- Email: [email protected]
CONCENTRATION OF HÆMOGLOBIN IN NORMAL HUMAN BLOOD.
1140
albuminous
complex
to
- sensitive, together with - elaborated
At King’s College an investigation is being made patient is into the constituents of the blood likely to produce protective The hay-fever patient asthma, particularly the calcium-potassium-carbon.
which the
a
substanceI1
it. which can be used in the dioxide balance. It seems that a disturbance of -excretes a treatment of another hay-fever patient, this balance partly explains both locality and food or .diagnosis but the proteose excreted by an asthmatic does not asthmas, and the results when applied to patients usually provoke a reaction in another asthmatic, are encouraging. The suggestion that asthma .except in cases of specific sensitisation ; for instance, is related to an alkaline state of the body is held - one case of horse asthma will react to the proteose to be confirmed by another investigation into the ,of another case of horse asthma. Proteose also effects of carbon dioxide on the bronchi. The appears in increased amounts in the urine in calcium environment of the bronchi has also been - eczema and certain forms of rheumatism, and these shown to affect profoundly their reactions to interesting experiments may perhaps have a wider foreign substances, and it has been found possible than was at first expected. Treat- to desensitise them without making them contract. ment by desensitisation-small doses of proteose A method has also been elaborated for assessing is still empirical, but has given very good results the nervous factor in asthma. in some cases though not in others. The other main line of research in this clinic is the investigation of the sputum. Many asthmatic sputa, it is CONCENTRATION OF HÆMOGLOBIN IN stated, contain a histamine-forming organism, NORMAL HUMAN BLOOD. but although histamine powerfully contracts the IT is 30 years since HALDANE and LORRAIN tbronchial tubes, it seems doubtful whether these bacteria can actually induce asthma. Thera- SMITH showed that the oxygen-carrying power of Tpeutieally, happy results are sometimes obtained blood varied in direct proportion to its colour with vaccines. Many other observations have and could be accurately determined colorimetrically seen made in addition to these two principal by comparison with blood of known oxygen capacity. objects of research, and many treatments have This was the basis of HALDANE’S modification of tbeen tested. Individuals, as is well known, the Gowers hsemoglobinometer in which he replaced ’occasionally derive benefit from unusual remedies, the uncertain and unstable standard of picrocarmine gelatin by a 1 per cent. solution of blood which have no success when applied to a group. At the Children’s Clinic at Great Ormond-street of known oxygen capacity saturated with carbon over 1000 children have already been studied. monoxide. Properly made and sealed, these In two out of every three cases an inquiry into the standards are permanent, are valid in any light history showed that some relative was also affected, since the standard and the unknown are the same :and the relative was twice as_ often found on the pigment, and can always be referred to an absolute mother’s side as on the father’s. Three times as and verifiable standard by comparing them with many boys as girls were affected before the age blood of which the oxygen capacity has been of puberty, after which the sexes were equally determined directly by the ferricyanide method. susceptible. These findings suggest that the The instrument in short is one of high precision asthmatic tendency is definitely transmissible, and very convenient, and it has for long been .and that the changes of puberty are beneficial to used by all serious observers in this country. the asthmatic boy and deleterious to the asthmatic In recent times, however, a rather general suspicion girl. Where a hereditary influence could not be has grown up that the average normal level
against proteose
- application
I
traced there was nearly always some severe determined bv HALDANE and LORRAIN SMITH pulmonary illness at the onset of the trouble, is now too low. From the examination of 24 suggesting that inhaled particles may bring about healthy men, they obtained an average oxygen .a supersensitive state through damage of the capacity of 18-5 c.cm. oxygen per 100 c.cm. of Homes were and the lung. investigated, greatest blood and marked this as 100 on the hsemonumber of sufferers was found among pampered globinometer scale ; from 18 women they got a only-children of skilled artisans and educated mean of 91 per cent. on the scale. In actual people. The commonest causes in the home practice however it has turned out that most appeared to be feather or horsehair beds, animal readings for normal males are 100 or more, and pets, and dust. Food played a minor part, but in the United States several sets of normal values when it was the cause the condition was usually have given means of more than 110. The difficulty associated with deficient acidity and consequent evidently wanted clearing up and this Dr. PBICEinability to digest proteins, together with deficiency JoNES at University College Hospital Medical of the liver’s power of dealing with sugar. The School has recently set out to do. In 100 healthy results of treatment have been good. In the food young men he found a mean value of 105 per cases the asthma can be prevented by supplying cent. on the Haldane scale, with a range of 96 to hydrochloric acid, and great success has attended 116 ; in 100 healthy young women 98 per cent., desensitisation in animal asthma and animal hay. with a range from 90 to 110. The normal 100 per fever. At Guy’s glucose and general hygiene are cent. of the instrument is evidently. too low now, the principal methods used, and open-air treatment though whether a larger series than they examined for many months in a convalescent home is advised would have given HALDANE and LORRAIN SMITH where the simpler methods fail. Once the habi1 the same figure in 1900 cannot unfortunately now of attacks is broken they commonly do not return 1 Jour. Path. and Bact., 1931, xxxiv., 779.
