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EMPIRICAL REMEDIES.
1053
(146 B.C. to 476 A.D.); then the Byzantine to 732 A.D. ; next come the Mohammedan and Jewish periods to 1096 A.D., the mediaeval period to 1438 A.D., and the Renaissance and Reformation period to 1600 A.D. The chapters which follow deal with the seventeenth, eighteenth, nineteenth, and twentieth centuries as periods in themselves. One valuable, and we think new, feature of Dr. GARRISON’S book is the sketch at the end of each period of the cultural and social aspects of medicine during that period; there are in addition two most valuable appendices dealing with medical chronoand medical bibliography respectively. The work is crammed with dates and bibliographical
logy
references, and the latter very
fully given,
a
point
we
are
which is
glad to see are frequently over-
But Dr. GARRISON being a librarian is naturally only too well acquainted with the slovenly manner in which references are often given, and has spared no pains to make his own accurate and easy to find. In a work of this size, which deals with so long a period and with so many dates, it is inevitable that there should be slips. Despite those which we have observed we have no hesitation in saying that Dr. GARRISON has given to the medical profession, and especially to those members of it who wish to study the history of their craft, a most valuable and informing work, and we have nothing but congratulations to offer him on the way in which he has accomplished the task he has set himself.
looked.
_______________
Annotations.
may be another side of the
argument which he- has not yet heard. The object of the author is first to show that it is a natural, right, reasonable, and desirable thing for one who would follow the good to associate sympathetically with Christians as a Christian during the interregnum, even when the balance of evidence may seem to him against Christianity; and secondly, not to prove the truth of Christianity, but to show that the case has not been finally closed against it by any of the rival systems in vogue. How far the author is successful in attaining either of his objects obviously must be settled by each individual reader for himself ; suffice it to say that the argument is clearly presented and shows it to be the work of one who has made theology a systematic study, and who has from his medical training an adequate knowledge of the tangential points of both medical and theological science. The 2 other book, "Forgiveness and Suffering," is a careful consideration of the current interpretations of the Christian doctrine of the Atonement and the problem caused by the presence of pain and evil in a world asserted to be created and controlled by a beneficent yet omnipotent and omniscient Being. In this case also the author, Dr. Douglas White, in virtue of his medical training, is apt to detect where the shoe of Christian dogma pinches the foot of scientific data. It would be out of place in THE LANCET to discuss the theology presented in either of these books. We such can, however, conscientiously applaud obviously sincere attempts on the part of excellently equipped members of the medical profession to extend a hand to earnest doubters in the slough of despond. To those who have finally adopted a mechanistic conception of life, and indeed to all but theists, the books make no pretence of appealing.
struggling
"Ne quid nimis."
EMPIRICAL
REMEDIES.
this week an article on the theravalue of the potato, recognising that it is a A FEW centuries ago the principal lights of the contribution which differs in some ways from those medical profession were clerics. With the recent generally published in THE LANCET. The personal growth of psychological science, and especially with experience of one man with a new therapeutic its excursus into the fields of therapy, has grown measure, unless reinforced by scientific reasoning, the requires, we consider, more support than the up a rather voluminous literature from theological side to re-establish the claims of statement that it has succeeded in a certain religious belief and practice as at least a very number of cases. Where the investigator is powerful auxiliary in the healing certainly of the not a qualified medical man there can be no mind, and to a great extent of the body also. But doubt that no account of a new treatment a further indication of the rapprochement between should be published until it has been fully tested the two professions of theology and medicine, which by medical men; and where the suggested treatin the latter half of the nineteenth century, and ment is obviously at variance with known physioeven further back, were becoming more and more logical or accepted medical doctrine the medical estranged, is to be found in the recent appearance of profession is right not to waste time in experimenttwo distinctly theological works from the pens of ing. This attitude is, of course, called narrowmedical men. The first bears the somewhat cryptic minded or short-sighted by the charlatan and by a title, "The Interregnum."1 It consists of 12 essays good number of people who ought to know better, on religious doubt. By the interregnum the author but it is one from which we could never depart in explains that he means that stage in a man’s mental the case of unqualified people. The idea of the development when the old beliefs and sanctions of treatment may be good, but it must be vouched for childhood are lost and he has not yet had time to by trained intelligence, or a delay most inimical form new views of his own. This period is charac- to the interests of the patient might be incurred terised by diffidence, for, as the author explains in But where a medical man valueless trials. by the introduction, the unsettled one finds experts invites medical cooperation by asserting that over disagreeing and feels himself incompetent to decide, a considerable period of time he has tried particular and is naturally chary of allowing himself to be pertherapeutic measures in particular pathological suaded by any elaborate argument, feeling that there 2 Forgiveness and Suffering: A Study of Christian Belief. By 1 The Douglas White, M.D., Trinity College, Cambridge. Cambridge : At the Interregnum. By R. A. P. Hill, B.A., M.D. Camb. At the University Press. 1913. Pp. 150. Price 4s. 6d. net. University Press. 1913. Pp. 133. Price 3s. net. THEOLOGY
FOR
MEDICAL MEN.
