The Handmaids of Medicine
AT the foot of the Acropolis in Athens is a small cave into which seeps a tiny spring. The traveler who visits it notices first the water, — for water is always worth notice in Athens, — then a little altar, next a slender candle or two, their meagre flames struggling with the close atmosphere. His eyes become accustomed to the dimness, and he sees, fastened here, there, and everywhere upon the walls, little metal plates impressed with the outlines of an arm, a leg, a human torso, or an infant in swaddling clothes — plates of tin, aluminum, nickel, or silver, according to the wealth of the ones who hung them.
This cave was once the holy of holies in the sanctuary of Asclepius, god of healing. Ruined memorials of his shrine still stand about the threshold; belief in the miraculous healing powers of his cave and spring still thrives, without a trace of ruin, in the hearts of the people near by. To obtain relief from their illnesses, or those of kindred and friends, they bring to the cave likenesses or symbols of the parts affected, go through the correct ritual, and wait for the cure.
A new divinity may have displaced Asclepius; a new therapy may have displaced the old one of incubation, — sleeping in the rotunda of the shrine, — a therapy of such potency, as attested by inscriptions erected in gratitude, that it could restore to soundness a painter who fell from his scaffold and was given up by leeches of his time, or a silver goblet mashed in a scuffle between rival butlers. It is interesting to observe, however, that here, as well as in many places elsewhere, a strong bond between the material and the spiritual is felt to exist in the mystery of healing, the water and the locality of the cave providing the material elements, the faith of the natives the spiritual.
Early in his search for a means of coping with discomfort, man imagined a close relation between religion and disease. Literature of centuries past and observation of peoples living today in a state comparable to the childhood of the race both indicate that man of times gone by considered disease a visitation of beings more powerful than himself. But just as the child eventually comes to the point where he realizes that the broom he straddles is a horse only by virtue of his own flight of fancy and that the stick he flourishes is a sword for the same reason, so man had to reach a stage where his mind separated what is substantial from what is his own attribute and interpretation of that substantial thing.
Out of the intermingling of the imaginary with the physical, man developed the concept of a natural world as opposed to the fanciful. Rivers with treacherous currents, for instance, came to be dissociated from the idea of a baneful demon presiding over them, and to have their dangers explained on more material bases. Whispering nymphs were discarded as reasons for the sighing of the forests, and rustling of leaves and topmost boughs of trees under the blast of the wind were substituted for them. And with the separation of fact from fancy is connected the development of modern medicine. The early beginnings, however, are not to be despised; for out of medicine’s original connection with religion grew a knowledge of the therapeutics of fasting and catharsis, even though ages passed before these were looked upon as anything other than spiritual devices. Out of that connection, also, arose that vast and complicated structure of magic lore, which, if one considers its symbolic drawings and tattooings, its weird concoctions of potions and philtres, its amulets, charms, and talismans, might be regarded as the mother of the sciences and the arts.
But modern sympathetic study of magic is revealing that its practitioners relied not so much as is imagined upon the supernatural. Behind the prescriptions calling for the use of ‘ fillet of a fenny snake . . . eye of newt and toe of frog, wool of bat and tongue of dog, adder’s fork and blind-worm’s sting, lizard’s leg,’ root of hemlock, and gall of goat, has been found a substantial natural justification, even though Macbeth’s witches may not have known its existence. Experimentation with snake poison, for instance, especially that of rattlers, has shown that it is useful in combating epilepsy. From the skin of a tropical toad the pharmacologist has extracted bufagin, a powerful heartstimulant similar to digitalin; and centuries ago Chinese magic-doctors employed toad-skin in cardiac difficulties. Now the student of gland therapy finds the administering of bile — gall of sheep or calf, to-day — a highly effective procedure in dealing with faulty bowel-elimination that has become chronic.
