BACKGROUND: THE BEGINNING OF THE SCANDINAVIAN SURGICAL SOCIETY
The Scandinavian Surgical Society (SSS) has a long history and is the oldest international surgical society in the world. “The person SSS has to thank for its creation is Prof. Eilert Adam Tscherning (Fig. 1) from Copenhagen,” said by Prof. John Berg from Stockholm at the association’s first scientific meeting on July 6, 1893, who himself also was a driving force behind the formation of the association.1
Countries with more widely recognized historical contributions to surgery such as Germany and France and their importance for the international surgical scientific collaboration, which also included several Nordic surgeons, served as an example for the formation of the SSS, as well as the national surgical societies founded in Germany in 1872, in the United States in 1880, in Italy in 1882 and in France in 1883.2 Prof. Tscherning’s idea and thought was, however, that united the surgeons of the four Nordic nations would be more capable to contribute to the great cultural debate than if they appeared individually. This seed he sowed in 1887, which emerges from a letter dated April 12, 1891.1
Prof. Tscherning had also another warm follower of his idea and an energetic collaborator for its realization in surgeon Kristian Jervell from Kristiania, who was in close contact with Prof. Tschering. Their strong will to bring about a society is seen as the basis for the society being formed. Kristian Jervell discussed the matter at home in Kristiania with Prof. Julius Nicolysen, who accepted the idea if the society would be a surgical-gynecological society. Jervell also spent a month in Stockholm, where he received a great understanding of the idea of forming a Nordic surgical society. Prof. Tschering had also been in contact with Prof. Lennander in Uppsala and where he met the Finnish surgeon colleague Prof. V. Bonsdorff, who promised to prepare Finland for the upcoming idea and society.
The preparative meeting for the formation of the society had been decided to be held in Gothenburg in 1891. To get suggestions on surgeons who could conceivably participate in the planned collaborative meeting, Prof. Tscherning undertook the task of contacting some prominent surgeons in each country. According to the reply-letter to Prof. Tscherning, he had asked Prof. Berg in Stockholm, Prof. Nicolaysen in Kristiania and Prof. af Schulten in Helsinki to appoint 3 to 4 representatives to the planning meeting in Gothenburg. The following surgeons were appointed: Prof. Studsgaard, Dr. O. Bloch, and Prof. F. Howitz from Denmark, Dr. Netzel, Dr. J. Berg, Dr. A. Lindh and Prof. Lennander from Sweden, Prof. Salzman, Prof. Heinricius, and Prof. af Schultèn from Finland, and Prof. Schönberg and Dr. Jervell from Norway.
On August 31, 1891, the initiators of the SSS meet in the Gothenburg Medical Society’s session hall at the Sahlgrenska hospital and signed the invitation to the formation of a SSS, which was proposed to be the name of the society with a meeting once a year.
On March 13, 1892, Prof. Tscherning asked for lecture titles for the first days of the meetings. During the 5 days of the meeting, 18 lectures with surgical or obstetrics-gynecological content were presented: Studsgaard: surgical treatment of osteoarthritis, Heinricius placenta emergence, especially in the carnivores, Jervell: plastic with salivary flap, Lennander: appendicitis. After the meeting, the surgeons met to establish the Nordic Surgical Society, 9 years before the International Surgical Society, which was established 1902, thus making SSS the oldest international surgical society in the world. The negotiations were led by Prof. Fr. Howitz. A. Lindh was elected as the chairman for the society, the other members were: J. Berg and W. Netzel from Sweden, J. Nicolaysen and E. Schönberg from Norway, M. W. af Schulten and G. Heinricius from Finland and Fr. Howitz and C. Studsgaard from Denmark.
The first scientific meeting of the SSS was held on July 6 to 8, 1893, in Gothenburg, and the SSS had taken its place among the scientific medical professional societies.1
SURGICAL HISTORY AND SURGICAL DEVELOPMENT IN THE NORDIC COUNTRIES BEFORE SSS
Surgical breakthroughs in the Nordic countries can be traced back to the late 1880s. A foundation had already started to take shape and set the stage for what became a rapid breakthrough in tandem with the founding of the SSS.
