Behind and beyond surgery

Dear reader,

Welcome to this issue of European Surgery, which includes a fascinating spectrum of papers. Outstanding groups of authors report on the surgery of inflammatory bowel disease of the colon, perioperative nutritional management before bariatric surgery, oxidative stress and angiogenesis during primary hyperparathyroidism, the impact of combined carcinoembryonic antigen (CEA) and fecal occult blood test for early cancer detection, the outcome after caudate resection for liver tumors and the role of ultrasound examination after kidney transplantation. A case report describes the feasibility of the two 5 mm trocar appendectomy. Taken together, European Surgery provides a round up of “hot spots” of diagnosis and therapy in general, endocrine, bariatric, colorectal, minimally invasive, and transplant surgery. Thus, I hope that you share my enthusiasm for the papers. If you find time for “essential” topics beyond surgery, medicine, and life, you may continue reading, otherwise you may skip the pages or return to this editorial in the future.

This editorial represents part II, i. e., last part, of the two volume attempt of the author to look behind and beyond surgery. The present article aims to outline a new concept regarding the understanding of a well-recognized, common pathogenesis and cause of almost all diseases. Interpretation of the patient histories, metabolic parameters (blood test data), the data obtained by metabolic imaging including PET MRI and PET CT scans, and recent experimental in vitro and in vivo studies reveal that the lack of energy drives the orchestration of disease. Based on the ancient Greek word “limos,” which translates into the English “lack, deficiency,” the phenomena underlying the disease are verbalized using the term “lack-limos” and “lack-limos state of energy” (=energy lack/deficiency). Limology represents a new discipline which examines, analyses, and treats phenomena as forms of deficiency. Diagnosis and treatment includes semiotics and outbalanced remedy of deficiencies, respectively. The necessity, relevance, and actuality of the topics presented within this editorial justify its length.

Brief summary of part I

In the recent issue of European Surgery, part I of the considerations entitled Behind and beyond surgery. Part I: world for happy times [1] showed that reasoning/thinking is not the cause for our perceptions. In contrast, perceptions from the “inner” and “outer” world are tuned (color, sound, sensation, taste, smell) and happen during reasoning and they happen against the background of our respective atmosphere, and stream of emotion. Essentially, knowledge in surgery and elsewhere equals the interpretation of states of emotion and atmosphere. The “inner” and “outer” world (the truth) includes what we can perceive (reality), what we suspect (possibilities), and what we are not aware of (the so-called “nothing”). If you ask yourself: what is now? You may answer: being, emotion, atmosphere, stream, and state of mood. Thus, you come to the conclusion: the essence of our existence is “being,” “being” is my current atmosphere and state of mood. Taken together, emotion decides on the interpretation of perceptions and atmosphere. Consequently, positive atmosphere will improve the outcome of surgery and other types of activities, cares, and projects (i. e., Pink Floyd orchestrated 50 years behind the dark side of the moon). Therefore, clever team leaders and designers of medical and other institutions will foster actions to provoke the maintenance of a positive, productive multidisciplinary atmosphere for their employees. All life is energy and assessed in the form of the interpretation of emotion (happiness, fear, anxiety, sorrow, believe, security). Man lives emotion and exists as being in tune. Outbalanced lifestyle discipline (healthy nutrition, sports, mental coaching) fosters success and superiority vs. others (Fig. 1). Finally, we found that the ancient concepts of physics, ethics, and logics are replaced by “computer technology,” “economy,” and “semiotics,” respectively. Surgery may also cut through unmeasurable energy. Therefore, let us go for a brief short cut through linguistic history, intraphysics and the essentials in surgery.

