisian professor Alfred Armand Louis Marie Velpeau. But Nikolai Ivanovich did not calm down on this. The usual method of preparation satisfied those who studied the structure of organs. Pirogov brought topography to the fore. He wanted the human body to be transparent to the surgeon. So that the surgeon mentally imagines the position of all parts in a section drawn in any direction through any point of the body. To find out how different parts of the body are located, anatomists opened cavities and destroyed connective tissue. The air, breaking into the cavities, distorted the position of the organs, their shape. However, it was impossible to achieve an accurate cut in the usual way. The location of the parts, their ratios, already distorted during the opening of the cavities, finally changed under the anatomist's knife. There was a situation sometimes encountered in science: the experiment itself interfered with obtaining the exact results for which it was carried out. It was necessary to find a new way. There is a legend that connects a random episode from the life of Pirogov with an idea that turned the whole of anatomical science onto a new path. “We, ordinary people,” writes one of Pirogov’s adherents, “pass by without attention the subject that gives rise to a creative thought in the head of a man of genius; so did Nikolai Ivanovich, driving along Sennaya Square, where in winter frozen pork carcasses were usually placed , paid special attention to them and began to apply what he noticed to the case. And indeed, there is a connection between the sawn carcasses on Sennaya Square and a new direction in anatomical research. But the idea came to Nikolai Ivanovich much earlier. Talking about his disputes with Amusse in Paris, the surgeon-scientist writes: "I told him about the result of my study of the direction of the urinary canal on frozen corpses." But Pirogov went to Paris as a Dorpat professor! Around the same years, Buyalsky made an interesting experiment at the academy: on a frozen corpse, which was given a beautiful pose, he exposed muscles; the sculptors made a mold and cast a bronze figure - future artists used it to study the muscles of the body. Consequently, the idea of using cold in anatomical studies appeared long before traveling around Sennaya Square. It is difficult to assume that Pirogov, with his craving for everything new, with his scope, lived in ignorance. Apparently, Sennaya Square again suggested a method, a technique, and did not give birth to an idea. “Which way did Pirogov go, achieving accurate data on the topography of the human body?” asks V.I. Porudominsky and answers. and deal with it in exactly the same way as with a tree, without fear of "neither the entry of air after opening the cavities, nor the compression of the parts, nor their disintegration." Like a tree! Pirogov sawed frozen corpses into thin parallel plates. He made cuts in three directions - transverse, longitudinal and anteroposterior. It turned out a whole series of records, "discs". Combining them, comparing with each other, it was possible to get a complete picture of the location of various parts and organs. Starting the operation, the surgeon mentally saw transverse, longitudinal, anterior-posterior incisions made through one or another point - the body became transparent. A simple hand saw was not suitable for this purpose. Pirogov adapted another, brought from the carpentry factory - there, with its help, they cut red, walnut and rosewood wood. The saw was huge - it occupied an entire room in the anatomical theater. The room was as cold as outside. Pirogov froze so that the corpses would not thaw. The work went on for hours. It would lose its meaning if each plate of the cut could not be preserved forever, made the property of all. Pirogov compiled an atlas of sections. The atlas was called: "Illustrated topographical anatomy of cuts made in three directions through the frozen human body." Right there in the cold room, the frozen cut plates were covered with glass lined into squares and exactly redrawn in full size on paper covered with the same grid. Pirogov struggled with "ice anatomy" for about ten years. During this time, he discovered another way to "apply cold" to his research - he came up with "sculptural anatomy". Now there are no cuts. The corpse was frozen even more - "to the density of the stone." And then, on a frozen corpse, with the help of a chisel and a hammer, the parts and organs needed for study were exposed from the icy layers. "When, with considerable effort, it is possible to remove the frozen walls, thin layers should be thawed with a sponge soaked in hot water until, finally, the organ under study is opened in its unchanged position." If each anatomical atlas of Pirogov is a step in the knowledge of the human body, then "Ice Anatomy" is the top. New patterns have been revealed - very important and very simple. For example, it became known that, with the exception of three small cavities (pharynx, nose and ear drum) and two channels (respiratory and intestinal), empty space is never found in any part of the body in the normal state. The walls of all other cavities fit snugly against the walls of the organs enclosed in them. Pirogov froze corpses in different poses - then on cuts he showed how the shape and ratio of organs change when the position of the body changes. He studied deviations caused by various diseases, age and individual characteristics. I had to make dozens of cuts to find one worthy of reproduction in the atlas. In total, there are a thousand drawings in the "ice anatomy"! Pirogov's anatomical atlas has become an indispensable guide for surgeons. Now they have the opportunity to operate, causing minimal injury to the patient. This atlas and the technique proposed by Pirogov became the basis for the entire subsequent development of operative surgery. Author: Samin D.K.
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