Editing Emil Theodor Kocher (section)

== Career ==
The call for an ordinary professorship at the University of Bern at the age of 30 was the first big career step for Theodor Kocher. In the 45 years he served as professor at the university, he oversaw the re-building of the famous Bernese [[Inselspital]], published 249 scholarly articles and books, trained numerous medical doctors and treated thousands of patients. He made major contributions to the fields of applied surgery, [[neurosurgery]] and, especially, [[thyroid]] surgery and [[endocrinology]]. For his work he received, among other honors, the 1909 [[Nobel Prize in Physiology or Medicine]]. According to Asher, the field of surgery has transformed radically during the time of Theodore Kocher and later generations will build on the foundations created by Kocher – if a future historian wanted to describe the state of surgery at the beginning of the 20th century, he only need mention Kocher's ''Text-Book of Operative Surgery''.<ref name="bonjour1981"/> <!-- page 63 -->

Three main factors contributed to Kocher's success as a surgeon, according to Bonjour (1981). The first factor was his consequent implementation of antiseptic wound treatment which prevented infection and later death of the patients. The second factor, according to [[Erich Hintzsche]], was his monitoring of the [[anesthesia]] where he used special masks and later used [[local anesthesia]] for [[goitre]] surgery which decreased or removed the dangers of anesthesia. As a third factor, Hintzsche mentions the minimal blood loss which Kocher achieved. Even the smallest source of blood during surgery was precisely controlled and inhibited by Kocher, initially because he thought that decomposing blood would constitute an infection risk for the patient.<ref name="bonjour1981"/> <!-- page 63–67 -->

=== Early career ===
Kocher first attained international recognition with his method to reset a dislocated shoulder published in 1870.<ref name="hls"/><ref name="gemsenjager2011"/> The new procedure was much less painful and safer than the traditionally used procedure and could be performed by a single physician. Kocher developed the procedure through his knowledge of anatomy.<ref name="bonjour1981"/><!-- Bonjour 1981 pg 60 --> In the same period, Kocher also studied the phenomena of bullet wounds and how they can cause [[bone fracture]]s. From these studies resulted one public lecture in 1874 ''Die Verbesserung der Geschosse vom Standpunkt der Humanitaet'' (English: ''The improvement of the bullets from the standpoint of humanity.'') and an 1875 manuscript ''Ueber die Sprengwirkung der modernen Kriegsgewehrgeschosse'' (English: ''Over the explosive effect of modern war rifle bullets.'') He showed that small caliber bullets were less harmful and recommended to use bullets with slower speed.<ref name="bonjour1981"/>

=== Relocation of Inselspital and call to Prague ===
As soon as Kocher became professor, he wanted to modernize the practices at the Bernese [[Inselspital]]. He noticed that the old building did not suffice the modern standards and was too small – half of the patients seeking medical attention had to be turned away.<ref name="bonjour1981"/> In spring 1878, he visited several institutions around Europe to evaluate novel innovations for hospitals and implement them if possible in Bern. He wrote down his observations in a lengthy report for the Bernese government, giving instructions even for architectonic details. In a speech on 15 November 1878, he informed the general public about the pressing needs of a new hospital building. Finally, he used his call to [[Prague]] to pressure the government: He would only stay in Bern if he was either granted 75 beds in the new building or would get money to increase his facilities in the old building. Finally, in the winter of 1884/1885 the new building was finished and the [[Inselspital]] could be moved.<ref name="bonjour1981"/>

At the time, [[Prague]] had the third largest university clinic in the German speaking world and it was a great honor for Kocher when he received a call as a professor to Prague in spring 1880. Many colleagues, especially international ones, urged Kocher to accept while Bernese doctors and colleagues begged him to stay.<ref name="bonjour1981"/> Kocher used this call, to demand certain improvements for the university clinic from the Bernese government. They accepted all his demands, the government promised him to begin building the new [[Inselspital]] building the next year, increased his credit for surgical equipment and books to 1000 franks and increased the number of beds for Kocher in the new Inselspital. Thus, Kocher decided to stay and many Bernese and Swiss students and professionals thanked him for it. He cited the affection of his students as one of his main reasons for staying. The university students organized a torchlight procession on 8 June 1880 in his honor.<ref name="bonjour1981"/>

