- Email: [email protected]
THE RÔLE OF THE BLOOD PLASMA IN DISEASE.
963
- day the redness quently a second
had diminished. Two days subsesimilar injection was made and it was observed that whilst the redness still diminished the descemitis persisted. Ten days were now allowed to elapse, at the end of which time ten drops of the cyanide solution Four days after redness had disappeared and were injected. the subsequent progress of the case was in all respects satisfactory. An objection to this mode of treatment is the extreme pain caused by the injection.
EPIDEMIC CEREBRO-SPINAL FEVER. SINCE our last issue there has been no special event to record in connexion with the epidemic of cerebro-spinal fever beyond the occurrence of sporadic cases in localities hitherto unaffected. In London a case has been removed from Shoreditch to the Eastern Hospital of the Asylums Board. Cases have been diagnosed at Hutton in Essex ard at Tipton in Staffordshire, and fatal cases have occurred in Salford and at Ripley, near Derby. In Edinburgh seven cases have been notified as presenting suspicious features; four of these have been removed to a hospital, four ,patients have died, and 14 remain under observation. In Glasgow the conditions show no alteration. There has The been an extension of the disease in Aberdeenshire. first case in this county was mentioned in our issue of March 23rd, p. 826, as occurring in the Cluny district, and .a niece of this patient has since been attacked at Kintore. A fatal case has occurred in Stirling. In Belfast the public health committee has decided to make no daily statement as to the progress of the epidemic but in future to give only a weekly return of the number of cases and the deaths that have occurred each week. Since the commencement of the outbreak in this city there have been 228 cases with 138
deaths. ____
THE
REGISTRATION
OF
PLUMBERS.
situation
exactly : " Really competent men would be certain a compulsory registration test. Incompetent men ought either to be compelled to make themselves competent or to be by law forbidden to practise."
to welcome
A SESSIONAL meeting of the Royal Sanitary Institute will be held at the Parkes Museum on Tuesday, April 9th, at 8 P.M., when a discussion will take place on the Aim and Scope of Women’s Work in Relation to Public Health. The discussion will be opened by Dr. H. Meredith Richards, medical officer of health of Croydon. General discussion is invited and Colonel J. Lane Notter, R.A.M.C., chairman of the council of the institute, will preside.
of the South-Eastern division of the Association will be held, by the courtesy Medico-Psychological of Dr. F. R. P. Taylor, at the East Sussex County Asylum, THE
spring meeting
Hellingly, 12
on
Wednesday, April 17th, commencing
at
noon. ____
A TELEGRAM from the Governor of Hong-Kong received at the Colonial Office on March 25th states that there were 3 cases of plague reported during the week ending March 23rd and 3 deaths from the disease.
THE RÔLE OF THE BLOOD PLASMA IN DISEASE. BY HARRY CAMPBELL, M.D., B.S. LOND., F.R.C.P. LOND., PHYSICIAN TO THE NORTH-WEST LONDON HOSPITAL AND TO HOSPITAL FOR DISEASES OF THE NERVOUS SYSTEM, WELBECK-STREET.
THE
VI.l THERAPEUTICAL DEDUCTIONS. WE have seen what a large part the plasma plays in shaping the destinies of the organism : in determining the various phases of evolution, in promoting senile decay, and in setting up morbid processes. As regards the latter it is no exaggeration to say that the role of the plasma in the genesis of disease is all-predominating, and that the future of pathology and therapeutics is essentially bound up in this
AN interesting leaflet has reached us in reference to this subject, being a reprint of a discussion on the matter which has recently been taking place in the columns of the Li1...e’l’pool .Daily Post. Mr. W. D. Caröe, the Master of the Worshipful Company of Plumbers, points out that the pro- subtly complex fluid. That the majority of the diseases which the physician is priety and utility of a system of registration of plumbers called upon to treat are plasmic in origin is made manifest were first publicly debated in Liverpool, when the British Medical Association held its congress there in 1883, while by a glance at the appended list of disorders which are in the following year, when the International Health Con- admittedly induced through the plasma. The classification adopted, though obviously not a logical one, suffices nevei.gress was held in London, the whole question of the means theless for our purpose. of insuring the qualification and responsibility of plumbers 1. All the bacterially induced diseases, such as the and the efficiency of their work in its sanitary relation was exanthemata and allied affections-e.g., scarlet fever, -considered by a great gathering of plumbers, architects, and measles, small-pox, typhus fever, typhoid fever, influenza, rheumatic diphtheria, and cholera ; such dis-sanitary authorities. It was then seen that inferior work orders as fever, mumps,cerebro-spinal fever, infantile parapneumonia, and appliances constituted in a great measure the cause of acute ascending paralysis ; a multitude of unnamed lysis, the falling into disuse of the apprenticeship svstem and the febricul2e, including "common colds"; the various tuberincrease of untrained men in the ranks both of employers culous affections-e.g., phthisis pulmonalis, tuberculous and employed. The education and registration of the meningitis, tuberculous kidney; gonorrhoea and syphilis in its multitudinous manifestations. plumber followed and at the present time we are happy to 2. All affections, with the exception of those note that 14,000 plumbers have been enrolled upon the due to inflammatory direct irritation from without (as may happen, for register. Much of the success of the Worshipful Company example, in gastritis, bronchitis, and dermatitis). of Plumbers in this matter is no doubt due to the fact 3. Diseases due to the introduction of poisons from withthat the Company exists solely for the benefit of the out-e.g., alcohol, opium, tobacco, tea, lead, arsenic, and public and the advancement of craftsmanship and that it is mercury. 4. Gout and those numerous allied affections grouped in no way concerned with trading or trade profits as such. under the term " rheumatic," such as muscular rheumatism The work of the Company would be easier and its benefits and fibrositis-e.g., lumbago. more widely spread if the public could be induced in their 5. Numerous non-gouty affections of the joints, such as own interests to give employment wherever possible to pyasmic and syphilitic arthritis, rheumatoid arthritis, chronic rheumatism, and many allied arthrites, impossible at present The avoidance of structural registered plumbers only. defects in the dwelling-house is one of the most important to classify. 6. The various hormonic disorders-e.g., Graves’s disease, factors in domestic hygiene, and the general health of Addison’s disease, and acromegaly. myxcedema, the community is not a little dependent upon the way in 1 Articles I., II., III., IV., and V. were published in THE LANCET of which the plumber carries out his work. The concluding Feb. 2nd 9th (p. 375), and 23rd (p. 535), and March 16th (p. 754) editorial remarks of the Liverpool Daily Post sum up the and 23rd (p. 313), (p. 827), 1907, respectively.
