DANIEL ANDERSEN

I N T E R A C T I O N B E T W E E N T H E O R Y A N D P R A C T I C E

IN T H E S U R G I C A L T R E A T M E N T O F U L C E R D I S E A S E

IN T H E P E R I O D O F 1 8 8 0 - 1 9 2 0

ABSTRACT. Newly developed techniques for anaesthesia and asepsis made it possible for surgeons to attempt operative attacks on diseases which had been previously incurable. The period around the turn of the century is sometimes portrayed as one of very active development of new surgical methods. This activity has been seen as a result of fertile scientific thinking. It is demonstrated in the paper that it was in fact a barren period with a prolonged adherence to an anatomical concept as the basis for problem solving. It is described in terms of Kuhnian periods of normal activity and crisis. It took about fifty years before theory and practice were harmonized under a physiological concept and real progress was made.

1. INTRODUCTION

The interaction between theory and practice in clinical science can advantageously be studied in periods of major change in knowledge and technical potential for development. If theory and practice work together properly, rapid progress in diagnosis and treatment takes place as seen in recent decennia, with the explosive growth in understanding of immunology and the resulting expanding practice of organ trans- plantation. If they are dissociated, even hectic practical activity will be futile. The surgical treatment of ulcer disease of the stomach and the upper part of the small intestine, the duodenum, during a period of about forty years beginning around the turn of the century, can serve as an example of such unfruitful interaction between theory and prac- tice. This may seem surprising since this period generally is considered an example of progress and expansion in the history of surgery.

Let us for a moment look at the scenario at the beginning of the 1880s. Surgeons had experienced a great breakthrough in their working conditions with the advent of anaesthesia and the application of micro- biology in aseptic and antiseptic operative techniques. This paved the way for pioneering treatment of diseases that surgeons had been unable to handle, e.g., diseases of the internal cavities of the body.

The scope of surgery was, however, still limited by a lack of under- standing of fluid therapy and respiratory function, and by the inability

Synthese 89: 63-73, 1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

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to perform blood transfusions. These deficiencies led to high mortality rates and produced a considerable amount of heroism among surgeons.

Anatomy was the predominant subject in the preclinical curriculum for medical students, while knowledge in physiology and biochemistry was scant. Pathoanatomy was an expanding area allowing the classifica- tion of many diseases in terms of macro- or microscopical derangement. It became a dominant view that non-infectious somatic disease was a manifestation of an abnormal or deranged anatomy, and that the pur- pose of surgery was to correct an abnormal anatomy or construct ana- tomic solutions to compensate for a deranged anatomy.

One could talk about a predominant anatomical concept within which surgery was practiced and developed in a kind of Kuhnian normal activity (Kuhn 1970). If an operation was unsuccessful, explanations for the defeat were sought in the surgical technique, and improvements were aimed at optimizing the mechanical function of the anatomical construction. The modem view that surgery should improve physiologi- cal function and that mechanical means must be subordinated to this goal had not been born yet.

Together, these conditions and views resulted in a therapeutic opti- mism, a pioneering spirit and a reliance on surgical correction of pa- thoanatomical abnormalities as a panacea.

2. T R E A T M E N T O F G A S T R I C C A N C E R

The pioneering achievement of the Viennese surgeon Theodore Billroth brought the fateful disease, gastric cancer, into the realm of surgery. He had realized that the pathological lesion often would occlude the gastric outlet (Figure 1), preventing the transmission of food to the small intestine, with unrelenting vomiting and nutritional depletion as results. He demonstrated (Billroth 1881) that the lesion could some- times be removed by a gastric resection. Frequently, however, the tumor was unresectable. In this case some palliation could be obtained, as shown by Billroth's assistant Anton WOlfler (WOlfler 1881), through construction of a by-pass between stomach and the upper small intestine (Figure 1). This operation did not cure the patient, but it afforded dramatic temporary relief from vomiting and allowed the patient to eat again. The by-pass was called a gastro-entero-anastomosis (abbreviated as GEA).