The Danish surgical breakthrough came already in 1736 when the Danish Surgeon Simon Crüger, who was King Chr VI’s royal doctor, established the royal theater (theatrum anatomo-chirurgicum), which was an educational institution for Danish and European Surgeons. Surgery was later established as a special discipline in 1787, when the Academia Chirurgorum Regia was established. Surgeons were examined at the Surgical Academy until 1842, when the speciality of surgery was established at the University of Copenhagen. In 1759, the Royal Frederiks hospital was founded and later in 1863 another large hospital in Copenhagen, the Municipal Hospital (Fig. 2)1 was established. From 1885, Oscar Bloch became professor at the Frederiks Hospital after competing with E.A. Tscherning, among others, who at that time was chief of surgery at the Municipal hospital. Oscar Bloch (who performed the first Mikulicz operation in 1886, 10 years before Mikulicz) was at that time in dispute with the judicial ministerium led by minister PA Alberti, who was later jailed for 8 years because of fraud. The dispute concerned interference from the ministerium in the work of the Royal Health Collegium in the early 1900s. Oscar Bloch changed professor positions with T. Rovsing at Frederiks Hospital. At the same time, the Royal Health Collegium complained to the King and dissolved itself. This, among other things, led to the jailing of Alberti. In 1908, the founders of the Danish Surgical Society (T. Rovsing and E.A. Tscherning) felt that the time was right to establish the society. The Danish Surgical Society has since then been a scientific and an advisory society for the national health service.3
In 1632, King Gustav II Adolf initiated the planning of a university in Finland, and later the Royal Academy in Turku was founded by Queen Kristina’s guardian government in 1640 and thus the academic medical education could begin in Finland. In 1784, thanks to a large donation, a professorship in anatomy, surgery, and obstetrics was established and Gabriel Erik Haartman was appointed to the position, according to the donor’s wishes. Three years later, the first full-time professor of surgery and obstetrics was founded, held by Joseph Pipping (Noble Pipping Shield), which was the beginning of scientific surgery in Finland. After the Turku fire in 1827, the now renamed Imperial Alexander University was moved to Helsinki in 1828, where Johan Agapetus Törngren became the first professor of surgery and obstetrics.1
Two years after, the Serafimerlasarettet was opened in Stockholm, King Adolf Friedrich granted 2 country hospitals in Finland in 1756, 1 in Turku, and 1 in Helsinki. In the years that followed, a few more smaller hospitals were founded and at the turn of the century there were a total of 60 healthcare facilities, one for every 15,000 residents. These hospitals obeyed the Seraphim Order of the Knights.
In the years 1808–1809, after the Finnish-Russian war, the country’s healthcare sector experienced a serious setback. The total number of doctors was 18 and to alleviate the great medical shortage in the country, Emperor Alexander I ordered the construction of a university hospital, Clinicum Institutum, in Turku. The hospital was completed in 1826, but was never used as the Academy was moved to Helsinki after the Turku fire in 1827, thus leaving the building idle. A new building was built in Helsinki in 1833 and later a new clinical institute was built at the same site. These 2 were merged in 1861 to become the Helsingfors Allmänna Sjukhus, which also served as the Uusimaa county hospital with a bed count of 350. In the beginning of the 20th century, there were close to 2500 healthcare facilities compared to 60 a century earlier. The era of modern healthcare had begun in Finland.
Surgery emerged as an independent specialty in Finland from 1857, when gynecology and obstetrics were separated from surgery into a separate specialty area. At the time of the formation of the SSS, surgeons could prevent severe hospital infections with antiseptics. A new surgical hospital was built in Helsinki in 1888 (Fig. 3).1 At the Alexander University, then the country’s only university, scientific surgery was represented by only one professor in the subject (Jacob August Estlander, 1860–1881; Fredrik Saltzman, 1883–1890; and Maximus Widekind of Schultèn, 1891–1898); the last 2 were founders of the SSS. Already at the first meeting of SSS, M.W. of Schulten proposed the idea of systematically organized joint research among Nordic surgeons.1
The Finnish Society of Surgery was founded in 1925 and serves today as the umbrella organization for all surgeons in Finland.
Although the first hospital in Norway was established in 1164, Norwegian hospitals were reserved for the treatment of poor people with chronic, mental, or venereal diseases, similar to other hospitals in Europe. Hospitals had been built in many Norwegian towns toward the end of the 17th century; however, most surgical procedures were performed in the patient’s homes. In 1881, a total of 1991 operations were recorded in the entire country; 471 were performed in hospitals and 1520 outside hospitals. In 1887, Alexander Malthe presented written instructions for the equipment of rooms used for operations in private houses. The old medieval hospitals were usually associated with monasteries or churches, but surgical development in Norway showed great progress; around the year 1800, there were 14 county hospitals with a total of 500 beds which rapidly increased to 55 hospitals and clinics with 2400 beds in 1900.