964 7. Spasmodic asthma, megrim, and diabetes. 8. Infantilism, delayed or premature puberty,
and
premature senility.
9. Such well-known affections of the blood as purpura, scurvy, chlorosis, pernicious anaamia,, and leucooytbsemia. 10. All the so-called " primarydegenerative affections of the nervous system, with the possible exception of such diseases as Friedreich’s and those which are excited by excessive functioning; most functional nervous disorders, including insanity, megrim, neuralgia, headache, and those multitudinous minor nervous disturbances to which almost all civilised human beings are occasionally liable. 11. Practically all the organic diseases of the cardiovascular system other than the congenital and those due to muscular strain. As instances of heart disease caused through the plasma may be mentioned the endocarditis, myocarditis, and pericarditis of rheumatic fever, the endocarditis of influenza and the exanthemata, the pericarditis of Bright’s disease, and the fatty degeneration of the myocardium resulting from chronic alcoholism. How large a part the plasma may take in causing cardio-vascular disease is further shown by the phenomena of chronic Bright’s disease. 12. Most diseases of the lungs, bronchi, and plasma. Consider the frequent involvement of these structures in the specific fevers, in gout, and Bright’s disease ; the frequency of bronchitis in improperly fed children ; and the large part which tuberculosis plays in pulmonary and pleural
affections.
Seeing, then, how dominating is the r6le of the plasma in disease, it follows that in every case which comes before him the physician should pay due regard to the condition of that fluid. Generally he will be safe in postulating some plasmic defect, and his chief concern should be to discover in what that defect consists, and having done this, to correct it. He should argue : " If I can bring about a normal condition of the
jhat it is through the digestive system that we can generally work most effectually. This is because digestion plays a preponderating part in determining the composition of the plasma, for disorders of it lead not only to the impoverishment but (what is of much greater pathological import) to Lihe poisoning of the plasma, and also because the digestive system, owing to its large bulk and the complexity of its functions, but still more to its wanton abuse, is very apt to De thrown out of gear ; so much so, indeed, that a sound digestion is but seldom met with among the civilised, the majority of whom suffer in greater or less degree from indigestion toxsemia—a condition responsible for much ill Be it remembered that sound health among us moderns. digestion generally means sound plasma and thus sound health, while defective digestion always implies unsound plasma and consequently imperfect health. This dependence 3f sound health upon sound digestion has long been rethe Chinese our "How do you do?" is sognised. Among rendered by "How is your stomach ? " We shall the better realise the prominent part played by the digestive system in determining the composition of the plasma if we reflect that of the sum total of material agencies operating upon the organism from withoutconstituting, that is, its material environment-food occupies the first place ; it is from the food that the tissues are built up, and it is from the food, together with oxygen, that the energy of the vital machine is derived. The conversion of this crude food into a form suitable for absorption and assimilation is a function of the first importance, one consuming a large share of the total energy expended by the organism, and requiring the constant activity of the most bulky system of organs in the body. This capacious system includes not only the liver and the pancreas, but some 30 feet of tubing furnished with many millions of glands, and it contains on an average not less than one half the total blood mass. Nor must it be forgotten that the function of the digestive glands does not end with digestion ; they also furnish enzymes and hormones which, entering the blood, play a necessary part in
plasma, I can make my patient well." Doubtless it is possible to effect a complete cure when there is grave structural change; nevertheless it is remarkable to what nutrition. extent even serious degenerative changes can be recovered Here I would point out that it is essentially through the from, provided a healthy state of the plasma is established. digestive system that climate benefits health. In most Consider, for example, how completely the patient can be diseases it may be said that the patient does best where cured of grave alcoholic neuritis if only he can be made to his digestion is best. No doubt other factors come into play, abandon his drinking habits. especially in such affections as bronchitis and rheumatism, The proposition healthy plasma implies health " is in the in which the good effect of climate is largely produced by main accurate. Exceptions may occur, for example, in such the direct influence of the atmosphere upon the skin and a disease as facial neuralgia resulting from a lesion of mucous membrane. Nevertheless, it is essentially the digesnot
but cases of this kind are comand the physician may rest assured that he will seldom fail to cure his patients if he can establish a perfectly healthy condition of the plasma. While assigning to the plasma this prominent role in disease I am not unmindful of the part played by the nervous system in pathogenesis, nor of the good which may be achieved through it. We should ever be careful to remove any reflex irritation, such as eye strain, that may be present, and to get all the good we can by mental treatment, be it through education, change of scene, suggestion, or what not. Yet even then, and when all is said and done, it will be found that it is largely through the plasma that the good effect is achieved. MEANS OF CORRECTING THE PLASMA.
