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    "title": "THERAPEUTICS",
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    "verified_text": "since 1910 very considerable changes have taken place in our knowledge, and our general con- ception of the problems involved has been correspondingly broadened. prevention.—pyrevention, the ideal aim of medicine, has greatly advanced in its practical application (in this country this has been fostered by the establishment of a ministry of health in 1919 which has greatly expanded the scope of work carried on by the local government board, and also by the activities of the medical research council founded in 1913 aspart of the national insurance scheme). preventive medicine includes, in addition to improvement of environmental conditions, prophylactic treatment in the very early stages of discase, such as can be provided in antenatal, school, dental and venereal clinics and so comes within the number of advances to be chronicled under the heading of therapeutics. a notable example of prophylactic treatment is the prevention of goitre (see goitre) or, as in this country it is often called, derbyshire neck; this is an endemic or local discase, probably depending, as lieut.-colonel r. mccarrison in india showed, on contamination of the water supply with micro-organisms; it is extremely prevalent in switzerland and in north america both therapeutics in men and lower animals in the neighbourhood of the great lakes, and has been found to be associated with a diminished content of iodine, which has a well-marked antiseptic action, in the thyroid gland. by the periodical administration of iodine to children in districts where the condition is prevalent it has been most successfully prevented. deficiency diseases —another aspect of the same question is presented by the group of “ the deficiency diseases ”’ or the avitaminoses, which depend on the absence from the food of the vitamins or “‘ accessory food factors.” as constituents of food these vitamins (g.v.), of which there are several, are remarkable for the contrast between the extremely minute amounts present and the striking changes resulting from their absence. their chemical constitution is unknown, but they are mainly formed in vegetables and plants, including yeast, and pass into herbivorous animals and so are available for those whose diet is confined to meat. their absence from the diet stops growth and causes cer- tain cliseases, such as beri-beri (see beri-beri) a disease of the nerves due to a diet of polished rice from which the husk con- taining the water-soluble b vitamin has been removed; if a man or animal suffering from beri-beri is given the rice polishings of the husks the disease disappears. scurvy (see tropicaal medicine), formerly a serious disease in the navy in long voyages, was banished just before the close of the 18th century by the empirical use of fresh vegetables and fruit juices, but recurred in the armies in certain areas during the world war, due to the absence of a vitamin named water- soluble c. infantile scurvy is sometimes seen in civil life in babies fed most carefully but too exclusively on boiled milk. rickets is due to deficiency of a fat-soluble vitamin (d); this antirachitic factor can be produced by the action of sunlight and ultra-violetraysonalarge number of foodstuffs, especially fats,and from cholesterol. another probable deficiency disease is pellagra, due to eating maize and a diet defective in protein (e.g., meat). tropical diseases ——the prevention of tropical disease origi- nated in great britain under sir ronald ross’s direction with the destruction of the mosquito, the carrier of the malarial para- site (see tropical medicine), has been much expanded by the rockefeller foundation, which has instituted many campaigns against diseases, such as malaria, yellow fever and especially a world-wide attack on ankylostomiasis, a disease due to a worm in the intestines (sce hookworm; malaria; yellow i°ever). yel- low fever, which formerly took such a terrible toll of life, has now been almost entirely eradicated from south america by destruction of mosquitoes, the carriers of the infection. inoculation.