Ann Thorac Surg 2000;69:651-654
© 2000 The Society of Thoracic Surgeons
Our Surgical Heritage
Rudolf Nissen’s years in Bosphorus and the pioneers of thoracic surgery in Turkey
Hasan F. Batirel, MDa,
Mustafa Yüksel, MDa
a Department of Thoracic Surgery, Marmara University Hospital, Istanbul, Turkey
Address reprint requests to Dr Batirel, Gökay Sok, No:7/22, 81090 Erenköy Istanbul, Turkey
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Abstract
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Rudolph Nissen is one of the most distinguished pioneers in thoracic surgery, well known for his pneumonectomy operation performed for the first time in surgical history. He migrated to Istanbul like most of his contemporary colleagues, avoiding the fascist regime in Germany in the 1930s. He was enthusiastically welcomed in Turkey and appointed as the Chief of the First Surgery Clinic in Istanbul University in 1933. He worked with discipline and in cooperation with his Turkish colleagues, such as Ahmed Burhaneddin Toker, Fahri Arel, Dervi
Manizade, and others, who were to become the leading authorities of general thoracic surgery in Turkey. During his 6 years of residence and working in Istanbul, he contributed highly to the practice of general and thoracic surgery. He had to leave for the United States in 1939 for treatment of his lung abscess due to a retained bullet from World War I. He stayed in New York and later in Basel until his death. He was presented an honorary professorship from Hacettepe University, Ankara in 1973.
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Introduction
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With the university reform by the Turkish government in 1933, most of the Jewish German scientists and physicians who arrived to Istanbul were in search of a future career. All were enthusiastically welcomed and placed in important positions in Istanbul University, the sole higher educational school of that time in Turkey.
Rudolf Nissen (1896 to 1981) was an assistant of the fascinating surgeon Sauerbruch (1875 to 1951) in Germany between 1921 and 1927 and then an associate professor in Berlin between 1927 and 1933. He was offered the head of the surgical clinic and a professorship in Istanbul University by 1933. Numan Menemencioglu, Minister of State, had undergone an operation in Berlin in Sauerbruch’s clinic and had further accompanied Nissen in his visit to Istanbul. Nissen visited Cerrahpasa Hospital with Sauerbruch and its First Surgical Clinic was offered to him. He was impressed with the panoramic view of the beautiful Marmara Sea while having his Turkish coffee on the balcony. He accepted the offer in August 1933 and began his 5.5-year stay in Istanbul [1] (Fig 1).
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Fig 1. Nissen (front row, fifth from the left) with academicians in the medical faculty and high-ranking military officers (courtesy of Professor Nuran Yildirim).
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The former head of the clinic was Ahmed Burhaneddin Toker (1890 to 1951), who had worked in Germany between 1914 and 1920. He had worked with Kirschner (1879 to 1942) and became an experienced surgeon in the treatment of orthopedic problems and thoracic surgery. He had also a mastership in radiology. Until Nissen’s arrival, he was the head of the surgical clinic in Cerrahpasa Hospital, which was under the direction of Istanbul Municipality. The hospital was later affiliated with Istanbul University, and thus became the famous First Surgical Clinic.
Dr Toker, other than pioneering orthopedic surgery, had written books in general thoracic surgery: Surgical Treatment of Pulmonary Tuberculosis (1927), Lung Abscesses (1938). He had also been the editor of the Turkish Journal of Surgery for many years [2, 3].
With the arrival of Nissen, Dr Toker became an associate professor. Nissen’s trip to Istanbul and his concerns about Turkey had very interesting aspects. Wilhelm His (1864 to 1934), famous physiologist and contributor on heart anatomy and physiology, had visited Turkey in 1917 and had written a book named Die Front Der Artze in Berlin in 1931. Nissen had acquired this book, which reflected the psychological and sociological relationships and conflicts between German soldiers and Turkish people in World War I, from Tevfik Sa
lam. When Dr Salam died, the book was revised, and a personal business card of Nissen’s was noticed on the pages relating to the Turkish people.
Nissen became the head of the First Clinic and his fame rallied throughout the country. Dervi Manizade (1912 to present) states in his memoirs [4]: " ... Nissen was one of the most famous surgeons of the world at that time. Lectures and seminars were carried out routinely in our clinic. Nissen was presenting interesting cases and discussing them with us. In the 1st surgery clinic gastric and intestinal resections, lumbar sympathectomies, thoracoplasties, Schede plasties and very dangerous operations for heart injuries were carried out... ." (Figs 2 and 3).