WE
peutic
Cambridge :
publish
1054
conditions, and has obtained successes to which he wishes to draw the attention of his brother practitioners, the matter is different. Hence the appearance in our columns of Mr. Howard’s plea for potatojuice in the form of a dressing and liniment in various common and painful conditions. The circumstances in which he recommends the drug are, it will be seen, not those where any serious harm could result to the patient if a certain amount of time in the early stages of the condition were employed in experiment, while a year ago reference was made in these columns to the statements concerning the anodyne and sedative properties of the potato. It will be seen, also, that many of the cases which he quotes are of exactly the kind where the symptoms spontaneously abate, making it difficult for the observer to see how much is due to the remedy and how much is due to nature. ’
RECURRENCE
OF DUODENAL ULCER AFTER OPERATION.
IN the Boston Medical and Surgical Journal of Jan. 29th Dr. William J. Mayo has published an important paper on recurrence of ulcer of the duodenum after operation. Gastro-jejunostomy was the method of choice in the majority of his The greater the obstruction, within limits, cases. the better were the results. The converse also held true : cases with slight or no obstruction gave the highest number of failures. Dr. Mayo divides the failures into two groups. In the first the operation does not relieve the stomach of its acid irritating secretions, and the ulcer is inadequately protected during the healing period. This occurs most frequently in cases of no or slight obstruction. The pylorus is open, and much of the food passes through it instead of through the gastro-jejunostomy. In such cases attempts have been made to close the pylorus by infolding with buried silk sutures, but the general experience is that permanent blockage is not produced, and the sutures are eventually passed into the lumen of the stomach with restoration of the channel. For some time a method devised in Germany has been practised at the Mayo clinic. A strip is cut from the gastro-hepatic or gastro-colic omentum, left attached at one end, and drawn twice about the stomach just above the pylorus or, if the ulcer is sufficiently far from the pylorus, the strip is passed about the duodenum above the ulcer. The site of blocking is diminished in size by the application of several interrupted sutures of fine silk to take the strain during healing. As far as can be ascertained the blockage has remained permanent since this procedure has been followed, but sufficient time has not elapsed to show its exact value. However, it is certain that living tissue drawn about the pylorus is more permanent than devices in which foreign bodies, such as thread, are used. In one case a patient was re-operated on after a year, and a strip of living tissue was found in place and covered with adhesions and the pylorus securely blocked. Another method, adopted by von Eiselsberg, is to divide the pyloric end of the stomach and close both ends, but it has a definite, though small, mortality. In duodenal ulcer without obstruction, when the conditions are favourable, Dr. Mayo excises the ulcer. In his early cases he excised the ulcer alone, but a considerable He therefore number relapsed within a year. found some drainage operation, either gastrojejunostomy or a plastic operation on ihe pylorus,
necessary. Following this, if the pyloric obstruction is slight the ulcer is infolded, as suggested by Sir Berkeley Moynihan, and the pylorus is If the -obstruction is blocked by living tissue. marked only gastro-jejunostomy is necessary. though infolding of the ulcer is advisable. When there is a history of haemorrhages the regional blood-vessels are caught by sutures and tied. In the second group of failures recurrence of the ulcer The trouble was due to imwas only apparent. proper suturing of the gastro-jejunostomy, at the site of which a new ulcer forms in consequence of heavy silk or linen sutures hanging in the suture line. The length of time these sutures will hang is remarkable; in one case it’ was 22 months. Eight cases of this kind were re-operated on in the Mayo clinic, in five of which the original operation had been done there. In two there were intercommunicating fistulæ between the stomach, jejunum, and transverse colon. In both of these cases there was fæculent material in the stomach. The finding of colon contents in the stomach after a gastro-jejunostomy is an indication of perforation of a gastro-jejunal ulcer into the transverse colon. In five of the cases heavy strands of silk or linen were hanging in the wound. In two of the cases the condition of the tissues was such that after removal of the suture it was thought wise to cut away the gastro-jejunostomy, completely restoring the wall of the stomach and jejunum by suture and then doing a plastic operation on the pylorus. This procedure proved so difficult that in later cases the gastro-jejunostomy was reopened in the suture line and the suture extracted. The then enlarged by a plastic operation, sutures. Such experiences teach that very fine silk should be used for gastrojejunostomy, that the bite should be as near the margin of the incision as possible, and that, if it is necessary to reinforce a weak suture line, interrupted fine silk sutures are advisable or such sutures should be used for part or the whole of the outer row. It has been Dr. Mayo’s practice for a long time to use catgut for the inner row, but it is not this which gives trouble.