the Gasserian
ganglion ;
tive factor that we have to rely on in the climatic treatment of disease. It will be found, for example, that the benefit which a tuberculous child derives from a stay at Margate is in direct proportion to the improvement which takes place in. the character of his motions. It is imperative that the physician should realise how large a part the establishment of normal digestion plays in treatment. Not until he does will he be able to secure a full measure of therapeutic success, no matter with what branch of medicine he may decide to identify himself. For this reason the study of dietetics and indigestion should occupy a prominent place in the student’s curriculum, and throughout the whole of his subsequent career be kept constantly in view. Nothing more forcibly shows the evils of ultra-specialism than the casual way in which these subjects are treated by many physicians. In whatever In every case of disease in which we believe the plasma direction he specialises a physician must at least learn the to be abnormal the first question to ask ourselves is : What is best that is known of the diagnosis and treatment of the nature of the defect ? Does it pertain to its nutrients, digestive disorders. hormones, enzymes, or excreta, and if so, what is its precise Let me here cite an incident which gives point to these character ? Unhappily, we can but rarely answer this ques- remarks. Fully imbued with the truth I have just sought tion with any degree of precision, though in the correct to emphasise, a physician of my acquaintance has for some answer to it lies the key to the diagnosis and the treatment time past been devoting himself to the study of diet, and in of most non-surgical diseases. I do not propose to enter this connexion he not long since made an examination of into the various methods at our disposal for discovering the jaws and teeth of that splendid collection of skulls conplasmic defects here-that would be altogether beyond the, tained in the museum of the Royal College of Surgeons. scope of these papers. I must content myself with briefly Now this greatly concerned an old friend of his who, having indicating the different ways of correcting them when found. docketed him neurologist, declared that he was gravely They may be grouped under the following heads : (1) methods jeopardising his professional success by not sticking to his directed to the digestive system ; (2) methods directed to neurological last, that his conduct in thus straying beyond the excretory organs ; (3) methods directed to the destruction his own proper field was strangely heterodox, not to say of bacteria, or the neutralisation of their products ; and eccentric, for (thus ran the argument) what in the name of (4) methods directed to the correction of defects in respect common sense can teeth have to do with nerves ? My friend of hormones and enzymes. contends, not, I think, without reason, that in point of fact Methods direoted to the digestive system.-In our endeavour there is a very close connexion between the two, and he is to bring about a healthy state of the plasma we shall find satisfied that his excursions into the realms of dietetics and
paratively
rare
965
anthropology have in no small degree enhanced his efficiency as a practical physician, and not the least so among those of his patients who suffer from nervous maladies. Methods directed to the excretory organs.-When the blood contains poisons an attempt may be made to get rid of them by promoting excretion, and from the earliest days of medicine eliminants in the shape of purgatives, diaphoretics, diuretics, and emetics have been used for this purpose. With the exception of the first of these, however, it cannot be said that they are of much help in purifying the blood and even purgatives act rather by preventing the absorption than by promoting the elimination of poisons. Diaphoretics A "cold " can someare of little value as blood purifiers. times be staved off by "getting the skin to act "-e.g., by wrapping the patient up in blankets or putting him in a is occasionally of warm bath ; and the Turkish bath therapeutic service, though not so useful as the natural diaphoresis provoked by exercise. In ursemia diaphoretics are practically, valueless, while as for such time-honoured practices as giving ammonium acetate in febriles states, few would contend that they can have any appreciable effect in ridding the blood of poisons. Nor can it be said that diuretics are any more valuable for this purpose, except in so far as they act by stimulating a failing heart and thus removing dropsical accumulations. And just as we cannot get much help from eliminants in relieving toxsemia. so, on the other hand, it is only exceptionally that any marked degree of toxsemia is attributable to defective elimination of normal excreta, except, perhaps, in the case of constipation. The fact is, such excreta are rapidly run out of the blood and only tend to accumulate seriously when there is grave organic disease of the heart, lungs, or kidneys. In short, toxsemia results from the absorption of poisons from without, or from the undue production of poisons within, rather than from failure in the eliminating organs ; and its treatment therefore should consist rather in the prevention of such absorption and such undue formation, or in treatment calculated to neutralise the poisons present, not in attempts to promote their
and digest them or by means of chemical subThese latter are of several kinds and include the lysins which actually dissolve the bacteria (as happens, for instance, in typhoid fever and cholera), and the opsonins which so affect the bacteria as to render them an easy prey
which
engulf
stances.
