Diathesis As A Factor in The Etiology of Disease. Part I

There is But One Disease: Colloidal Disequilibrium
The Relation of Dental Disease to Physical Abnormalities is Discussed in
“DIATHESIS AS A FACTOR IN THE ETIOLOGY OF DISEASE” Part I

By F. W. Broderick, M.R.S.C., L.R.C.P., L.D.S, Bournemouth, England

The second part of this article will appear in the July issue.

                In April last, the following letter of mine appeared in the British medical Journal. As this expresses my beliefs in as short and compact from as I am able to express then I feel that I cannot do better than use it as a text for this paper. I wrote as follows: “In the Journal of March 30 appear two letters, one by Dr. H.W. Barber on ‘The Nature of Acidosis,’ the other by Dr. J.B. Christopherson on ‘Chronic Respiratory Disorders and the Autonomic System,’ which, at first sight, might appear to be taken together contain the essence of the etiology of chronic disease.

“Barber considers that seborrhea may be found in two distinct classes of patients; The fair, robust and active individuals; and in the dark, pallid, thick-skinned, hypotonic type of person; that in the former there exists an acidosis, with a high ammonia combined free acid ratio in the urine, and in the latter an alkalosis with a low ratio of combined to free acid. That is to say that in a disturbance in the acid-base balance of the tissue, which may well be compensated completely so far as the blood pH is concerned, but in which urinary analysis will show a disturbed, metabolism in either direction, skin lesions may arise, which can be successfully treated by correcting the imbalance. This suggests that seborrhea is not so much a disease entity as a symptom of a constitutional upset. Now the two types mentioned by Barber are outstanding examples of differences in constitution depending upon vegetative balance, as visualized by Kraus and Zondek, in which not only is the vegetative nervous system disturbed, but which depend also upon changes in the proportion of ‘H’ and ‘OH’ ions (acidosis or alkalosis) on the ratio of the ions of the divalent kations (Ca) to those of the monovalent (K); on hormonal influences, chiefly of the thyro-adrenal system; and on colloidal disequilibrium. Here we get a connection between the thought underlying Barber’s letter and that of Christopherson, who contends that such conditions as chronic bronchitis and asthma are essentially due to autonomic dysfunction, and thus become, once again, not diseases but symptoms of some constitutional disturbance.

A paper read at a meeting of the Eastern Counties Branch of the British Dental Association, Northampton. Reprinted from the British Dental Journal, January, 1936.

“I have for years contended that dental caries and pyorrhea come into the same etiological category;that they depend primarily upon vegetative disturbances in opposite directions. The former in the direction of sympathetic excess, with an excess of ‘H’ ions over those of ‘OH’ and excess of calcium over potassium, an excess of thyro-adrenal activity, and a tendency to the break-up of the colloidal system (dehydration). Whereas pyorrhea depends upon a disturbance in the opposite direction: an increase in ‘OH’ ions are compared with ‘H’ ions, an overbalance of potassium over calcium, a diminution in thyro-adrenal activity, and a hydration, a tendency to enlargement and precipitation, of the colloidal system. Thus, again, these became symptoms and not diseases. A biochemical investigation of patients showing these dental lesions in aggravated form upholds these suggestions, and if, in addition, an ultra-microscopic picture of the blood plasma is undertaken, as advocated by J.E.R. McDonagh, it becomes evident that here we have the fons et origo of dental lesions.

“If this approach to the nature of disease is considered it will be seen how enormously medicine is simplified thereby; hardly any of the conditions which to-day are dignified with the names of disease are, in reality, disease entities at all: many of them are but symptoms of disturbed vegetative function, others but end-points of disease, as Christopherson contends are emphysema and bronchiectasis. Disease, that is a departure from perfect health, becomes, essentially and simply, vegetative imbalance in the one or the other direction which, in fact, explains the well-known antagonism of diseases. Furthermore, as soon as we realize this important fact we are in a position to appreciate the very beginnings of disease, and to commence preventive treatment before the end points have developed. For these changes in ionic balance; in hormonal function; in colloidal equilibrium, all of which are interdependent and interrelatated, are diagnosable by comparatively simple tests, and may be corrected in a number of ways. Whether we approach the matter, with Barber, by way of the acid-base balance; by stressing autonomic system; or through the chemico-physical properties of matter in the colloidal state, as does McDonagh, is immaterial, as the ultimate object and the ultimate result will be the same. If we appreciate that immunity, in so far at any rate as chronic infection is concerned, is a matter of vegetative balance rather than of the development of specific antibodies, then that which Christopherson calls the bacterial heresy ceases to trouble, and focal sepsis takes its proper place in the etiology of disease as but another consequence of inefficient vegetative function.