Fig. 1

Limos (Greek = deficiency, lack, hunger) of energy represents the cause for disease and may lead to metabolic, emotional, and physical stress. Therapy includes remedy by nutritional, mental, and physical outbalance, as described in the text. Discipline fosters success

Summary of the history “essentials in surgery”

Human reasoning applies different terms for the description of the unmeasurable energy which resides within the objects (Latin: ob-jectum = thrown against “perceptions”): we “know” of “soul,” “spirit,” “consciousness” and model it against the background of space and time. Conceptually, time is modeled as infinite, cyclical, or periodical. As a matter of fact, intraphysics are beyond our perception, express as emotion and define the “all, which knows you.” Intraphysics describe the atmosphere of a specific emotional horizon, which only manifests in short moments, where you are allowed to be–feel–think yourself and no-thing-else: the window (old German/Gothic wind auga = wind eye), through which blows the marvelous stream and cosmic brilliance of the being. Around intraphysics exist visible, measurable physics and their justification, i. e., metaphysics [1].

“Essentials” are terms which serve to describe states of affairs which are essential for the explanation, understanding, and maintenance of the existence of man. “Essentials” are pictured within myths and mirror “being,” “after-life,” “eternity,” “emotion,” “space,” “time,” and cosmic phenomena (gods, snakes, thunderstorms, lightning). Since ancient times man created “essentials,” which have been passed down to our present world. “Essentials” are legacies and harbor a spectrum of “meanings” and verbalize the full horizon of our existence against the background of emotion and atmosphere. The time line of those “essentials” speaks of gods and cosmic images: a‑ton (old Egypt; sun god); adonis (Greek: lord, sir); adonai (Hebrew: lord, god); e‑on (Greek: being, existence); on (Greek: being); einai (Greek: being, existence); Anna and Johannes/Ioannes/Anu (old Sumerian fish-woman/man, interestingly related to the a-ton of the old Egyptians; e‑on, einai of the ancient Greeks). For at least 1500 years the land of the origin of the ancient Greeks, i. e., the Levante, has been under the intensive cultural, economic, and political influence of Egypt during the periods of the old, middle, and new kingdom (appoximately 2500–1000 B.C.). May it be allowed to speculate that the ancient Egyptian term “a-ton” (sun god = “being”) gave the ground for the ancient Greek e‑on, on, einai (being, existence), noein (perceive, sense, recognize, assess), which in turn gave rise to the English term “know”? May it be just by chance that the “noein” appears in one of the most important ancient Greek sayings, where Parmenides (about 460 B.C.), within his didactic poem, states that “noein” and being are the same? May it be allowed to speculate that terms of our present time, i. e., hil-ton, sher-aton, contain the trace of a linguistic time capsule, which serves to remember the legacies of very ancient times (more than 3000–4000 years B.C.)? As thus “knowledge” may translate into the wonderful balance between theory (being) and praxis (our existence).

The “essentials” in surgery include the understanding and knowledge of surgical anatomy (“right layers and planes”), histopathology, pathophysiology, and psychology. Learning and teaching offer the maintenance of the “essentials.” Without the open minded discipline for continuous learning of the “essentials,” any surgery becomes a dangerous disaster, which most likely will serve for the feed of the graveyard (i. e., the population circulating above the downhill slope of the Kaplan–Meier estimator curve).

Web-based surgery

The internet rules, dominates, designs, and creates the medical sciences. Most of the web-based knowledge, as provided by the internet (PubMed, Scopus, Google, Yahoo, Facebook, Twitter, etc.) repeats the opinion of experts. Frequently, at least in part, but not always, the interpretation of the clinical and experimental studies follows the opinion of the experts and is published if the studies “please,” i. e., support the expert opinion. This opinion is powered by the dominance of the public view. Over time this opinion becomes the accepted state of affairs and, thus, commences to become knowledge and “truth.” Today the benefits of web-based surgery are essential for e‑learning and education, telemedicine, and health care. It remains to be questioned how to balance the fruits of the loom: the pros and cons?