1141
be found out ; it is quite possible that the normal cent. on the Haldane scale, the van Slyke method level has risen, possibly because more adequate consistently giving slightly higher results than the hearts enable a more viscous blood to be circulated Haldane, though the difference is not nearly conveniently. This new figure was, however, enough to account for a mean of 112 in Boston still discrepant with the normals in America. against 105 in London. Dr. PRICE-JONES is Over there the Haldane haemoglobinometer is inclined to attribute the relative polycythaemia almost never used ; either the oxygen capacity in America to the habitual and persistent use of of blood is determined directly from a vein sample saloon motor-cars and the consequent slight That polyor the colour is matched against some standard chronic carbon monoxide poisoning. be and can is which is calibrated actually produced in this oxygen capacity determina- cythaemia tions. As it happens, these are done there by way has been fully established, and it is certainly the van Slyke method, while in England Haldane’s curious that American figures for normal women ferricvanide method has always been used in making are not higher than those found in London. In Buenos Aires too ORIAS found a mean of 103 per standard solutions for the no of two cent. for soldiers, III for students, and 97 for serious the Curiously enough comparison methods of determining oxygen capacity has ever women, and the general demand for " sunshine been made, and it seemed possible that here lay roofs " may be an empirical herd response to the the explanation of the difference between the normal avidity of haemoglobin for carbon monoxidelevels of haemoglobin in the two countries. So Finally, we should like to express the hope that Dr. PRICE-JONES went to Boston where in a series no attempt will be made in the light of these of 20 healthy young men he determined the results to alter the standard at which the Haldane oxygen capacity colorimetrically with the same instrument has always been set. The important hsemoglobinometer he had used in London, while thing is to determine with it the oxygen-carrying Prof. D. B. DILL and Dr. G. P. WRIGHT determined power of the blood, and it is no matter if it by the van Slyke and Haldane methods in the the normal level is 105 on the scale instead of technique of which they are respectively experts. 100. Any change would make for nothing but The several means came out as 112, 112, and 109 per confusion.
by
haemoglobinometers.
