RELATIONSHIP OF PHYSIOLOGY TO MEDICINE AND SURGERY.

1361

Special Articles. RELATIONSHIP OF PHYSIOLOGY TO MEDICINE AND SURGERY. An Address to Members of the Inter-State PostGraduate Assembly of North America, delivered at Edinburgh on June 6th, 1927, BY SIR EDWARD

SHARPEY-SCHAFER, F.R.S.,

PROFESSOR OF PHYSIOLOGY IN THE UNIVERSITY OF

EDINBURGH.

PHYSIOLOGY forms the basis of Medicine and Surgery. Until lately it was known in this University as the Institutes of Medicine, which, being interpreted, means the Foundations of Medicine ; the term is still used in Trinity College, Dublin. Literally physiology means the science of nature, but is now restricted to mean liring nature. It is therefore the science of life, also known as biology. Animal physiology is the science of animal life, human, physiology that of human life. Physiology must be studied in living organisms, or in living-i.e., surviving—parts of the organism, such as separated As with every organs, or tissues, or isolated cells. other branch of science it, can only progress by experiment, and, since it deals with life, experiments can only be made on the living subject. Some experiments can be and are made on man. Every patient must always be the subject of experiment, and in that sense every doctor has the opportunity of advancing the knowledge of physiology. We shall, in fact, see that physiology owes much to the observations and experiments of clinicians. But most experiments in physiology cannot be carried out on the human subject ; they must be performed on the lower animals, and the results—so far as possibletransferred to man. Hence the necessitv for " viviVivisection is performed every day by section." the operating surgeon upon his human patients, but

only

of the living body, the other with the chemical changes. But we cannot understand the working of a machine without a knowledge of its structure, and this is where anatomy comes in. h’uWher, since tbe functions of the body are actually performed by the living cells and tissues composing it, the microscope becomes an essential instrument to the physiologist, who needs to observe both the microscopic structure of the living cell and the changes it undergoes as a result of activity. On this account histology or microscopic anatomy has in this country always been taught along with physiology, although it has been the custom in Germany and America to associate it rather with the teaching of anatomy. But since uo problem in physiology can be considered completely solved until it is brought down to the bed-rock of the changes occurring in the living cell, the importance of the microscope as an adjunct to physiological methods becomes apparent. This is beginning to be recognised in the United States; witness the microdissection methods of Chambers of New York, the observations on renal activity of Richards of Philadelphia, and the interesting results obtained with surviving tissues by flarrison of Yale, and by Carrel of New York. The physiologist who neglects the use of the microscope eventually fincls himself in a blind alley beyond which lie can make no further progress. If it is true of physiology that the microscope is an essential instrument of investigation it is still more evident for the daughter sciences of pathology and bacteriology, in which all the methods of physiology are employed, and for both of which the And since at the microscope is a first necessity. present day the progress of medicine hinges on those ’’ " two ologies it is scarcely too much to aver that is the most important instrument for microscope the advancing our knowledge of medical science. No one understood this better than the great Lister, who expressly tells us how itzvaluable for his later researches he found the early training in the use of the microscope which he obtained from his father, to whom, as is well known, we owe the modern form of this instrument.

indignation amongst unreasoning people performed upon animals for the benefit Rational Medicine and Surgery. of humanity. Only those who are callous to human In considering the relations of physiology to suffering can reasonably contend that experiments medicine we must recognise and accentuate the fact upon living animals should be put a stop to because that medicine is no longer an art, but has developed it may involve the infliction of pain upon them. into a science. That a good deal of empiricism remains It, involves no more pain than operations upon man is inevitable by reason of attached to its - -usually none at all-since the animal under our ignorance of practice the causation and exact course of like a is under operation, subject surgical operation, many affections ; until these are known there can be kept anæsthetised during the whole time. An animal no rational treatment of them. But all patients look is generally killed while still anæsthetised. Even for treatment of some sort, whether rational or not ; if the experiment requires that it should be kept they naturally expect you to do something for them, alive for the subsequent result of the operation to if because that is what they pay you for. Your only be observed, it will suffer no more than the surgical own experience or that of your teachers may have from an in patient recovering operation—indeed, most shown that. whatever the reason for a particular cases far less. Operation on or inoculation of the line of treatment or the administrationit, of a particular lower anirnals is the only way we have of extending drug will alleviate the symptoms of a disease regarding our knowledge of medicine and surgery in man; which you know of no rational remedy, and you unless we are to make our experiments upon man therefore employ that line of treatment, although himself. which few would, I think, contend to be may be well aware that it is purely empirical. justifiable, even if, as would indeed be the case, there you Regarding this we must bear in mind that empirical were men and women brave enough to offer themwhich have been constantly employed in In the methods selves as the subjects of experiment. (such, for example, as those referred to days past investigation of diseases which are peculiar to man it in the libellous I physicks; epigram on Lettsom, is sometimes necessary that inoculation should be arouses

