The big brag preceded the big bang as a human
possibility. Any demonstration that the earth revolves
about the sun, while offensive to the authorities in
charge, did not presume that we could reverse its
course. Any proof of a natural law called gravity did
not presuppose that man could make apples fall up;
designers of supersonic planes, indeed, still take account
of the apple. To the frontiersmen of science the
discovery of natural laws meant no more than that we
had explored certain forces governing the dispositions of
man. But for many a hoi-polloi scientific settler who
came after the frontier such discoveries meant something
quite different: Man could master nature.
The cardinal psychological prerequisite for accepting diseases, death and their democracy is the realization that the denial of these lies in the realm of the impossible. The task before us is to discover certain natural forces and laws governing the nosologic (noso = disease) and the thanatologic dispositions of man. And such discovery reveals to us the trans-scientific nature of human disease and death.
A word about trans-science: Weinberg, introducing this concept and term, defines ‘trans-science’ questions as those that can be asked of science, but cannot be answered by science. Epistemologically, these are questions of facts presentable in the language of science but to which science has no rational answers; such questions transcend science. For example, about the ‘why?’ of the invariable variability of a person, from birth through death, questions have been asked of medical science, but have not been answered by medical science. Modern medicine, in its ostensibly scientific optimism, has not accorded due consideration to factors that are not only trans-modern-medicine but trans-any-science.
At the root of medicine’s failure in providing an answer to the questions of what, when, how, where and who is an assemblage of four independent biological factors; time, uncertainty, relativity, and normality. These abstract principles govern all that appears concrete in medicine be it laboratory research or the development of a person, physiological parameters, disease, and death. Such an approach is both an analysis and a synthesis, discussed in the order of time, relativity, normality, uncertainty, and the overall implications thereof.
Time is as fundamental as space and holds perhaps the essence of all reality. If matter has been understood as but configured energy, then life needs to be understood as configured time. Isn’t man, from his very start as a zygote, a calendar of timed events? Human development, in the mother’s womb, is charted with remarkable precision in terms of weeks, days, and hours.
Lest the proposition that every life-form represents a unique, individualized space-time entity appear preposterous, it is pertinent to allude to Einstein’s concept that regards matter as the expression of an inner dynamic will that is natural, meaningful or even divine. If matter can be assigned such individualized qualities as ‘will’ and ‘inner essence’, there should be no objection to assigning each individualized life-form the status of a unique space-time unit. In a symposium titled Man and Time, Portmann characterizes any life-form as configured time, while Van der Leeuw pithily concludes: ‘We are time’. Burnet relates time to disease and senescence. He describes senescence as assuming similar form in each species as evidence by the physicochemical changes in collagen, the incidence of vascular degeneration or the high incidence of cancer, the whole gamut of events being guided by a genetic ‘programme in time’ specific to each species.
Van der Leeuw, talking in a similar vein as Burnet, states that we are time, we are timed, we are the timer. ‘We are temporal . . . The man of nine thirty is not the same as the man of nine twenty five.’ The most important point in the foregoing regarding man’s disease and dying is the apparently sweeping generalization that the man two and half minutes ago is not the same as the man two and a half minutes later. This bold generalization carries with it the ability to resolve many a paradox witnessed in modern medical practice - the puzzle, for example, of a person just dropping dead while full of life, or soon after being given a clean bill of health.
Nelson Rockefeller, ‘the richest man in the world,’ dropped dead, ‘working at his desk’ at the age of 70. The press particularly added that ‘Mr. Rockefeller had no history of heart trouble and he used to joke with his children that he was going to live up to a hundred years.’ Dean Acheson, the former American Secretary of State, died in a similar manner: ‘Full of years and honors, he slumped forward on his desk, without a moment’s agony or suspense.’ Pope Paul IV suffered a heart attack while resting in bed, and soon died. The deceased Pope was replaced by John Paul I, who died a bare 33 days after his appointment, probably from a massive stroke he suffered in his sleep. Winston Churchill’s wife died of a heart attack, at 92, while eating lunch at her London home. Similarly, Charles de Gaulle: ‘One neighbor had seen him in the afternoon on business and had come away feeling that le vieux was in superb health. At a few minutes past seven in the evening, he was about to sit down and thumb through some papers and perhaps play a game of patience. He merely had time to clutch his side and gasp, "It hurts", before collapsing. The doctor was summoned, as was the local priest who administered the last rites. Less than two weeks before his 80th birthday, Charles de Gaulle was dead from a ruptured blood vessel.’ The fact that all these deaths occurred to individuals who were resting, relaxing, or relaxedly working gives the lie to the medical theory of some ‘stress’ as the basis of such deaths.
