René Leriche, Philosophy of Surgery. 1951
Book we came across after reading Gregorio Marañón in his work Vocación y Ética. René is a leading figure of what would become “scientific surgery” and is clearly a humanist, as can be seen from his numerous essays that compile reflections on human nature, ethics, and the practice of surgery. I felt compelled to share this fragment and I believe the book (which is very hard to find) is highly recommended reading for surgeons in any field. Even though there is a significant gap in time, it should not be difficult to find parallels with contemporary practice and experience.
Edited Selection from the Introduction to Philosophy of Surgery
Excerpted and summarized from the book La philosophie de la chirurgie (chapter: Introduction) by René Leriche, published in 1951 1 2.
The Advancement of Surgery, Its Art, and Its Human Value
(…) Only a few years ago, it still seemed to us that the course of surgery was laid out in a straight line. Its progress could only continue by following the same principle. And now our means of investigation have gone beyond our ability to comprehend. We can no longer see clearly. Everything has become so complicated in biology that, confronted with the human being, one no longer dares to think synthetically; we lose ourselves in partial—though necessary—analyses, which obscure problems instead of clarifying them. (…)
Nonetheless, surgery currently rests on certainties it has never before possessed. In reality, the surgical pathology problems that we once deemed simple, in those halcyon days of the Pasteurian era, today appear terribly complex, involving numerous hereditary, psychological, nervous, vascular, endocrine, and allergic factors. (…)
This leads us to believe that the underpinnings of our pathology are less straightforward than we once thought. We have yet to achieve a complete understanding of the individual in his or her physical existence. Clinical practice, therefore, is also steeped in uncertainty and, I would say, in a provisional state.
We must take advantage of this physiological oversight, and my aim remains to examine the two problems at the root of a philosophy of surgery: the problem of knowledge and the problem of action, because to know and to act are the very fabric of the work of our hands.
It may have seemed, at a certain time, that this manual endeavor was sufficient in itself, with ever more standardized gestures refined through extensive training. Even today, one might think that as its sphere of influence widens, surgery is increasingly ruled by techniques. These are so numerous and demanding that they lead to the fragmentation into specialties, almost hermetic to one another, to the point where surgery as a whole might be reduced to a code of techniques. The impression produced by this apparent evolution is reinforced by an encroaching trend to replace clinical judgment with anonymous and encoded tests intended to provide an exact measure of disease levels and human worth: the pursuit of numbers, the supreme goal of all science.
X-ray imaging had already gone a long way toward replacing the vagueness of older clinical impressions with a more precise and impersonal vision. And it had a favorable outcome. Today, the individual’s chemical profile, curves, graphs, and numerical data all tend to banish the intuitive sense of good or bad risk—an assessment once mistakenly labeled “subjective,” when in fact it was the synthesis of many small objective notes. We can already glimpse the time when the most serious decisions may be made and carried out without the practitioner ever having any prior contact with the patient.
No one would deny that such a systematic examination represents immense progress and that it has improved our statistics. Yet I cannot help thinking that when surgery becomes impersonal, it will lose a great deal of its human value.
The person we operate on is not a mere physiological mechanism. He thinks, he fears; his very structure trembles unless consoled by a sympathetic gaze. Nothing could replace, for him, the soothing contact of his surgeon, the exchange of looks, or the sensation that someone is taking charge with at least the apparent certainty of success. These are imponderable elements that we have no right to sacrifice.
A being with emotions as well as flesh, a human being needs to be understood and supported in his fears. I strongly doubt that confidence in the excellence of an impersonal organization dedicated to tests can bring about the calm offered by the cool hand of a caregiver on warm skin. Moreover, no matter how greatly I trust numerical data, I still regard as precious the intuition of someone who, by virtue of experience, instantly perceives the gradual values that numbers express so bluntly.
Thus, while we take into account the useful data that contemporary research provides, we must not lose sight of the fact that surgery is a discipline far more elevated than what some would reduce it to.
It would be a regrettable mistake to focus only on appearances.