Until the second half of the 19th century, the practice of surgery was limited due to pain and infections. This changed in the second half of the century. In New York, the dentist Horace Wells demanded and received the first nitrous oxide anesthetic on December 11, 1844. William Morton, a colleague of Horace Wells, introduced ether narcosis in Massachusetts 1846. These techniques were quickly adapted in Norway; the same year the surgeon Frans Christian Faye introduced ether at the University Hospital in Norway. The Scottish surgeon Joseph Lister (1827–1912) published an article on carbolic acid disinfection of operating fields in 1867, and already the next year professor Julius Nicolaysen (1831–1909) introduced this method in Norway. Together with Christen Heiberg (1799–1872), Nicolaysen was one of 2 professors of surgery who were born in Bergen. He must have been one of the new bold surgeons encouraged by the new era in anesthesiology and the reduction of infections. For example, he nailed a medial collum femoris fracture in 1893, 2 years before the first x-ray.
The first blood transfusion was performed in 1836 by Christian Egeberg, one of the best-known surgeons in private practice at the time. He also suggested that gastrostomy might be used in the treatment of esophageal strictures, although he never performed this procedure. Gastrostomy was performed for the first time in Norway in 1874 by Johan Hjort. Oophorectomy was performed in 1843 by Egeberg and Heiberg in 1845; they both lost their patients. The first successful oophorectomy was performed in 1866 by Nicolaysen. A cesarean section was first done in 1843 by Lars Backer, a practicing surgeon in Holmestrand outside Oslo.
Appendectomy “a froid” was performed in 1889 by Alexander Malthe, a practicing surgeon in Oslo (Fig. 4).1 He was the first to use cocaine as local anesthesia. Appendectomy for acute appendicitis was performed for the first time in 1891 by Kristian Jervell, who also performed the first prostatectomy in 1905. Hagbarth Strøm Strøm was the first to introduce surgical treatment of gallstones in 1880–1885. He died of septicemia in 1912 due to acute cholecystitis.
In 1880, black operating gowns were changed to white by Hjalmar Schiøtz (1850–1927), who also introduced the use of rubber gloves invented by the American surgeon William Halsted in 1889.
The first surgical society in Norway was the Surgical Society in Christiania (Oslo) (Den kirurgiske forening I Christiania) in 1894. Before this, the surgeon Christian Egeberg initiated a Nordic meeting for “natural sciences” in Gothenburg. In these meetings, a surgical section developed, and in 1892, it was decided to establish a separate Nordic Surgical Society, which was founded the next year. The Norwegian Surgical Society was founded in 1911 with the first chairman Otto Johan Borchrewink.4
The beginning of the 1880s was a great period in the Swedish medical scene. The optimism for the coming decades was primarily due to the use of antiseptics and later aseptics in the surgical theater.
Although university hospitals and physicians played the most significant role in surgical development in the 19th century, forward-looking county councils and local hospital authorities also made considerable efforts.
At the time of the formation of the SSS, it was the state of Uppsala that played a significant role in surgical development in Sweden. Led by Prof. Carl Benedict Mesterton, the construction of a new hospital began in 1867. Upon completion, this hospital was considered to be the most advanced within the Nordic region (Fig. 5).1 C.B. Mesterton was followed by the 32-year-old Karl Gustav Lennander, who was enormously interested in science and thus corresponded with almost all leading surgeons in the world. During his career as a practicing surgeon, he made ground-breaking progress in thyroid and bile surgery and in skeletal and breast cancer surgery.
Also the Royal Seraphim Hospital in Stockholm has played a major role in education of surgeons and in surgical care in Sweden.