=== Aseptic surgery ===
It is unclear whether Kocher directly knew [[Joseph Lister, 1st Baron Lister|Joseph Lister]], who pioneered the antiseptic (using chemical means to kill bacteria) method, but Kocher was in correspondence with him.<ref name="bonjour1981"/> Kocher had recognized the importance of aseptic techniques early on, introducing them to his peers at a time when this was considered revolutionary. In a hospital report from 1868, he attributed the lower mortality directly to the "antiseptic Lister's wound bandaging method" and he could later as director of the clinic order strict adherence to the antiseptic method.<ref name="bonjour1981"/> Bonjour (1981) describes how his assistants were worried about wound infection for fear of having to explain their failure to Kocher himself.<ref name="bonjour1981"/> Kocher made it a matter of principle to investigate the cause of every wound infection and remove every potential source of infection, he also banned visitors from his surgeries for this reason.<ref name="bonjour1981"/>

He published multiple works on aseptic treatment and surgery.<ref name="choong2009"/>

=== Contributions to Neurosurgery ===
Kocher also contributed significantly to the field of neurology and [[neurosurgery]]. In this area, his research was pioneering and covered the areas of [[concussion]], neurosurgery and [[intracranial pressure]] (ICP).<ref name="bonjour1981"/> Furthermore, he investigated the surgical treatment of [[epilepsy]] and spinal and cranial trauma. He found that in some cases, the epilepsy patients had a brain tumor which could be surgically removed. He hypothesized that epilepsy was caused by an increase in ICP and believed that drainage of cerebrospinal fluid could cure epilepsy.<ref name="hildebrandt2012"/>

The Japanese surgeon [[Hayazo Ito]] came to Bern in 1896 in order to perform experimental research on epilepsy. Kocher was especially interested in the ICP during experimentally induced epilepsy and after Ito returned to Japan, he performed over 100 surgeries in epilepsy patients.<ref name="hildebrandt2012"/>

The American surgeon [[Harvey Williams Cushing|Harvey Cushing]] spent several months in the lab of Kocher in 1900, performing cerebral surgery and first encountering the [[Cushing reflex]] which describes the relationship between [[blood pressure]] and [[intracranial pressure]]. Kocher later also found that [[decompressive craniectomy]] was an effective method to lower ICP.<ref name="choong2009"/>

In his surgery textbook ''Chirurgische Operationslehre'', Kocher dedicated 141 pages of 1060 pages to surgery of the nervous system. It included methods of exploration and decompression of the brain.<ref name="hildebrandt2012"/>

=== Contributions to Thyroid surgery ===
Thyroid surgery, which was mostly performed as treatment of [[goitre]] with a complete [[thyroidectomy]] when possible, was considered a risky procedure when Kocher started his work. Some estimates put the mortality of thyroidectomy as high as 75% in 1872.<ref name="chiesa2009" /> Indeed, the operation was believed to be one of the most dangerous operations and in France it was prohibited by the Academy of Medicine at the time.<ref name="chiesa2009" /> Through application of modern surgical methods, such as antiseptic wound treatment and minimizing blood loss, and the famous slow and precise style of Kocher, he managed to reduce the mortality of this operation from an already low 18% (compared to contemporary standards) to less than 0.5% by 1912.<ref name="choong2009"/> By then, Kocher had performed over 5000 <!-- 4250 by 1909 according to Gemsenjäger, 7052 in total, 5314 by Kocher himself. According to Bonjour, the mortality went down to 0.1% in 1917-->thyroid excisions.<ref name="choong2009"/>  The success of Kocher's methods, especially when compared to operations performed by [[Theodor Billroth]] who was also performing thyroidectomies at that time, was described by [[William Stewart Halsted]] as follows:
{{Blockquote|text=I have pondered the question for many years and conclude that the explanation probably lies in the operative methods of the two illustrious surgeons. Kocher, neat and precise, operating in a relatively bloodless manner, scrupulously removed the entire thyroid gland doing little damage outside its capsule.  Billroth, operating more rapidly and, as I recall, with less regard for the tissues and less concern for hemorrhage, might easily have removed the parathyroids or at least have interfered with their blood supply, and have left fragments of the thyroid.  |sign=[[William Stewart Halsted]] |source=Halstead WS. The operative story of goitre. Johns Hopkins Hosp Rep 1919;19:71–257. – Quoted in Morris et al.
<ref name="morris1990"/>}}