S U R G I C A L T R E A T M E N T OF U L C E R D I S E A S E 65

Fig. 1. A gastro-entero-anastomosis (GEA) . (b) has been constructed in order to relieve the obstruction created by a malignant tumor at the gastric outlet (a),

3. T R E A T M E N T OF O B S T R U C T I N G U L C E R S A T T H E

G A S T R I C O U T L E T

Ulcers in the lower part of the stomach or the upper part of the small intestine were known as frequent causes of gastric outlet obstruction (Figure 2). It was thought natural to treat this kind of narrowness with the same treatment method (a GEA) used for a cancerous obstruction. The similarity in anatomic location and functional result appealed to the general propensity for the confinement of problem-solving to ana- tomical concepts.

Temporary success was achieved. The original ulcer healed and ob- struction was relieved. Two problems, however, became apparent (for a review, see Roed-Petersen 1986). First, many patients after an interval varying from a few months to several years, got a new ulcer (though not in the original location but, rather, in the GEA), a so-called anasto- motic ulcer. Second, there were malfunctions of the by-pass. Besides allowing food to pass into the intestine, it also allowed bile and other intestinal secretions to take the reverse route into the stomach, resulting in bilious vomiting, which is discomforting and sometimes life threat-

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Fig. 2. Obstruction at the gastric outlet by a benign ulcer (arrow).

ening. These problems could not readily be explained within an anatom- ical concept.

4. T R E A T M E N T OF N O N - O B S T R U C T I N G U L C E R S

The immediate success of the GEA in the alleviation of ulcer-associated obstruction and the observation that it also frequently relieved the ulcer pains led to the extension of this procedure to treat patients with non- obstructing but painful ulcers. The rationale behind this was that the healing of the ulcer and the relief of the symptoms could be attributed to a protection of the ulcer-bearing area from mechanical irritation by the passage of food (Roed-Petersen 1986). This hypothesis was not absolutely unreasonable, but it was unfounded in any experimental evidence. It was a conjecture fitting well into the anatomic concept of the time, pointing as it did to an anatomical solution to the problem.

The widening of the indications for the GEA, from a restricted use for terminal cancers and obstructing ulcers to a generalized use for uncomplicated cases of a benign and very common disease, made the aforementioned problems with recurrent ulcer and bilious vomiting clearly visible. Not only were very many patients operated on, but suffering from a benign disease, they had plenty of time to experience all sorts of complications.

SURGICAL TREATMENT OF ULCER DISEASE 67

5. PROBLEM SOLVING

In accordance with the anatomical concept prevailing in surgical think- ing, an enormous attempt was initiated to solve the problems by ana- tomical means. This can be seen as a period of Kuhnian normal clinical science. Surgeons speculated about what could possibly be wrong with the construction of the by-pass (Petersen 1901). Numerous hypotheses were tested in smaller and larger series of patients in the following years.

Fig. 3. A GEA with the intestinal loop placed in front of the transverse part of the large intestine.

In order to facilitate the emptying of the stomach with the least possible mechanical irritation and best possible assurance of appropriate direction of the flow, attempts were made to position the anastomotic intestinal loop in one direction or the other (Figure 3 vs. Figure 4), and to place the loop in front of the large intestine or behind it to the back of the stomach (Figures 3 and 4 vs. Figure 5). Also, very long or very short loops were constructed.

Between 1881 and 1917, fifty-two modifications of the GEA were devised (Table I) without any real success. The patients went on vomit- ing bile and having recurring ulcers. The puzzle was developing into a Kuhnian anomaly. A proliferation of conjecture took place. A special ulcer diathesis in some patients was postulated (Eiselsberg 1914), and a chronic inflammation of the tonsils, teeth and appendix was suspected

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Fig. 4. A GEA with the intestinal loop placed in front of the transverse part of the large intestine, but with the flow direction opposite to that in Fig. 3.

xZ2y-'-"r Fig. 5. A GEA with the intestinal loop placed behind the transverse part of the large

intestine and opening into the back side of the stomach.

S U R G I C A L T R E A T M E N T OF U L C E R D ISE A SE 69

TABLE I The number of modifications of gastro-entero-anastomosis (GEA) during various time

intervals.

1881-89 1890-99 1900-09 1910-19

10 30 8 4

(Roed-Petersen 1986)

to cause decreased resistance in the gastrointestinal mucosa (Moynihan 1919). Many tonsils and appendices were removed on this account.

A dramatic development in the history of the GEA took place when the renowned surgeon Anton von Eiselsberg (Eiselsberg 1895) carried the principle of protecting the ulcer area against mechanical irritation to its extreme by his so-called exclusion-operation (Figure 6). He con- structed an impenetrable barrier between the digestive stream and the ulcer area at the gastric outlet by the transsection of the stomach and positioning of the GEA in the upper segment of the stomach.