Embryology creates surgical anatomy

Any unpleasant truth originating from a minority has to undergo hard times before getting accepted by the community. Furthermore, medical diagnosis and treatment concepts, which require endurance and discipline, are unpopular and thus will get rejected by the public view. To be honest, I would recommend to re-examine the surgical anatomy of the pancreas, liver, thyroid, colon, rectum, and the esophagus. Most surgeons have forgotten their embryology and histopathology lessons. However, embryology creates the anatomical “reality” during health and disease. Therefore, the “embryological” understanding of the correct anatomical plains, layers, and folds will profoundly add to improve surgical oncology and cancer prevention (lower pelvis, diaphragmatic hiatus, unfolded lobes of the liver along the bile to the papilla axis, polyfoliated structuring of the pancreas). During the upcoming annual congress of the Austrian Surgical Society, June 28–30, 2017 in Vienna (Prof. Windhager; President; Prof. Tuchmann; General Secretary), the US surgeon Prof. Tom DeMeester and the US pathologist Prof. Parakrama Chandrasoma will present a splendid example of the above considerations. They and others will demonstrate that for a long period of time surgeons and gastroenterologists have managed gastroesophageal reflux disease (GERD, i. e., esophagitis gastrica ± symptoms, esophagopathia gastrica ± symptoms ± cancer risk) and Barrett‘s esophagus (cancer risk-positive esophagitis gastrica, esophagopathia gastrica), against the background of a “false” and “unfounded” understanding of the anatomy and physiology of the upper gastrointestinal tract. At least in part, this fact seems to be responsible for the inadequate recognition of reflux-related cancer risk and the increase of reflux-associated esophageal cancer within the last 25 years in the USA, Europe, and other Western civilizations. Lack of attention fosters disease.

Lack-limos concept: the unique cause for disease

Disease indicates impairment of life quality and productivity due to symptoms (pain, depression, anxiety, sleeping disorder, hypertension, headache, migraine, arthritis, diarrhea, constipation, etc.) and/or tumor/cancer development. If you, as a surgeon, accurately and adequately take your time to listen to the patient history, the patient will tell you the cause for her or his disease. Adequate interpretation of the description of the patient history, the symptoms, and the clinical data aims to reveal the common underlying cause. Therefore listen to the story of the patients. They report that they feel tired, weak, depressed, feel pain, and discomfort within their body. In addition, they frequently report that the symptoms aggravate after, but not during the consumption of a meal. They report that the symptoms commence and increase during episodes of hunger, psychological, mental, emotional, and physical stress. May it be just by chance that strokes, heart attacks, migraine, and hypertensive episodes most likely develop during the early morning hours of a day, following a 6–12 h fasting period? May it be just by chance that gastric pain, symptoms of irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD; i. e., esophagitis gastrica, esophagopathia gastrica) resolve during eating and return 30–60 min after a meal? May it be just by chance that migraine attacks are preceded by an episode of hunger and ravenous appetite, i. e., the sign for energy deficiency? Again the ancient Greeks seemed to have adequately sensed the reason and cause for these phenomena.

Limos: a legacy from the ancient world

Within the Theogony, Hesiod (700 B.C.) recognized two reasons for distress, sorrow and pain: limos and lethe. The ancient Greek term limos indicates hunger, deprivation, deficiency, lack, and absence of something that should be present. The ancient Greek term lethe speaks of oblivion. Therefore, the terms limos and lethe seem to remember a highly important and significant legacy from a very ancient world: the lack-limos of energy (hunger) and lack-limos of knowledge (oblivion) seem to orchestrate the development of a disease. Going in line with the above-mentioned information obtained by the patient history, disease represents the manifestation of a lack-limos state of being. Lack-limos is the ground and cause for a disease. Next we have to assess the forms and types of lack-limos, which lead to the manifestation of a disease. Disease is the manifestation of an underlying lack-limos state of energy (lack of energy state; deficiency, deficit). The composite term lack-limos aims to remember the ancient legacy of the concept.