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Fig 2. Nissen (front row, fourth from left) in front of the first surgical clinic with his staff. Ahmet Burhaneddin Toker (front row, second from left) and Fahri Arel (left of Nissen) is also with him (courtesy of Professor Kemal Alemdarolu).
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Fig 3. Nissen (middle row, fifth from right) and his staff in the medical faculty lecture amphitheatre. Ahmet Burhaneddin Toker is right of him. Fahri Arel is left of him (courtesy of Professor Kemal Alemdarolu).
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In the book Lung Abscesses by Burhaneddin Toker written in 1938, Toker reports 59 cases operated between 1934 and 1938: three lobectomies, one pulmonary artery ligation, and 27 plombage thoracoplasties were performed. The time period is that of Nissen’s era in Istanbul. Dervi Manizade also states that Nissen was to present 13 cases of pulmonary hydatid cysts in a surgical congress in Switzerland. But he was unable to attend the congress, so he requested that Manizade present his series, and Manizade performed this presentation with success, achieving admiration of famous surgery professors of Europe (personal communication, Hasan F. Batirel and Dr Manizade).
Nissen performed his first Nissen fundoplication operation in Istanbul on a 28-year-old man with a distal esophageal ulcer in 1936 [5]. He resected the distal esophagus and proximal stomach and reconstructed it in a fashion that embedded the esophageal stump into the wall of the stomach. He later recalled this technique in 1955 and established his famous antireflux procedure, namely Nissen fundoplication [6, 7].
Through the fifth year of his practice, he noticed the need for a modern surgical clinic. Thus, he requested that Professor Heizmann, another German refugee in Istanbul in the Academy of Fine Arts, draw the plan of a new surgical clinic. He discussed this issue with Manizade and gave these plans to him. The plans were passed to officers in the Ministry of Health, but, unfortunately, financial support was not found until later, and the clinic was not completed until 1943, 4 years after Nissen’s departure for the United States.
Dervi Manizade was a surgical resident in Second Surgery Clinic of the University of Vienna under the supervision of the famous surgeon Wolfgang Denk (1882 to 1961) [8]. He became an assistant of Nissen in 1938 and tried to establish a detailed archive system in the clinic. He adapted the Mayo clinic archive system to the surgical clinic with support from Nissen and led its practice for several years. Manizade became an ordinarius professor of surgery and is well known along with Toker to be the leading pioneers of orthopedic surgery in Turkey.
Fahri Arel (1894 to 1976), another associate professor in the First Surgical Clinic, had worked with Nissen for the duration of his stay, and in later years, he has become the most well known pioneer of general thoracic surgery in Turkey. He wrote a thoracic surgery textbook in 1950 and an expanded second edition in 1964 [9]. He notes in the foreword that this book was the product of his experience in the First Surgical Clinic after 1933 and in the United States after 1939. Fahri Arel became an ordinarius professor and worked for the development of general thoracic surgery in Turkey.
Another thoracic surgery clinic in Ankara University under the direction of Galip Urak (1913 to present) was established beginning in 1950. Galip Urak had wished to join Nissen’s staff in 1939, but he was unlucky because of Nissen’s unexpected departure. So, he became a general surgery resident in Istanbul University and later pursued his career in the London Chest Hospital. He began thoracic surgery practice in Ankara with a lack of professional staff and instruments, but his clinic developed rapidly after 1960, performing the first sleeve pulmonary resection in 1968 in Turkey. One of his first assistants, Professor Erdoan Yalav, was trained under the direction of Denton A. Cooley and Michael DeBakey. Other assistants, Professor Vedat 
çöz and Professor Erol Iin, were also trained in distinguished centers in the United States. They returned in the mid 1960s and carried the clinic into a stronger position in Turkey.
Nissen was an exceptional figure in Istanbul. His kindness as a Berlin gentlemen and his delicate wife made him noticed throughout Istanbul among other German-origin clinicians. He attended monthly surgical meetings and gained countrywide fame in a short time. His rise and shift to private practice in his final years caused some of his colleagues to criticize him, mostly due to academic and economic conflicts.