ANNOTATIONS truth. The position is not exactly the same for the anaesthetist as it is for the physician and the THE professorial system, with its " units," has surgeon. This arises from an essential difference in been in force enough years now at several teaching the relationship between the patient and the surgeon hospitals in London for sound opinion to be formed on the one hand, and the patient and the anaesthetist of its merits or demerits in comparison with the older on the other. Anaesthetics are inevitably a secondary arrangement alongside of which it is at work. That not a primary need. The surgical patient requires the newer method is not a complete success in London primarily an operation, we may suppose, and for medical schools is evident, for some hospitals in which that operation an anaesthetist is generally, though it was adopted have after trial gone back to their not always, necessary. But it never happens that former arrangements and in others the unit staffs the anaesthetist is the patient’s primary need. He do not receive the wholehearted sympathy of their is wanted only through the surgeon. Consequently colleagues. Nevertheless, there are certain advan- the hospital anaesthetist depends for his livelihood tages accruing both to and from the physician or mainly on the surgeons with whom he works in surgeon whose time is wholly given up to hospital hospital, and it is on the chance, the probability, practice, and these advantages have been fully of earning fees through them if his work is satisfactory utilised, we believe, by those holding leading that he is willing and able to put in many hours of positions in the units. The benefits - shouldbe, unpaid work at hospitals. When these hours are and we believe are, manifest in research, in teaching, spent with the surgeon of a unit, who does no operating and in the additional time available for devotion to outside the hospital, the anaesthetist is not only doing the patients’ welfare. There are directions in which unpaid work, but is doing it generally just at a time the unit system appears to be incongruous with the when he might be earning a fee in private practice. other method of employing the staffs of voluntary He gets no reward except that bestowed on him by hospitals, and there is certainly one class of worker the consciousness of meritorious charitable labour. to whom the system is definitely unjust. We allude This fruit of toil however is apt to lose its savour, to visiting anaesthetists who are required to work for for the anaesthetist feeds on it in abundance. His. the surgeons of units, and their unfortunate position work is, as Mr. Morley Roberts observed somewhere, is described in the letter from Dr. Howard Jones " an honourable but not a fertile occupation." It which appears on p. 1156. The honorary anesthetists seems to us plain that where surgical units at teaching at the London hospitals receive of course but slender, hospitals are concerned the anaesthetists’ lot should if any, direct remuneration in return for their services be made, not less honourable, but, at any rate,. at the institutions to which they are attached. It more fertile. He is surely an essential part of a is presumably supposed that just as the physician properly constructed surgical unit. The leader ofor the surgeon is unpaid and takes his chance of that unit is paid, his assistants are paid, and so should earning a decent income through the reputation the anaesthetist be paid. Under existing conditionss and the practice which may fall to him owing to his it must happen that the anaesthetist’s sense of duty hospital appointment, so the anaesthetist is in an sometimes gives way before necessity and he delegates exactly similar position. This is however not the his duties to a junior, to the resident anaesthetist, or ANÆSTHETISTS TO SURGICAL UNITS.
albuminous
complex
to
- sensitive, together with - elaborated
At King’s College an investigation is being made patient is into the constituents of the blood likely to produce protective The hay-fever patient asthma, particularly the calcium-potassium-carbon.
which the
a
substanceI1
it. which can be used in the dioxide balance. It seems that a disturbance of -excretes a treatment of another hay-fever patient, this balance partly explains both locality and food or .diagnosis but the proteose excreted by an asthmatic does not asthmas, and the results when applied to patients usually provoke a reaction in another asthmatic, are encouraging. The suggestion that asthma .except in cases of specific sensitisation ; for instance, is related to an alkaline state of the body is held - one case of horse asthma will react to the proteose to be confirmed by another investigation into the ,of another case of horse asthma. Proteose also effects of carbon dioxide on the bronchi. The appears in increased amounts in the urine in calcium environment of the bronchi has also been - eczema and certain forms of rheumatism, and these shown to affect profoundly their reactions to interesting experiments may perhaps have a wider foreign substances, and it has been found possible than was at first expected. Treat- to desensitise them without making them contract. ment by desensitisation-small doses of proteose A method has also been elaborated for assessing is still empirical, but has given very good results the nervous factor in asthma. in some cases though not in others. The other main line of research in this clinic is the investigation of the sputum. Many asthmatic sputa, it is CONCENTRATION OF HÆMOGLOBIN IN stated, contain a histamine-forming organism, NORMAL HUMAN BLOOD. but although histamine powerfully contracts the IT is 30 years since HALDANE and LORRAIN tbronchial tubes, it seems doubtful whether these bacteria can actually induce asthma. Thera- SMITH showed that the oxygen-carrying power of Tpeutieally, happy results are sometimes obtained blood varied in direct proportion to its colour with vaccines. Many other observations have and could be accurately determined colorimetrically seen made in addition to these two principal by comparison with blood of known oxygen capacity. objects of research, and many treatments have This was the basis of HALDANE’S modification