when it is

"

carried out on man, and there have never been lacking doctors who are willing to take the risk of serious illness or even death in order that the aetiology of such affections should be cleared up, Self-sacrifice of this kind is as heroic as that of the battlefield and is no less deserving of recognition, although it rarely, if ever, receives it. Ancillary Sciences. For the study of physiology a prior knowledge of three other sciences is essential. These are physics, chemistry, and anatomy. The application of physics to physiology or biology is termed biophysics ; that of chemistry, biochemistry. The one deals with the physical changes associated with the functions

bleeds and sweats ’em ") are now abandoned as But these abandoned methods useless or harmful. were in their day recognised as efficient by the whole profession of medicine. We must therefore remember that such empirical methods as may be in fashion in our own time are liable to meet with a similar fate. Only if there is a scientific reason for any course of treatment can you justly repose confidence in it. A great advance has been made in the administration of drugs, the action of which is much better understood than was formerly the case, so that their empirical Even the laity use is being gradually relinquished. is beginning to ask the reason for administering this or that medicine. And the great drug-manufacturing companies now not only have chemical but also

1362 laboratories belonging to them in order although many did not acknowledge it. It was indes d that the medicaments they produce may be tested long ere the empiricisin which characterised medicing t and standardised b3- their action upon animals before was abandoned; nor, as we have seen. i- !t being sent out for the use of the profession. wholly given up. But with the growtand deve lopMany cases, as we know. require not only a careful ment of physiology and its daughter sciences medic me physical examination of the body, but in addition the has becojne gradually built up into the imposite chemical and microscopical examination of the urine. edifice of which to-day it is constitated. It It iq not with orre aspect only mF physiology that and in certain instances of the blood as well. For only was no doubt a simpler proceeding to determine the the luedical man of to-day is interested. nature of the disease merely by visual inspection, which an increased knowledge of the function of each several need not have embraced the patient himself. but may organ rendems advance possible in the treatment of havemerely consisted of an inspection of his urine. diseases of that organ. ’I’his is well illustrated hB th. Yon will remember how Falstaff sends his page work of Bernard oil secreting glands. of Ferriet and others on the functions of the brain. of Pavlev on to the doctor with a sample of urine in order that the digestive organs, and bv more recent discoventies it may be cast." Falsta,tj: Sirrah, you giant, ’what says the doctor to regarding the influence of internal secretionson many functions of the hody. perhaps the most jay water ?:’ page: He said, sir, the water itself was a good healthy striking’ illustration of the direct application of water ; but for the party that owed it, he might have more physiological research to medicine is to be found in diseases than he knew for. the recent discovery of insulin, which has enabled King Henry 1 T-., Act I. Scene II. life of the diabetic to be prolonged to the normal the At any rate the patient had no doubt as to the lirnit and has restored him not oniy to health but to doctor’s ability to effect both a diagnosis and a a condition of usefulness and freedom frmlm anviety prognosis in this manner. But 1 do not think that which was impossible to be achieved by diet et im t reatthe method would satisfy even the most confiding ment alone. Training of Fledical Men. patient of the present day. If Medicine now takes rank as a science, this is Apart from the effect the advances in physielogy even more true regarding Surgery, Not that the have had in promoting corresponding advances in ort of Surgery will ever for after all is medicine, work in physiology affords the best possible said about its scientificaspect the work of the surgeon training fur the practising physician or surgeon. will always be a form of handicraft; and in every Many instances might be adduced of the effects of handicraft there must be individual differences. such training upon individual physicians hot!) ill Nevertheless no surgical operation can be undertaken the past and in the present. As regards surgeons it These has been customary to assume that what they without a knowledge of certain sciences. deal respectively with (1) the structures to be chiefly require is an accurate knowledge of anatomy. encountered (anatomy) ; (2) the probable effects of although I well remember one of my own teachersthe operation, immediate and remote (physiology) ; an eminent surgeon, but of the slap-dash kind- (3) the nature of the disease or injury (pathology); whose favourite advice to the student was "Don’t (4) the risk of contamination with micro-organisms let your anatomy spoil your surgery." f hope we (bacteriology) ; and (5) the administration of the most of us allowed the advice to pass unheeded; anaesthetic and the after-treatment of the case. but the idea that only a precise knowledge of anatomy whether by drugs or otherwise (pharmacology and is required by the surgeon was long prevalent and i-:, therapeutics). Of all these the surgeon must possess if possible, even more unsound. For it must be an adequate knowledge. remembered that et-ery surgical case is always in the first instance a medical case. and requires for Beginning of Physiology. and treatment all the methods of the The dependence of Medicine upon Physiology is diagnosis as well as the physician special methods of surgery. evidenced by the fact that all forms of treatment These methods are based on those of physiology; were purely empirical before a correct conception of it therefore follows that a training in physiology is of physiology was introduced--i.e.. before the study for the surgeon as for the physician. as physiology, in the modern sense of the word, had Theimportant effect of such training on the development of This beginning dates from almost their science is well illustrated really begun. by the career of many exactly 300 years ago. Harvey had been teaching Butby far the most of the day. present surgeons his doctrine of the circulation of the blood for several eminent is the case of Joseph Lister. example in lectures of to the Physicians years Hoyal C’ollege it is not very generally known. Lister’s of London, but he did not give it to the world until Althoughwas mainly physiological, and al! bis early training 1628 when his immortal work on the heart and work If was of a purely character. circulation was published. This book-the original he had not developed into the greatest surgeon of edition is rare ; the University of Edinburgh is all lie would have become a great physiologist. fortunate enough to possesss a. copy—must be regarded ITistime, work is characterised by an physiological as indicating the beginning of physiology as we extraordinary accuracy of observation and ingenurty v For until the action of the understand the term. of method, and it was the experience be gained in heart and the course of the blood was comprehended his physiological researches which enabled him to no clear notion regarding the functions of any part to the triumphal termination we know the of the body could be had ; everything was guess-work. carry which led to the discoveryof the investigations The famuus epitaph composed by Pope on Newton, of antisepsis, on which, in its more modern principles -N,ature and Nature’s laws lay hid in night : form of asepsis. the whole practice of modern smallry God said. " Let Newton be" and all was light, is based. The Reciprocal Obligation. might equally well apply to Harvey so far as the T have said is concerned, Until his time perhaps enough to indicate th. living body about in complete darkness, but as soon obligations of medicine and surgery to physiology. was as his doctrine was enunciated light was at once It would he possible to expatiate on this these to thrown on the functions of the body and the any extent, but T wish to deal very brietly with another foundation of physiology was laid. ’Although the aspect of the subject of this address. and tlmt is the evidences he adduced appear to us convincing, his obligations of physiology to medicine and sugery. doctrine was by no means at once universally acc-c pted. fn this T shall restrict myself to examples drawn So difficult is it for men to disabuse their minds of from the internally secreting organs. partly hecanse ideas winch have long persisted and with which in to do anything else would occupy far too much their education they have become thoroughly imbued. tinx’. partly because it is the subject wih which1 however decisively these ideas may have been shown arrt personally most familiar. to be erroneous! Nevertheless, the foundation of In the fir’st place. then. I would remind you that scieutitic medicine was being laid at the same time. the discovery that the suprarenal capsules cadienals