Causes of Dental Caries Revert to Systemic Changes

“If, again, as suggested by Hahne, and more recently by McDonagh, the vitamins act, not by virtue of their chemical composition, but physically upon the colloidal particles of the plasma, hydrating or dehydrating these as the case may be, and thus maintaining or disturbing vegetative efficiency, the deficiency diseases themselves come into line. Again, when we consider such work as that of Cannon and of Crile on the effects of emotional disturbance upon the thyro-adrenal system, and through this upon the vegetative system, the place of psychology in medicine is explainable. Thus not only do we arrive at a point where we can separate diseases from symptoms, and commerce treatment before organic changes have taken place in organs and tissues, but the old classifications of disease according to the organs and tissues affected, which Christopherson laments, disappear and become meaningless, and specialism, in medicine if not in surgery, so condemned by Sir James Mackenzie as being the obstacle to the advance of knowledge of the beginnings of disease, ceases to exist. Medicine becomes one unified whole.”

As this is a combined meeting of medical and dental men I wish to emphasize my conviction that there is no special and specific etiological causes of dental disease, any more than there is any special or specific cause of any disease: the symptoms, and finally the physical signs, of any disease depend upon the reaction of the body to some particular insult, and this reaction will be essentially the same whatever that insult may be: whether this be the invasion of the body by micro-organisms, the entrance of some foreign protein, or the effect of some trauma, the reaction will be similar, will be chemical and physical in kind, and will depend absolutely upon the reactivity of the vegetative system. The effects, the end-points which will eventually come about, will differ according to the situation, the structure and the environment of the organs attacked, and to the direction in which the vegetative system will be upset: this latter depending upon the constitution, the diathesis, of the individual. Sir Archibald Garrod has said: “To our chemical individualities are due our chemical merits as well as our chemical shortcomings, and it is very nearly true to say that the factors which confer upon us our predispositions to, or our immunities from, the various mishaps which are spoken of as disease, are inherent in our very structures, and even in the molecular groupings which confer upon us our individualities, and which went to the making of the chromosomes from which we sprang.”

Now of the various factors which together make up the vegetative system, as distinct from the vegetative nervous system, it cannot be said that one is more important than another, except in so far as changes in all, or any, affect the stability of the colloidal state. All living matter is colloidal, life can only exist as colloid, as soon as this is disturbed, within very narrow limits, death supervenes. It will be obvious, therefore, why there exists such an efficient and complicated mechanism to preserve intact all the factors on which this depends, of which that relating to the compensation of disturbance in the acid-base balance of the body tissues is such an excellent example. Here we have the blood buffers, the kidneys, the liver, and the respiratory system, all actively concerned in regulating and maintaining the balance.

Colloidal State of Matter Important Factor

I have demonstrated to you an ultra-microscopic picture of the colloidal particles of the blood plasma, with the aid of which you will be able to visualize changes which may take place in a colloidal system. A few words, perhaps, on the chemico-physical properties of matter in the colloidal state may not be out of place. All matter in dispersion is either in solution, that is in molecular dispersion, in coarse dispersion, or in the colloidal state, the difference depending upon the size of the particles. Sugar, for example, dissolves in water, that is it is present in molecular dispersion; sand does not dissolve, it slowly settles down, the particles precipitating and falling to the bottom of the vessel holding the water. Between these two types of dispersion lie limit within which matter is neither in solution nor in precipitated particles but is present in what is known as the colloidal state. Quite arbitrarily the size of a colloidal particle has been fixed as between 0’1 of a micron and 1’0 of a millimicron, a micron being 1/10,000 and1/1,000,000 of a millimeter. Particles of this size are invisible with the highest power of a microscope, but they are too large to pass through the pores of a parchment membrane; they are, however, visible with the ultra-microscope, which differs in principle from the microscope in showing not the particles themselves but their reflected images. Matter in molecular solution is invisible even with the ultra-microscope, and the particles are sufficiently small to pass through a parchment membrane; this constitutes matter in a crystalloid state: on the other hand matter in coarse dispersion has particles which, when not visible to the unaided eye, are visible under the microscope.