The development of magic marks a step forward in the development of medicine. How much of the advance was conscious and how much unconscious, contributed by human love of the mystifying, no one can say. As yet, however, the evolution is far from complete. Microscopic organisms, the ‘germs’ of common talk, have been substituted in the popular mind for the worms and snakes of primitive medicine. The theory that many pathological states are due to abnormal internal secretions has been substituted for the old doctrine of the ‘humors.’ And one might, with little stretch of the imagination, find for the psychic aspects of the early relation between religion and disease a modern counterpart in the Freudian use of the unconscious — a use which has permitted the adoption of the principle of determinism in the mental sphere and has put investigation in that sphere more nearly on a plane with investigation in the physical sciences.
Medicine, chemistry, physics, biology, and psychology — these are the ends, at least the visible, modern ends of the thought started when the first Job was visited with boils or trodden upon by a mastodon. The nature of the catastrophe is immaterial. Medicine is the patriarch of the group, but a patriarch who has only recently come to mobilize the entire forces of his family in the age-old feud with disease.
Although in ancient Egypt, in the land of Chemi, where priests experimented with simple substances for the making of curative concoctions, there was a close union between chemistry and medicine, these two sciences became separated for many centuries. The chemist, as illustrated in the pioneer work of Agricola on metallurgy, turned his knowledge largely to the production of wealth in the industries. This defection has resulted in much suffering which closer coöperation between physician and chemist might have spared humanity. For instance, the thirteenth century saw the discovery of ether. Not until 1846 did physicians recognize its value as an anæsthetic; for over five hundred years was the race denied the benefits of this queller of pain. Magnesium sulphate was known to chemists in 1694; two hundred years elapsed before the knowledge came that it would relieve lockjaw, burns, and strychnine poisoning. Twenty-three years passed between the chemist’s discovery of amyl nitrite and the physician’s discovery that it relieves the tortures of angina pectoris.
To-day the pharmacologist presiding over a well-supplied laboratory in an institution of research represents perhaps the best blend of physician and chemist. The maximum of success in the alleviation of suffering is, however, to be attained only when the pharmacologist serves as the medium between chemist and physician: when all three work in recognized interrelationship.
One modern department of medicine stands out prominently for the coöperation it has produced between chemist and physician. That is the department of gland therapy or endocrinology. Not only has development in this field emphasized the early relation between the chemist and the leech, — alchemist the former must have been in those days, — but it has also directed thought to the primitive connection of these two with the priest. When, by means of the administering of thyroid extract, a cretin — a person whose development has been arrested so far as to make him an imbecile — is transformed into a person approaching normal form and intellect, popular imagination, at least, is justified in seeing a similarity between this miracle and the ancient one of casting out devils.
But the miracles of to-day are more complex than those of days gone by. Every human body is now conceived to be a chemical laboratory, in which the most complicated transformations are continually taking place. Every man, even in the midst of health, is a walking drug-store, the pharmacologists maintain; and the impairment or inadequacy of his drug-supply may result in diseases such as gout, diabetes, goitre, giantism, and insanity. Even invading disease-germs accomplish their fell work in many cases through chemical agencies, their toxins being potent drugs that act upon the heart, respiratory nerve-centres, or some other vital apparatus. Sometimes also, failing of specific action, they gradually poison the whole system.
The approach to endocrine therapy has been devious and dark. Long periods were devoted by the anatomist to outlining the glands and noting their positions. Painstaking efforts were made to determine the spheres in which the various glands were active. And then the anatomist and the pharmacologist secured secretions, the powers of which were anything but precisely defined. In this work of isolation and definition, the success of Professor Abel of Johns Hopkins, whose investigations led to the isolation of adrenalin, the pure principle of the adrenal glands, is a signal one. Perhaps another isolation is not far ahead, for the same scientist has recently obtained a tartrate extracted from the pituitary gland. When experiments show that this extract must be diluted 18,750,000,000 times for actual use — one ounce thereof would turn into pituitary extract all the water in a one-foot pipe running from New York to San Francisco — one is amazed at the potency of these internal drugs. Wonderful as the results here seem, one is told that they are but the beginning, and that there is much need of the chemist’s aid for future success.