of tbeen tested. Individuals, as is well known, the Gowers hsemoglobinometer in which he replaced ’occasionally derive benefit from unusual remedies, the uncertain and unstable standard of picrocarmine gelatin by a 1 per cent. solution of blood which have no success when applied to a group. At the Children’s Clinic at Great Ormond-street of known oxygen capacity saturated with carbon over 1000 children have already been studied. monoxide. Properly made and sealed, these In two out of every three cases an inquiry into the standards are permanent, are valid in any light history showed that some relative was also affected, since the standard and the unknown are the same :and the relative was twice as_ often found on the pigment, and can always be referred to an absolute mother’s side as on the father’s. Three times as and verifiable standard by comparing them with many boys as girls were affected before the age blood of which the oxygen capacity has been of puberty, after which the sexes were equally determined directly by the ferricyanide method. susceptible. These findings suggest that the The instrument in short is one of high precision asthmatic tendency is definitely transmissible, and very convenient, and it has for long been .and that the changes of puberty are beneficial to used by all serious observers in this country. the asthmatic boy and deleterious to the asthmatic In recent times, however, a rather general suspicion girl. Where a hereditary influence could not be has grown up that the average normal level
against proteose
- application
I
traced there was nearly always some severe determined bv HALDANE and LORRAIN SMITH pulmonary illness at the onset of the trouble, is now too low. From the examination of 24 suggesting that inhaled particles may bring about healthy men, they obtained an average oxygen .a supersensitive state through damage of the capacity of 18-5 c.cm. oxygen per 100 c.cm. of Homes were and the lung. investigated, greatest blood and marked this as 100 on the hsemonumber of sufferers was found among pampered globinometer scale ; from 18 women they got a only-children of skilled artisans and educated mean of 91 per cent. on the scale. In actual people. The commonest causes in the home practice however it has turned out that most appeared to be feather or horsehair beds, animal readings for normal males are 100 or more, and pets, and dust. Food played a minor part, but in the United States several sets of normal values when it was the cause the condition was usually have given means of more than 110. The difficulty associated with deficient acidity and consequent evidently wanted clearing up and this Dr. PBICEinability to digest proteins, together with deficiency JoNES at University College Hospital Medical of the liver’s power of dealing with sugar. The School has recently set out to do. In 100 healthy results of treatment have been good. In the food young men he found a mean value of 105 per cases the asthma can be prevented by supplying cent. on the Haldane scale, with a range of 96 to hydrochloric acid, and great success has attended 116 ; in 100 healthy young women 98 per cent., desensitisation in animal asthma and animal hay. with a range from 90 to 110. The normal 100 per fever. At Guy’s glucose and general hygiene are cent. of the instrument is evidently. too low now, the principal methods used, and open-air treatment though whether a larger series than they examined for many months in a convalescent home is advised would have given HALDANE and LORRAIN SMITH where the simpler methods fail. Once the habi1 the same figure in 1900 cannot unfortunately now of attacks is broken they commonly do not return 1 Jour. Path. and Bact., 1931, xxxiv., 779.
1141
be found out ; it is quite possible that the normal cent. on the Haldane scale, the van Slyke method level has risen, possibly because more adequate consistently giving slightly higher results than the hearts enable a more viscous blood to be circulated Haldane, though the difference is not nearly conveniently. This new figure was, however, enough to account for a mean of 112 in Boston still discrepant with the normals in America. against 105 in London. Dr. PRICE-JONES is Over there the Haldane haemoglobinometer is inclined to attribute the relative polycythaemia almost never used ; either the oxygen capacity in America to the habitual and persistent use of of blood is determined directly from a vein sample saloon motor-cars and the consequent slight That polyor the colour is matched against some standard chronic carbon monoxide poisoning. be and can is which is calibrated actually produced in this oxygen capacity determina- cythaemia tions. As it happens, these are done there by way has been fully established, and it is certainly the van Slyke method, while in England Haldane’s curious that American figures for normal women ferricvanide method has always been used in making are not higher than those found in London. In Buenos Aires too ORIAS found a mean of 103 per standard solutions for the no of two cent. for soldiers, III for students, and 97 for serious the Curiously enough comparison methods of determining oxygen capacity has ever women, and the general demand for " sunshine been made, and it seemed possible that here lay roofs " may be an empirical herd response to the the explanation of the difference between the normal avidity of haemoglobin for carbon monoxidelevels of haemoglobin in the two countries. So Finally, we should like to express the hope that Dr. PRICE-JONES went to Boston where in a series no attempt will be made in the light of these of 20 healthy young men he determined the results to alter the standard at which the Haldane oxygen capacity colorimetrically with the same instrument has always been set. The important hsemoglobinometer he had used in London, while thing is to determine with it the oxygen-carrying Prof. D. B. DILL and Dr. G. P. WRIGHT determined power of the blood, and it is no matter if it by the van Slyke and Haldane methods in the the normal level is 105 on the scale instead of technique of which they are respectively experts. 100. Any change would make for nothing but The several means came out as 112, 112, and 109 per confusion.