Correct Metabolism Dependent upon Many Forces

Thus we see, not only that there are three kinds of matter in dispersion, but that matter in the colloidal state itself may have particles of different size within limits in which the state is possible. Now matter in this form possesses certain chemico-physical properties which differentiate it from all other, and to which are due all the possibilities of life. The chief importance of the colloidal state in the living body lies in the enormous development of surface area which it allows. You will appreciate that in the almost infinite subdivision which this state entails the surface area increases out of all proportion to the minuteness of the particles. This increase in surface area involves an enormous multiplication of interfaces at which energy is produced, at which, in fact, the processes of metabolism take place, the transference of food into energy. In addition, however, to this great increase in surface area and in the number of interfaces which the colloidal state makes possible, certain other characteristics are inherent in matter in this state of dispersion of which the most important is that of the power of adsorption of ions from the medium in which they are dispersed; which, indeed, constitutes the method by which metabolism is carried on. We have to consider, not the colloid micelle as separate and distinct things, tiny particles of matter floating in a fluid, so much as the relation of these micelle to the medium in which they are surrounded; any change in the constitution of which immediately affects the character of the micelle themselves, enlarging or diminishing their size through changes in surface tension, and therefore changing their metabolic possibilities, for the larger the particles the smaller will be the surface area and the fewer the interfaces, and vice versa.

With perfectly functioning particles all these constituents are firmly held to the nucleus, but in certain conditions they tend to pass out of the colloidal complex, loose, as it were, into the surrounding medium, as the adsorptive power of the particles diminishes. When the colloidal complex tends to break up in this manner, as a result of changes in the dispersal medium, away come these constituents, commencing with electrons, which, being dissipated as heat, raise body temperature; and, as the break becomes more and more severe, followed by the other constituents, on order from without inwards, according to the amount of disturbance, the particles getting progressively smaller until they eventually go into solution, and cease to be colloid. On the other hand, the particles may enlarge, due to changes in surface tension, when they will hold these constituents still closer, adsorbing more from the surrounding medium, in which case these latter may even disappear altogether from the blood plasma, and being changed from a crystalloid to a colloidal form will be incapable of being differentiated by ordinary analysis. This is the explanation of such conditions as hypoglycemia and hypocalcemia on the one hand, and of hyperglycemia on the other. As, when the particles get smaller in this way and lose their adsorptive properties, they give up water, and when they enlarge and increase their adsorptive properties they take up water, they are spoken of as dehydrated and hydrated particles respectively. In this way we get three kinds of colloidal particles: the normal, as small as is consistent with the colloidal state, giving a normal adsorptive power and enormous surface area; the dehydrated particles, still small but consisting of imperfect particles in that they have lost absorbed constituents; and large, hydrated particles, with increased adsorptive powers and lessened area, tending to become coarse dispersion and to precipitate. Further, it is possible, in fact most usual, to find at any one time both hydration and dehydration present together, in varying degrees, for reasons which I have no time to discuss now, when the effects of the condition will depend upon the proportion of each present and which, consequently, predominates.

From this short and, I realize, quite inadequate description of the colloidal state you will realize its importance in medicine, at any rate from the point of view of metabolism; when one appreciates that dehydrated colloid exists in conditions of acidosis, calcium excess, sympathetic overaction, and thyroid and adrenal plus; and hydrated colloid with alkalosis, calcium deficiency, parasympathetic excess, and thyro-adrenal minus, one is able to correlate metabolic inefficiencies and the varying symptoms which accompany it. But we can go much further than this: McDonagh contends that the whole matter of immunity, susceptibility and hypersensitivity is wrapped up in the colloidal state of the individual at the time of the possible infection. He believes that electrical condensation of the colloidal particles of the blood-plasma is the only important consideration. The bodies of micro-organisms are themselves composed of colloidal particles, as otherwise they would not be alive; when these meet the colloidal particles of the plasma there is immediately brought about a state of colloidal disequilibrium, in which the more condensed particles (in an electrical sense), whether those of the organisms or of the body, will withdraw electrons from the less condensed and tend to drive them into solution. If, then, the colloidal particles of the individual are properly disseminated, that is neither hydrated nor dehydrated, the micro-organisms pass into solution (bacteriolysis) and are destroyed, and he is immune, where as if the particles of the patient are less condensed than those of the organisms, then these latter pass into solution and the patient is susceptible.