to the phagocytes. 2. The bacterial poisons are neutralised by the antitoxins, substances which have been administered with great successs in diphtheria, tetanus, and botulismus. These poisons, allied as they are to the foodstuffs, are capable of being linked on to the molecules of the living protoplasm, such
assimilative union interfering with the normal vital activities of the cells. Now the antitoxins combine with the bacterial poisons and thus prevent the latter from entering into union with the cell protoplasm, thus giving time for the process of bacterial destruction to be carried through. The treatmpnt of bacterial diseases by the application of nature’s own method consists for the most part in the administration of antitoxins and of substances calculated to For this latter increase the opsonic power of the blood. method we are indebted to the classic researches of Wright and Douglas. In order that this treatment may be successful the quantity of the substance administered has to be carefully regulated in relation to the opsonic index. By due attention to this particular Wright, Bulloch, and others have been able to obtain striking results in local tuberculosis, as well as in acne, furunculosis, and sycosis. When we reflect what brilliant results have in so short a time been achieved by this method of treatment, may we not confidently anticipate a splendid future for it?° Treatment by drugs, dating back though it does some thousands of years, has with a few exceptions yielded but barren results. It was hoped that great things would come from a study of their physiological action and that a reign of rational, as distinguished from empirical, drug treatment had by it been inaugurated ; but, alas, such hopes have not been realised. While many useful drugs will doubtless be discovered in the future the treatment by drugs seems destined long to remain essentially empirical. At last, however, a method of treatment has been discovered which is in elimination. the truest sense of the term scientific and rational, based as Methods of coping mith bacteria and their prodcets.-We it is on the very method nature herself employs. now know that the human organism has special methods of -Jlethods d;,rected to the correction {If defects in respect of its own for striking at pathogenic bacteria and their pro- hnr1nones and enzYl1ws.-Whenever disease is due to a horducts, methods which have been steadily evolving from the monic or enzymic defect the treatment obviously consists in very beginning of animal life. No branch of therapeutics correcting that defect. To do this we must first discover holds out greater promise than that which is based on these its exact nature, and this is seldom possible in the present natural methods. Treatment of this kind, rendered possible state of our knowledge. We know that myxcedema is by the labours of such men as Pasteur, Bebring. Koch, and due to deficient thyroid action and are able to cure the Wright, is eminently scientific and rational. Before their affection by the administration of thyroid extract. Certain time the treatment of bacterially induced diseases was for the cases of infantilism, again, are apparently due to some most part empirical. It is true that abscesses have long been defect in the pancreas and can be greatly benefited, as Byrom treated by rational surgical means and that the treatment of Bramwell has shown, by means of an extract of this gland. typhoid fever by cautious dieting and of hyperpyrexia by the On the other hand, though there are good reasons for conapplication of cold may be regarded as genuinely rational; cluding that Graves’s disease, Addison’s disease, and acrobut speaking generally, it must be conceded that, prior to the megaly are due to perverted hormonic function of definite advent of the new system, the treatment of microbic diseases tissues, the treatment of these diseases by the administration was essentially empirical, and very poor at that. In the of an extract of the affected tissue has hitherto proved discase of such affections as pneumonia, diphtheria, and the appointing. Similarly, while evidence seems to point to the exanthemata, our treatment, so far as any good has come of conclusion that pancreatic diabetes results from the absence it, has essentially consisted, not in worrying the patient by from the blood of a pancreatic enzyme, no satisfactory treatfussy interference, but in leaving him severely alone and ment of that disease has yet been discovered. But although trusting to careful nursing. While we have been hugging at present we can do but little for this (probably large) class ourselves with the belief that we have "pulled him of disorders, we may reasonably hope for greater success as through " by a specific line of treatment, it is Nature whc our knowledge of their pathology becomes more accurate. has all the time been doing stern battle with the malignant <7oMCMMOM.—The object of these papers has been to foe. And how ineffectual and stupid our worrying applica the great importance, from the point of view of emphasise tions to the diphtheric throat now seem in the light of th< treatment, of fixing the attention on the plasma. The whole modern serum treatment! How pathetically puerile ou art of consists in acting directly on brain and nerves finicking treatment of pueumonia (on which whole librariei’ (as byhealing education, "suggestion," the removal of peripheral of treatises have been written), when we learn that at thl and in correcting a faulty plasma-neither more irritation) crisis the opsonic index of the blood leaps upwards, in tokelnor less-and we may sum it up in the aphorisms, ’’ Tend that the great strategist Nature has completed her plan the mind and the nerves ; correct the plasma." There is for the final phagocytic onslaught, which is to annihilate no form of medical treatment but is embraced by one or the pneumococci and thus remove the essential cause of th other of these injunctions, and of the two the second is diseaseI Had we a Temple of Healing much the more important. We have still a great deal to learn on the subject of im over one of its doorways the words, Nervos atque mentem munity. So far as our present knowledge goes the mean ’ cura, might fittingly be inscribed, but over the main portal adopted by the host for coping with bacteria would appea in letters of gold should be placed the admonition 2to fall under two heads-those adapted (1) to destroy th Corrige Plasma. bacteria ; and (2) to neutralise the poisons which the ’
engender.
Speaking broadly, we may destroyed in one of two ways, 1.
say that the bacteria ar either by the phagocyte
2 It is scarcely necessary to say that it is impossible to express these aphorisms in classical Latin, which has no word either for the "nerves" or the blood "plasma."