opening
was
using interrupted
SPLENECTOMY AND INCREASED RESISTANCE TO THE TUBERCLE BACILLUS.
OBSERVATIONS directed to show evidence of any power of aiding the body defences against organisms must receive careful consideration. In relation to the tubercle bacillus especially are they of value. Some striking experiments upon the results following removal of the spleen in mice and rats, which appear to demonstrate an increase in the power of resistance to the tubercle bacillus, have been recorded by Lewis (Paul A.) and Margot (A. G.) in the Journal of Experimental Medicine (1914, Vol. XIX., p. 187). Into the peritoneal cavity in 21 albino mice was injected a culture of bovine tubercle bacilli; the quantity varied from 1 to 5 mgr. in different animals. Within a time varying from a few hours to a few days all these animals died, and postmortem examination showed extensive infection of many organs. A similar proceeding applied in 13 mice of similar weight, from which, however, the spleen had been removed, but which had fully recovered from the effects of the operation, showed that a marked lessening of the effects of the inoculations had occurred. Four of the animals were still living at the time of writing. the rest survived a longer time than did the non-splenectomised animals. Further, the range of
and
(146 B.C. to 476 A.D.); then the Byzantine to 732 A.D. ; next come the Mohammedan and Jewish periods to 1096 A.D., the mediaeval period to 1438 A.D., and the Renaissance and Reformation period to 1600 A.D. The chapters which follow deal with the seventeenth, eighteenth, nineteenth, and twentieth centuries as periods in themselves. One valuable, and we think new, feature of Dr. GARRISON’S book is the sketch at the end of each period of the cultural and social aspects of medicine during that period; there are in addition two most valuable appendices dealing with medical chronoand medical bibliography respectively. The work is crammed with dates and bibliographical
logy
references, and the latter very
fully given,
a
point
we
are
which is
glad to see are frequently over-
But Dr. GARRISON being a librarian is naturally only too well acquainted with the slovenly manner in which references are often given, and has spared no pains to make his own accurate and easy to find. In a work of this size, which deals with so long a period and with so many dates, it is inevitable that there should be slips. Despite those which we have observed we have no hesitation in saying that Dr. GARRISON has given to the medical profession, and especially to those members of it who wish to study the history of their craft, a most valuable and informing work, and we have nothing but congratulations to offer him on the way in which he has accomplished the task he has set himself.
looked.
_______________
Annotations.
may be another side of the
argument which he- has not yet heard. The object of the author is first to show that it is a natural, right, reasonable, and desirable thing for one who would follow the good to associate sympathetically with Christians as a Christian during the interregnum, even when the balance of evidence may seem to him against Christianity; and secondly, not to prove the truth of Christianity, but to show that the case has not been finally closed against it by any of the rival systems in vogue. How far the author is successful in attaining either of his objects obviously must be settled by each individual reader for himself ; suffice it to say that the argument is clearly presented and shows it to be the work of one who has made theology a systematic study, and who has from his medical training an adequate knowledge of the tangential points of both medical and theological science. The 2 other book, "Forgiveness and Suffering," is a careful consideration of the current interpretations of the Christian doctrine of the Atonement and the problem caused by the presence of pain and evil in a world asserted to be created and controlled by a beneficent yet omnipotent and omniscient Being. In this case also the author, Dr. Douglas White, in virtue of his medical training, is apt to detect where the shoe of Christian dogma pinches the foot of scientific data. It would be out of place in THE LANCET to discuss the theology presented in either of these books. We such can, however, conscientiously applaud obviously sincere attempts on the part of excellently equipped members of the medical profession to extend a hand to earnest doubters in the slough of despond. To those who have finally adopted a mechanistic conception of life, and indeed to all but theists, the books make no pretence of appealing.
struggling
"Ne quid nimis."
