Perspective
The Importance of the Number Six (and its Multiple Twelve)
Giovanni D. Tebala*
Department of Gastrointestinal and Laparoscopic Surgery, Noble’s Hospital, Isle of Man
*Corresponding author: Giovanni Domenico Tebala, Department of Gastrointestinal and Laparoscopic Surgery, Noble’s Hospital, Strang Douglas, Isle of Man IM4 4RJ, Isle of Man
Published: 07 Dec, 2016
Cite this article as: Tebala GD. The Importance of the
Number Six (and its Multiple Twelve).
Clin Surg. 2016; 1: 1232.
Perspective
Undoubtedly, the number six and its multiple have fascinated the human race for many
centuries. There should be a sort of divine inspiration to explain the obsession of some exponents of
human race towards this number. Hands up those within the medical community who are not used
to book follow-up clinical appointments “in six weeks” at least once in their life. Why? There is no
apparent reason… It could be 4 weeks, a month (which is slightly more than 4 weeks), 8 weeks…
Why six? There is no clinical reason to follow up a patient after 1 month and a half...
Quite recently, during the dispute on the new job plan of junior doctors, the UK secretary of
state for Health, Jeremy Hunt, declared he was “ready to impose a new contract if negotiations are
not successful within six weeks”. Why did he establish this precise deadline?
It came to me that the word “six” is most definitely the shortest and quickest to pronounce
within the whole row of natural numbers and twelve – twice six – are the signs of the zodiac, but I
am not at all sure those are the main reasons for the obsession with the number six.
The truth is that six and its multiple are divinely inspired symbols with many biblical references,
in particular in the form of “twelve”.
My experience and knowledge is limited to the Holy Bible but I am sure the same concepts can
be found also in the Quran and in many other Holy Books.
In the Bible, the number six and its multiple are reported more than one thousand times. The
linguistic analysis of the numbers of the Bible – and in particular of the Old Testament, which is the
basis of the Kabbalah – is terribly interesting but is beyond the scope of this editorial. However, I feel
I got to recall some fundamental points.
During the Creation of the World, God “worked” for six days, and got a bit of rest only on day 7,
so men are supposed to work six days a week and devote the seventh to God. Noah was six hundred
year-old when the Flood came. Six hundreds where the Hebrew men – besides women, children and
animals - who escaped the Egyptian captivity according to the Exodus. Even more interesting is the
symbolism linked to the number 12, which is the first multiple of 6. The tribes of Israel, one for each
of Jacob’s sons, were twelve, as Jesus’ Apostles. According to the book of Apocalypse (Revelation),
the number of “sealed” and saved at the end of times will be one hundred and forty-four, which is
clearly 12 square and a multiple of 6 – as 144 = (22 x 3)2.
So why this Continuous Reiteration of the Number Six and What is its Role in Surgery
According to a basic kabalistic interpretation, six - 3 x 2 - means the divine – 3 - intervention
in human affairs - 2. Twelve – or 144,000 – men have been chosen by God to be saved. In six - 3 x
2 - days God made Man and his World.
Six is the encounter between divine and human, between transcendent and immanent. Twelve
and his square 144 are just multiple which are meant to reinforce the kabalistic concept.
I wonder if this is the hidden reason why these numbers are so frequent in Medicine and in Surgery.
A D1 lymphadenectomy for gastric cancer entails removal of nodes of the stations 1 to 6, whereas with the more extensive D2 lymphadenectomy the surgeon should be able to clear the stations up to n.12.
Even more intriguing is the obsession for the number twelve in bowel cancer surgery. The
number of lymph nodes removed and analysed after colorectal
resection for cancer is traditionally considered to be a quality indicator
of the effectiveness of the surgical resection. However, the number of
lymph nodes analysed from a specimen of bowel resection for cancer
is not a direct function of the surgical technique, but is more often
dependent by other factors, such as the technique of nodal harvesting
in the laboratory, skills of the pathologist, time and workload of the
pathologist. So, far from being a direct indication of the quality of the
surgical lymphadenectomy, the number of lymph nodes analysed is
considered to be a general indicator of the global quality of the team
dealing with bowel cancers [1].
At the 1990 World Congress of Gastroenterology in Sidney it
was – quite artificially – established that the optimum number of
lymph nodes to be sampled is twelve [2]. This has subsequently been
endorsed by European and US guidelines [3-4].
