[*] Oration in Surgery. Delivered at the 147th Annual Meeting of the
Medical Society of New Jersey, at Spring Lake, N. J., June 11, 1913.
In this address the paragraphs which were taken from the preceding
paper, "A Mechanistic View of Psychology," have been omitted,
those portions only being republished in which the premises have
been applied in a discussion of certain medical problems rather
than of psychological problems.
The human body is an elaborate mechanism equipped first for such
conflict with environment as will tend to the preservation
of the individual, and second for the propagation of the species,
both of these functions, when most efficiently carried out,
tending to the upbuilding and perfection of the race.
From the date of Harvey's discovery of the circulation of the blood,
to the present day, the human body has been constantly compared
to a machine, but the time for analogy and comparison is past.
I postulate that the body is itself a mechanism responding in every
part to the adequate stimuli given it from without by the environment
of the present and from within by the environment of the past,
the memory of which is stored in the central battery of the mechanism--
the brain.
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* * * * * * * * * *
If the full history of the species and of the individual
could be known in every detail, then every detail of that
individual's conduct in health and disease could be predicted.
Reaction to environment is the basis of conduct, of moral standards,
of manners and conventions, of work and play, of love and hate,
of protection and murder, of governing and being governed, in fact,
of all the reactions between human beings--of the entire web of life.
As Sherrington has stated, "Environment drives the brain, the brain
drives the various organs of the body," and here we believe we find
the key to a mechanistic interpretation of all body processes.
On this basis we may see that the activities of life depend upon
the ability of the parts of the body mechanism to respond adequately
to adequate stimulation. This postulate applies not only to stimuli
from visible forces, but to those received by the invasion of
the micro-bodies which cause pyogenic or non-pyogenic infections.
In the case of dangerous assaults by visible or invisible enemies,
the brain, through the nerves and all parts of the motor mechanism,
meets the attack by attempts at adaptation. Recovery, invalidism,
and death depend upon the degree of success with which the attacking
or invading enemies are met. Questions regarding disease become,
therefore, questions in adaptation, and it is possible that,
when studied in the light of this conception, the key to many hitherto
unsolved physical problems may be found.
Perhaps no more convincing proof of our thesis may be secured
than by a study of that ever-present phenomenon--pain. In whatever
part of the body and by whatever apparent cause pain is produced,
we find that it is invariably a stimulation to motor activity--
whose ultimate object is protection. Thus by the muscular action
resulting from pain we are protected against heat and cold;
against too powerful light; against local anemia caused by prolonged
pressure upon any portion of the body. So, too, pain of greater
or less intensity compels the required emptying of the pregnant
uterus and the evacuation of the intestine and the urinary bladder.
It should be noted that in every instance the muscular activity
resulting from pain is specific in its type, its distribution,
and its intensity, this specificity being true not only of pain
which is the result of external stimulation, but also of the pain
associated with certain types of infection.
Pain, however, is not the only symptom of the invasion of
the body by pyogenic or parasitic organisms. Fever, invariably,
and chills, often, accompany the course of the infections.
Can these phenomena also be explained as adaptations of the motor
mechanism for the good of the individual?
As the phenomena of chills and fever are most strikingly exhibited
in malaria, let us study the course of events in that disease.
It is known that the malarial parasite develops in the red
blood-corpuscles, and that the chills and fever appear when
the cycle of parasitic development is complete and the adults
are ready to escape from the corpuscles of the blood plasma.
Bass, of New Orleans, has proved that the favorable temperature
for the growth of the malarial organism is 98'0, and that at 102'0
the adult organisms will be killed, though the latter temperature
is not fatal to the spores. The adult life of the malarial
parasite begins after its escape into the blood plasma, and it is
there that the organism is most susceptible to high temperature.
We must infer, therefore, that the fever is an adaptation on the part
of the host for despatching the enemy.
What, then, may be the protective part played by the chill?
A chill is made up of intermittent contractions of all the external
muscles of the body. This activity results in an increase
of the body heat and in an anemia of the superficial parts
of the body, so that less heat can be lost by radiation.
By this means, therefore, the external portions of the body contribute
measurably to the production of the beneficent and saving fever.
It must be remembered that this power of adaptation is not peculiar
to man alone, but that it is a quality shared by all living creatures.
While the human body has been adapting itself for self-protection
by producing a febrile reaction whereby to kill the invading organisms,
the invaders on their side have been adapting themselves for a life
struggle within the body of the host. In these mortal conflicts
between invaders and host, therefore, the issue is often in doubt,
and sometimes one and sometimes the other will emerge victorious.