physiological

"

’

disappear,

physiological

groping

medicine

1363 possess any function at all was due to the clinical observations of Dr. Addison, of Cuy’s Hospital, London. who, I may remark in passing, received his medical training in Edinburgh, but another Scot migrated south and stayed there. Addison, in 1855, described the affection which bears his name, and showed it to be invariably accompanied by destructive disease of the suprarenal capsules, and to be as invariably fatal. This announcement led to a number of experiments on animals to determine whether the ablatiun of these organs was equally fatal in them. The question was answered in the affirmative by Brown-Sequard, and his verdict is now The attention of the generally accepted. physiologist having been thus directed to the suprarenal capsules they have ever since remained objects of interest, not only to him but also to the physician. If you look through any file of physiological literature you will find that relating to the suprarenal capsules to uccupy a bulk entirely disproportionate to the size of these small and apparently insignificant structures. As a second example I will take the discovery of It the functions of the thyroid and parathyroids. was noticed about the year 1883, by certain Swiss surgeons (Theodor Kocher, and J. L. and A. Reverdin) that after surgical removal of the tumour fulmed by the enlarged thyroid in cases of endemic goitre the patients became apathet.ic. their mental processes were dulled, and in the worst cases they lapsed into a condition indistinguishable from idiocy. This condition was accompanied by a peculiar cedematous affection of the integument and by other physical signs which I need not further specify. Some of the operated cases also exhibited the symptoms of the affection known as tetanv. This was also at first ascribed to the loss of the thyroid, but is now known-thanks to the work of Gley-to be due to the inclusion the parathyroids in the extirpation. Some time before-namelv, in 1871-the clinical observations of Sir William Cull in I-,ondon showed the existence of a syndrome characterised by atrophy of the thyroid. and having the same symptoms as were later shown to be caused by surgical removal of that organ ; to this disease the name myxœdema was given by Ord. Subsequently it was found that grafting portions of thyroid after extirpation of the whole gland would prevent the characteristic myxcedematous symptoms and still later that subcutaneous injection of thyroid juice or extract (Murray) or even administration of thyroid bv the mouth would entirelv combat the effects of thyroid removal or atrophy in man. These clinical observatiuns led-like those of Addison on the suprarenals-to physiological experiments upon animals. The experiments showed that loss of the thyroid is. in most cases at all ages (in young animals always), productive of a condition of depressed mentality—so far as it is possible to determine this in animals—similar to that which occurs in man, as well as most of the other physical ss-mptulms which had been described clinically. It was further found that the condition could be entirelv obviated by grafting portions of thyroid and by subcutaneous or oral administration of the gland or its juice. And it has recently been shown (Collip) that parathyroid extract is effective in combating the symptoms of tetany caused by removal of parathyroids. Thus all the physiological work on the thyroid and parathyroids had its origin in clinical observations. My third illustration is derived from the pituitary body. About 1:0 years ago the eminent Paris physician, Pierre Marie, gave a description of a peculiar syndrome characteii.sed by the appearance of greatly enlarged extremities—hands, feet, and face (although the hypertrophy which causes this enlargement affects tin- whole osseous and connective tissue structure of the body). To this affection he gave the name acromegaly. and showed that it is always associated Those tumours with tumours of the pituitary body. he supposed to be destructive, and to test this hypothesis physiologists set to work to destroy the