by
haemoglobinometers.
ANNOTATIONS truth. The position is not exactly the same for the anaesthetist as it is for the physician and the THE professorial system, with its " units," has surgeon. This arises from an essential difference in been in force enough years now at several teaching the relationship between the patient and the surgeon hospitals in London for sound opinion to be formed on the one hand, and the patient and the anaesthetist of its merits or demerits in comparison with the older on the other. Anaesthetics are inevitably a secondary arrangement alongside of which it is at work. That not a primary need. The surgical patient requires the newer method is not a complete success in London primarily an operation, we may suppose, and for medical schools is evident, for some hospitals in which that operation an anaesthetist is generally, though it was adopted have after trial gone back to their not always, necessary. But it never happens that former arrangements and in others the unit staffs the anaesthetist is the patient’s primary need. He do not receive the wholehearted sympathy of their is wanted only through the surgeon. Consequently colleagues. Nevertheless, there are certain advan- the hospital anaesthetist depends for his livelihood tages accruing both to and from the physician or mainly on the surgeons with whom he works in surgeon whose time is wholly given up to hospital hospital, and it is on the chance, the probability, practice, and these advantages have been fully of earning fees through them if his work is satisfactory utilised, we believe, by those holding leading that he is willing and able to put in many hours of positions in the units. The benefits - shouldbe, unpaid work at hospitals. When these hours are and we believe are, manifest in research, in teaching, spent with the surgeon of a unit, who does no operating and in the additional time available for devotion to outside the hospital, the anaesthetist is not only doing the patients’ welfare. There are directions in which unpaid work, but is doing it generally just at a time the unit system appears to be incongruous with the when he might be earning a fee in private practice. other method of employing the staffs of voluntary He gets no reward except that bestowed on him by hospitals, and there is certainly one class of worker the consciousness of meritorious charitable labour. to whom the system is definitely unjust. We allude This fruit of toil however is apt to lose its savour, to visiting anaesthetists who are required to work for for the anaesthetist feeds on it in abundance. His. the surgeons of units, and their unfortunate position work is, as Mr. Morley Roberts observed somewhere, is described in the letter from Dr. Howard Jones " an honourable but not a fertile occupation." It which appears on p. 1156. The honorary anesthetists seems to us plain that where surgical units at teaching at the London hospitals receive of course but slender, hospitals are concerned the anaesthetists’ lot should if any, direct remuneration in return for their services be made, not less honourable, but, at any rate,. at the institutions to which they are attached. It more fertile. He is surely an essential part of a is presumably supposed that just as the physician properly constructed surgical unit. The leader ofor the surgeon is unpaid and takes his chance of that unit is paid, his assistants are paid, and so should earning a decent income through the reputation the anaesthetist be paid. Under existing conditionss and the practice which may fall to him owing to his it must happen that the anaesthetist’s sense of duty hospital appointment, so the anaesthetist is in an sometimes gives way before necessity and he delegates exactly similar position. This is however not the his duties to a junior, to the resident anaesthetist, or ANÆSTHETISTS TO SURGICAL UNITS.