To the development of the germ theory, fundamentally a biological one, medicine is heavily indebted. Without Pasteur, Koch, Behring, Flexner, and many others, medicine could not have acquired many of its modern approaches to exactness. Both bacteriologist and pathologist, however, have now reached a point where they must turn to chemistry for the solution of their most important problems. The antitoxins which are injected into human bodies are at best but crude mixtures, laden with undesirable and to some extent harmful ingredients. These most powerful weapons for combating invading germs are chemical substances of specific curative power, but of unknown composition.
The theory behind the use of antitoxins involves introducing into the human system a weakened or dead virus that is calculated to hasten development of immunity and sometimes, as in the case of meningitis, to neutralize the toxin caused by the germ of the disease. To secure an antitoxin for meningitis, for instance, dead bacteria of that disease are injected into a horse previously watched and studied to determine its healthfulness. At intervals of eight days, for a period of four months to a year, doses are repeated, until the horse can withstand large injections, not of dead but of living bacteria. From the blood of this horse is then obtained the serum which is sent out to physicians for use.
The antitoxins, it may readily be seen, are significant examples of human ingenuity in employing animals as living chemical factories; but there is no way of checking up on the output of these factories. Chemical methods applied to the isolation of the pure principles of antitoxins would enable medicine to make a great advance. Such an application might give the practitioner the power to combat an infection by swift, exact, and sufficiently potent doses, whereas now he acts often with hesitation and misgivings.
In addition to the assistance needed by medicine to perfect recognized remedies, there are projected medicaments, ghosts of drugs, as it were, which the chemist is asked to help to turn into real substance. For example, it is known to-day that a modification of quinine gives promise as a specific for pneumonia. It destroys the pneumococcus germ in glass vessels; it is used successfully in external pneumococcus infections, as of the eye; but it is still too poisonous to be used in sufficient strength in the blood to combat the multitudes of invading germs in pneumonia itself. As inspiration for investigation into this quinine product stands the work done on cocaine. Although a valuable local anæsthetic, cocaine was often found to be poisonous. Chemical study revealed that it was a complex compound, some parts of which produced a beneficial anæsthetic, whereas others were definitely poisonous. Part of the poisonous material is closely related to the deadly principle of the hemlock, famous as the poison which Socrates was made to drink, and still another part is akin to nicotine.
With this knowledge of cocaine established, the chemist was in a position to improve on nature and invent a number of local anæsthetics with the virtues of cocaine and without its poisons. Some of these superior anæsthetics are procaine (introduced under the name of novocaine), beta-eucaine, apothesine, and, more recent, benzyl alcohol. Now even major operations for appendicitis, hernia, and uterine troubles are being performed under local anæsthesia; and it is expected that general anæsthesia, with its grave fundamental danger of poisoning the whole system with ether, chloroform, or laughing gas, will eventually be reserved for unusually painful or unusually prolonged operations.
Then too there are the brilliant advances in the studies of colloids which have been thought capable of application to the problems of the body. In nerve and cell, muscle and organ, many of the questions are felt to be largely those of colloidal chemistry. The vital fact about colloids is that, instead of dissolving in water, as salt or sugar does, they form suspensions. Milk is a common illustration of such a suspension of fat globules and cheesy components in water, together with some salt and sugar. The chemist who has specialized in the colloids may find a wide field in the human body, where all the tissues are grist for his mill.
The economic aspects of the coöperation of the physician and the chemist are not to be overlooked. A recent committee of the American Chemical Society has estimated that the annual drug bill of the nation is $500,000,000, of which amount $300,000,000 is spent for so-called patent medicines. Thirty years ago, the report of this committee says, 2699 drug items were reported to be upon the market, whereas to-day they are held to number 45,000. The increase is beyond all proportion to scientific research. The elimination of ineffective drugs cannot but carry with it better health-investment and less exploitation for those who pay this $500,000,000.
