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Revista argentina de cirugía

versión On-line ISSN 2250-639X

Rev. argent. cir. vol.112 no.4 Cap. Fed. dic. 2020

http://dx.doi.org/10.25132/raac.v112.n4.1473.ei 

Articles

The Scientific Nature of Surgery. History and Philosophy

Raúl I. Chullmir* 

Introduction

When we speak about surgery, what are we speaking about? Do we refer to a technique, a craft? Can surgery be considered a science?

If philosophers of science were asked about medicine, most of them would answer as Ortega y Gasset did in 1957.

“No one will consider medicine as a model of science. So amusing as poorly founded on reason, for the doctor uses and handles the results of some sciences. But he is usually not, little or much, a man of science. A theoretic soul.”1

Relevant philosophers -like Stephen Toulmin (1922-2009)- agree with this stance, which does not differ from the position in the 2015 Argentine Philosophical Association Congress.

“(...) pretending to discuss medicine in epistemic terms is as bold as wanting to make a philosophy of tennis, or of how to fly a plane.”

This is a recurring topic among physicians themselves, who often compare the surgeon to the pilot of an airplane, usually evaluated for his ability to solve difficult situations. The same occurs with classical epistemology that evaluates technical disciplines -such as surgery- for their effectiveness and not for their contribution to scientific knowledge. An unfortunate stance that assumes that surgery is what happens in the operating room, ignoring the theoretical background the knowledge includes2.

If medicine is not considered a science, what is left for surgery? The most technical of its disciplines. Most epistemologists agree with this premise. Since surgeons could not justify their work in any science - although progress is not denied-, surgery could never be judged as a science.

We are not discussing the scientific method that both disciplines use but the concept of science, understood as the capacity to create knowledge (scientific theories).

Many philosophers of science -and also some physicians- consider medicine as a practice that applies knowledge from other disciplines, but without its own theoretical creation3. The Argentinian physician and epistemologist César Lorenzano was the first to analyze it in order to reveal its theoretical structure4.

“Medicine is scientific not because it can cure but because it gives plausible explanations about the ailments affecting human beings.” (C.J. Lorenzano, 1977)

In practical disciplines such as medicine, there are no theoretical formulas that describe diseases, as is the case in physics* or chemistry. In medicine, theories (diseases) are described through propositions. For instance, pneumonia disease is characterized by cough, sputum, and signs of lung condensation. When students see a patient with those symptoms, they are expected to recognize the condition by similarity.

Those models -used to learn and characterize a scientific discipline- are called paradigmatic exemplars5.

Paradigmatic exemplars

The ‘paradigmatic exemplar’ is a historical model to learn a discipline.

In the case of surgery, we set up five goals to identify its theoretical component:

1. It should cure or alleviate the condition;

2. It should do it with low morbidity and mortality;

3. It should respect or restore the organ function;

4. The surgeon’s results should be scientifically and methodologically assessed; and

5. The reasons why surgery does what it does should be justified on scientific grounds6.

The history of surgery includes the French surgeon Ambrose Paré (1510?-1590) as the Father of Surgery, and the Englishman, John Hunter (1728- 1793), as the first to conduct experimental research. It has been possible for them to fulfill the first three goals, although it is the last two that scientifically define surgery. Therefore, it was necessary to find the exemplar that would also meet the other two goals.

Historical analysis

Until halfway through the 19th century, foul-smelling was common in operating rooms. Simple hygiene measures were not taken. The same sponges that were used for surgery were reused, unwashed, for other patients 7. Not surprisingly, minor procedures ended up in sepsis and death. In Great Britain, James Simpson said:

“(...) the man laid on a hospital operating table was exposed to more chances of death than the English soldier was on the field of Waterloo.”

Yellow and creamy pus oozing from the wound was considered part of a normal postoperative period. It was called healthy pus because it indicated that bad humors were oozing from the wound. The idea of healthy pus was so deeply rooted that, if for some reason it did not ooze, the surgeon acted on the wound to favor it8,9.

In history books, it is often stated that the

*The formula F = ma, expressed in words, means that the net force on an object is equal to the mass of the object multiplied by the acceleration of the object.

advance of surgery during the 19th century was the result of two great technological innovations: anesthesia and antisepsis. While we subscribe to the idea, there are three other milestones -from the 18th and 19th centuries- that also triggered the development of modern surgery.

