The trans-technique aspects of disease and death.
The technological triumphs of this century outweigh and outclass the aggregate achievements of the entire human past; yet modern man has been denied the elixir of cure for his disease and death. A logical survey of medicine's failures reveals that it is not that the technology per se is ineffective but that what technology has solved is trivial, and what it just can't touch is crucial, being beyond any technique. Most of human disease and death is trans-technique.
Technique in medicine is whatever a diagnostician, therapist or researcher does to a patient. Trans-technique aspects of disease and death are those innate, ordinary, day-to-day features of human living and dying that le technique can in no way modify to a patient's advantage.
Seemingly, technology has reached its apogee, its Ultima Thule; the march is unimpeded, for the would-be-obsolete CT scan is likely to be replaced by the could-be-obsolete NAM imaging. However, a dispassionate, epistemologic evaluation of medicine's gains reveals them to be imagery, accessive, analytic associative, and amplificatory. The more the physicistic science and the physicianly art interact, the greater is the variety in which medical imagery can be obtained. Yet, to take but an example, roentgenography, xerography, CT scan, ultrasonography and NAM imaging have left a cancer where it was-diagnosed always a little too late. The ability to cannulate the pancreatic duct/artery towards the diagnosis/treatment of pancreatic cancer is an accessive advance that leaves the cancer's autonomy untouched. Increasingly refined biochemical techniques allow many a substance to be measured with picoprecision, thus analytically telling us a lot about heart attack, diabetes mellitus or rheumatoid arthritis, but without the liberty to predictably/ and/or favourably alter the course of the disease. Epidemiology connects the husband's cigar to the wife's cancer, coffee to cardiovascular disease, and HLA-antigen to a host of maladies-an associative exercise that makes more anxiety than sense. The E/M amplifies the size of a T-lymphocyte n-tuple times only to amplify our ignorance on the cell to the same magnitude. In the modern medical setting, technology glitters, but is, often not gold.
A quartet of diverse medical men,, , ,  in its recent generalization, is not far from the truth that 90% of the bad things that happen to man are beyond the ken of modern medicine. Armed with technical might, the doctor can, with vis medicatrix naturae providentially at the patient's beck and call, revert to eu-states acute physiologic crises, set fractures, fix retinae, deliver babies facing dystocia, remove lumps and cataracts, replace a valve or a joint, correct mechanical defects such as cleft lip or hernia, all this comprising the 10 per cent of man's maladies that medicine can manage. The rest is trans-technique. Let us see how, and why.
Four biomedical factors account for the trans-technique scenario that we are witnessing. These are Cellularity, Systemicity, Uniqueness and Herdity. An integrated appreciation of these factors will help us understand medicine's limits, no matter what its technical might.
Cellularity: Celldom Unconquered
There are features of a mammalian cell that make disease and death trans-technique in more ways than one. It is a fitting paradox that what advanced cytologic techniques have revealed about the cell has snowballed to drive home the truth that a cell's behavior, in health or disease, can hardly be trifled with.
The microsize of a cell accounts for the fact that before a scan discovers a cancerous lump measuring one cubic mm and weighing one mg., the smallest tumor mass that one could ever hope to detect clinically-the cancer is already a million cells strong and several years, old; early diagnosis of cancer is only a myth. The same considerations apply to an atheromatous plaque, held by some as mitotic in origin. Even if we end up with a -scanner that can spot a single wayward cell, the latter could mislead by exhibiting the Shakespearean repertoire of looking benign despite malignant intentions and vice versa. Any attempt at flooding the body with antiabnormal-cell-agents (radiation, chemicals) fails because of the selfsameness of all body cells, rendering selective destruction of undesired cells impossible. Supposing that a highly specific drug is developed and administered, the target cell can recall its microbial past to readjust its genetic machinery-mutate-to KO the drug, the mutative repertoire of a human cell bordering close to 25& followed by 2.4 billion zeros. Transplanted, the guest cells refuse to merge their identity, their unique self-ishness, as much as the host cells, and all hell is let loose. Each of our body cells carries in its bosom a decision in advance of performance. The thousand inner shocks that the flesh is heir to are indelibly programmed into it ab initio; all that we see is an unfolding of a built-in story with the flow of time.
The human body is a holon that starts as a single cell, and sui generis, builds up a cytogalaxy that behaves as a single, concerted unit whose seemingly disparate parts form, grow, and decay in unison.