If one accepts the definition of chemistry as ‘the fundamental science of the transformation of matter,’ and that of physics as ‘the fundamental science of the transformation of energy or power to work,’ one finds in these sciences the outline of life itself. For all life, from the lowest to the highest forms, is a complex transformation of matter and energy. A link between the two sciences is furnished by the physical chemist, whose work in tackling life problems has to do, among other things, with the laws of speed in chemical action and with the relation of these laws to the body. Upon the time factor as it affects the interdependent actions of the body, the rate of the heartbeat, respiration, assimilation of food, and elimination, life is heavily dependent. Digestion within a normal time, for instance, produces bodily well-being. Digestion in time which is prolonged results in fermentation, gas pains, nausea, and all the symptoms of indigestion. The study of the large number of enzymes — accelerators or catalyzers, among which pepsin is the most powerful — offers the physical chemist almost unlimited opportunity for discoveries.
But there is need of pure physics as well. The phenomena of transfusion and capillarity and some other sections of physics, notably those pertaining to sight and hearing, have long been recognized as important to the study of medicine. The extraordinary development of physics in the last quarter of a century, of which the X-rays and radioactive transformations and discoveries arising from these are only a small part, has placed physics in a fundamental position as regards sciences in general. The work of Professor Bragg, of the University of Manchester, for instance, in employing X-rays for the analysis of the atomic structure of crystals, invites one to contemplate the time when the mysteries of the living cell, so far as concerns structure, will no longer be mysteries. Inertia and elasticity, diffusion of gases, solution of gases, partial pressures, osmosis, adsorption, thermodynamics, electricity, and magnetism — all these and many more present physical problems in medicine.
To be more specific as to points of contact between the two, one may show the aid of physics in the adaptation of electrical methods to the determination of hydrogen ion concentration. The electrical action-current of muscles, until recently considered only of academic and theoretic interest, has within a decade come to be of great value in measuring the action current of the heart. The string galvanometer, developed by neither physicist nor engineer but by Professor Einthoven, a physician of Leyden, has made possible the application of this theory. And the string galvanometer, in turn, demonstrates the value of an adequate knowledge of physics and mathematics on the part of the biologist. Perhaps the physicist may be able to contribute a portion of the solution needed for the modern problem of heart diseases — diseases which Dr. Emery R. Hayhurst, of the Ohio State University, points to as the cause of 22,000 deaths annually in people under forty-five years of age. And Dr. Hayhurst’s figures are based solely upon a study of people engaged in industrial pursuits.
In medicine’s pursuit of a cure for rickets the physicist has been of signal help. By means of Roentgen photographs the peculiar conditions of the bones of the head and of the ribs were revealed in cases of rickets in children. Howland, at Johns Hopkins, by direct analysis showed the characteristic beaded condition of the bones to be due to a deficiency of lime or of phosphate in the blood.
Huldschinsky effected cures by exposure of patients to the radiation from a quartz lamp with mercury vapor as the radiant, especially strong in ultraviolet rays. Hess attained cures by using ordinary sunlight. McCollum and Park at Johns Hopkins, working on rats, caused rickets through a deficiency of calcium or phosphorus in their diet and cured it definitely with sunlight. Then it was demonstrated that the portion of the solar spectrum really effective here was only the ultra-violet in the neighborhood of 300 millimicrons — rather, all below 320.
Pfund, working in the Hopkins physics laboratory at Johns Hopkins, on a problem connected with the darkening of certain paint-pigments when exposed to sunlight, discovered a device for measuring the intensity and dosage of the ultra-violet radiation to be used in curing rickets. It consists of an exposure-meter, in which a fresh area of paint-pigment known as lithopone is rapidly darkened by the rays from about 320 down, until it matches a standard tint.