1. The surgeon’s admission to the medical rank: Surgeons were not part of medicine at that time. Surgeons were only allowed to treat external injuries.

2. The abandonment of the Galenic-humoral theory, in force for more than two thousand years.

3. The role of surgeons in scientific research.

It is interesting to stress this last point. The importance of research for postoperative infection management.

“Wound fever”, as it was then called, was responsible for the death of up to 50% of operated patients. To research on this condition, surgeons left the operating room and turned their attention to areas that were not their domain, from where the first surgeons trained in applied scientific experimentation emerged10. One of them was the German physician Theodor Billroth (1829-1892).

Billroth: paradigmatic exemplar of modern surgery

Billroth, a music lover and Brahms’ friend, was essentially a researcher. Trained as a surgeon by von Langenbeck (1810-1887) in Berlin, he had planned to specialize in pathology. And only after having failed in the application for the chair of Pathology in the hands of Rudolph Virchow (1821-1902), he decided to continue his career as a surgeon (1856)11,12.

While working as a professor at the Zurich cantonal hospital (from 1860 to 1867), his research topic was bacteriology13-15. With the new weapons of hygiene and anesthesia, Billroth saw the possibility of attacking cancer in deep organs. First the upper esophagus, then the larynx, and finally, the project of stomach cancer resection.

It was a bold idea. The stomach was the king of digestion, and removing it meant leading the patient to certain death. In the animal surgery laboratory, Billroth posed a series of hypotheses as a problem before the beginning of the phase in humans.

▪▪Could the animal survive after the stomach removal?

▪▪How can the continuity of the digestive system be solved?

▪▪What type of suture material should be used?

After a series of dogs that survived the operation more than a year, Billroth managed to perform the first gastrectomy due to cancer on a 42-year-old woman on January 28, 1881.

Those who believe that the operation I refer to today could have been boldly performed on a human being should not have any concerns. Gastric resection has been an operation me and my pupils developed on anatomical, physiological and technical grounds, the way any operation in my service has been performed16.”

Billroth’s was an authentic paradigm because it changed the rules.

At the beginning of the 19th century, only one fifth of the medical papers published in scientific journals were from the surgery arena. By the end of the century, the trend had changed. Papers on surgery covered more than 50%.

Surgery had become the most innovative specialization of medicine. The surgical criteria that once served to classify external diseases, began to be applied in internal diseases. The inclusion of the surgeon’s epistemological framework was called surgicalization of medicine17,18. It meant leaving aside the circulating humors, and shifting medical attention on the organs. A mortal blow for the already moribund Galenic-humoral theory.

Does surgery create knowledge?

Once the existence of a paradigm has been demonstrated, it remains to be seen whether surgery is capable of creating knowledge. In other words, whether or not a technical discipline such as surgery could trigger scientific knowledge19,20.

Traditional epistemology has always stated that technical disciplines such as surgery are unable to create scientific knowledge21. However, several sciences have owed their origin to technique. Wright Brothers’ flying machine was prior to the aerodynamic theory. The art of building machines was carried out before mechanics or physics were developed. Alan Turing’s computer was prior to cybernetics and systems theories22.

If it was the right path to follow, we had to demonstrate that something similar had happened in surgery, but we had to find a “paradigmatic exemplar” in its history to prove it. We have found that paradigm in Emil T. Kocher’s work (1841-1917) between 1889 and 1892, whose research focused on what happened after complete resection of the thyroid.

The technological origin of medical knowledge

Thyroid function was unknown by the end of 1870s. Multiple small, fluid-filled cavities -generically called “thyroid juices”- were observed under the microscope.

By that time, the thyroid was attributed picturesque functions, such as lubricating the trachea, or some aesthetic role because it helped contour the female neck. Researchers -such as Moritz Schiff (1823- 1896)- had conducted experiments suggesting that it should have certain importance, because the animal died after its removal. But the cases were only a few due to an incomplete resection technique23.

In those mountainous areas, goiter was a common disease, and the advance of surgery had made it a topic of interest to surgeons. However, the resection was very complicated due to rudimentary techniques; the scalpel edge was not sharp enough, the type of forceps available forced to take large portions of tissue, and bleeding was difficult to manage. Either because of bleeding or infection, the result was very bad, and therefore it was suggested to stop performing it.