Causes for energy deficiency/deficit

Energy can be offered to a person by energy carriers including solid, liquid, fluid, gaseous food (nutrition, taste), air (ventilation, breath, oxygen, smell), acoustics (sound), tactile sensing (caress), and emotion (care, love, hate, greed, envy). Energies are processed in the form of metabolism (i. e., what happens after the bolus; i. e., after swallowing). Conceptually, three main causes may induce a lack-limos state of energy following the administration of energy (Figs. 1 and 2):

• 1. The body harbors an energy consumer (tumor, polyp, inflammation, emotional and physical stress), which consumes more energy than the normal tissue and, thus, fosters a lack-limos state of energy in the normal tissue.

• 2. The offered energy (food) is inadequate, does not meet the requirements, and/or induces a metabolic response, which in turn favors the development of the lack-limos state of energy.

• 3. Episodes of fasting foster energy deficiency (hunger).

Fig. 2

Pathogenesis of disease. Hunger (absence of food), food (concentrated sugar), and/or the presence of an energy consumer (*) including polyps, tumors, inflammation; psychological (emotional), physical stress induce a psycho-physical-metabolic stress, which in turn causes a lack of energy state, as described in the text. Involving immune, nerve, and epithelial cells, the lack of energy state is sensed by those cells and induces a neurohumoral flush response, which orchestrates disease, cancer, and the impairment of life quality and productivity, as outlined in the text. This algorithm follows the principles of surgical limology, as described in the text. Note: Limologically, disease unfolds as a response to the lack of energy (limos)

All three causes (energy consumer, presence of the “wrong food,” absence of food = hunger) may exist alone or in concert and induce the emptying of the body battery and the maintenance of the lack-limos state of energy. Taken together, the lack-limos state of energy may be due to an energy consumer (tumor, inflammation, emotional, physical stress) and/or the dysfunction of the metabolism. Next, we have to examine the consequence of the lack-limos state of energy for diagnosis and therapy.

Pathogenesis of lack-limos and disease

It all starts with the nerve cells (perception, sensing, emotion, world, thinking, reasoning). The lack-limos state of energy activates nerve cells. Embryology teaches that nerve cells originate from the ecto-ento-dermal germ cell layer, which gives rise to the outer and inner skin and the brain and the nerve cells connecting the inner and outer skin and the brain. Due to their function (mechanical, acoustical, optical, biochemical signal transduction), nerve cells are polarized cells and may grow in the form of trees with roots and branches or in the form a cigarette pack, when they cover the inner or outer surface of the body, i. e., epithelial cells. Polarization is essential for the processing of information and the maintenance of signal transduction and communication. One part of the nerve cell works for the acquisition of biochemical information (receiver part); the other part works for the release of biochemical information to other, adjacent cells (epithelial cells, nerve cells, immune cells, bacteria within the gut lumen, food compounds). Thus, nerve cells generate and transform information. Due to the polarization, epithelial cells (pancreas, liver, gut, thyroid, adrenals, etc.) harbor a basolateral and an apical cell membrane, which are connected by the so-called belt of tight junctions, connecting and anchoring the cell membranes of neighboring cells. Basolaterally epithelial cells are anchored to the basement membrane (basal lamina). Cerebral or peripheral nerve cells harbor a root part for data acquisition and a sending part for the release of biochemical information (transmitter part). Taken together, nerve cells represent the functional basis for perception, recognition, attention, and reasoning, as described in part I of the attempt [1]. Now let us examine how nerve cells respond to the lack-limos state of energy.

