El carácter científico de la Cirugía. Historia y Filosofía / The Scientific Nature of Surgery. History and Philosophy

RESUMEN ¿Se puede hablar de ciencia cuando nos referimos a la cirugía? No, de acuerdo con la epistemología clásica, que dice que para que una disciplina sea considerada científica debe alcanzar requisitos que la cirugía parecería no cumplir. Esto es, ser parte de un paradigma y crear conocimiento científico. Por lo que, si queremos afirmar la cientificidad de la cirugía, debemos investigar la existencia de ejem plares que podrían ser paradigmáticos, ya que son ellos los que fundamentan su estructura epistémi ca. Junto a esto debemos demostrar que su práctica crea conocimiento científico. Para ello, postulamos cinco objetivos que la cirugía debe cumplir. Además, a los personajes históricos clásicos a quienes se les atribuye haber fundado la cirugía moderna ‒Ambrosio Paré y John Hunter‒, solo pudieron alcanzar los tres primeros. Pero esto no basta para que se considere a la cirugía como parte de la ciencia. Debimos avanzar en la historia y encontrar esos ejemplares paradigmáticos. El primero corresponde al trabajo de investigación en fase animal, previa a la realización de la primera gastrectomía exitosa rea lizada en seres humanos por el cirujano alemán Theodor Billroth, en el año 1882. El segundo corres ponde a la investigación en fisiología tiroidea realizada por Emil T. Kocher, con la que ganó el premio Nobel en Medicina y Fisiología en año 1909. Se hace un análisis del desarrollo epistémico de la cirugía a partir de ellos y se evalúan las consecuen cias mediante el concepto de ciclo epistémico. Hipótesis clave para entender la creación del conoci miento científico a partir de disciplinas técnicas como la cirugía.

ABSTRACT Can we talk about science when we speak about surgery? Not, accordingly to classical epistemology. To consider a discipline as scientific, it must meet certain requirements that surgery would not seem to satisfy: being part of a paradigm and creating scientific knowledge. Therefore, if we want to affirm the scientific nature of surgery, we must investigate the existence of exemplars that could be paradigmatic, since they are the ones that support its epistemic structure. Along with this, we must demonstrate that their practice creates scientific knowledge. We've postulated five objectives that surgery had to satisfy. We've seen in classic history, that the main characters which are considered founders of modern surgery -Ambrosio Pare and John Hunter- were only able to reach the first three, and as we'll see, were not enough to consider surgery as part of science. Moving forward in history, we are able to find the first paradigmatic exemplars. The first corresponds to the research work in the animal phase, prior to the first successful human gastrectomy performed by the German surgeon Theodor Billroth, in 1882. The second corresponds to the research in thyroid's physiology carried out by Emil T. Kocher; thanks to this, he won the Nobel Prize in medicine and phy siology in 1909. An analysis of the epistemic development of surgery is made from them, and the consequences are analyzed using the concept of the epistemic cycle. Those key hypotheses are important to understand the creation of scientific knowledge in technical disciplines as surgery.

Professor Monastyrski N.D. (1847-1888): One of the Forgotten Pioneers of Biliary Surgery.

Today, the ingenious and untimely deceased surgeon Monastyrski's name is almost lost in the history of medicine and means little, if anything, to young surgeons. Monastyrski Nestor Dmitrievich was born in 1847 in Czerniowce and graduated from the medical faculty of the University of Vienna. Deeply inspired by the stars of European medicine and surgery: Billroth, Kaposi, Mikulicz, he became a brilliant surgeon and teacher. Monastyrski performed the first gastroenterostomy in Russia and was one of the pioneers of the aseptic method in Russia. In May 1887 he performed the historical first cholecystojejunostomy in the world. In 1888, exhausted by a tumor of the right kidney, Monastyrski insisted on surgery which resulted in his death several hours later. The department of surgery which was founded by Monastyrski N.D. in the Clinical Institute of Grand Duchess Elena Pavlovna (today - North-Western State Medical Academy named after I.I. Mechnikov) was named after him.

[Theodor Billroth: more than a century of artistic greatness]. / Theodor Billroth: más de un siglo de su grandeza artística.