- day the redness quently a second
had diminished. Two days subsesimilar injection was made and it was observed that whilst the redness still diminished the descemitis persisted. Ten days were now allowed to elapse, at the end of which time ten drops of the cyanide solution Four days after redness had disappeared and were injected. the subsequent progress of the case was in all respects satisfactory. An objection to this mode of treatment is the extreme pain caused by the injection.
EPIDEMIC CEREBRO-SPINAL FEVER. SINCE our last issue there has been no special event to record in connexion with the epidemic of cerebro-spinal fever beyond the occurrence of sporadic cases in localities hitherto unaffected. In London a case has been removed from Shoreditch to the Eastern Hospital of the Asylums Board. Cases have been diagnosed at Hutton in Essex ard at Tipton in Staffordshire, and fatal cases have occurred in Salford and at Ripley, near Derby. In Edinburgh seven cases have been notified as presenting suspicious features; four of these have been removed to a hospital, four ,patients have died, and 14 remain under observation. In Glasgow the conditions show no alteration. There has The been an extension of the disease in Aberdeenshire. first case in this county was mentioned in our issue of March 23rd, p. 826, as occurring in the Cluny district, and .a niece of this patient has since been attacked at Kintore. A fatal case has occurred in Stirling. In Belfast the public health committee has decided to make no daily statement as to the progress of the epidemic but in future to give only a weekly return of the number of cases and the deaths that have occurred each week. Since the commencement of the outbreak in this city there have been 228 cases with 138
deaths. ____
THE
REGISTRATION
OF
PLUMBERS.
situation
exactly : " Really competent men would be certain a compulsory registration test. Incompetent men ought either to be compelled to make themselves competent or to be by law forbidden to practise."
to welcome
A SESSIONAL meeting of the Royal Sanitary Institute will be held at the Parkes Museum on Tuesday, April 9th, at 8 P.M., when a discussion will take place on the Aim and Scope of Women’s Work in Relation to Public Health. The discussion will be opened by Dr. H. Meredith Richards, medical officer of health of Croydon. General discussion is invited and Colonel J. Lane Notter, R.A.M.C., chairman of the council of the institute, will preside.
of the South-Eastern division of the Association will be held, by the courtesy Medico-Psychological of Dr. F. R. P. Taylor, at the East Sussex County Asylum, THE
spring meeting
Hellingly, 12
on
Wednesday, April 17th, commencing
at
noon. ____
A TELEGRAM from the Governor of Hong-Kong received at the Colonial Office on March 25th states that there were 3 cases of plague reported during the week ending March 23rd and 3 deaths from the disease.
THE RÔLE OF THE BLOOD PLASMA IN DISEASE. BY HARRY CAMPBELL, M.D., B.S. LOND., F.R.C.P. LOND., PHYSICIAN TO THE NORTH-WEST LONDON HOSPITAL AND TO HOSPITAL FOR DISEASES OF THE NERVOUS SYSTEM, WELBECK-STREET.
THE
VI.l THERAPEUTICAL DEDUCTIONS. WE have seen what a large part the plasma plays in shaping the destinies of the organism : in determining the various phases of evolution, in promoting senile decay, and in setting up morbid processes. As regards the latter it is no exaggeration to say that the role of the plasma in the genesis of disease is all-predominating, and that the future of pathology and therapeutics is essentially bound up in this
AN interesting leaflet has reached us in reference to this subject, being a reprint of a discussion on the matter which has recently been taking place in the columns of the Li1...e’l’pool .Daily Post. Mr. W. D. Caröe, the Master of the Worshipful Company of Plumbers, points out that the pro- subtly complex fluid. That the majority of the diseases which the physician is priety and utility of a system of registration of plumbers called upon to treat are plasmic in origin is made manifest were first publicly debated in Liverpool, when the British Medical Association held its congress there in 1883, while by a glance at the appended list of disorders which are in the following year, when the International Health Con- admittedly induced through the plasma. The classification adopted, though obviously not a logical one, suffices nevei.gress was held in London, the whole question of the means theless for our purpose. of insuring the qualification and responsibility of plumbers 1. All the bacterially induced diseases, such as the and the efficiency of their work in its sanitary relation was exanthemata and allied affections-e.g., scarlet fever, -considered by a great gathering of plumbers, architects, and measles, small-pox, typhus fever, typhoid fever, influenza, rheumatic diphtheria, and cholera ; such dis-sanitary authorities. It was then seen that inferior work orders as fever, mumps,cerebro-spinal fever, infantile parapneumonia, and appliances constituted in a great measure the cause of acute ascending paralysis ; a multitude of unnamed lysis, the falling into disuse of the apprenticeship svstem and the febricul2e, including "common colds"; the various tuberincrease of untrained men in the ranks both of employers culous affections-e.g., phthisis pulmonalis, tuberculous and employed. The education and registration of the meningitis, tuberculous kidney; gonorrhoea and syphilis in its multitudinous manifestations. plumber followed and at the present time we are happy to 2. All affections, with the exception of those note that 14,000 plumbers have been enrolled upon the due to inflammatory direct irritation from without (as may happen, for register. Much of the success of the Worshipful Company example, in gastritis, bronchitis, and dermatitis). of Plumbers in this matter is no doubt due to the fact 3. Diseases due to the introduction of poisons from withthat the Company exists solely for the benefit of the out-e.g., alcohol, opium, tobacco, tea, lead, arsenic, and public and the advancement of craftsmanship and that it is mercury. 4. Gout and those numerous allied affections grouped in no way concerned with trading or trade profits as such. under the term " rheumatic," such as muscular rheumatism The work of the Company would be easier and its benefits and fibrositis-e.g., lumbago. more widely spread if the public could be induced in their 5. Numerous non-gouty affections of the joints, such as own interests to give employment wherever possible to pyasmic and syphilitic arthritis, rheumatoid arthritis, chronic rheumatism, and many allied arthrites, impossible at present The avoidance of structural registered plumbers only. defects in the dwelling-house is one of the most important to classify. 6. The various hormonic disorders-e.g., Graves’s disease, factors in domestic hygiene, and the general health of Addison’s disease, and acromegaly. myxcedema, the community is not a little dependent upon the way in 1 Articles I., II., III., IV., and V. were published in THE LANCET of which the plumber carries out his work. The concluding Feb. 2nd 9th (p. 375), and 23rd (p. 535), and March 16th (p. 754) editorial remarks of the Liverpool Daily Post sum up the and 23rd (p. 313), (p. 827), 1907, respectively.