Energy deficiency-induced neurohumoral flush

Food contains energy carriers including oxygen, water, ions, vitamins, proteins, sugars, fiber. Nerve cells sense the absence, lack or deficiency of energy carriers. The lack or absence of energy carriers induces a nerve cell response. Due to the lack-limos state of energy, the nerve cell becomes “activated” and releases nerve cell transmitter proteins and ions including substance P, vasoactive intestinal peptide, histamine, serotonin, neurotensin, growth factors and thyroid, adrenal, sexual hormones, etc. The nerve cell-released mediators orchestrate a neurohumoral flush response within a tissue (Fig. 2). In addition to the local effects of a neurohumoral flush, we know of long-distance communication within the human being. Via the blood stream the neurohumoral flush can be taken to distant organs and tissues (i. e., from the thyroid, adrenals, ovaries, scrotum to the skin, gut, liver, brain, and bones; from the pancreas to the liver and lungs; neuroendocrine tumor concept). Interestingly the same neurohumoral routes are taken during the formation of cancer metastasis (vascular, lymphatic vessels, and nerve cells). The genetic and epigenetic (environmental, emotional, nutritional) formatting and the age of the body decide where and how the neurohumoral flush manifests. Thus, the (epi)genetics decide which organ represents the target for the manifestation of the nerve cell induced neurohumoral inflammatory response. Taken together, the lack-limos state of energy induces a nerve cell-mediated neurohumoral flush response in the tissue, which in turn causes the symptoms and signs, i. e., pain, inflammation, increased cell turn over, tumor growth (Fig. 2).

Depending on the target organ(s), the manifestation of the energy-lack response affects the brain (headache, migraine, tinnitus, depression, anxiety, sleeping disorder, eating disorder), the cardiovascular system (hypertension, arteriosclerosis, angina pectoris, cardiac infarction, arrhythmia), the gut (irritable bowel syndrome, inflammatory bowel disease, esophagitis gastrica, esophagopathia gastrica, achalasia), metabolism (obesity, fatty liver disease, diabetes), the connective tissue (rheuma, arthritis, scleroderma), the skin (lupus, psoriasis), autoimmune and allergic reactions of inner and out skins (neurodermatitis, eosinophilic esophagitis, Hashimoto thyroiditis, coeliac disease, asthma), any form of cancer or a combination of two or more of the above. In addition, this lack of energy state may present in the form of cold sweat (during the night), weakness and tiredness (i. e., so-called paraneoplastic syndrome). At this stage of our examination let us address the cause for the lack-limos state of energy.

The answer to this question lists three forms of energy consumers: concentrated sugar (metabolic energy consumer) and/or a tumor (tissue-derived energy consumer), and/or emotional and physical stress (Fig. 1, 2 and 3).

Fig. 3

Limology approach of disease management. Energy deficiency (lack/limos) causes symptoms, as described in the text. Following the exclusion and elimination of an energy consumer (polyps, tumors, inflammation; metabolical, psychological, physical stress), therapy includes healthy lifestyle modifications (nutrition, sports, mental coaching)

Lack-limos diagnosis and therapy

Food and beverages contain concentrated sugar, artificial sugar and conservatives (E substances). During life, man develops a hypersensitivity (“allergy”) for concentrated and artificial sugar and conservatives. Normally nutrition aims to add energy and recharge the body battery. Due to the (epi)genetic formatting and age, concentrated and artificial sugar and conservatives stimulate a metabolic response which leads to the lack of energy state and which in turn fosters the neurohumoral response, as described above. In contrast to sugar, the other energy carriers (protein, fiber, ions) are well tolerated in the concentrated and nonconcentrated forms.

In addition, the lack of energy state is maintained in the presence of a tumorous energy consumer, i. e., polyp, cancer, inflammation. And this is well proven by a fascinating test: CT or MRI glucose uptake scan (PET scan). Interestingly, this imaging test is only used for the assessment of tumor metastasis, but nobody ever suggested that this test directly shows the underlying mechanism of disease. The increased glucose uptake indicates that the tumor is an energy consumer. The tumor takes up more energy, when compared to the normal tissue. As a consequence, the normal tissue lacks energy (glucose) and the above nerve cell-mediated responses are induced. Therefore, cold sweat, hypertension, migraine are listed as so-called paraneoplastic syndromes, i. e., manifestations of the tumor-induced energy loss. Finally emotional and physical stress foster the emptying of the body battery and induce episodes of energy deficiency. The understanding of the lack-limos concept leads to successful diagnosis and therapy for disease management.