It may be argued that the above group comprised aged people who did not take enough exercise. Opie and others, in The New England Journal of Medicine described the deaths from heart attack, in a boy of 19 1/2 and a man of 35, both accomplished athletes in the peak of physical fitness. LES, 49, a surgeon in South Dakota, died following a cerebral hemorrhage while he was operating on a patient. SG, a surgeon studying for his Fellowship in London, died of a heart attack at 29.
The sudden, unanticipated death from heart attack of say, Rockefeller at 70, and DLK, an orthopaedic surgeon, at 30, both fighting fit and with no history of heart trouble, cannot be related convincingly to any anatomical, physiological, pathological, or genetic factors. Many a person with any or all the presumed predisposing factors, even to a more severe degree, carries on admirably well, regardless, to eventually die unexpectedly and inexplicably of something else. Rockefeller died at 70, DLK at 30, incidentally of heart attack, both ages falling well within the age distribution of heart attack and resultant death, or of overall human mortality. A death hormone has been postulated; a death mechanism obeying an individual’s timer may be operative, doing what it wants to and when, and giving a disease a bad name. In an analysis of the death-rates in four major diseases by Zumoff and others, the startling finding was that the death-rate was neither related to the severity of the disease nor to its earliness or lateness, but to some undefined physiological systems governed solely by the passage of time.
What really killed all these people, and would kill most of us, is not this disease or that, but the fact, ascertainable only a posteriori, that the time was up, as declared by a timer inside. The allegorical timer inside is a pointer to the fact that, as of today, modern medicine can talk about the time of death of anyone healthy, diseased or more diseased, only after the death has occured. No list of predisposing factors including the medical prognosis of doom nor the findings at the anachronistic clinicopathological conferences allow a tenable correlation between the medical data and the why and when of death. It is the subservience of death to time alone as determined by the timer inside that allows a Tito or a Karen Ann Quinlan to tick on and on in the teeth of adverse opinion of medical experts, and a de Gaulle or Acheson to slump down dead when medically least expected to do so. We are time; we are ended by time.
Dobzhansky speaking from a biologist’s point of view talks of death as the climax of our proportioned and programmed development. Ageing, diseasing, senescence and death are held as built-in processes mediating biological maturation consisting of a series of gradual changes through time from conception to death. ‘To die, a man needs no disease. When the time is up, he dies with disease or without, regardless of full health and vigour. Like a ripened fruit falling off a tree on its own, man passes away on getting the call from the inner clock. People often wonder: "Oh, he was happy, healthy, active, and yet he died!". (Bhave) Death reigns, indifferent to the thousand man-made ifs and buts. The healthy may not survive, the diseased may not die.
Vinoba Bhave’s aphorism explains why people, in the pink of health and in the prime of their life, die a ‘natural death,’ and people who are manifestly afflicted with a major disease, or diseases not only drag on, but even seem to thrive. Leonid Brezhnev ruled the roost despite a rich assortment of chronic illness - gout, leukemia, emphysema, cardio-vascular problems needing a pacemaker, and also, possibly a jaw cancer, brain tumor, and chronic pneumonia. Golda Meir, the ‘tough maternal, legend,’ already had a lymphoma when she became the premier in 1969. It took her cancer 13 years before she succumbed to its ‘complications’ at the age of 80. Many a person afflicted with medically certified ‘killer diseases ‘ survives long enough to falsify the prognosis of doom.
The best example of the above is offered by an experimental study in the United States. In order to study the development of major diseases in relation to age in rats, Simms and co-workers created ideal animal quarters which, because they offered the test animals board and lodging, comparable to a Waldorf-Astoria, came to be known as the Rat Palace. Visitors who had come in contact with other rats elsewhere were strictly forbidden in order to preclude the possibility of their transferring any contagious disease to the rats in the Rat Palace. And yet in this rat-utopia, diseases and death occurred with predictable timing and frequency. Comparing the findings of this experiment on rats with those in man, the authors concluded that, barring the differences in the time scale, the findings on rats were easily applicable to man and that the factors that determine longevity (or mortality) of the two species seemed to operate in a closely comparable fashion. Needless to say, the diseases in rats bore the same relation to death, as in man: death and disease occurred independent of each other. This comparison between rat and man brings us to the next important factor - namely, relativity.