Then oil began to thicken the pathology plot just as it has done recently to the political; but this time it was cod-liver oil, not petroleum. For it was found that the feeding of cod-liver oil produced the same good results in rickets as did the ultra-violet rays.
A further step was made at the University of Wisconsin, where it was discovered that certain ordinary foods, subjected to radiation before feeding, produced the same effect as the codliver oil. Kugelmass, formerly at Johns Hopkins but now at Yale, shows that cod-liver oil, when it oxidizes, emits ultra-violet rays, and that it is probably the effect of these rays upon the calcium or phosphorus salts in the intestinal tract that renders them available for absorption into the blood-stream, whereas without such excitation they are not in condition for assimilation.
Probably it is not a very wide guess, in view of the foregoing, that from the medical standpoint light is comparable to coal tar, and is a crude product, capable of infinite refinement and adaptation.
There are, however, a host of discomforts caused neither by germs nor by faulty internal action, but by external irritants to which men are exposed, especially in given occupations. How the physicist may help in combating these is illustrated by Dr. Pfund’s ‘gold screens.'
It had long been known that men working before furnaces developed cataract. Extreme cases of exposure were found to produce even bursting of the eyeballs. Investigation revealed that the infra-red and the ultra-violet rays in the glare of the furnace were responsible. Evidently some device was needed which would eliminate these rays, but at the same time transmit to the eye sufficient light for seeing. The ‘gold screens’ have entirely filled the need. They consist of yellowish glass, upon which is placed a coating of gold. As gold leaf is not apt to be sufficiently uniform in thickness to use before the eye, the gold was distilled upon the glass in a high vacuum. The method of distillation also produced a much thinner coating than gold leaf could have provided. The infra-red rays were reflected by the gold, so that the glass did not become hot; the glass absorbed the ultra-violet rays; and the eyes were spared. Tests at the Bureau of Standards have shown that goggles made with ‘gold screens’ have eliminated 99 per cent of the total radiation from a furnace at a temperature of 2000 degrees centigrade.
Miraculous as the advance has been in physics in the last quarter of a century, that advance has been paralleled in the other sciences. The cell theory in biology has opened an avenue of study that ends in infinity; and who knows but what 1950 will see a theory of atomic structure so perfected as to be of great service to the medical man in the contemplation of complex lifeproblems.
For the solution of these problems the biologist too is indispensable. Study of the chemical materials and physical laws of life cannot progress without life itself. The biologist must always furnish the needed verification or check for the other scientists, for his material can be relied upon to provide the biological test, the age-old method of trying it out on the dog. The chemistry of man is incapable of dealing with the infinitely small amounts of material that the chemistry of life employs; and Nägeli’s oligodynamische Wirkung — discovered in spirogyra’s susceptibility to a solution of copper no stronger than that formed in water left in the faucet overnight — opens a field beyond test tube and microscope.
And in this field of the infinitely small, at the present time attention is being directed most intently to the socalled filtrable viruses. It is a known fact that certain organisms — one may use the term ‘organism’ here for want of better, although there are doubts in scientific circles as to its appropriateness — are so tiny as to pass through filtering devices. This is quite unlike the bacteria and microbes of modern acquaintance, which remain behind in the filters when strained from the liquids in which they live.
An outstanding disease held due to a filtrable virus is the leaf mosaic of tobacco. If some of the juices of an infected tobacco-plant were extracted and placed in a tube for culture of bacteria, if the culture were given adequate time to mature and then strained off, the filter would show, as usual, a number of varieties of bacteria, some perhaps deadly, but most of them innocuous. A portion of the clear liquid which passed through the filter might be examined in the microscope, but the examination would reveal no contents — even under the ultramagnifying system the human eye has so far seen nothing but clear liquid here. No chemical test has been able to produce staining, reaction, or change to indicate the presence of other than clear liquid. Yet an inoculation of a healthy tobacco-plant with this liquid will produce leaf mosaic in that plant. The spread of the mosaic in the host is interpreted by science as indicative of the power of reproduction in this something beyond the range of human vision — rather, scientific vision. Only as they act in connection with living tissue can the filtrable viruses be studied; hence they are uniquely the problem of the biologist.