like many

physiological of

pituitary

in animals, in the

might show

a

that the effect

destruction

expectation that they But they found exactly the opposite ; if the

similar syndrome. was

effected in a growing animal it " to grow. Evidently, then, the boot was on the tumour was not a destructive other leg " ; but an adenoma—i.e., an enlargement of the itself. And this supposition is corroboiated by the observation that " giants" are subjects who, during the process of growth, have undergone enlargement of the pituitary body-at least of its anterior part ; this enlargement has produced the same effects as those seen in acrumegaly, with the addition that the long bones have grown in length owing to the fact that the enlargement of the pituitary has occurred before the diaphysis and epiphysis of these bones had undergone ankylosis. Since Marie’s observation the attention of physiologists has been directed to this minute organ, the functions of which were until then unknown. And although much remains to be elucidated a great deal has been discovered respecting these functions, not only in connexion with growth. but—as regards its posterior lobe—with the activity of involuntary muscle (especially of the heart. blood-vessels, and utcrus). with the functions of the kidney, and with those of many other organs of the body. Indeed. the literature of the present day relating to the pituitary body is to probably greater in amount than that any other subject, not even excepting the thyroid and were

ceased

the one,

gland

relating

the

suprarenals.

Advance of Knowledge. obligations of physiology to surgery cannot be evidenced by mere illustrations such as those I have given for Medicine. The progress of Physiology at the present day goes hand in hand with the progress of Surgery ; they are mutually interThe physiologist employs in his dependent. experiments all the methods of modern surgery and, as surgical technique improves, each improvement is adopted by the physiologist. And in advancing his subject the experimental surgeon becomes a physiologist and advances physiology at the same time. No sharp line of demarcation can be drawn between the two subjects ; nor, indeed, between any The

of the branches of science associated with medicine. In one direction Physiology borders on Pathology : in another on Pharmacology ; in another on Chemistry ; in another on Physics ; in another on General Biology It is, indeed, a mere both of animals and plants. axiom that no branch of science can be properly dealt with unless its relation to others is taken into account. and to none does this more directly apply and than to the mutual relationship of

Physiology

Medicine.

(FROM

BUCHAREST. CORRESPONDENT.)

OLR OWX

War on Mosquitoes. ACCORDING to a report recently issued by the Ministry of Health, malaria is claiming; a considerable number of lives because the protective organisation is inadequate. The yearly average of deatlis caused by the disease is nearly 5000 and about 100,000 persons are infected. They are mostly of the workingclasses, and especially agricultural labourers, who are not protected at all, whereas indnstrial workmen, being under the control of the sickness insurance uf1ices, come up front time to time for medical supervision. According to Dr. Banu. Secretary of the Ministry of Health, the greatest obstacle to efficient prophylaxis is the lack of physicians in the counties most infested with malaria. This grievance is to be remedied by offering good salaries to young doctors willing to settle in these districts. A central bureau will be established in Bucharest, and here the various problems will be thoroughly studied. In every county in the infested district a laboratory is to be established, adequately equipped and with a competent medical