For several criteria of relative time, all mammals live about the same span. All mammals , for example, breathe about the same number of times in their lives. The problems of middle and old age that bother man do not spare the animals. Most spontaneous cancers in animals, as in man, occur in middle-aged or elderly animals. It is also true of atherosclerosis, be it man, swine or killer whale. These observations and the Rat Palace experiments of Simms and his co-workers drive home the relativistic nature of animal / human senescenece and death. Collagen, although physicochemically similar in man, horse, dog, rat and mouse, exhibits maximal, and very closely comparable, age-changes in these animals respectively at 70, 25, 12, 3 and 2 years. Thus man, in terms of ageing and death, is a mouse whose time scale has been enlarged 35 times.
The relativity that prevails at the collagen-level, disease- level, and lifespan-level, is clearly reflected in the number of times the embryonic cells can multiply - the upper limit of the capacity being known as the Hayflick limit. Hayflick has demonstrated that the duplicating capacity of the cells from the embryo of an animal relates closely to its lifespan - the greater the lifespan, the greater is the number of times the cells can serially multiply.
We now have sufficient information to reach an understanding of the relativity of biological lifespan. Although the cells and the collagen fibers of all mammals are very similar, they age at a rate that is inversely proportional to their lifespan. Further, given the time-adjustment between different species (that is 3 years for a rat corresponds to 70 years for man), both the cells and the collagen fibers reach the same endpoint in all mammalian species. In terms of cells and fibers (cytofibernetics), we are forced to conclude that man is no more than 70/2 or 70/12 times a longer lived mouse or dog respectively. Man’s ageing is relatively slow, that of the dog less slow, that of the mouse slower still. The rates differ, but not the basic style. The problem is, strictly, one of relativity, Jacqueline Susann, in a novel about her dog Josephine presents this relativity in the most telling manner: She said, ‘That’s a cute puppy you’ve got. How old is it?’
I said ‘Six.’
‘But she is forty-two years old,’ the woman insisted. Who was forty-two? Even Josephine looked interested. Josephine was forty-two, the woman insisted. A dog’s life is seven to our one. At six, Josie was forty-two. A middle-aged woman.
Such differing rates of ageing are seen even within the human herd, where, despite the genetic similarity of one man to another, one lives for 19 years the other for 91 years, one grays earlier and the other later, one woman gets cancer and the other escapes, and so on. The basis of this differences lies in the bioforce of normality as governs a given herd. While relativity explains the differences between species, normality underlies the differences within a species.
To say what things are normal, one must know what is abnormal. Alas, medicine has not been able to define what constitutes the normal, be it the blood sugar or the blood pressure. It is high time that normal / normality is accorded its pristine status of a field-concept that is thoroughly irrelevant and inapplicable at an individual level.
The current widespread problem concerning the normal and normality is traceable to carpentry, geometry, and arithmetic. Norma means the carpenter’s square, and hence in geometry, normal connotes perpendicular, as also a line perpendicular to the tangent to the point of a curve. By extension, normal implies the point at which this perpendicular line intercepts the X-axis. Since in a Gaussian curve, this point of interception falls on the arithmetic average on the X-axis, normal is regarded as synonymous with mean or average and everything to its right or left becomes deviation error, or what is worse, abnormal. The etymological errors multiply to equate ‘normal’ with ‘sane, natural, prevalent, regular, typical’ and by virtue of all this, ‘ideal’. In this jungle of verbal distortions, what has been lost sight of is the fact that the appellation ‘normal’ refers to a form of frequency distribution, also called Gaussian distribution. Such a distribution provides a graph or a curve that is bell-shaped, symmetrical, with its two ends stretchable to infinity, thus allowing the widest variations of a parameter, say, blood pressure readings, to fall within normality. The law of normality prevails in the inanimate sphere with as much felicity as in the animate world.