—the world war proved the enormous value of prophylactic or protective inoculations against certain diseases on the same lines as edward jenner’s vaccination against small- pox (q.v). just before the south african campaign sir almroth wright started the method of protection against typhoid fever (see ismxcunity) by injection with a vaccine composed of killed cultures of the bacillus typhosus; this inoculation sets up changes in the body which render the individual immune for a time, probably about four years, to this form of infection, in the same way as an attack of the disease. after the south african campaign cases were observed resembling typhoid fever but due to different though allied bacilli, and two additional forms, paratyphoid a. and paratyphoid b., of fever became recog- nised, the three diseases being collectively described as enteric fever (see [infectious fevers). in order to protect against infec- tion of these three forms of fever, it is necessary to inoculate the individual with the three vaccines, and soon after the outbreak of the world war paratyphoid fever attacked the troops in flanders and did not spare those inoculated against typhoid fever only; the three vaccines, known collectively as t.a.b., were then given, and the wonderful freedom of the army from enteric fever, which in past wars has killed as many as bullets, is a triumph for preventive medicine. in a like manner men who were wounded and so likely to be infected with bacillus tetant (see tetanus), which appeared to be common in the much culti- vated belgian soil, were at once injected with the antitetanic serum and so protected from tetanus or lockjaw. therapeutics - dysentery (see dyssentery) is another war disease, and there were many cases among the troops at gallipoli and elsewhere in the east. there is more than one kind of dysentery. one of them, amoebic dysentery, is prone to be followed by liver ab- scess, the amoeba passing to the liver. before the war it was found that emetine, an alkaloid of ipecacuanha long known as an empirical remedy for dysentery, was extremely efficient in curing this form of dysentery and also the hepatitis or inflamma- tion of the liver which precedes the formation of an abscess. our soldicrs suffering from dysentery were injected almost as a routine with emetine and the number of cases going on to liver abscesses was surprisingly few. the other common form of dvsen- tery due to a bacillus was treated with an antidysenteric serum, but not with such success. as a result of the large numbers of officers and men who suf- fered from war strain and its effects, often called shell-shock, during and after the war, the psychotherapy (see psycho- therapy) of these nervous disorders has greatly developed. endocrine therapy. when any of the endocrine glands, the thyroid, adrenals, pituitary, which pour an internal secretion into the blood and keep the body in health, are diseased or fail to do their work properly, signs of disorder or disease result. the secretion may be suppressed or diminished, excessive or altered in character (see endocrinology). when the secretion is diminished an attempt to provide it can be made, and in the case of thyroid, which when inadequate produces myxoedema, or in early life cretinism, brilliant results have long been obtained by this substitution therapy or giving the thyroid gland or an extract of it by the mouth. in rorg e. c. kendall of the mayo clinic, rochester, minnesota, obtained in a pure form the active principle—thyroxin—which is extremely effective. the para- thyroid glands, small bodies close to the thyroid gland in the neck, manufacture an internal secretion which passes into the blood and exerts an action apparently opposed to that of the thyroid. whereas the thyroid is concerned with the control of iodine in the body, the parathyroids deal in a similar manner with calcium salts. deficiency in the action of the parathyroids appears to lead to a diminished quantity of calcium salts in the body and to an irritable state of the nervous system, and is thought to be responsible in children for the contracture of the hands and feet known as tetany, though on this question there is considerable discussion. recently the extract of the parathyroid glands has been given in a number of diseases of a chronic infec- tive nature, especially in sprue (see sprue), a tropical disease characterised by diarrhoea, want of digestion of food so that the patient wastes as if from starvation. it has also been recom- mended for ulcers slow to heal and other obstinate conditions. organotherapy—an outstanding advance on organotherapy is the insulin treatment of diabetes mellitus (see diabetes). in this disease the patient, who is unable to utilise sugar and starch- es, passes sugar in the urine, wastes and may eventually die in coma. the pancreas, or sweetbread, is a gland concerned with the digestion of food, including starches, in the alimentary canal, and at the same time that it provides this external secretion pours an internal secretion into the blood which enables the body to make use of sugar. this internal secretion is manufactured by structures in the pancreas known as the islands of langerhans, and the extract from them is called insulin. after many trials the technical difficulties in obtaining a satisfactory insulin (see insulin) were surmounted in 1922 by f. c. banting and c. h. best of toronto, and a remedy was thus made available, which though it does not cure diabetes, any