Kocher and others later discovered that the complete removal of the [[thyroid]] could lead to [[cretinism]] (termed ''cachexia strumipriva'' by Kocher) caused by a deficiency of thyroid hormones. The phenomena was reported to Kocher first in 1874 by the general practitioner [[August Fetscherin]]<ref name="hintzsche1970"/> and later in 1882 by [[Jacques-Louis Reverdin]] together with his assistant [[Auguste Reverdin]] (1848–1908).<ref name="hls"/> Reverdin met Kocher on 7 September in [[Geneva]] at the international hygienic congress (''internationaler Hygienekongress'') and expressed his concerns about complete removal of the thyroid to Kocher.<ref name="schlich1998"/> Kocher then tried to contact 77 of his 102 former patients and found signs of a physical and mental decay in those cases where he had removed the thyroid gland completely.<ref name="troehler2010"/> Ironically, it was his precise surgery that allowed Kocher to remove the thyroid gland almost completely and led to the severe side effects of [[cretinism]].

Kocher came to the conclusion that a complete removal of the thyroid (as it was common to perform at the time because the function of the thyroid was not yet clear) was not advisable, a finding that he made public on 4 April 1883 in a lecture to the German Society of Surgery and also published in 1883 under the title ''Ueber Kropfexstirpation und ihre Folgen'' (English: ''About Thyroidectomies and their consequences'').<ref name="kocher1883"/> Reverdin had already made his findings public on 13 September 1882<ref name="schlich1998"/> and published further articles on this topic in 1883; yet still Kocher never acknowledged Reverdin's priority in this discovery.<ref name="hls"/><ref name="gemsenjager2011"/> At the time, the reactions to Kocher's lecture were mixed, some people asserted that [[goitre]] and [[cretinism]] were different stages of same disease and that cretinism would have occurred independently of the removal of the thyroid in the cases which Kocher described.<ref name="schlich1998"/> <!-- pg 52 https://books.google.com/books?id=SInlUoFTKZcC&pg=PA52 --> In the long run however, these observations contributed to a more complete understanding of thyroid function and were one of the early hints of a connection between the thyroid and [[Congenital hypothyroidism|congenital cretinism]]. These findings finally enabled thyroid hormone replacement therapies for a variety of thyroid related diseases.<ref name="morris1990"/>

=== Further contributions to science ===
Kocher published works on a number of subjects other than the thyroid gland, including [[hemostasis]], antiseptic treatments, surgical infectious diseases, on gunshot wounds, acute [[osteomyelitis]], the theory of strangulated [[hernia]], and abdominal surgery. The Nobel Prize money he received helped him establish the Kocher Institute in Bern.  <!-- TODO expand -->

A number of instruments (for example the [[Craniometry|craniometer]]<ref name="schueltke2009"/>) and surgical techniques (for example, the [[Kocher manoeuvre]], and [[Laparotomy#Types of incisions|kocher incision]]) are named after him, as well as the [[Kocher-Debre-Semelaigne syndrome]]. The Kocher manoeuvre is still a standard practice in orthopaedics.<ref name="gautschi2009"/> Kocher is also credited for the invention in 1882 of the Kocher's Surgical Clamp, which he used to prevent blood loss during surgery.<ref name="gemsenjager2011"/>

One of his main works, ''Chirurgische Operationslehre'' (Text-Book of Operative Surgery <ref>{{cite book|url=https://archive.org/details/textbookofoperat00koch|title=Text-book of operative surgery|first1=Theodor|last1=Kocher|first2=Harold Jalland|last2=Stiles|date=7 January 1895|publisher=London: Adam and Charles Black|access-date=7 January 2018|via=Internet Archive}}</ref>), was published through six editions and translated into many languages.<ref name="choong2009"/>

During his life, Kocher published 249 articles and books and supervised more than 130 doctoral candidates.<ref name="gautschi2009"/> He was [[Rector (academia)|rector]] of the university in 1878 and 1903.<ref name="bonjour1981"/> He was president of the Bernese and the Swiss physicians association and co-founded the Swiss society for surgery in 1913 and became its first president.<ref name="bonjour1981"/>

In 1904 or 1905 he built a private clinic called "Ulmenhof" which had space for 25 patients. Here Kocher catered to the wealthier patients, which in many cases were international.<ref name="bonjour1981"/> He also treated the wife of [[Lenin]], [[Nadezhda Krupskaya]] and operated on her in Bern (in 1913<ref name="g26"/>).<ref name="gemsenjager2011" />