The effect upon the protein particles of the plasma, which constitute the resistance of the host, of an invasion of the body by micro-organisms, or of some chemical poison, is essentially the same whatever the irritant may be; these cause first of all a slight dehydration of the particles which, as susceptibility gives place to immunity, bring about a hydration; the differences between the effects of organisms and certain foreign proteins lie only in the powers, as a condenser, of the irritant. The more powerful the type of hydration will be one that will tend to pass into a dispersion of the particles. An explanation of the different types of hydration in McDonagh’s conception of the origins of disease would take as too far afield for this paper, it must suffice to say that invaders, whether bacterial or of chemical origin, have different powers of penetration of the colloidal complex, which, together with the chronicity of the invasion, tend to change the quality of the subsequent hydration which takes the place of the preliminary dehydration which the invasion brings about.

Now the more the particles are dispersed the more the surface area will they present and the greater will be their electrotonic capacity, through which they will be enabled to destroy the colloid particles of an organism in a subsequent invasion, more especially if this happens to be by a similar organism: this is immunity. The chemical allergens being substances with a great condensing power the type of hydration produced by an invasion will be great and lasting, and a second invasion will tend to still further increase this hydration, with a consequent precipitation—this is hypersensitization; and according as to where this precipitation takes place will depend the symptoms of the disease.

Here we get an explanation of the cause not only of anaphylaxis, with a sudden precipitation of hydrated particles in many parts of the body, but also of all the allergic disease where this precipitation takes place in some particular part of the body; as, for instance, in the capillaries of the lungs in asthma, in the nasal mucous membrane in hay fever, in the portal system in mucous colitis, and so on; the symptoms being produced by an irritation and vasodilatation of the capillaries in the situation where they are precipitated.

But it will be seen that it will only be in those individuals who tend to have large hydrated particles, as their usual, constitutional, trend, who will suffer hypertensitisations; that is to say, those who are dominated by the parasympathetic portions of their vegetative nervous systems; who tend towards an alkalosis; in whom the calcium ions are deficient; and who are deficient in thyro-adrenal stimulation. Here we have the reason for the particular physiological and biochemical reactions of the allergics, as, at the same time, the reason for their comparative immunity from dental caries; and the reason why the salts of calcium, and the acids, are useful in the treatment of these conditions.

Dental Caries: A Disturbance of Body Chemistry

Having gone so far let me turn to the production of the dental lesions for a further illustration: I have said that I believe that dental caries rests upon a disturbance of body chemistry in the direction of an acidosis; this will be associated with a dehydrated colloid; with a predominance of acid over alkaline ions; with an increase of calcium over potassium in the body cell: with an increase thyroid and adrenal activity; and with excessive sympathetic function. All this will bring about a special type of individual, who will present quick pulses, high blood pressures, increased metabolic rates, with increased katabolism, and other features with which our medical friends will be familiar. There is, however, one class of individuals who get excessive caries who do not come into this category, with which I will deal shortly. The method of the production of the caries is simple to visualize; the excess acidity will be mirrored in the reaction of the saliva, and there will come about a passage of calcium ions from enamel to saliva which will eventually lead to a decalcification of the tooth; as to the exact spot at which the decalcification will the soonest reach the dentine will depend upon local circumstance, the food plaque and so on; but without the acidosis the food plaque and fermentable carbohydrate will matter not at all, whereas with it no amount of cleanliness will preserve the tooth.