964 7. Spasmodic asthma, megrim, and diabetes. 8. Infantilism, delayed or premature puberty,
and
premature senility.
9. Such well-known affections of the blood as purpura, scurvy, chlorosis, pernicious anaamia,, and leucooytbsemia. 10. All the so-called " primarydegenerative affections of the nervous system, with the possible exception of such diseases as Friedreich’s and those which are excited by excessive functioning; most functional nervous disorders, including insanity, megrim, neuralgia, headache, and those multitudinous minor nervous disturbances to which almost all civilised human beings are occasionally liable. 11. Practically all the organic diseases of the cardiovascular system other than the congenital and those due to muscular strain. As instances of heart disease caused through the plasma may be mentioned the endocarditis, myocarditis, and pericarditis of rheumatic fever, the endocarditis of influenza and the exanthemata, the pericarditis of Bright’s disease, and the fatty degeneration of the myocardium resulting from chronic alcoholism. How large a part the plasma may take in causing cardio-vascular disease is further shown by the phenomena of chronic Bright’s disease. 12. Most diseases of the lungs, bronchi, and plasma. Consider the frequent involvement of these structures in the specific fevers, in gout, and Bright’s disease ; the frequency of bronchitis in improperly fed children ; and the large part which tuberculosis plays in pulmonary and pleural
affections.
Seeing, then, how dominating is the r6le of the plasma in disease, it follows that in every case which comes before him the physician should pay due regard to the condition of that fluid. Generally he will be safe in postulating some plasmic defect, and his chief concern should be to discover in what that defect consists, and having done this, to correct it. He should argue : " If I can bring about a normal condition of the
jhat it is through the digestive system that we can generally work most effectually. This is because digestion plays a preponderating part in determining the composition of the plasma, for disorders of it lead not only to the impoverishment but (what is of much greater pathological import) to Lihe poisoning of the plasma, and also because the digestive system, owing to its large bulk and the complexity of its functions, but still more to its wanton abuse, is very apt to De thrown out of gear ; so much so, indeed, that a sound digestion is but seldom met with among the civilised, the majority of whom suffer in greater or less degree from indigestion toxsemia—a condition responsible for much ill Be it remembered that sound health among us moderns. digestion generally means sound plasma and thus sound health, while defective digestion always implies unsound plasma and consequently imperfect health. This dependence 3f sound health upon sound digestion has long been rethe Chinese our "How do you do?" is sognised. Among rendered by "How is your stomach ? " We shall the better realise the prominent part played by the digestive system in determining the composition of the plasma if we reflect that of the sum total of material agencies operating upon the organism from withoutconstituting, that is, its material environment-food occupies the first place ; it is from the food that the tissues are built up, and it is from the food, together with oxygen, that the energy of the vital machine is derived. The conversion of this crude food into a form suitable for absorption and assimilation is a function of the first importance, one consuming a large share of the total energy expended by the organism, and requiring the constant activity of the most bulky system of organs in the body. This capacious system includes not only the liver and the pancreas, but some 30 feet of tubing furnished with many millions of glands, and it contains on an average not less than one half the total blood mass. Nor must it be forgotten that the function of the digestive glands does not end with digestion ; they also furnish enzymes and hormones which, entering the blood, play a necessary part in
plasma, I can make my patient well." Doubtless it is possible to effect a complete cure when there is grave structural change; nevertheless it is remarkable to what nutrition. extent even serious degenerative changes can be recovered Here I would point out that it is essentially through the from, provided a healthy state of the plasma is established. digestive system that climate benefits health. In most Consider, for example, how completely the patient can be diseases it may be said that the patient does best where cured of grave alcoholic neuritis if only he can be made to his digestion is best. No doubt other factors come into play, abandon his drinking habits. especially in such affections as bronchitis and rheumatism, The proposition healthy plasma implies health " is in the in which the good effect of climate is largely produced by main accurate. Exceptions may occur, for example, in such the direct influence of the atmosphere upon the skin and a disease as facial neuralgia resulting from a lesion of mucous membrane. Nevertheless, it is essentially the digesnot
but cases of this kind are comand the physician may rest assured that he will seldom fail to cure his patients if he can establish a perfectly healthy condition of the plasma. While assigning to the plasma this prominent role in disease I am not unmindful of the part played by the nervous system in pathogenesis, nor of the good which may be achieved through it. We should ever be careful to remove any reflex irritation, such as eye strain, that may be present, and to get all the good we can by mental treatment, be it through education, change of scene, suggestion, or what not. Yet even then, and when all is said and done, it will be found that it is largely through the plasma that the good effect is achieved. MEANS OF CORRECTING THE PLASMA.