more than thyroid extract cures myxoedema, yet for some hours makes the previous dia- betic practically a normal person as regards the utilisation of starch and sugar. the hypodermic administration of insulin must be repeated at least once daily, but this treatment keeps the disease in abeyance and has thus prolonged and saved innu- merable lives. in diabetes insipidus, a comparatively rare clisease, in which large quantities of urine free from sugar are passed, relief for some hours is similarly obtained by hypodermic injection of extract of the posterior lobe of the pituitary gland. the success of thyroid and insulin treatment has stimulated 769 research and trial in the case of other glands and numerous com- mercial preparations have been placed on the market; but the claims sometimes made for various forms of organotherapy have yet to be confirmed. ; chemiotherapy.—chemiotherapy, or the use of a drug which has a selective affinity for a germ and leads to its destruction without damaging the tissues of the body, was the conception of paul ehrlich of frankfort-on-main who in 1910 discovered the specific remedy ‘‘ 606” or salvarsan which rapidly leads to the destruction of the spirochaeta pallida (sce venerfal diseases), the protozoan responsible for syphilis. it now appears that the action is not independent of the activities of the patients’ bodies and that the germ is not poisoned and killed off solely by the drug, which indeed may damage the tissues of the patient very severely and even cause death, so that the ideal of chemiotherary has not been realised. remedies of this class are, like quirine in malaria, specific, lead to a complete cure, and are therefore of the greatest importance in opening a new vista in medicine. since its introduction salvarsan and its modification neo-salvar- san “‘o14”’ and allied organic preparations of arsenic have been increasingly used in the numerous results of syphilis with great success; but this treatment has its limitations, for when the para- site of syphilis gets inside the central nervous system and causes locomotor ataxia and general paralysis of the insane the drug cannot follow the spirochaete and the disease is little if at all influenced. recently it has been found that inoculation with the malarial organism and an attack of the disease benefits patients with general paralysis, but how far this is a permanent cure re- mains to be proved (see malaria). trypanosomes, animal (or protozoan) parasites closely akin to spirochaetes are responsible for diseases, such as trypanosomiasis and african sleeping sick- ness (to be distinguished from quite a diflerent clisease epidem- ic to encephalitis [see encephalitis lethargica] popularly called sleepy sickness) which are also curable by the organic arsenical compounds atoxyl and arsacetin. tartar emetic, a salt of antimony, acts like arsenic on trypanosomes and in addition effects a cure in bilharziasis (see bilharzusis) (a disease due to flukes), filarial disease and kala-azar, three tropical infections (see kala-azar; puarmacology). serum therapy.—just as in enteric fever, so in cerebro-spinal (“spotted ’’) fever and pneumonia (see cerebro-spinal fever) bacteriology (g.v.) has shown the existence of several strains or types of the causal micro-organism; these though morphologi- cally indistinguishable are so biologically different that each is most efficiently treated by an antitoxic serum, obtained from an animal injected with, and so immunised to, that particular type. before the recognition of these types antitoxic serums were em- ployed, but they might or might not correspond to the exact strain of the micro-organism present in an individual case. in 1913 douchez and gillespie, working at the rockefeller institute, new york, isolated four types of pneumococci, the micro-organ- ism causing acute pneumonia; but it is only the antitoxic scrum corresponding to pneumococcus type i that is curative. during the war, especially in 1915, epidemic cerebro-spinal meningitis or cerebro-spinal (‘‘ spotted ’’) fever became preva- lent among the fighting forces, especially in young recruits. it is due to the afeningococcus intracellularis (see serum thera- py), and in order ellectively to neutralise its effects simon ilex- ner of the rockefeller institute prepared an antitoxic serum from animals immunised from 4o different strains (multivalent). this serum is injected by lumbar puncture into the (subdural) space around the spinal cord, so that it can come into direct con- tact with the meningococci which chiefly select the central ner- vous system. the prevalence of the disease stimulated research and strains of meningococci were isolated; mervyn gordon, working for the medical research committee (now council) which devoted all its energies with great effect to the conditions of diseases in the