Based on the above considerations (lack-limos concept), diagnosis aims to exclude a tumorous energy consumer (Fig. 3). Therapy (cancer prevention) includes the elimination of the energy consumer (removal of a premalignant lesion: polyp, adenoma, Barrett’s esophagus, etc.) and optimization of nutrition (Fig. 3). The low carb diet eliminates concentrated sugars, artificial sugars, conservatives for the large meals and provides intermittent regular meals (every 1–2 h) to maintain an adequate energy state. NOTE: it is not enough to breath 3 times per day! The same is true for food and water. Avoid fasting! As a matter of fact, the lack/deficiency of lifestyle discipline (i. e., nutrition, drugs, sports) fosters disease. Outbalanced mental and physical exercise programs are recommended to counteract emotional and physical stress, respectively (Fig. 3).

Finally, we have to recognize in as much the lack of emotional energy (psychological stress) may contribute to the orchestration of a disease (psychosomatic mirror of the world). Existence teaches that man lives within her or his truth filled with a spectrum of expectations. If these expectations are adequately met, the person is happy, satisfied, and outbalanced. Modern life gives rise to a large scale of imbalances: greed, envy, hate provoke the competitive economy and emotional stress. Lack of respect, attention, and care foster negative emotions including anxiety, loneliness, discontent, and isolation. The lack of attention may be compensated by unhealthy nutrition and lifestyle (alcohol, nicotine and drug consumption; no sports). It remains to be questioned if the “lack-limos concept” may be applied to other fields and observations (phenomena)?

The future of limology

Here we outline the principles of a new discipline, an alternative way (method; Greek: meth-odos = the way after/beyond; a way to follow, seek, search for the logos = knowledge, truth, the obvious and evident) of reasoning: limology. As a new discipline, limology describes, defines, assesses, diagnoses, and treats phenomena as manifestations of deficiency. Limology examines any form deficiency and its manifestation: the lack of energy, number, value, money, attention, sound, light, air, wind, color, taste, space, time, balance, harmony, hemostasis, well-being, etc. Limology is a multidisciplinary science involving a large spectrum of specialties including architecture, music, history, archeology, sociology, politics, biology, pharmacy, medicine, ethics, physics, logics, linguistics, geography, geology, astronomy, philosophy, psychology, mathematics (zero equals quantification of positive or negative limos?), semiotics, computer and communication sciences, economy and statistics, etc. Every discipline aims to assess the observations and knowledge within and against the background of limos (deficiency, absence, hunger). Furthermore, limology will recognize positive (useful, i. e., askesis) and negative (i. e., economic inflation; dryness in the dessert) forms of limos. Archaic manifestations and “therapies” of limos include greed, envy, hate, and will for power. Limology establishes diagnosis and therapy, using semiotics (holistic interpretation of signs) and outbalanced remedy of deficiencies (comprehensive joining), respectively.

Surgical limology aims to design in vitro and in vivo studies to examine the molecular biological pathways, mechanisms, and manifestations of the nerve cell-mediated responses, which are stimulated by energy deficiency (molecular and endocrine limology). The data obtained in these studies may be the basis for alternative holistic medical, nutritional, and lifestyle therapies for the remedy (chemo-resonance: sound teaches, what you need). Deficiency represents the common underlying theme for the manifestations and phenomena of our present civilization (ethics, morals, economy, sociology). Thus, limology aims to develop a conduct of reasoning which will help us to better meet and outbalance the requirements of our present and future civilization.

Limology is of relevance because it happens in man and in surgery and today. The lack-limos of the modern civilization contributes to the development and the maintenance of diseases. Modern man lives within the oblivion of an archaic legacy regarding healthy food, lifestyle and beneficial communication. As a consequence man has to “feel” the manifestation of the lack of knowledge, the oblivion of wisdom. Taken together and going in line with the above considerations on the Theogony of Hesiod, limos (lack of energy) and lethe (oblivion of healthy life) round up the existence of modern man. Thus, the question of the outlook for the future remains.