We must believe that a similar adaptive response exists in all
parasitic infections--the cycles varying according to the stages in
the development of the invaders. If the bacteria develop continuously,
the fever is constant instead of intermittent, since the adequate
stimulus is constantly present.
Bacteriology has taught us that both heat and cold are fatal
to pathogenic infections; for this reason either of the apparently
contradictory methods of treatment may help, _i. e_., either hot
or cold applications. It should be borne in mind, however, that we have
to deal not only with the adult organisms, but with the spores also.
The application of cold may keep the spores from developing,
while heat may promote their development, and the course of the disease
may vary, therefore, according to our choice of treatment.
From this viewpoint, we can understand the intermittent temperature
in a patient who is convalescing from an extreme infection,
as peritonitis, pylephlebitis, multiple abscess of the liver, etc.
In these conditions there may occur days of normal temperature,
followed by an abrupt rise which will last for several days--
this in turn succeeded by another remittance. This cycle may be
repeated several times, and on our hypothesis we may believe it
is caused by the successive development to maturity of spores
of varying ages.
If these premises are sound, the wisdom of reducing the temperature
in case of infection may well be questioned.
On this mechanistic basis the emotions also may be explained
as activations of the entire motor mechanism for fighting,
for escaping, for copulating.
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The emotions, then, are the preparation for phylogenetic activities
(Fig. 48). If the activities were consummated, the fuel--glycogen--
and the activating secretions from the thyroid, the adrenals,
the hypophysis, would be consumed. In the activation without
action these products must be eliminated as waste products
and so a heavy strain is put upon the organs of elimination.
It is obvious that the body under emotion might be clarified
by active muscular exercise, but the subject of the emotion is so
strongly integrated thereby that it is difficult for him to engage
in diverting, clarifying exertion.
* * * * * * * * * *
* * * * * * * * * *
So, as we have indicated already, certain deleterious effects are
produced when the body mechanism is activated without resultant action.
For example, the output of adrenalin is increased, and, as a consequence,
arteriosclerosis and cardiovascular disease may occur in persons
who have been subjected to prolonged emotional strain, since it
has been proved that the prolonged administration of adrenalin
will cause these conditions. We have stated that the emotions cause
increased output of glycogen. Glycogen is a step toward diabetes,
and therefore this disease, too, is prone to appear in persons
under emotional strain. It is most common in those races which
are especially emotional in character, so we are not surprised
to find it especially prevalent among Jews. So common is this
particular result of prolonged emotion that some one has said,
"When the stocks go down in New York, diabetes goes up."
Nephritis, also, may result from emotional stress, because of the strain
put upon the kidneys by the unconsumed activating substances.
The increased heart action and the presence of these activating
secretions may cause myocarditis and heart degeneration.
Claudication also may result from the impaired circulation.
The emotions may cause an inhibition of the digestive secretions
and of intestinal peristalsis. This means that the digestive processes
are arrested, that putrefaction and autointoxication will result,
and that still further strain will thus be put upon the organs
of elimination. Who has not observed in himself and in others when under
the influence of fear, anger, jealousy, or grief that the digestive
processes and general well-being are rapidly and materially altered;
while as tranquillity, peace, and happiness return the physical
state improves accordingly?
Dentists testify that as a result of continued strong emotion the character
of the saliva changes, pyorrhea develops, and the teeth decay rapidly.
Every one knows that strong emotion may cause the hair to fall
out and to become prematurely gray.
As to the most important organ of all--the brain--every one is
conscious of its impaired efficiency under emotional strain,
and laboratory researches show that the deficiency is accounted
for by actual cell deterioration; so the individual who day by day
is under heavy emotional strain finds himself losing strength slowly--
especially do his friends note it. By summation of stimuli
his threshold becomes lowered until stimuli, which under normal
conditions would be of no effect, produce undue responses.
"The grasshopper becomes a burden," and prolonged rest and change
of environmental conditions are necessary for restoration.
If in a long emotional strain the brain is beaten down;
if the number of "low-efficiency" cells increases, the driving
power of the brain is correspondingly lessened and therefore
the various organs of the body may escape through the very
inefficiency of the brain to produce in them forced activity.
On the other hand, if the brain remains vigorous, the kidneys
may take the strain and break down; if the kidneys do not break,
the blood-vessels may harden; if the blood-vessels are not affected,
the thyroid may become hyperplastic and produce Graves' disease;
if the thyroid escapes, diabetes may develop; while if the iron
constitution of the mechanism can successfully bear the strain
in all its parts, then the individual will break his competitors,
and their mechanisms will suffer in the struggle.