troops, isolated four types of meningococci and prapared four corresponding mono-type sera; when a case was bacteriologically proved to be due to infection with one of these strains, the corresponding serum was given; while waiting for the bacteriological decision as to the responsible type, a mixture of 770 type i and type ii serum was given, as 80 to 85% of the cases were due to these strains. tuberculosis —the search for a specific remedy for tubercu- losis, such as a new form of tuberculin, an antitoxic serum ora metallic preparation analogous to salvarsan or tartrate of anti- mony in protozoan diseases, has continued, but no finality has been reached (see tuberculosis). spahlinger’s treatment by vaccines and serums has received intermittent attention, mainly in the lay press; dreyer in 1923, by removing the fatty material from tubercle bacilli, obtained a vaccine, called diaphyte, which has been tried on human beings, and from experiments on ani- mals was at first thought to have an increased effect, as compared with other vaccines; later reports have not been favourable, but both experimentally and clinically it may still be premature to decide about its ultimate value. quite recently sanocrysine (a gold compound) has been introduced by mellgaard of copen- hagen and is at present on trial; it is a powerful remedy which kills the tubercle bacilli and, by liberating their poisons, may pro- duce severe constitutional reactions; knud faber, from his clini- cal experience, points out that in order to avoid these dangerous results, the doses should be small. in pulmonary tuberculosis a great factor in obtaining arrest and cure of the disease is rest, and in order to immobilise the lung the production of artificial pneumothorax (g.v.) is now widely practised. air is introduced into the pleura—the space between the lung and the chest wall—on the other side of the affected lung which then collapses and comes to rest, all the work of respiration being carried on by the other lung. this procedure has given very good results in selected cases. treatment in sana- toria is of great value in arresting the progress of pulmonary disease and in teaching the patient the laws of health that he must follow, but it is now becoming recognised that there is urgent need for a more prolonged protection from the strain of ordinary life in the environment of cities, and that tuberculous colonies in the country are required for this purpose, such as papworth near cambridge and preston hall near maidstone. the treatment of leprosy (see leprosy) by intravenous and intramuscular injections of soluble products of chaulmoogra, hydnocarpus, soya bean and cod-liver oils, as advocated by sir leonard rogers, has been shown by reports from leper asylums in various parts of the world to have had beneficial effects and to have reduced the death-rate in a remarkable manner. ali- though there are very few lepers in this country, there are 300,000 in the empire, and at a conservative estimate 1,700,000 in the world, so that any efficient remedy is obviously important. protein therapy.—_by a turn of the wheel the strictly scientific employment of vaccines composed of the micro-organisms thought to be responsible for the morbid condition has led by an empirical process to non-specific protein therapy. it was found, sometimes accidently, not only that the administration of a vac- cine specific for one form of infection benefits a morbid condition due to another infection, but that intravenous injection of for- eign protein, such as peptone and milk, may when they set up a reaction, namely fever, shivering and illness, (‘‘ protein shock therapy ”’), produce a beneficial effect, just as one disease some- times cures another. this protein shock therapy has been em- ployed particularly in asthma and in chronic rheumatoid arthritis. after an attack of many infective diseases there develops an immunity so that a second attack is rare; the reverse of immunity is an exaggerated susceptibility or hypersensitiveness; this is what is meant by idiosyncrasies and the proverb ‘‘ what is one man’s meat is another man’s poison.” this is seen in various diseases, such as recurrent colds and asthma. a method of cure is to desensitise the subject of one of these toxic idiopathies by the administration, usually by hypodermic injection, of the sub- stance, a bacterial or other protein, to which the individual is hypersensitive. thus a patient subject to hay fever is injected with the pollen of the plant which excites an attack; or a patient with bronchitis and asthmatic seizures is injected with an emul- sion of dead bacilli (vaccine) obtained from the expectoration. in many cases of disease and ill-health the cause is a “ septic therapeutics focus ” or a local collection of micro-organisms, for example, in the teeth (see dentistry), tonsils, appendix, gall bladder and intestines, which poison the body and may produce chronic painful conditions, such as chronic arthritis, sciatica, lumbago, fibrositis. the removal of such foci is therefore the important and indeed the first step in treatment; after that vaccines made from the predominant micro-organism present in the focus, and spa treatment may complete the cure. anaemia.