EMPIRICAL
REMEDIES.
this week an article on the theravalue of the potato, recognising that it is a A FEW centuries ago the principal lights of the contribution which differs in some ways from those medical profession were clerics. With the recent generally published in THE LANCET. The personal growth of psychological science, and especially with experience of one man with a new therapeutic its excursus into the fields of therapy, has grown measure, unless reinforced by scientific reasoning, the requires, we consider, more support than the up a rather voluminous literature from theological side to re-establish the claims of statement that it has succeeded in a certain religious belief and practice as at least a very number of cases. Where the investigator is powerful auxiliary in the healing certainly of the not a qualified medical man there can be no mind, and to a great extent of the body also. But doubt that no account of a new treatment a further indication of the rapprochement between should be published until it has been fully tested the two professions of theology and medicine, which by medical men; and where the suggested treatin the latter half of the nineteenth century, and ment is obviously at variance with known physioeven further back, were becoming more and more logical or accepted medical doctrine the medical estranged, is to be found in the recent appearance of profession is right not to waste time in experimenttwo distinctly theological works from the pens of ing. This attitude is, of course, called narrowmedical men. The first bears the somewhat cryptic minded or short-sighted by the charlatan and by a title, "The Interregnum."1 It consists of 12 essays good number of people who ought to know better, on religious doubt. By the interregnum the author but it is one from which we could never depart in explains that he means that stage in a man’s mental the case of unqualified people. The idea of the development when the old beliefs and sanctions of treatment may be good, but it must be vouched for childhood are lost and he has not yet had time to by trained intelligence, or a delay most inimical form new views of his own. This period is charac- to the interests of the patient might be incurred terised by diffidence, for, as the author explains in But where a medical man valueless trials. by the introduction, the unsettled one finds experts invites medical cooperation by asserting that over disagreeing and feels himself incompetent to decide, a considerable period of time he has tried particular and is naturally chary of allowing himself to be pertherapeutic measures in particular pathological suaded by any elaborate argument, feeling that there 2 Forgiveness and Suffering: A Study of Christian Belief. By 1 The Douglas White, M.D., Trinity College, Cambridge. Cambridge : At the Interregnum. By R. A. P. Hill, B.A., M.D. Camb. At the University Press. 1913. Pp. 150. Price 4s. 6d. net. University Press. 1913. Pp. 133. Price 3s. net. THEOLOGY
FOR
MEDICAL MEN.
WE
peutic
Cambridge :
publish
1054
conditions, and has obtained successes to which he wishes to draw the attention of his brother practitioners, the matter is different. Hence the appearance in our columns of Mr. Howard’s plea for potatojuice in the form of a dressing and liniment in various common and painful conditions. The circumstances in which he recommends the drug are, it will be seen, not those where any serious harm could result to the patient if a certain amount of time in the early stages of the condition were employed in experiment, while a year ago reference was made in these columns to the statements concerning the anodyne and sedative properties of the potato. It will be seen, also, that many of the cases which he quotes are of exactly the kind where the symptoms spontaneously abate, making it difficult for the observer to see how much is due to the remedy and how much is due to nature. ’
RECURRENCE
OF DUODENAL ULCER AFTER OPERATION.