No one has better defined what surgery should be than Xavier Bichat. In the handwritten notes he drafted at the Hôtel-Dieu, in Desault’s ward around 1795, he wrote:
“An operation is, according to the usual definition, the methodical application of the hand, alone or aided by an instrument, on certain parts in order to produce in them a salutary effect. Seen in this light, surgery would have very limited scope and offer us less a science to be cultivated than a trade to be practiced; and more laborers than artists, we would become mere tools guided by routine.
The art of operating can, to some extent, be acquired by habit; skill adds a certain polish, and anyone can achieve it in a relatively short time. But the art of operating at the right moment, of knowing which cases call for an operation and which require abstention, of identifying the proper time and means to perform such operations, the circumstances influencing their success or failure, the many varied modifications resulting from the countless circumstances that accompany them and the means to lessen their burdensome effects—this is the surgeon’s difficult art: that which constitutes the science; the rest is merely a trade.
A course on operating, then, is not simply a compilation on how to handle instruments. In that sense, surgery is vast, embracing all of medicine’s great principles, or rather sharing them, for the art of healing is a trunk of which medicine and surgery are branches; those branches intertwine everywhere, blending into each other.”
The Knowledge of Surgical Disciplines
The men who shaped surgery into what it has become—who fostered the regional developments that today are pursued as specialties—did not do so purely out of manual concerns.
They were not pressured by technical requirements to specialize. Instead, they were impelled by a vivid sense of the difficulties they encountered while determining how to apply their procedures. They had to discover on their own both the local and general consequences of the disease they dealt with, learn to identify lesions, guess their significance, and above all define the physiological setting in which they had to operate.
(…) Harvey Cushing wrote in 1913, at the International Congress in London:
“There was a time, not long ago, when a surgeon, relying solely on a neurologist’s diagnosis, made reckless attempts at a type of surgery for which he was unprepared. This combination of the physician-as-brain and the surgeon-as-instrument was a serious mistake. Such pairings have always led to significant failures. Great advances were not possible until the day that surgical neurology was undertaken by people with a genuine interest in it and sufficient knowledge of the nervous system and its disorders (…). In other words, surgery did not advance quickly until physicians with a physiological understanding began to practice their own brand of surgery. (…)”
Among these deliberate achievements of modern surgery, it was the physiopathological contribution that drove its progress, not technical advances. Undoubtedly, specialization refined technique, making it more precise, easier, and better suited. It achieved the effect of having the specialist convey the impression of a flawless job—a true work of art—but it was not the deciding factor in how surgery was created.
Technique, ultimately, is governed by the demands of knowledge, by a need—an appetite—for understanding that unfortunately ends up consuming the specialist. Forever on the front lines, he finds himself out of breath chasing unending discoveries that refine, modify, and enrich what he once believed to be definitively known. Like a modern Sisyphus, even the most self-possessed surgeon can never stop. If he slackens his efforts, he is immediately overtaken and becomes inadequate to his task. (…)
Sometimes, to describe a surgeon’s style, it is said that he is merely a pure technician, as though he were just a pair of hands (…). This view is somewhat artificial. The truly brilliant technician is the one who has previously considered all the myriad aspects of the pathology to which he applies his talent; who knows how to assess the real state of the lesions at a single, swift, and sure glance; and who, thanks to his extensive experience, avoids obstacles and circumvents difficulties. The so-called pure technician is, in truth, a highly cautious individual with a considerable level of prior knowledge, yet who adopts a certain modesty to hide the lessons of a long apprenticeship. (…)
For us, the era of the condottiero surgeon is over. That is, nobody operates (or should operate) without knowing everything pertaining to the patient and the illness. There is no surgeon without an immense body of knowledge, which is why studying the paths and methods of a science that continues to take shape every day can be beneficial.
Referencias
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Leriche, René La philosophie de la chirurgie. Paris: Flammarion, 1951 ↩
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Leriche, René, translated by Julio Gómez de la Serna. Filosofía de la cirugía. Madrid: Colenda, 1951 ↩