The successes with yellow fever and malaria — biological successes — are milestones already passed. If one accepts the theory that every highly organized living thing is but a mass of coöperating cells, and with it the theory long recognized in form but never so strongly in fact as in the present day, that each cell is inherently different from its neighbors in some minute particulars, then the key to the solution of many of life’s mysteries is to be found in the lower forms of life. An example of how laws observed pretty well down the scale of life may be extended to man is involved in Dr. Raymond Pearl’s theories on human population. In his laboratory, Dr. Pearl constituted a number of small universes consisting of test tubes filled with air and food. Within these universes he placed fruit flies as inhabitants, fruit flies being selected because their span of life is comparatively short, a cycle from egg to egg being completed within twelve days. Fly population rose rapidly at first. As the universes grew old, however, the progress became less and less marked. A curve could be plotted, however, to show the first rapid development, the climactic point, and the order of dwindling growth; and this curve, studied with the help of vital statistics kept by various nations of the world, has been a factor in Dr. Pearl’s observations on human population. Not the least significant of these is his theory that the world as a whole has already passed the period designated by the first part of his curve, wherein economic production and growth in population rise in a proportion not calling for anxious contemplation.
The ultimate cause of many afflictions, however, is to be found neither in external irritant nor in organic invasion. Primitive man gave promise of his future mental development when he recognized a psychic element in disease. That the substitution of analysis for intuition has caused the scientist to assume toward this psychic element an attitude different from primitive man’s is not to be observed to the latter’s discredit.
Among the countless things assigned to the war is the strengthened tendency among physicians to admit as purely psychic the causes of many mental diseases. It can scarcely be said that the doctrines of Freud are generally accepted, but these doctrines are no longer subjected to the neglect or reprobation they received before the war. Morbid processes which Freud attributed to faults in the operation of the sex-instinct the war has produced in its awakening of suppressed tendencies of the fundamental instinct of self-preservation. Warring Europe furnished one of the most amply supplied laboratories the physician and psychologist have ever seen for the study of powerful instincts; and the war neuroses have indicated that sex is not the sine qua non of psychoanalysis. With this indication reached, many are ready to accept parts of Freud’s doctrine and at least to suspend judgment upon what they formerly condemned. It is now pretty generally admitted that functional nervous and mental disorders depend essentially upon disturbances of the instinctive and emotional states of mind. Out of this admission may develop — has developed in many cases — a drugless, knifeless healing, based purely upon the remorseless probing of the patient’s past for emotion wounds and emotion foreign-bodies, the treating of which will reëstablish sound health.
The big opportunity for psychic medicine, however, lies in its following the line of action adopted by the rest of the science and devoting itself to prevention as well as cure. Modern knowledge of dietetics, for example, is far from exact, but it is of tremendous value in treating or avoiding disorders. Should psychic medicine approach exactness no more closely than does dietetics, and should it evolve something more definite than conjectural rules for the keeping of an active, healthy mind, much of the work of bodily medicine would be lightened.
With chemistry, physics, biology, and psychology advancing as they are, and coöperating with medicine as desired, medicine must inevitably itself approach the plane of the exact sciences. But it can approach only as a variable approaches its limits. Owing to the vast variety of aspects presented in the human problem, — for each person may be thought of as offering a new variation of some medical law, — perhaps medicine can never be anything but empirical. But herein lies the greatest hope for its advance. ‘ Empirical’ relates to experience gained by test and trial. That which tests and tries may evolve many things. The medicine of 1950 may make that of to-day seem crude, even recklessly dangerous; and the medicine of 2000 A.D. may look back with indulgence on that of 1950.