Any biological characteristic that can be measured, exhibits normal distribution. This could be human birth weight, under conditions ‘normal’ or ‘abnormal’, blood cholesterol level, or intelligence. Must it not be for reasons of normality that the brain size varies widely on either side of the mythical normal (that is to say average) brain, with Anatole France enjoying a mere half of the brain size of Lord Byron or Oliver Cromwell, with Einstein in between, near the average? Again, would not the normality of distribution of intelligence, independent of the brain size, account for the brightness of Anatole France, the genius of Einstein and the mental retardation of individuals with oversized brains?
If physiological features such as blood pressure or acid secretion in the stomach exhibit normality in their distribution, pathological features - even of the most serious nature - are no less normally distributed. In any population, it is the normality of distribution of the so-called pathological traits that determines the occurrence, severity, age at diagnosis, post-diagnostic/ post-treatment survival, or the age at death, of such diverse diseases as congenital malformations, peptic ulcer, hypertension, diabetes mellitus, cancer, heart attack, etc.
The discussion on normality can be concluded with the realization that each of the many features, physiological or pathological, that comprises a human being, is unpredictably and unalterably distributed on the normal curve, independent of all other features. To the utter chagrin of modern medicine and its specialists, such a ‘normal’ state of affairs makes uncertain the what, when, why of every disease, forcing modern medicine to be plagued by uncertainty at the level of the individual patient. Let us now understand the fourth element, namely, uncertainty.
Uncertainty, the alter ego of Pascalian probability, is the child of normality, the science of quantitative differences between human beings. Modern medicine, without doubt, has spawned a gargantuan technocracy, unmindful of the quantitative nature of all human differences - anatomical, physiological, psychic, pathologic or thanatologic. The seemingly gross differences between two persons - one with elementary intelligence the other with creative genius, one with high stomach acid and no ulcer the other with low acid and ulcer, one surviving cancer, the other succumbing to it, and so on - are all a matter of quantitative variations normally distributed throughout the species.
In health and in disease, human beings differ, one from another, but the difference that modern medicine can detect, given its most sophisticated gadgetry, is not qualitative, but quantitative, not one of character but of measurement. Human beings quantitatively differ very widely, this being the nature of any parameter normally distributed. And there is no way of telling which human being , healthy or diseased, would show what reading, and why. This makes for the nagging uncertainty that modern medicine can not dispel while dealing with an individual patient.
It is the uncertainty principle which lends medical practice its mysterious element of unpredictability that charms and challenges the man of action - the medical man. It is uncertainty, backed by temporality and normality that accounts for an esophagus declared normal today but found cancerous tomorrow and ECG (EKG) being assured as all right today, and worrisome tomorrow, the patient given up as lost today, surviving to attend his physician’s funeral, tomorrow. But for uncertainty, medical practice would not have been half as fascinating.
Time, uncertainty, relativity and normality universally govern development, disease and death - concepts that allow an intellectual ratiocination of both the trans-science and trans-medicine aspects of disease and death.
These concepts have some wider implications for modern medicine. They put modern medicine in its place, dismissing as naive modern medicine’s causalism - fat causes heart attack, coitus causes cancer. These concepts further promise to cure modern medicine of its characteristic obsession that every ill - congenital or acquired - is a preventable outcome of some molecular, genetic or cytological aberration. The borderliness that modern medicine has created stand erased, for we realize that the difference between the ‘normal ‘ and the ‘abnormal ‘ is not that between black and white but between shades of gray, with no diving line anywhere. The phenomenon of death acquires the status of an independent, physiological function: we are purposely, unalterably programmed to die. All major problems - congenital, cardiovascular, cancerous, or metabolic - that medicine is claiming to be intensely researching upon, are, in essence, unresearchable. Science etymologically means knowing, not doing. Disease and death are not trans-science if we aim to understand them. They are so only if we want to manipulate them. More correctly, aren’t they trans-technique?
The choicest implication of this chapter, however, may be its integration of physical laws and biological laws, physicists and physicians, matter and man. By hinting at the integral relationship between time, relativity and uncertainty - hitherto only in the domain of matter - and man, the borderline between the living and non-living grows fainter. In the telling words of Ardrey, ‘Time and death and the space between the stars - these are the ingredients of the woman who prepares your breakfast, or of the man who gets off the train as you get on.’ This chapter amplifies a poetic insight in order to put into place laws that may govern you, the person who prepares your breakfast, as also the men you meet in the street. It’s but a peremptory perspective on the democracy, the immense impartiality, the trans-science temper, the Upanishad or the Tao of human development, disease and death.