Man belongs to nature. Application counts. Any development and achievement can be used for good or bad. The invention of fire, concrete, current, machines, cars, airplane, printing, biochemistry, computer technology implemented the positive and negative applications and could not inhibit the exploitation of nature. Therefore, the same is true for the global digital “village.” It is us who decide. If not, the computers will decide for us and we will become the slaves of the robots. Some of us will escape this slavery and move to remote areas, where the outstanding value of “analogue” care, handicraft, and communication (group of regulars) is still warranted (Africa, South America). We should go for more balance, respect, and understanding. Cultures are different, but all human beings want the same: to be happy, secure, cosy and safe; treated with acceptance, humility, and respect. We are not allowed to know all, but all knows us. Let us reason to orchestrate a positive world for the beauty of our planet. Maybe limology will help us to better address these issues.

Conclusion

Taken together, the attempt of the author described in this (part II) and the recent issue of European Surgery (part I) recognizes that any statement translates our own or copied reasoning. Whenever we make a statement it should start with cogito sum, “I think, I am ….,” instead of cogito ergo sum. Cogito ergo sum originates from a logically consistent understanding of my existence: if there is a manifestation, there must be a cause. Thus, it goes in line with the reasoning operated in modern physics: planets move because of power, force, and motion. However, they may also move during “limos”! Man thinks; therefore (ergo) he is. But: essentially being happens without “because/ergo” and occurs during “limos:” there is always something we miss, hope, wish, want to have, and “must have.” All life is limos.

The “ergo” makes the difference. The “ergo” created the methodological difference (i. e., limos/deficiency) leading to a unique form of limos compensation: the technical revolution (will for must!). Without the “ergo” (limos of “ergo”), we arrive at a completely different statement. Cogito sum accepts that we are not allowed to know why we are. Here the limos of the “ergo” appears to be positive: the cogito sum, the “I think, I am” understands that I am DURING thinking and reasoning. Thus, the attempt of the author concludes:

• Being is positive and relates to our existence within the continuous stream of mood. My individual being and atmosphere during thinking are the same. Perception against the background atmosphere of my tune of mood orchestrates my being future. It remains to be questioned how to get outbalanced and think positive.

• All life is tuned emotion of atmosphere; the most important of which is love!

• A positive reasoning assesses the unique beauty of our planet. This may nourish the idea that we are guests and not masters of this planet. We overlook that there exists no possession, all is borrowed for a limited episode of life. We are not the gods, we are not the heroes. We are allowed to live, love, and enjoy.

• As a new multidisciplinary method, limology recognizes, explains, and treats phenomena as manifestations of deficiencies. Unfolding all space of time, management includes remedy of deficiencies using the perfect balance between essence-based reasoning (theory) and multitasking (praxis) to meet the requirements of the modern world.

Outlook

There is no successful surgery without knowledge, effort, expertise, discipline, patience, and the technologies provided by the medical and pharmaceutical industries (Fig. 4). But we should avoid becoming a tool for the economic interests of these industries and forms of despotism. Surgeons should recognize that technologies fascinate. Technologies attract our attention away from the essence of being a surgeon and away from the essence of a disease: existence in the form of being sick. Thus, the being of a surgeon deals with the very essence of our existence, i. e., the manifestations during “limos” (deficiency).

Fig. 4

Surgery with a smile. Outbalanced harmony between theory and praxis foster success in surgery

At this point the attempt of the author comes to an end. The author thanks the reader for having taken his/her time to “listen.” Following a period of introverted silence, limology and music will come into being and sound may foster the new age of man (aquarius = limos of fish). If life is on your side in the morning, do not let it go away during the day! Enjoy YOUR summer, think positive, and act with a smile of love (limos of hate).