Acknowledgedly, cancer is a disease of the whole organism. In the brain, wherefrom cancers usually do not spread, it is a disease of the whole brain. A cancer thus does not lend itself to complete destruction by surgery, radiation, chemotherapy, or immunotherapy. Even if we were to nab the last cancer cell, the next normal cell would foil the attempts by turning cancerous, through a process named neocanceration or recruitment. The sole curative triumph against gestational choriocarcinoma is due entirely to the fact that such an eventuality of neocanceration is ruled out by the absence of the normal progenitor cells that comprise the discarded fetal part of the placenta. The appellation, a disease of the whole organism, is no, less applicable to any form of blood vessel disease, be it the coronaries or the cerebrals. A bypass takes care of the block that the operator sees or has access to, but what of the vessels beyond, or before, or elsewhere. This explains why a patient of angina shows normal coronary arteriogram and the patient having normal coronary arteriogram can die a sudden coronary death. As for diabetes, euglycemic agents touch the proverbial tip of the metabolic iceberg, affecting in no way the generalized, accelerated vaso-occlusion that is now an accepted part of the diabetic process.
Variability, it's said, is the only invariable law of biology, a natural propensity that unfailingly varies one cancer from another, one heart attack from the next. If the uniqueness of every individual is an unsolved problem of biology, then uniqueness of every disease is the unsolved/unsolvable problem of medicine: "There are," Carrel axiomatized, "as many different diseases as patients." The presumed identicality of the genotype in homozygous twins is unable to circumvent the Carrelian code, a nosologic nonconcordance that is well-known but as yet poorly accounted for.
Cancer, indisputably traceable to precisely pinpointable/culturable culprit cancer cells, provides a remarkable example of what Dubos would call the unprecedented, unparalleled, and unrepeatable nature of a disease. Writing on the 'Uniquenes of malignant tumours,' Spriggs and co-workers concluded that naturally occurring cancers are extremely diverse even when they carry the same diagnostic label. No two cases of coronary artery disease/stroke/diabetes/arthritis/ auto-immune disease are identical either in their presentation or in their progress. The behavioral uniqueness of a disease, with its unpredictability, forms the basis of unexpected successes and the equally unexpected failures, given the same treatment. Cancers have been classified into good and bad, the good ones curable by any treatment, the bad ones by none-a retroactive judgment applicable to any other disease and fully justifying the Chinese proverb that a therapy works in a patient destined to survive.
Vis-a-vis the celebrated and honored practice of prognosing, what the doctors know are group statistics but when it comes to a disease in an individual, the physician has to contend with unknowns stacked upon unknowns, a situation that merits the title of a book by Francisco Sanchez, published in 1581: Quod Nihit Scitur-Nothing Can Be Known. In a recent study, in Bombay, of 535 sudden coronary deaths, 66% of the cases did not show coronary occlusion and 78% failed to show any myocardial infarct; in many of these, the heart was too good to die. And what of diabetes with the SMA-12 at the behest of the clinician! It is true in diabetes mellitus as in other chronic diseases that the prognosis for the patient is extraordinarily individual.
The unique reality of medical practice is that, be it Paul Dudley White and his patient Chales Thierry, on James Herriot and the dog Jock, it is a one-to-one encounter where the uniqueness of the individual, his disease, his very biologic trajectory is unpredictable, unalterable, and overwhelmingly important. For modern medicine, the most chastizing part of an individual's biologic trajectory is its refusal to provide any quantitative correlationship between the earliness/lateness of a disease on the one hand, and the probability of the disease/death it may beget, on the other. The healthy do not necessarily survive; the diseased do not necessarily die.
Herdity could well be described, at the very outset, as a corporate programme subserved by individual performance. Cellularity, systemicity and uniqueness are features innate to an individual; herdity is a force that the human herd exerts on the individual. The individual-herd relationship is a remarkable biologic feature that more than vindicates John Donne's intuitive generalization that no man is an island of itself; every man is a part of the main.
As Dobzhansky put it, mankind was, and is, a single inclusive Mendelian population and is endowed with a single corporate genotype, a single gene pool. Apposite to this is Carrel's description of an individual as one who extends, in time as in space, beyond the frontiers of his body, and who is linked to the past and to the future, regardless of the ephemerality of his present. Add to this, the conceptual framework of quantum physics that reveals a basic oneness of the universe wherein at a deep and fundamental level, the seemingly separate parts of the universe are connected in an intimate and immediate way, in a complicated web of relations between the various parts of the whole.,  We are now poised to view an individual's body, his disease, his cancer-each unfailingly unique-as a spatiotemporal manifestation of a cosmic order. I am what I am, and allowed to be so, for I know who all others were, are, and will be so as not to duplicate them, and they in turn know of me so as not to make a duplicate of me or of my disease at any time.