Christian Albert Theodor Billroth, a German surgeon of great artistry and immense culture and promoter of abdominal surgery, who drove the length of the physiology of the surgical field through the use of experimental surgery, is considered the leading German medical figure of the second half of the 19th century in Europe. His works and techniques transcended through time and continue to be implemented (albeit with modifications). He founded a new school of surgery based in criticism, the influence of which affected the development of numerous European and American surgeons. He was also a born artist who excelled in the music field, with many interests in music criticism and public events.

Master of surgery in Archiv für Klinische Chirurgie.

INTRODUCTION: After the routine use of ether narcosis and surgical antisepsis, the evolution of surgery experienced fascinating and genuinely surgical technique-related advancements. Surgeons from Germany contributed strongly to the upturn of operative treatment in the second half of the nineteenth century. DISCUSSION: B. von Langenbeck inaugurated in 1852 an osteosynthese device in a patient with pseudoarthrosis. He is credited to be the very first in introducing the principle of fixateur externe. Th. Billroth performed in 1873 the first extirpation of the larynx in a patient with a malignant tumor. Postoperatively, the patient was cared with an artificial larynx. The first successful resection of the distal stomach inaugurated by Th. Billroth in 1881 was later called the Billroth II procedure. Rydygier from Kulm and Billroth from Wien are the first who successfully performed resection of the lower part of the stomach with anastomosis to the duodenum (Billroth I type of resection). In 1883, Th. Kocher from Bern reported 101 cases of thyroidectomy, the largest single-surgeon experience. L. Rehn from Frankfurt did in 1887 the first successful suturing of a beating heart to repair a large stab wound. A. Braun, Königsberg presented in 1892 his techniques of side-to-side anastomosis of the intestine to avoid a circular intestinal anastomosis. F. Sauerbruch from Breslau published in 1904 his thoracotomy chamber with space for two surgeons opening routine access to intrathoracic tissues protecting pulmonary ventilation during surgery. W. Kausch from Berlin reported in 1912 about three successful pancreatic head resections for peripapillary cancer. The first successful pancreatic head resection was performed in 1909 in a patient with a cancer of the papilla. The patient survived for a long term.

The first successful gastrectomy.

Today, gastrectomy is a routine surgical procedure which any competent abdominal surgeon is expected to be able to perform efficiently and, in a reasonably fit patient, to achieve a speedy and safe recovery. It is worth remembering that the first successful gastrectomy, performed in the late 19th century, was hailed as something of a miracle and opened the way for modern elective abdominal surgery.

Acid secretion after gastric operations.

In the early 20th century, the commonest surgical treatment of peptic ulcer was gastroenterostomy. Crohn and Wilensky demonstrated that this operation did not achieve its aim of markedly reducing gastric acidity or of accelerating motility. These results were highly controversial, but led to Lewisohn visiting Haberer in Austria in 1922, and convincing Dr. A.A. Berg to abandon gastroenterostomy and use partial gastrectomy as the standard ulcer operation, with additional vagotomy in those patients with duodenal ulcer with high acidity. In 1929, a few patients were treated by vagotomy and gastrojejunostomy by Dr. Ralph Colp, with discouraging results. It was only in the 1940s that Mount Sinai surgeons adopted transthoracic or subdiaphragmatic vagotomy and gastroenterostomy (or later, pyloroplasty) as their standard, effective acid-lowering treatment of peptic ulcers.

[100 years of Braun anastomosis]. / 100 Jahre Braun-Anastomose.

Although in his time a well-known and high esteemed surgeon, the data of Heinrich Braun's life are nearly forgotten, but his (now 100 year old) description of enteroanastomosis as a routine addition to gastroenterostomia made his name immortal. The author himself was not too enthusiastic about his idea, because he applied the new technique only to a few patients suffering from inoperable cancer. Apparently he never thought of the possibility nor expected the great success of the combination with the Billroth II operation as it is practised nowadays.

Perspectives a century later on the "Ansa en Y" of César Roux.

During the last 100 years, since César Roux began utilizing his "Ansa-en-Y" procedure for gastric outlet obstruction, the procedure at first fell into disuse but was later adapted for other applications. This article discusses the background of the procedure and compares the original indications with the author's current experience. Current applications in this series were for chronic pancreatitis (26 patients), alkaline gastritis (22 patients), biliary duct obstruction (7 patients), pancreatic pseudocyst (3 patients), and gastric substitution (3 patients).