The Swedish Surgical Society, which was founded in 1905 and got its current name in 1929, is a society of surgeons active in Sweden or who have a significant connection to Swedish surgery. The purpose of the society is to promote the development of surgery in a scientific and collegial manner. Education for surgeons is a central part of the activities of the society.1
The number of physicians in Iceland was minimal in the beginning of the nineteenth century. The first hospital in Iceland was in Nes, founded in 1763 (Fig. 6), and hosted by the first “Landsphysicus” Bjarni Pálson, the first medical doctor with a university examination. Before that time there are sources, the old sagas, which suggest there were hospitals, even as early as the 1300, but there the treating personal were mostly priests. The hospital in Akureyri was founded in 1900 and St. Joseph’s hospital (Landakot) in 1902. Landspitali, which later became the University hospital, was founded in 1930. The first practicing surgeon in Iceland was Guðmundur Björnsson, who was later nominated as the Chief Medical officer in Iceland when he ended his surgical career. The number of surgeons gradually increased, and in 1930 there were nine active surgeons in the country. Although the Icelandic surgical society was founded in 1957, Icelandic surgeons were active within the SSS long before. Snorri Hallgrimsson was the first Icelandic surgeon to become president of the SSS in 1971 in the first SSS meeting ever held in Iceland.1
ACTIVITIES IN SSS OVER THE YEARS
The activities and major events of the first 80 years of SSS can be found in the book Nordisk Kirurgisk Förening Åttio År1 (www.scandsurgicalsociety.com). The book contains a unique Nordic history in the field of surgery. The book describes not only the activities of authoritative surgeons and the organization, but also discusses the current surgical topics of the time, scientific issues, and the spirit of a touch of time. This book is highly recommended for all surgeons interested in the history of this field.
The Discovery of Forgotten Material
In 2020, a board member (N.C.L.) of the SSS was given old material on the early days of the SSS by professor Caj Haglund, a former secretary of the SSS. In one of these folders, a document stating that the society wishes to establish an archive at the University library in Lund was found. Soon after, the society indeed found an archive and the material that had been archived measured up to 4.4 m in nondigital format, as described at Alvin, a platform for digital collections and digitalized cultural heritage. The archive consists of different types of documents, letters, financial documents, and manuscripts. This archive will be revealed by the board in the near future. More historical materials found can also be viewed on the web pages of the SSS (www.scandsurgicalsociety.com)
The member countries of the SSS, Denmark, Iceland, Norway, Sweden, and Finland are today represented by the Dansk Kirurgisk Selskab, Skurdlaeknafelag Island, Norsk Kirurgisk Förening, Svensk Kirurgisk Förening, and Kirurgföreningen i Finland, respectively.
With the globalization that has taken place since the inception of the society, the activity within the society has declined. The excess of worldwide congresses that exists in present times weakens the activities of small societies and associations. For smaller surgical societies to exist in the future, a renewal of activities needs to take place together with utilizing all the advantages the globalized world has provided. In the modern world, international guidelines on treatment methods apply, but it has been clearly emphasized that a Nordic perspective is still needed.
Scandic Visit Program
An audit program has been established by the board of the SSS, named the Scandinavian Visit Program. The aim of the program is to enable any surgeon in Sweden, Denmark, Norway, Iceland, or Finland to visit hospitals in other Nordic countries, according to the wish of the visiting surgeon. The goal of the program is to promote the surgical collaboration among surgeons in the Nordic countries, thereby following the founding guidelines of the first statutes by the society.
In 2013, young surgeons from Sweden and Denmark met and shared ideas regarding future collaboration. Norway joined in 2014 and the three countries meet informally twice a year. The associations representing each member country are Kirurger Under Utbildning, Yngre Danske Kirurger, and Forening For Unge Norske Kirurger. The collaboration between young surgeons and SSS is appreciated and thus representatives from the young surgeons are present at the board meetings of SSS.
The Future of SSS
The saying in Swedish that there is not a bad thing that does not bring something good with it (every cloud has a silver lining) is also applicable to the COVID-19 pandemic and SSS. The rapid digital change and jump into virtual meetings has initiated a new era of Nordic collaboration in SSS. The first trauma webinar (Fig. 7) arranged by the board of SSS was successfully implemented May 25, 2021 on Global Surgery Day, a day that “aims to spread awareness and recognition regarding the inequity in surgical access and outcomes for patients around the world.” Times have changed and surgical developments over the years have been enormous. However, by finding new collaboration forms, togetherness and friendship among Nordic surgeons continues.
We thank Nils Liedberg and co-workers for the “Nordisk Kirurgisk Förening Åttio År, En krönika – På uppdrag av Nordisk Kirurgisk Förening” for the texts, which were used in this article.