With a rigorous technique and new instruments, Kocher had managed to remove the entire thyroid gland and, based on his positive outcomes, the procedure began to be performed all over the world24.

However, reports of the first patients suffering from “cretinous” changes -apparently due to the absence of the thyroid gland- raised concern. The Swiss surgeon Jacques-Louis Reverdin (1842-1929) called it operating myxedema, because of the similarity to myxedema.

Kocher acknowledged the problem during a congress. He recalled the case of a girl whom he had operated eight years ago. Strictly speaking, the story had begun six months after the procedure. The village clinician, in charge of the girl’s follow up, had written to Kocher saying that she had been undergoing severe changes since the operation. The girl, always of good height and weight, intelligent and sharp, was becoming slow and overweight. Almost an idiot.

Determined to investigate, he sent letters to the rest of his patients to follow-up their condition. All of them presented with the same pattern of physical and mental deterioration. Only two patients had not suffered alterations, but had developed recurrent goiter.

(…) Not before four or five months (from the operation), patients began to complain of fatigue, weakness, and heaviness. (...) Their mental alertness decreased. It was noticed by teachers of school-aged children. (…) Children who were among the brightest regressed (…) many of them who were aware of losing their skills (…) asked their mothers to stay home and not go to school because of their frustration (…) I prefer, for the time being, to give an entirely innocuous name for this symptom-complex (...) I will use the name “cachexia strumipriva.”

What did this disease have to do with the operation? It was not known. But “it is not necessary to live in a land of cretins to become myxedematous.”

What was certain was that surgeons should be warned not to continue performing total thyroidectomy, at least until research was completed. But it was necessary to prove that the origin of the “spontaneous” cases was the same as the origin for operated patients.

Kocher asked Moritz Schiff to continue his research. Schiff again proved what he already knew: the effect of complete thyroidectomy in humans was no different from that in other mammals25. However, this time his research showed something new; if thyroid tissue was temporarily transplanted to the abdomen, animals with typical symptoms of myxedema soon reverted their effects. Schiff suggested preparing “a thyroid paste” for injections in operated patients, but explained that his laboratory conditions were not suitable for such a project26,27.

In 1892, Kocher started an oral therapy based on thyroid juice in patients he had operated on. Soon the comments came to the fore. With amazement, a miraculous transformation was witnessed. In a short time, patients changed their physical and mental condition, and turned into normal people.

Kocher proposed to work ex juvantibus***, that is, to offer thyroid extract to the patients.in case of diagnostic doubt. If the substance helped and the patient improved, the case was labeled as hypothyroidism. Defining the disease based on the response to a treatment was a true diagnostic innovation.

Kocher’s research had a great impact on the physiology of thyroid, and he received the Nobel Prize for Medicine and Physiology in 190928.

Analysis

In the epistemic analysis of the techniques, the idea of “failure or anomaly” is key.

“As long as technics succeed, on the contrary, scientific thought is not called upon to emerge. When technics fail, science is near. Science corresponds to a problematic formulated at the level of technics, but unable to find a solution at the technical level.” 29.

We are not talking about an error or events that occur as a result of a negligent action. What is important here is the novelty emerging after properly performed technical procedures. Treated patients not responding as expected. In an epistemic community avid for knowledge, this novelty poses hypotheses to explain what happened, triggering new theories that will be confirmed experimentally. 30,31,32,33,34,35,36,37

In a diagram:

César Lorenzano called this process epistemic cycle. Through a paradigmatic exemplar, he explains how a technical discipline produces scientific knowledge38. (Fig. 1)

Figure 1 

Conclusions

The scientific nature of surgery is determined by the type of research involved. Every action the surgeon performs is justified by theoretical elaboration.

Historically, we have managed to situate the beginning of scientific research in surgery. The research in animals was the stepping stone to the phase in humans.

“Surgicalization” of medicine was a shift in medical attention on the organs, which was a mortal blow for the already moribund Galenic-humoral theory.

Much of the medical knowledge is scientific, and is the result of therapeutic action that triggers complete scientific theories when analyzed in a timely and methodological manner by a community avid for new knowledge.

The study of historical paradigmatic exemplars leads us to confirm the scientific nature of surgery and give credit to claim for its place in the science world

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Received: April 27, 2020; Accepted: July 14, 2020

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