IN the Boston Medical and Surgical Journal of Jan. 29th Dr. William J. Mayo has published an important paper on recurrence of ulcer of the duodenum after operation. Gastro-jejunostomy was the method of choice in the majority of his The greater the obstruction, within limits, cases. the better were the results. The converse also held true : cases with slight or no obstruction gave the highest number of failures. Dr. Mayo divides the failures into two groups. In the first the operation does not relieve the stomach of its acid irritating secretions, and the ulcer is inadequately protected during the healing period. This occurs most frequently in cases of no or slight obstruction. The pylorus is open, and much of the food passes through it instead of through the gastro-jejunostomy. In such cases attempts have been made to close the pylorus by infolding with buried silk sutures, but the general experience is that permanent blockage is not produced, and the sutures are eventually passed into the lumen of the stomach with restoration of the channel. For some time a method devised in Germany has been practised at the Mayo clinic. A strip is cut from the gastro-hepatic or gastro-colic omentum, left attached at one end, and drawn twice about the stomach just above the pylorus or, if the ulcer is sufficiently far from the pylorus, the strip is passed about the duodenum above the ulcer. The site of blocking is diminished in size by the application of several interrupted sutures of fine silk to take the strain during healing. As far as can be ascertained the blockage has remained permanent since this procedure has been followed, but sufficient time has not elapsed to show its exact value. However, it is certain that living tissue drawn about the pylorus is more permanent than devices in which foreign bodies, such as thread, are used. In one case a patient was re-operated on after a year, and a strip of living tissue was found in place and covered with adhesions and the pylorus securely blocked. Another method, adopted by von Eiselsberg, is to divide the pyloric end of the stomach and close both ends, but it has a definite, though small, mortality. In duodenal ulcer without obstruction, when the conditions are favourable, Dr. Mayo excises the ulcer. In his early cases he excised the ulcer alone, but a considerable He therefore number relapsed within a year. found some drainage operation, either gastrojejunostomy or a plastic operation on ihe pylorus,
necessary. Following this, if the pyloric obstruction is slight the ulcer is infolded, as suggested by Sir Berkeley Moynihan, and the pylorus is If the -obstruction is blocked by living tissue. marked only gastro-jejunostomy is necessary. though infolding of the ulcer is advisable. When there is a history of haemorrhages the regional blood-vessels are caught by sutures and tied. In the second group of failures recurrence of the ulcer The trouble was due to imwas only apparent. proper suturing of the gastro-jejunostomy, at the site of which a new ulcer forms in consequence of heavy silk or linen sutures hanging in the suture line. The length of time these sutures will hang is remarkable; in one case it’ was 22 months. Eight cases of this kind were re-operated on in the Mayo clinic, in five of which the original operation had been done there. In two there were intercommunicating fistulæ between the stomach, jejunum, and transverse colon. In both of these cases there was fæculent material in the stomach. The finding of colon contents in the stomach after a gastro-jejunostomy is an indication of perforation of a gastro-jejunal ulcer into the transverse colon. In five of the cases heavy strands of silk or linen were hanging in the wound. In two of the cases the condition of the tissues was such that after removal of the suture it was thought wise to cut away the gastro-jejunostomy, completely restoring the wall of the stomach and jejunum by suture and then doing a plastic operation on the pylorus. This procedure proved so difficult that in later cases the gastro-jejunostomy was reopened in the suture line and the suture extracted. The then enlarged by a plastic operation, sutures. Such experiences teach that very fine silk should be used for gastrojejunostomy, that the bite should be as near the margin of the incision as possible, and that, if it is necessary to reinforce a weak suture line, interrupted fine silk sutures are advisable or such sutures should be used for part or the whole of the outer row. It has been Dr. Mayo’s practice for a long time to use catgut for the inner row, but it is not this which gives trouble.
opening
was
using interrupted
SPLENECTOMY AND INCREASED RESISTANCE TO THE TUBERCLE BACILLUS.
OBSERVATIONS directed to show evidence of any power of aiding the body defences against organisms must receive careful consideration. In relation to the tubercle bacillus especially are they of value. Some striking experiments upon the results following removal of the spleen in mice and rats, which appear to demonstrate an increase in the power of resistance to the tubercle bacillus, have been recorded by Lewis (Paul A.) and Margot (A. G.) in the Journal of Experimental Medicine (1914, Vol. XIX., p. 187). Into the peritoneal cavity in 21 albino mice was injected a culture of bovine tubercle bacilli; the quantity varied from 1 to 5 mgr. in different animals. Within a time varying from a few hours to a few days all these animals died, and postmortem examination showed extensive infection of many organs. A similar proceeding applied in 13 mice of similar weight, from which, however, the spleen had been removed, but which had fully recovered from the effects of the operation, showed that a marked lessening of the effects of the inoculations had occurred. Four of the animals were still living at the time of writing. the rest survived a longer time than did the non-splenectomised animals. Further, the range of
and