This whole train of deleterious results of body activation without
action may be best observed and studied in that most emotional
of diseases--exophthalmic goiter. In this disease the constantly
stimulated distance ceptors dispossess the contact ceptors from
the common path, and drive the motor mechanism to its own destruction,
and the patient has the appearance of a person in great terror,
or of a runner approaching the end of a Marathon race (Figs. 16
and 48 to 54).
Exophthalmic goiter may result from long emotional or mental stress
in those cases in which the thyroid takes the brunt of the strain upon
the mechanism. As adrenalin increases blood-pressure, so thyroid
secretion increases brain activity, and increased brain activity
in turn causes an increased activation of the motor mechanism
as a whole.
We know that a deficiency or lack of thyroid secretion will inhibit
sexual emotion and conception, will produce stupidity and inertia;
will diminish vitality. On the other hand, excessive thyroid secretion
drives the entire mechanism at top speed; the emotions are intensified;
the skin becomes soft and moist, the eyes are brilliant and staring;
the limbs tremble; the heart pounds loudly and its pulsations often
are visible; the respiration is rapid; the stimulation of the fear
mechanism causes the eyes to protrude (Fig. 16); the temperature
mounts at every slight provoca-tion and may reach the incredible
height of 110'0 even. In time, the entire organism is destroyed--
literally consumed--by the concentration of dynamic energy.
It is interesting to note that in these patients emotion gains complete
possession of the final common path; they are wild and delirious--
but they never have pain.
All the diseases caused by excessive motor activity may be called
kinetic diseases. Against the conditions in life which produce
them man reacts in various ways. He intro-
{illust. caption = FIG. 51.--CROSS-COUNTRY RACE. Winner of six-mile
cross-country race showing typical expression of exhaustion.
(Copyright by Underwood and Underwood, N. Y.) duces restful variety
into his life by hunting and fishing; by playing golf and tennis;
by horseback riding; by cultivating hobbies which effectually.
turn the current of his thoughts{illust. caption = FIG. 52.--{A B
and C} from the consuming stress and strain of his business
or professional life. These diversions are all rational
attempts to relieve tension by self-preservative reactions.
For the same reason man attempts to relieve the strain of
contention with his fellow-man by unions, trusts, corporations.
In spite of all efforts, however, many constitutions are
still broken daily in the fierce conflicts of competition.
We know how often the overdriven individual endeavors to minimize
the activities of his motor mechanism by the use of agents which diminish
brain activity, such as alcohol, tobacco, and various narcotics.
Occasionally also, some person, who can find no respite from his own
relentless energies, seeks relief in oblivion by suicide.
Most fortunately, two fundamental instincts--self-preservation and
the propagation of the species--act powerfully to prevent
this last fatal result, and instead the harassed individual
seeks from others the aid which is lacking within himself.
He may turn to the priest who seeks and often secures the final
common path for faith in an over-ruling Providence, a faith which in
many incontrovertible instances has proved sufficient in very truth
to move mountains of lesser stimuli; or he turns to a physician,
who too often treats the final outcome of the hyperactivity only.
The physician who accepts the theory of the kinetic diseases,
however, will not only repair as far as he may the lesions caused
by the disordered and forced activities, but will, by compelling and
forceful suggestion, secure the final common path for right conduct,
that is, for a self- and species-preservative course of action
as opposed to wrong conduct-a self- and species-destructive
course of action.
By forcefully imparting to his patient the knowledge of the far-reaching
effects of protracted emotional strain, of overwork, and of worry,
the physician will automatically raise his threshold to the damaging
activating stimuli which have produced the evil results.
Even though some parts of his organism may have been permanently disabled,
a patient thus protected may yet rise to a plane of poise and
efficiency far above that of his uncontrolled fellows.
In extreme cases it does not seem unreasonable to believe that the
uncontrolled patient might be rescued by the same principle which has
proved effective in saving patients from the emotional and traumatic strain
of surgical operations--the principle of anoci-association. That is,
by disconnecting one or more of the activating organs from the brain,
the motor mechanism might be saved from its self-destruction.
Under this hypothesis, that man in disease, as in health,
is the product of his phylogeny as well as of ontogeny, the sphere
of the physician's activities takes on new aspects of far-reaching
and inspiring significance. Prognosis will become definite in proportion
to the physician's knowledge not only of the ontogenetic history of
the individual patient, but also of the phylogenetic history of the race.
As that knowledge increases, as he appreciates more and more keenly
the significance of environment in its effect upon individual development,
in so far will the physician be in a position to contribute mightily
to the welfare of the race.