In 1939, during an operation, he experienced sudden tremor and high fever. He was aware that the retained bullet from World War I in his lung had caused a lung abscess. Also, his wife had left for the United States and was expecting a baby. So, he left for the United States with permission. A few months after his departure, World War II began, and although he had a chance for return, the circumstances were not suitable. By 1943, the Nissen-designed, First Surgical Clinic of Istanbul University began its service. Nissen was always in contact with his Turkish colleagues in later years (Fig 4).
In 1973, Aydin Aytaç, professor of cardiothoracic surgery, one of the leading pioneers of adult and congenital cardiac surgery in Turkey, visited him in his office in Basel as the dean of the Hacettepe University Medical School in Ankara. He delivered an official message to him that he was to be awarded an honorary professorship by Hacettepe University. Dr. Aytaç states that Nissen was delighted to hear that, but unfortunately, he could not attend the ceremony for medical reasons. Dr. Aytaç also recalls that Nissen showed him the letter he received from Evarts A. Graham stating that Nissen was the first surgeon in the world to perform a pneumonectomy (personal communication, Hasan F. Batirel and Aydin Aytaç) [10].
Nissen died in 1981 in Basel after a long and productive life. He had made 61 presentations and wrote two books during his time in Istanbul. Nine residents completed their program during Nissen’s stay, and two of them after his departure. Most of them became distinguished surgeons in their fields and served as pioneers for their country. General thoracic surgery, which had a long background going back to Cemil Topuzlu Pacha, was further advanced during and after Nissen’s stay by Burhaneddin Toker and Fahri Arel.
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Comment
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The university reform in 1933 enabled foreign physicians to be employed in important positions in Istanbul University. Nissen was one of these, and he came to Istanbul due to the unstable political situation in his own country. The alliance between Germany and the Ottoman Empire in World War I constructed a close relationship between these countries, and this may have played a significant role in Nissen’s preference. When he came to Istanbul as a young professor, he found a suitable environment with limited facilities, but a qualified and motivated crew. Most of the surgeons working with him were trained in famous European hospitals and were familiar with contemporary surgical techniques. Besides, surgery in Turkey had a strong tradition for excellence, starting with 
erefeddin Sabuncuolu and continuing to Cemil Topuzlu Pacha, and so his Turkish colleagues adapted his style easily [11–13].
Nissen caused an uplift in surgical practice and academic productivity. Thoracic surgery was carried beyond routine thoracoplasties and lung resections; esophageal and mediastinal surgeries were instituted. Regarding heart injuries, I have personally seen a newspaper article from those times, mentioning a successful repair of a superficial penetrating myocardial wound in a young patient by Nissen.
Nissen’s chapter in Istanbul represents the hospitality and kindness of the Turkish people, as evidenced some 500 years earlier by accepting Jewish refugees from Spain, as well as the devotion of Nissen himself to surgical and academic excellence with a foreign crew. This harmonious work has yielded invaluable outcomes, shaping today’s surgical practice.
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Acknowledgments
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I am grateful to Professor Nuran Yildirim and Associate Professor Gülten Dinç for their kind documentary support, and to Professor Aykut Kazancigil, Aydin Aytaç, and Dervi Manizade for sharing their invaluable memories with me and helping me track down correct sources. I also would like to acknowledge the kind permission obtained from the President of Istanbul University, Professor Kemal Alemdarolu, to reproduce the photographs of Nissen and his team from the surgical museum.
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References
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Toker AB. Akcier Tederrününün Cerrahi Tedavisi. stanbul: Kader Matbassi, 1927.
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Toker A.B. Akcier Abseleri. Ankara: Kader Basimevi, 1938.
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Manizade D. 65 Yillik Cerrahpaa Hastanesi: 39 Yilda Duyduklarim ve Gördüklerim. stanbul: .Ü. Cerrahpaa Tip Fak Yay., 1976.
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Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Z Chir 1937;249:311-316.
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Ellis F.H. The Nissen fundoplication. Ann Thorac Surg 1992;54:1231-1235.[Abstract/Free Full Text]
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Hurt R. The history of cardiothoracic surgery from early times. London: Parthenon Publishing Group, 1996:325.
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Arel F. Göüs Cerrahisi, 2nd ed. stanbul: .Ü. Tip Fak Yay, No. 62, 1964.
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Dogan T., Bayramiçli M., Numanolu A. Plastic surgical techniques of erefeddin Sabuncuolu in the fifteenth century. Plast Reconst Surg 1997;99:1775-1779.[Medline]
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Abstract
Introduction