—the fatal form of anaemia (q.v.) called pernicious or addisonian after its describer thomas addison of guy’s hos- pital (see anaemia) is the result of chronic infection of the stom- ach and alimentary canal, whichinits turn may be due to a septic focus, but it now appears from the observations of arthur f. hurst, also of guy’s hospital, that an important factor is absence of the hydrochloric acid in the gastric juice which enables the micro-organisms causing pernicious anaemia to take root and live instead of being, as in normal people, destroyed. it has, | therefore, been treated by supplying the absent hydrochloric acid by its medicinal administration by the mouth, with a suc- cess which is due to investigation of the chemistry of the stomach. in this, as in anaemia due to haemorrhage, the operative pro- cedure of transfusion of blood (see bloop transfusion) has been carried out, after the blood of the donor has been compared with that of the patient to see that they are compatible and after measures have been taken to avoid transmitting diseases, such as influenza, malaria and syphilis from the donor. transfusion of blood is a very old method of treatment and was performed as long ago as 1667, but it is only recently that the tests for the com- patibility of the blood based on the existence of four blood groups in man have rendered the procedure less dangerous. transfusion of blood with these precautions was employed on a large scale in the war for haemorrhages and severe shock, as from gunshot and shell wounds, and has also been used in conditions popularly called blood poisoning. a recent development of blood transfu- sion is to immunise by means of vaccines, made from the micro- organism infecting the patient, the blood of the donor, and then to transfuse his blood into the patient. radiotherapy.—x-rays, though mainly employed for diagnosis, have from their power of destroying the tissue cells, many thera- peutic uses. thus enlarged glands and the spleen in various diseases of the blood, and especially in lymphadenoma, are much reduced by x-ray exposure. the recent erlanger treatment of internal cancer by intensive x-rays has the grave disadvantage of making some patients extremely ill (see radiotherapy). radium bromide, the rays of which are much the same, has been much used in the treatment of inoperable carcinoma and in quite superficial growths of the skin, especially rodent ulcer on the face, which, though classed as malignant, is much less viru- lent. in cancer of the uterus radium has proved of unquestion- able value; from a combination of operation and radium good results have been obtained in cancer of the breast; but in malig- nant growths of the tongue, mouth and throat its use has gen- erally been disappointing. gye and barnard’s discovery of the long sought parasite of cancer brings nearer the possibility of obtaining a cure, by a vaccine or a serum. (see cancer and microscopy.) the important advance in the diagnosis of disorders of the heart and the mechanism of its beat have been followed by a more accurate knowledge of how to give digitalis and by the employment of quinidine in the disorders known as auricular fibrillation and paroxysmal tachycardia. numerous researches have been undertaken with the view of devising reliable tests for the functional activity of the liver, and it is clear that sugar is the food which most readily protects and repairs the damaged liver cells. iteliotherapy—recent years have shown an increasing ten- dency to utilise to the full the vis medicatrix naturae in open air treatment, improved ventilation, heliotherapy which has indeed been imitated by the use of ultra-violet rays (see heliotherapy), baths and waters, and exercises. the prophylactic measures based on experience and empirical use have been elaborated by the teaching of scientific research and as a result physiotherapy thermit—thermo-electric pyrometer or physical therapeutics, which includes massage and the various forms of electrical treatment, has considerably advanced in knowledge and application. medical hydrology has been studied and taught on these rather than on purely empirical lines, and it may be noted that spas did excellent work during and after the war for invalided soldiers. hand in hand with open air treat- ment and heliotherapy has come less surgical activity in the way of operating in tuberculous disease of bones and joints. 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