The result was, however, disastrous. The primary ulcer healed as

Fig. 6. Eiselsberg's exclusion operation with the GEA placed in the upper segment of the transsected stomach.

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expected, but the patients developed recurrent ulcers in the GEA rapidly - often within a few weeks of the operation - and dramatically as well - often with perforations and bleeding. Instead of being an improvement over the simple GEA, the exclusion proved far worse.

This discovery was quite unsuspected. The course of events could not be understood within the anatomical concept, but it was so impor- tant that it could not be dismissed as a trivial occurrence. With the knowledge we have today, we can easily explain it in terms of disturbed physiological feeding-back mechanisms in the regulation of acid produc- tion in the stomach. This kind of reasoning was, however, remote from the lines of thinking among clinical scientists at the time.

6. T H E A N A T O M I C A L C O N C E P T I N C R I S I S

After the sad experience with the von Eiselsberg operation, the anatom- ical concept was in obvious crisis. No known complementary hypotheses could explain the events within the anatomical concept. The whole question of ulcer pathogenesis had to be reconsidered.

Surgeons started to look into the physiologists' laboratories. Gradu- ally the anatomical concept gave way to a physiological concept, seeking explanations for ulcer development in acid production and anomalous stimulations of acid secretion, and for bilious vomiting in disturbances in gastro-intestinal motility patterns. Surgical methods based on this theoretical ground gained territory, and acid-reducing gastric resections and nervous transsections, so-called vagotomies, became dominant and successful techniques (even to this day). Thus, physiological methods, to a considerable degree, replaced anatomical methods as treatment for ulcer disease.

7. P A R A L L E L R E S E A R C H I N E X P E R I M E N T A L L A B O R A T O R I E S

It is ironic that during the feverish activity in the prolonged period of normal scientific endeavor and the crisis, much experimental work took place in physiological laboratories which could have put things right much earlier, if the results had been known to the surgeons or if surgeons' experiences had been known to physiologists.

Ivan Petrovich Pavlov performed his famous experiments in the 1890s proving that the acid secretion of the stomach was partially under nervous control. It was found (Edkins 1906) that acid secretion was

S U R G I C A L T R E A T M E N T O F U L C E R D I S E A S E 71

also under hormonal influence. Experiments were performed (Exalto 1911) on dogs proving the extreme ulcer liability after operations. These experiments were very similar to von Eiselsberg's operation of exclusion at a time when von Eiselsberg continued to recommend his method (Eiselsberg 1914).

This information should have been sufficient to convince surgeons that the anatomical concept was inadequate for the design of thera- peutic strategies in ulcer disease.

Experimental work was also done in these years (Latarjet 1922) with the design of operative methods for selective section of nerve branches to the stomach, a so-called selective gastric vagotomy, in order to reduce acid secretion. This method is used with success today when operative treatment of ulcers is deemed necessary. In the days of the anatomical concept, such radically new thoughts were suppressed. It was not until the 1960s that vagotomy came into general use.

8 . R E A S O N S F O R T H E L O N G E V I T Y O F T H E A N A T O M I C A L

C O N C E P T S

It was quite understandable that mechanical solutions were sought to surgical problems in 1881, but why did it take more than fifty years for the full impact of what had happened to be realized and the anatomical concept to be abandoned among surgeons in general? Several reasons can be given.

First, it took many years to learn how bad the results of surgery were. Surgeons did not regularly re-examine their patients. When the anatomical abnormality was corrected it did not occur to them that the cure was not permanent. Their experience with failures was casuistic and, therefore, they did not become aware of the real frequency. Even the catastrophic results of the von Eiselsberg procedure went unnoticed for many years (Eiselsberg 1914). Only gradually did experience weigh against the procedure so to undermine its practical applications.

Second, there is the general issue of authority. When a central Euro- pean chief of a surgical clinic performed an operation, it was no less than sacrilege to doubt its permanent beneficial effect. The climate was probably not much different in Anglo-Saxon clinics. When patients complaints occasionally became known, they were interpreted as any- thing but a recurrent ulcer. Concepts and authority were thus preserved.

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When failures became obvious, belief in anatomical solutions was sus- tained by complementary hypotheses.

