StoriesPart of Revolutions in Surgery
Part3

The case of the cancerous stomach

Decades of medical research and development allowed the talented surgeon Theodor Billroth to successfully remove a cancerous tumour of the stomach in 1881. This exciting medical first gives him a unique place in the history of abdominal surgery.

Words by Thomas Morris and artwork by Emily Evans

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Stomach illustration by Emily Evans
The stomach. © Emily Evans for Wellcome Collection.

Little is known about Therese Heller except a few sketchy biographical details, but this courageous woman deserves a prominent place in the history of medicine. In January 1881 she volunteered to undergo a new procedure to remove a malignant tumour from her stomach – an operation so audacious that it redefined the possibilities of surgery.

Therese was Austrian, and at the age of 43 was the mother of eight surviving children. She had always been healthy until October 1880, when she started to suffer from indigestion. Within half an hour of every meal she would throw up most of what she had eaten, and lost weight with worrying rapidity. By Christmas she was emaciated and bedridden, and the only thing her fragile stomach could tolerate was sour milk, which she would consume a few spoonfuls at a time.

A mid-19th-century lithograph depicting an operation being performed on the lower abdomen.

On 25 January she was admitted to hospital in Vienna, where doctors examined her and discovered the likely cause of her illness. Beneath the wall of her abdomen, near her navel, they could feel a hard but moveable mass, an object described as “the size of a small fist”. The physicians were confident that they knew what this was: a large malignant tumour of the stomach.

Cancers of the lung, breast, prostate or bowel are all more prevalent today, but in the mid-19th century it was stomach cancer that was the number-one killer. It was also a horrible way to die, since progressive obstruction of the digestive tract made it impossible to eat. Many patients simply starved to death. Drugs were useless in halting the march of this relentless disease: the only other conceivable option was cutting out the tumour – something that had never been done.

Agonising experiments without anaesthesia

The idea of surgically removing a stomach tumour had first been suggested 70 years earlier. In 1810 a young German physician, Karl Theodor Merrem, proposed an operation to cut out the lower part of the stomach, the pylorus, and then stitch the remaining portion of the organ to the small intestine.

He even demonstrated the procedure on three dogs – an act of horrifying cruelty, since he had no anaesthetics and the dogs were therefore fully conscious at the time. It does not take much imagination to appreciate why this treatment was not attempted on a human patient.

The idea of operating inside a patient’s abdomen remained an impossible dream until two important discoveries changed everything. The first of these was anaesthesia, introduced in the late 1840s; and then in 1867 the Glasgow surgeon Joseph Lister showed that the use of antiseptics drastically reduced postoperative mortality.

Suddenly it was possible for surgeons to operate methodically and at leisure on an unconscious patient, and to open the major cavities of the body without infection being the near-inevitable consequence. The stage was set for a golden age of surgery.

For Theodor Billroth, devising a new operation was as much an act of creativity as it was scientific research.

It was fortunate that this exciting new era coincided with the rise to fame of Theodor Billroth, a German-born surgeon of many talents. His first love was music, and he was such a close friend of Johannes Brahms that the great composer dedicated two of his three string quartets to him. Billroth once suggested to Brahms that “science and art spring from the same source”; for him, devising a new operation was as much an act of creativity as it was scientific research.

In the mid-19th century it was stomach cancer that was the number-one killer. It was also a horrible way to die.

By the early 1880s Billroth already had a reputation as an innovative and methodical investigator. He had pioneered several operations, including the first successful removal of the larynx for cancer. He only attempted such new procedures after years of careful preparation and thought, perfecting his techniques in the laboratory before taking them into the operating theatre.

A resounding surgical success

When Billroth first encountered Therese Heller he could see at once that she was gravely ill. But he spent several days examining and observing her before he suggested that he might cut out her stomach cancer – an operation that had been attempted before, but never successfully. Therese agreed without hesitation: she was physically at a low ebb, and convinced that her end was near.

The operation took place on the morning of 29 January. Theodor Billroth and his assistants had been preparing for this moment for several years. Two of his students had practised the stomach-reducing procedure successfully on dogs, while Billroth himself had developed an unrivalled knowledge of such tumours by performing thousands of autopsies.

The surgeon was at pains to dismiss any idea that it was a “foolhardy experiment”, declaring firmly that the procedure was “physiologically, anatomically and technically sound… it must and will succeed.

His optimism was justified, although Billroth also appreciated quite how difficult the operation would be. Unusually, he delegated the task of administrating the anaesthetic to a colleague, and instructed his assistants not to say a word unless it was absolutely necessary.

This oil painting shows a tumour restricting the entrance to the stomach, which would have made it increasingly difficult for the patient to eat.

When he opened Therese’s abdomen, making an 11 cm incision just above her navel, he soon found that a tumour the size of an apple had engulfed the pylorus, the lower part of her stomach. First he had to dissect this object clear of the surrounding tissues, meticulously tying off any blood vessel that threatened to bleed. Then came the most terrifying part of the operation. With two large incisions he removed a significant portion of the stomach – the pylorus and the cancerous tissue around it. 

With the tumour excised, Billroth then had to attach the small intestine to the remaining part of the stomach, a tedious and intricate task that involved inserting more than 50 silk stitches. Once the repair was complete, the stomach was sponged with antiseptic to prevent infection and replaced inside the abdomen, and the original incision was finally closed. The operation had taken an hour and a half.

The lasting legacy of Billroth I

Considering that Therese had been near death a few days earlier, her recovery was remarkable indeed. She progressed from sour milk to coffee, port and biscuits, and 20 days after surgery ate one of Vienna’s famous veal schnitzels. The following day she consumed a large steak – a menu unthinkable to the invalid of a few months earlier.

She was soon able to leave hospital, and by mid-April was described by her doctors as cured. But there was a wretched end to her story: the cancer had already spread, undetected, to her liver and other organs, and on 24 May she died.

Therese may have survived for only four months, but those were four months she would not otherwise have enjoyed. Billroth’s operation was greeted by newspapers worldwide as a medical marvel, the beginning of a new era of surgery. That assessment has stood the test of time; the same procedure, known as Billroth I, is still used – slightly modified – to this day.

But Theodor Billroth’s contribution was not merely a single operation. He had shown his colleagues that, given the right equipment and techniques, virtually no part of the human body was beyond the reach of the scalpel. Within a few years, surgeons were operating not just on the stomach, but the kidneys, liver and intestines too; and Theodor Billroth would for ever be known as the father of abdominal surgery.

About the contributors

Photograph of Thomas Morris

Thomas Morris

Author

Thomas Morris is author of ‘The Matter of the Heart’ and more recently ‘The Mystery of the Exploding Teeth and Other Curiosities from the History of Medicine’. He has worked as a radio producer for the BBC on such programmes as ‘Front Row’, ‘Open Book’ and Melvyn Bragg’s ‘In Our Time’, and his journalism has appeared in publications including the Lancet and the Times.

Photograph of Emily Evans

Emily Evans

Illustrator

Emily Evans is a medical illustrator and anatomist. After her role as a senior demonstrator of anatomy at Cambridge University, alongside her career illustrating medical and surgical books for over a decade, she now writes and publishes books about anatomy and art, such as ‘Anatomy in Black’, while running her brand, Anatomy Boutique.