Pyorrhea Disturbances Present Complications

Pyorrhea, on the other hand, is a much more complicated problem, here we have to be able to explain not just one single circumstance like enamel destruction, but a number, viz., the immunity from caries that co-exists; the gingivitis which, in varying degrees accompanies the condition; the loss in immunity from the ordinary saprophytes on the mouth, which allows them to become parasitic and pyogenic; the deposition of a certain type of calculus under the gum margins; and the absorption of the alveolar bone. Now if we consider the opposite type of individual to that liable to dental caries; those dominated by their parasympathetic side of the vegetative system, in whom the alkaline ions are in excess; where there ions of potassium overbalance those of calcium; where there exists a deficiency of the thyro-adrenal system; and whose protein is hydrated; we have the explanation of all these special phenomena. The immunity from caries will be brought about by a reversal of the process which produced enamel destruction, and a hypercalcification will come about, on account of an alteration in salivary reaction to the alkaline side, according to the laws of ionization. The explanation of the gingivitis, in varying degrees, I wish to leave for the moment. The suppuration due to a loss in immunity to ordinary saprophytes is explainable along the lines of vegetative imbalance, which indeed, although it is too long a story to tell here, provides the non-specific immunity of all tissues, which is far more important to health, from the point of view of chronic disease at any rate, than the production of antibodies. It is alteration in vegetative balance, which exists in all pyorrhea patients, which allow, not only the penetration of the tissues by micro-organisms, but which so alters their characteristics that they become disease-producing organisms; in fact, which provides the soil necessary for this chance. The deposition of subgingival calculus is entirely a matter of colloidal disequilibrium, and is, in every way analogous to the formation of gall-stones. Given a medium tending towards alkalinity, and a colloid in a particular form, the formation of this type of calculus, which differs essentially from that soft, yellow variety which is deposited, not below the gum margin, but upon the gums and the surfaces of the teeth, follows according to the laws of colloidal depositions.

The matter of the alveobar destruction needs a few words of explanation, for here, at first sight, appear some definite contradictions. Accompanying the alveolar destruction there occurs a sclerosing jaw, and oftentimes, as we know to our disadvantage, some degree of exostosis of the tooth rose. Here we have a peculiar disposition of calcium, a being destroyed in one situation, and laid down in another. Now the newer work on the physiology of bone, that of Leriche and Policard, explains the peculiarity. They say, in effect, that bone deposition and resorption depend entirely upon circulatory efficiency; where this is increased bone is resorbed, where it is diminished bone is laid down. Further, they contend, that where bone is being actively resorbed in one situation the calcium thus freed is available for utilization elsewhere near at hand where circulatory circumstances allow. There are, of course, other factors, all of which are chemical and which are intimately related with vegetative function, as is indeed the matter of the circulation. This matter has been recognized recently in surgery, and the operation sympathectomy, the division of those nerves which carry the sympathetic fibres to a part, is now utilized in cases of fracture, arthritis, and other conditions in which it is required to influence bone resorption or deposition. With a parasympathetic dominance, associated with hydrated colloid, such as that to which I attribute pyorrhea, the blood vessels will become dilated and more permeable, and this increase in circulation, more particularly in such situations as the alveolar borders, which are end-points of circulation, will affect the bony tissues in the direction of a resorption, and will be associated with a deposition  of bone elsewhere. Thus all the symptoms of pyorrhea are explainable along the lines of a parasympathetic dominance with hydrated colloid, as I contend no other theory will explain them.

Category of Pyorrhea and Dental Caries

McDonagh builds a ladder with reference to colloidal disequilibrium, in which the lower rungs are associated with dehydration, the next with dehydration combined with small amounts of hydration; as we ascend this ladder, the hydration gets progressively greater and greater until in the upper rungs hydration is almost pure. In the center of this ladder that space where dehydration and hydration tend to equal one another occur, according to his teachings, all the inflammatory conditions. Now if we attempt to associate dental conditions with the various rungs of this ladder we get caries at the bottom, where dehydration very greatly predominates; caries with gingivitis as we climb upwards into the regions where the inflammatory phenomena commence; gingivitis alone as we approach the center of this area; gingivitis with pyorrhea as we reach the position where hydration commences to predominate; and pyorrhea without gingivitis after we have left the inflammatory zone, and reach that spot where hydration tends to become pure.

Gottlieb, in his classification of the various forms of pyorrhea, stresses a clinical type in which the gingivitis is very small or absent, which he designates alveolar atrophy; and the experience of all of us must, I think, show that the amount of gingivitis differs very considerably in different individuals. This visualization will explain these differences and will show that it is quite unnecessary to search for differences in etiology between these clinical types when, in fact, they represent simply degrees of the same disturbance.

 

July 25, 2017 · jagdish1 · No Comments