the Gasserian
ganglion ;
tive factor that we have to rely on in the climatic treatment of disease. It will be found, for example, that the benefit which a tuberculous child derives from a stay at Margate is in direct proportion to the improvement which takes place in. the character of his motions. It is imperative that the physician should realise how large a part the establishment of normal digestion plays in treatment. Not until he does will he be able to secure a full measure of therapeutic success, no matter with what branch of medicine he may decide to identify himself. For this reason the study of dietetics and indigestion should occupy a prominent place in the student’s curriculum, and throughout the whole of his subsequent career be kept constantly in view. Nothing more forcibly shows the evils of ultra-specialism than the casual way in which these subjects are treated by many physicians. In whatever In every case of disease in which we believe the plasma direction he specialises a physician must at least learn the to be abnormal the first question to ask ourselves is : What is best that is known of the diagnosis and treatment of the nature of the defect ? Does it pertain to its nutrients, digestive disorders. hormones, enzymes, or excreta, and if so, what is its precise Let me here cite an incident which gives point to these character ? Unhappily, we can but rarely answer this ques- remarks. Fully imbued with the truth I have just sought tion with any degree of precision, though in the correct to emphasise, a physician of my acquaintance has for some answer to it lies the key to the diagnosis and the treatment time past been devoting himself to the study of diet, and in of most non-surgical diseases. I do not propose to enter this connexion he not long since made an examination of into the various methods at our disposal for discovering the jaws and teeth of that splendid collection of skulls conplasmic defects here-that would be altogether beyond the, tained in the museum of the Royal College of Surgeons. scope of these papers. I must content myself with briefly Now this greatly concerned an old friend of his who, having indicating the different ways of correcting them when found. docketed him neurologist, declared that he was gravely They may be grouped under the following heads : (1) methods jeopardising his professional success by not sticking to his directed to the digestive system ; (2) methods directed to neurological last, that his conduct in thus straying beyond the excretory organs ; (3) methods directed to the destruction his own proper field was strangely heterodox, not to say of bacteria, or the neutralisation of their products ; and eccentric, for (thus ran the argument) what in the name of (4) methods directed to the correction of defects in respect common sense can teeth have to do with nerves ? My friend of hormones and enzymes. contends, not, I think, without reason, that in point of fact Methods direoted to the digestive system.-In our endeavour there is a very close connexion between the two, and he is to bring about a healthy state of the plasma we shall find satisfied that his excursions into the realms of dietetics and
paratively
rare
965
anthropology have in no small degree enhanced his efficiency as a practical physician, and not the least so among those of his patients who suffer from nervous maladies. Methods directed to the excretory organs.-When the blood contains poisons an attempt may be made to get rid of them by promoting excretion, and from the earliest days of medicine eliminants in the shape of purgatives, diaphoretics, diuretics, and emetics have been used for this purpose. With the exception of the first of these, however, it cannot be said that they are of much help in purifying the blood and even purgatives act rather by preventing the absorption than by promoting the elimination of poisons. Diaphoretics A "cold " can someare of little value as blood purifiers. times be staved off by "getting the skin to act "-e.g., by wrapping the patient up in blankets or putting him in a is occasionally of warm bath ; and the Turkish bath therapeutic service, though not so useful as the natural diaphoresis provoked by exercise. In ursemia diaphoretics are practically, valueless, while as for such time-honoured practices as giving ammonium acetate in febriles states, few would contend that they can have any appreciable effect in ridding the blood of poisons. Nor can it be said that diuretics are any more valuable for this purpose, except in so far as they act by stimulating a failing heart and thus removing dropsical accumulations. And just as we cannot get much help from eliminants in relieving toxsemia. so, on the other hand, it is only exceptionally that any marked degree of toxsemia is attributable to defective elimination of normal excreta, except, perhaps, in the case of constipation. The fact is, such excreta are rapidly run out of the blood and only tend to accumulate seriously when there is grave organic disease of the heart, lungs, or kidneys. In short, toxsemia results from the absorption of poisons from without, or from the undue production of poisons within, rather than from failure in the eliminating organs ; and its treatment therefore should consist rather in the prevention of such absorption and such undue formation, or in treatment calculated to neutralise the poisons present, not in attempts to promote their
and digest them or by means of chemical subThese latter are of several kinds and include the lysins which actually dissolve the bacteria (as happens, for instance, in typhoid fever and cholera), and the opsonins which so affect the bacteria as to render them an easy prey
which
engulf
stances.