Climbing down from cosmic considerations to clinical reality allows us to appreciate the role herdity plays in the distribution of disease in any given group. As the general statistics go, the incidence of, say, acute lymphatic leukemia is 1 in 33,000, of cleft palate/neural tube defect is 1 in less than 1,000, of cancer 1 in 5, of blood vessel disease 1 in 2, at random, country after country, year after year. "Anybody who spends a little time brooding over the statistics of cancer must be struck by their unexpected constancy. From year to year the figures for each form of cancer show remarkably little variation." Having so generalized, Glemser cites precise figures: "Here there are 5,355 cases of cancer of the pancreas one year, 5,427 cases of the cancer of the pancreas two years later-almost the same number. Or in another country, there are 218 cases of cancer of pancreas one year, 221 cases of pancreas the following year." These regional constancies and interregional variations merge into a constant, global, human character when it is realized that although the anatomic distribution of cancer in different parts of the world is extremely varied, the overall death-rate from cancers at all sites is remarkably constant for humans the world over. The age-specific mortality rates from cerebrovascular disease, year after year, decade after decade, and country after country "fit quite closely the same line." There is something fundamentally human in the global impartiality with which disease and death treat mankind. The prevalence of diabetes mellitus is more or less constant for all countries. Cancer, stroke, diabetes, hypertension, heart attack and so on are an integral part of humanity, of human herdity. This remarkable herd-certainty and individual-probability of pathologic events is a function of a corporate herd programme that finds expression at the level of an individual who has crossed a critical genetic threshold.3 Herdity, thus, is a reciprocal relationship between an individual and his herd, what geneticists have been describing as polygenic inheritance.
The evolution of the concept of polygenic inheritance has brought a shift in genetic thinking, from heredity to herdity, for polygenic inheritance is necessarily a statistical concept that concerns not the individual but Mendelian populations or population aggregates.,  Polygenic inheritance has been invoked to explain a wide variety of diseases, ranging, from congenital malformations to cancer, porphyria to peptic ulcer. This means that most diseases do not have a cause. Causeless diseases cannot be prevented; they are an integral part of man's growing; cause-wise and course-wise they are trans-technique. Herdity is trans-technique.
The noumenon of herdity governs all the phenomena in relation to disease and death in a herd. The herd determines who will get what and when, in whom the disease will be slow, in whom fast, and so on. This would explain why the commonness of prostatic cancer beyond the age of 50 is paradoxically matched by the uncommonness of its malignant behaviour and how persons with bad coronary angiograms outlive those with good ones.
The most compelling evidence in favour of herdity is, in general, the programmed herd mortality that, as a physiologic function, is seen in man, in animals, in drosophila. Gompertz9 saw this as a constant increment in mortality beyond the fifth quinquennium of human life, doubling every 8 years, a phenomenon no medical advance has been able to stem. John Knowles, as President of The Rockefeller Foundation, wrote in 1977 on "The responsibility of an individual" charging the latter's "personal misbehaviour and environmental conditions" for over 99% of illnesses. Knowles' faith in reasoned behavior did not prevent the pancreatic cancer that killed him in 1979. He was but one of the 19,000 that develop pancreatic cancer and die from it in USA, every year. Knowles died at 52, some do at an earlier age, others at a later age, all a part of herd distribution; of herdity. That human herdity has been exercising such influences from times immemorial may be realized from the fact that King Herod of Judea, died of pancreatic cancer, in 73 B.C., at the age of 69. Cancer as a trans-technique problem has been curing itself of research and researchers, and may one day eliminate them altogether.
Systemicity, Uniqueness, Cellularity and Herdity of diseasing and dying can be read as the latter's SUCH-ness, a Kantian ding-an-sich or as the Zennist Alan Wats summed up, This is it. The evolution of the trans-technique concept, based on SUCH-ness, explains technology's failures and limits, exercises restraints on this age of inflated expectations, encourages us to be radical enough to abjure straight-line solutions and many a technologic trap-to wit, the tyranny of mass-screening, debilitating therapies, or killjoy preventionism. Jacob-Bigelow lamented, in the last century, that most men have an exaggerated opinion of the powers of medicine.
A recent editorial titled "The toss-up" bears eloquent testimony to the rationale of the foregoing. It is common experience that, on a given case, the proposed diagnostic/therapeutic thrust ranges from medical conservatism to surgical ultraradicalism: After attributing such divergence in medical thinking to the idiosyncracies of the physicians, the authors propose: "Perhaps all these factors are involved in clinical controversies, but we propose that one explanation has not been sufficiently recognized; that it simply makes no difference which choice is made. We suggest that some dramatic controversies represent 'toss-ups'-clinical situations in which the consequences of divergent choices are, on the average, virtually identical." The identicality of the consequences, no matter what the investigations and what the therapy, is a function of the basic fact that the problem being tackled is beyond the limits of technology.
Scientia est potentia: knowledge is power. The knowledge that a lot in medical practice is beyond medical technique can, as a concept, propel us towards not doing in medicine. Munsif, an eminent Bombay surgeon, was fond of aphorizing that a good surgeon is one who knows when not to operate. What a medical man needs to learn, in today's technicalized scene is when not to act, an intellectual and a therapeutic revolution that can safely rest on the concept of trans-technique.