Third, there is the scientific isolation in which surgical techniques developed. Surgeons worked in their own world without cooperation with other scientific disciplines, i.e., surgeons were unaware of the work in the physiological laboratories and vice versa. Instead of reconsidering the basic concepts of their work, surgeons tried to overcome the prob- lems by methodological modifications within their narrow concepts. A stubborn adherence to anatomy was combined with an excess of enthusiasm about the favorite techniques to such a degree that all evidence speaking against them was denied, explained away or sup- pressed. Very small differences in the construction of the GEA were considered decisive, and the surgeons who invented the modifications had a quite unrealistic confidence in their contribution to the solution of the problems (Mayo 1906; Moynihan 1908).

The resulting inventive activity might seem to testify to scientific fertility. What we observe, however, bears testimony to a confusion, a bewildered search by the method of trial and error.

Gradually the GEA was given up and replaced by methods which were founded on the growing understanding of the important role played by acid secretion for the development of ulcer disease. Anatomy was replaced by physiology as basis for therapeutic invention.

9. L E S S O N S F R O M T H E P A S T

Trial and error studies with patients who were not informed about the experimental nature of their treatment have been replaced by an orderly sequence of studies beginning with animal studies, pilot studies in a few consenting patients, and controlled, randomized studies with care- ful follow-ups over a relevant time period.

The paternalism which dominated surgical clinics until after the middle of this century has been replaced by a respect for patients' autonomy. Patients are not exposed to new treatments unless they can be presented with a rationale for such treatment and unless there is a reasonable prospect of beneficence. Also, a multidisciplinary approach has become the rule when new treatment modalities are contemplated and attempted.

These conditions should ensure that forthcoming crises in scientific concepts will be addressed much earlier, and new concepts formed

S U R G I C A L T R E A T M E N T OF ULCER DISEASE 73

without such long delays as in the past. In other words, they should make the interaction between theory and practice more harmonic and fertile.

A C K N O W L E D G E M E N T

I am indebted to Dr. Karsten Roed-Petersen for permission to repro- duce Figures 1, 3, 4 and 5 from his vivid and thorough thesis on the history of gastro-entero-anastomosis.

R E F E R E N C E S

Billroth, T.: 1881, 'Offenes Schreiben an Herrn Dr. L. Wittelsh6fer', Wiener Medizinische Wochenschrift 31, 162-66.

Edkins, J. S.: 1906, 'The Chemical Mechanism of Gastric Secretion', Journal of Physiol- ogy 34, 133-44.

Eiselsberg, A.: 1895, 'Ueber Ausschaltung inoperabler Pylorus-Stricturen nebst Bemer- kungen tiber die Jejunostomie', Archiv fur klinische Chirurgie 50, 919-39.

Eiselsberg, A.: 1914, 'The Choice of the Method of Operation in the Treatment of Gastric and Duodenal Ulcers', Surgery, Gynecology and Obstetrics 19, 555-63.

Exalto, J.: 1911, 'Ulcus jejuni nach Gastroenterostomie', Mitteilungen aus den Grenzge- bieten der Medizin und Chirurgie 23, 13-41.

Kuhn, Thomas S.: 1970, The Structure of Scientific Revolutions, University of Chicago Press, Chicago.

Latarjet, A.: 1922, 'Resection des nerfs de L'Estomac: technique operatoire', Bulletin de l'Acaddmie Nationale de Medicine (Paris) 87, 681-91.

Mayo, W. J.: 1906, 'The Technique of Gastrojejunostomy', Annals of Surgery 43, 537- 42.

Moynihan, B. G, A.: 1908, 'The Direction of the Jejunum in the Operation of Gastro- enterostomy', Annals of Surgery 47, 481-85.

Moynihan, B.: 1919, 'Disappointments after Gastro-enterostomy', British Medical Jour- nal 2, 33-36.

Petersen, W.: 1901, 'Anatomische und chirurgische Beitr~ige zur Gastro-Enterostomie', Beitriige zur klinische Chirurgie 29, 597-616.

Roed-Petersen, Karsten: 1986, Gastro-jejuno-stomiens historie, Odense Universitets- forlag, Odense (Danish with an English summary).

WNfler, A.: 1881, 'Gastro-Enterostomie', Centralblatt far Chirurgie 8, 705-08.

Dept. of Surgical Gastroenterology University Hospital of Odense DK-5000 Odense C Denmark