Once again, there is no specific, high quality clinical reason for the
choice of this number. The statement of the Sidney World Congress
was only a grade C recommendation based on low-level evidence [1].
Good evidences demonstrate that the higher is the number of
lymph nodes sampled, the better is long term survival, without any
clear cut-off [5]. This can be explained by the fact that patients where
more lymph nodes have been analysed are more likely to receive
adjuvant chemotherapy.
On the contrary, setting a precise cut-off only offers an excuse to
both surgeons and pathologists to perform a suboptimal job, at the
same time fulfilling the written guidelines. Some surgeon may in fact
decide to perform an easier and quicker limited resection removing
only pericolic lymph nodes - more than enough to get 12 nodes - or
some pathologist may decide to pick up only 12 nodes, of the many
more present on a good surgical specimen, just to fulfill the standards,
without going the extra mile and trying and get the most from that
pathologic examination. This risk is clearly demonstrated by the fact
that in some series the median number of nodes examined is exactly
twelve [6]. Clearly, this behavior has important ethical and medicolegal
implications.
Correctly it has been recently recalled that the surgeon must
always perform an oncologically correct resection, removing the
whole mesocolon or mesorectum with their lymph nodes and the
pathologist must sample and analyze all the lymph nodes present
in the specimen or at least as many as possible [1]. New sampling
techniques, such as fat dissolution or vital staining, can be helpful
in picking up more lymph nodes than with the usual macroscopic
dissection [7-8].
Although still in the guidelines, the “totem” represented by the
number 12, first multiple of six, is progressively losing his central
role in oncologic colorectal surgery, but so strongly is the archetype
buried in our human mind that someone has recently proposed to
increase the minimum number of nodes to be examined to 21 [6],
which is evidently the graphical reverse of 12!
However, 21 has a deeper significance, being the results of 3 x
7. Three is the number of God, the quintessential perfect number.
The number seven has even a deeper role, being considered the
representation of the Whole and the Creation. With respect to 12,
21 has lost its “human” factor, bearer of error and fault. It is a divine
number that had and has a central role in many different cultures.
Seven is the number of the deep research – the alchemical acronym
VITRIOL (“Visita Interiora Terrae et Rectificando Invenies Occultam
Lapidem” can be translated as “Look in the depth of the Earth and
following the right path you will find the hidden stone”) is formed
by 7 letters…
Is there anything deeper than abdominal and pelvic
lymphadenectomy?
It necessarily follows that 21 can be interpreted as going deep into
the unique God-derived human body to find its hidden significance,
as a surgeon dissects the human tissues to find an answer to his/her
prognostic questions.
Being a pure divine number, twenty-one is the ideal candidate
to replace twelve in the collective imagination and as a totemic
oncologic number.
References
- McDonald JR, Renehan AG, O’Dwyer ST, Hanoubi NY. Lymph node harvest in colon and rectal cancer: current considerations. World J Gastrointest Surg. 2012; 4: 9-19.
- Fielding LP, Aresnault PA, Chapuis PH, Dent O, Gathright B, Hardcastle JD, et al. Clinicopathological staging for colorectal cancer: an international documentation system (IDS) and an international comprehensive anatomical terminology (ICAT). Working party report to the World Congress of Gastroenterology, Sidney 1990. J Gastroenterol Hepatol. 1991; 6: 325-344.
- National Bowel Cancer Audit Annual Report 2013. Health and Social Care Information Centre. London. 2013.
- Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal surgery. J Natl Cancer Inst. 2001; 93: 583-596.
- Gleisner AL, Mogal H, Dodson R, Efron J, Gearhart S, Wick E, et al. Nodal status, number of lymph nodes examined, nd lymph node ratio: what defines prognosis after resection of colon adenocarcinoma? J Am Coll Surg. 2013; 217: 1090-1100.
- Choi HK, Law WL, Poon JTC. The optimal number of lymph nodes examined in stage II colorectal cancer and its impact on outcomes. BMC Cancer. 2010; 10: 267.
- Shia J, Wang H, Nash GM, Klimstra DS. Lymph node staging in colorectal cancer: revisiting the benchmark of at least 12 lymph nodes in R0 resections. J am Coll Surg. 2012; 214: 348-355.
- Ong MLH, Schofield JB. Assessment of lymph node involvement in colorectal cancer. World J Gastrointest Surgery. 2016; 8: 179-192.