Tuesday, October 9, 2012
As a brief prelude, those who know a little about English history will remember that Henry VIII “dissolved” the monasteries so that he could grab their cash. My teaching hospital, St Bartholomew’s, was founded by a monk named Rahere in 1123 as a monastery in “the smooth field”, now known as Smithfield in the City of London. Thus “dear old Henry” dissolved it! Later when he became sick from syphilis he wanted somewhere that would treat him so he refounded it and became known paradoxically as the founder. Thus there is a statue of him over the entrance gate to this day. As a young intern in this, my teaching hospital, I had an experience that I have remembered through 64 years of medical practice. One night I was confronted with a middle aged man with pneumonia. This was before the days of antibiotics: the first sulfonamide had just been synthesized. The patient was known to have chronic tuberculosis and the pneumonia was an additional factor. There was little that we could do for him. In the morning I was standing in the ward entrance. The hospital was made up of wards for males and females separately and each consisted of about 30 beds. The only privacy was a curtain that was used to surround each bed as required. Each ward was presided over by a head nurse who was called Sister. Her flowing cap and the name Sister were inherited from the time when monks were the doctors and lay sisters were the nurses in monasteries. Every physician in an English hospital and especially young interns listened to Sister at his peril. She ruled the ward with an iron rod. She is truly a historical figure. The next morning, while I was standing in the ward entrance, my “chief” had entered and was standing behind me. He said “O, I see you have a dying patient” and of course, I asked him how he knew. “Well,” he said, pointing to my patient with pneumonia, “you see how that patient’s fingers are picking at the edge of the bed-sheet, occasionally pointing at the ceiling and picking at thin air: that is consistent with what we recognize as a toxic brain”. Well, of course, he died and the autopsy showed that his entire body was infiltrated with micro-abscesses filled with staphylococci. The lab work before he died showed nothing that would even hint at disease. The white cell count was normal: he had no elevated temperature and other blood tests were all normal. Laboratory tests are used really to see how a sick person is responding to any form of “stress”, including any form of infection. They really demonstrate how the body defenses are responding to an attack. It was clear that he had not put up any kind of defense at all. In fact, due to poverty, poor diet and the ensuing tuberculosis, his defense mechanisms were simply not functioning. The important factor that I learned the hard way was that the part of his brain that acts as a computer below conscious level was “sick” and that it had failed to organize any kind of defense. The next time I saw this phenomenon was when I was an assistant in a family practice in Leicester, a Midlands city. One evening two young women came into the surgery (office) at the end of evening hours and said “we want you to come and see our Dad”. I asked whether it could wait until morning and they said “no—we want you to come now. He’s got a cough”. When I entered the bedroom I saw a middle aged man who was kneeling on a bed with a single blue light bulb over the bed as the only lighting. He was looking at me with sightless eyes, pointing at me and “picking at thin air”. He proved to have meningitis caused by a pneumococcus, an unusual organism for meningitis but a common one for pneumonia. The family had failed to call me for his “cough” that was due to pneumonia that had preceded the meningitis. Because of his extreme disability through poverty, lousy diet and poor living conditions, the organism that had caused pneumonia had spread to the spinal tissues to cause meningitis. He had the same situation as the one already described. It has been a vivid memory that has guided me to see how the brain is responsible for our body defenses in any sort of attack, whether it be an infection, an injury or virtually any form of “stress”. So, it is fascinating now to see that research has indeed shown how the brain “gets into the act”. It has recently been found that the lower part of the brain, the computer, receives information that an organism is attacking. It then dictates what has come to be known as the “inflammatory reflex”. It organizes this vital defensive mechanism because of messages from the attacked tissue to the brain through an important nerve called the vagus. This nerve runs from the lower part of the brain to many organs in the body, carrying signals from and to them. Thus it turns on the inflammatory reflex, controls the right degree of inflammation and then turns it off. We need inflammation as a defense but it has to be carefully controlled. If something goes wrong with it, an important part of our defense is compromised. The mechanism depends on chemistry (and probably electricity) derived from food that supply our cells with the ingredients to synthesize cellular energy that enable this vital reflex to function. Both these unfortunate patients were killed by organisms that quickly overwhelmed their depleted natural defenses. Thus, you might say that the attacking organisms were opportunists. They “cashed in” on an easy opportunity to win what is essentially a war between us and our environment. We are bombarded with stressors that we cannot see, against which we have to mount a defense. As Darwin theorized, it is the survival of the fittest. The term “opportunist” is officially reserved for organisms that attack us only when our ability to defend ourselves has been damaged severely enough through disease to threaten death. For example, candida albicans is a yeast, known as “opportunist” since it is generally considered never to launch an attack unless serious illness has prevailed. We all know, of course, that Louis Pasteur introduced us to the fact that organisms that could only be seen with a microscope could kill us. This was really the first paradigm in medicine that led us ever since to seek ways and means to “kill the enemy”, whether it be bacteria, virus or cancer cell. I find it fascinating that Pasteur is said to have remarked on his death bed “I was wrong! It is the body defenses that matter”. Thus, perhaps Louis Pasteur indicated the next medical paradigm. I think that we should consider all pathogenic micro-organisms to be potentially “opportunist”. In recent years I have seen many children with autism who commonly develop yeast infections and although they are certainly biochemically compromised, they are not by any means “near death”. We are seeing diseases caused by infections with organisms like chlamydia that appear to be classified as “opportunist” but I believe that our profligate diet, the air we breathe, water and food pollution are all combining to weaken our defenses so that organisms that do not usually attack are being given a better opportunity to win the war. I believe that we should regard any pathogenic micro-organism as an opportunist, because it is much less likely to win a war when our bodily defenses are well organized. Think of the body as like an old fashioned fortress. There was a central control in the shape of a commander and the defenders obeyed his orders. If the commander was asleep or otherwise out of commission, any attack on the fortress would be potentially doomed. I have been engaged in answering patient’s questions on a new website called ”Health Tap”. This is where a great deal of free answers are provided by a large group of doctors who give some of their time to this beneficial connection between doctor and patients. What surprised me was that the answer I have had to give to so many of these questions has been “diet”. It was so common that I must look like a “broken record” to some. The fact is, however, that the nature of our fuel supply is one of the very few things that we can do preventively to maintain health. As long as we drive a two ton machine to a supermarket and buy our food in cardboard boxes, we are like cars that have been provided with the wrong fuel. The resulting failure to synthesize sufficient cellular energy winds up by supplying our only natural enemies with plenty of opportunity. It was not doctors that stopped the common appearance of tuberculosis. It was better housing, hygiene and less starvation. It is not too surprising that this dread disease has recently made its reappearance and is Mother Nature’s comment on our modern diet. The only difference is that we have swung from too little food to too much of the wrong food, the Yin and Yang that rule the natural order of things.