to the phagocytes. 2. The bacterial poisons are neutralised by the antitoxins, substances which have been administered with great successs in diphtheria, tetanus, and botulismus. These poisons, allied as they are to the foodstuffs, are capable of being linked on to the molecules of the living protoplasm, such
assimilative union interfering with the normal vital activities of the cells. Now the antitoxins combine with the bacterial poisons and thus prevent the latter from entering into union with the cell protoplasm, thus giving time for the process of bacterial destruction to be carried through. The treatmpnt of bacterial diseases by the application of nature’s own method consists for the most part in the administration of antitoxins and of substances calculated to For this latter increase the opsonic power of the blood. method we are indebted to the classic researches of Wright and Douglas. In order that this treatment may be successful the quantity of the substance administered has to be carefully regulated in relation to the opsonic index. By due attention to this particular Wright, Bulloch, and others have been able to obtain striking results in local tuberculosis, as well as in acne, furunculosis, and sycosis. When we reflect what brilliant results have in so short a time been achieved by this method of treatment, may we not confidently anticipate a splendid future for it?° Treatment by drugs, dating back though it does some thousands of years, has with a few exceptions yielded but barren results. It was hoped that great things would come from a study of their physiological action and that a reign of rational, as distinguished from empirical, drug treatment had by it been inaugurated ; but, alas, such hopes have not been realised. While many useful drugs will doubtless be discovered in the future the treatment by drugs seems destined long to remain essentially empirical. At last, however, a method of treatment has been discovered which is in elimination. the truest sense of the term scientific and rational, based as Methods of coping mith bacteria and their prodcets.-We it is on the very method nature herself employs. now know that the human organism has special methods of -Jlethods d;,rected to the correction {If defects in respect of its own for striking at pathogenic bacteria and their pro- hnr1nones and enzYl1ws.-Whenever disease is due to a horducts, methods which have been steadily evolving from the monic or enzymic defect the treatment obviously consists in very beginning of animal life. No branch of therapeutics correcting that defect. To do this we must first discover holds out greater promise than that which is based on these its exact nature, and this is seldom possible in the present natural methods. Treatment of this kind, rendered possible state of our knowledge. We know that myxcedema is by the labours of such men as Pasteur, Bebring. Koch, and due to deficient thyroid action and are able to cure the Wright, is eminently scientific and rational. Before their affection by the administration of thyroid extract. Certain time the treatment of bacterially induced diseases was for the cases of infantilism, again, are apparently due to some most part empirical. It is true that abscesses have long been defect in the pancreas and can be greatly benefited, as Byrom treated by rational surgical means and that the treatment of Bramwell has shown, by means of an extract of this gland. typhoid fever by cautious dieting and of hyperpyrexia by the On the other hand, though there are good reasons for conapplication of cold may be regarded as genuinely rational; cluding that Graves’s disease, Addison’s disease, and acrobut speaking generally, it must be conceded that, prior to the megaly are due to perverted hormonic function of definite advent of the new system, the treatment of microbic diseases tissues, the treatment of these diseases by the administration was essentially empirical, and very poor at that. In the of an extract of the affected tissue has hitherto proved discase of such affections as pneumonia, diphtheria, and the appointing. Similarly, while evidence seems to point to the exanthemata, our treatment, so far as any good has come of conclusion that pancreatic diabetes results from the absence it, has essentially consisted, not in worrying the patient by from the blood of a pancreatic enzyme, no satisfactory treatfussy interference, but in leaving him severely alone and ment of that disease has yet been discovered. But although trusting to careful nursing. While we have been hugging at present we can do but little for this (probably large) class ourselves with the belief that we have "pulled him of disorders, we may reasonably hope for greater success as through " by a specific line of treatment, it is Nature whc our knowledge of their pathology becomes more accurate. has all the time been doing stern battle with the malignant <7oMCMMOM.—The object of these papers has been to foe. And how ineffectual and stupid our worrying applica the great importance, from the point of view of emphasise tions to the diphtheric throat now seem in the light of th< treatment, of fixing the attention on the plasma. The whole modern serum treatment! How pathetically puerile ou art of consists in acting directly on brain and nerves finicking treatment of pueumonia (on which whole librariei’ (as byhealing education, "suggestion," the removal of peripheral of treatises have been written), when we learn that at thl and in correcting a faulty plasma-neither more irritation) crisis the opsonic index of the blood leaps upwards, in tokelnor less-and we may sum it up in the aphorisms, ’’ Tend that the great strategist Nature has completed her plan the mind and the nerves ; correct the plasma." There is for the final phagocytic onslaught, which is to annihilate no form of medical treatment but is embraced by one or the pneumococci and thus remove the essential cause of th other of these injunctions, and of the two the second is diseaseI Had we a Temple of Healing much the more important. We have still a great deal to learn on the subject of im over one of its doorways the words, Nervos atque mentem munity. So far as our present knowledge goes the mean ’ cura, might fittingly be inscribed, but over the main portal adopted by the host for coping with bacteria would appea in letters of gold should be placed the admonition 2to fall under two heads-those adapted (1) to destroy th Corrige Plasma. bacteria ; and (2) to neutralise the poisons which the ’
engender.
Speaking broadly, we may destroyed in one of two ways, 1.
say that the bacteria ar either by the phagocyte
2 It is scarcely necessary to say that it is impossible to express these aphorisms in classical Latin, which has no word either for the "nerves" or the blood "plasma."