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Annotations.

PRACTITIONERS AND DANGEROUS DRUGS.

" Ne quid nimis."

EFFECT has now been given to the recommenda-tion, made by the Departmental Committee onMorphine and Heroin Addiction, that a medicaltribunal should be set up to consider the case ofmedical practitioners addicted to drugs or supplyingthem for purposes of addiction. As already fore-shadowed,l this tribunal is to consist of three medical- practitioners, assisted by a legal assessor, and as

from July 29th last the Home Secretary is no longerobliged to chase an offending doctor into the police-court in order to obtain the withdrawal of his authorityto supply and possess habit-forming drugs. It wasthe feeling of the Departmental Committee that atribunal with a strong medical element would servethe double purpose of protecting from himself adoctor who had unfortunately become a drug addict.and protecting his patients by preventing him fromprescribing dangerous drugs in excess. The newRegulations will achieve this purpose and at thesame time avoid unseemly publicity in a distressingbut happily very small class of cases. The otherRegulations which came into force on the same datemake it an offence for a person to go to a seconddoctor for a supply or prescription of habit-formingdrugs unless he first discloses that he has been receiv-ing treatment from another practitioner. Doctors,dentists, and veterinary surgeons are now required- to keep records of all supplies of dangerous drugspurchased or obtained by them, whether or not theydispense or otherwise supply the drugs. Copies ofthese Regulations, amending the Dangerous Drug-Regulations of 1921, are obtainable from H.M.Stationery Office..

GASTROSCOPY. - THERE is significance in the fact that endoscopic’.examination of the stomach was being attempted inLondon before the war, whereas to-day the practiceis so rare as to be almost unknown. The difficultiesand dangers of the procedure have caused it to fallinto ’abeyance. Nevertheless, it is still employedquite frequently both in Germany and in Austria,"and it seems clear that -if it could be brought to,a more perfect state of technique it would be of theutmost importance both in diagnosis and for watchingthe effects- of treatment. When we realise the,immense issues determined by the examination ofan X ray shadow the potential value of a directview of the gastric mucosa is apparent. Stimulatedby such views Dr. Jean Rachet,2 working with Dr.Bensaude at the Hopital Saint-Antoine in Paris,has recently published a study of his clinical andexperimental observations with this instrument.The modesty and-logic of his conclusions are suchthat we feel them worthy of reproduction here.

Gastroscopy must remain an exceptional method ofgastric examination ; -, it occupies a position in themeans at our disposal after radiographic examinationbut before laparotomy. Gastroscopy demands the.exercise of the greatest prudence, the greatest- patience, and the greatest gentleness. The methodcannot be looked upon as an everyday means ofinvestigation and should remain in the hands ofexperts trained in its use. The safety of its employ-ment must not be sacrificed even for the benefit ofprogress. It is impossible with a gastroscope to

explore the whole of the stomach and consequentlya negative finding does not permit of the exclusionof organic disease. A straight, rigid gastroscope forindirect vision is advocated by Dr. Rachet, and heinsists on the importance of scrupulous preliminary

1 THE LANCET, June 19th, p. 1218.2 La Gastroscopie. By Dr. Jean Rachet. Paris : Octave

Doin. 1926. Pp. 117. Fr.20.

examination of the patient. The passage of theinstrument is made with the patient in the position ofleft lateral decubitus, local anaesthesia is employed,and a guiding thread is first swallowed by the patient.After detailing the technique necessary to obtain anadequate view of the greater part of the stomach,the author points out the value of the method forstudying recent peptic ulcers and for identifyingearly malignant growths. As regards the latter, henotes the disappointment that must result from thefact that patients experience symptoms so late thateven by the most accurate means of diagnosis earlycancer will rarely be discovered. In the study oftrue gastritis the instrument holds out hope ofprogress in our knowledge, for it is only when directvision is added to our armamentarium that we canhope for any real advance concerning this disease."

Gastroscopy," Dr. Rachet concludes, " appears tobe a method promising rich results ; but it requiresgreat prudence and much further research to establishits’final value. It should in no case supplant othermeans of investigation, and it is by the accumulationof clinical facts that it will acquire its right to bequoted as a first-class means of examining cases

of digestive disturbance."

MEDIÆVAL MEDICINE.

AN excellent epitome has been made from the fourvolumes already published of Mr. R. T. Gunther’slarger work, " Early Science in Oxford," in orderthat a large number of students for whom the cost ofthe original book was prohibitive may have an

opportunity of studying some of the subjects thereinmentioned. The present workl is in seven chaptersdealing respectively with Early Medicine, Medicinein the Seventeenth Century and After, Anatomy,Physiology, Zoology, Botany, and Geology. Thebook is of a size handy to read, admirably printed,has many illustrations, and is altogether delightful.Mr. Gunther has a wonderful flair for extractinggems from the various ancient mines in which hehas been working, and many of them show how trueis the aphorism that there is nothing new under thesun. For instance, the following excerpt, takenfrom the diaries of one Simon Forman (1552-1611),of Magdalen College, puts modern professors ofrejuvenation in the shade : " and myselfe did boill2 snakes in my strong water when I distilled it andafter I drank of that water and yt made me to befresh and take away all my gray hairs when I was56 yers old and many toke me not to be above40 or 42." Another would, if he reads it, make SirArthur Conan Doyle extremely envious. It concernsa Fellow of Trinity, by name Th. Allen (1542-1632),noted for his skill in mathematics and astrology.The vulgar looked upon him as a magician and hisservitor would tell them " that he met the spiritscoming up the stairs like bees." Few outside themedical profession, or we might even say within it,know that the architect of St. Paul’s was the same Dr.Christopher Wren, Fellow of All Souls, to whom aredue the beautiful anatomical drawings in illustrationof Willis’s work on the brain, and that he was alsothe originator of intravenous injections. The dis-covery of a method of injecting bodies with a solidi-fying fluid is due to Boyle, as also the method ofkeeping moist anatomical preparations in spirit.Richard Lower, a pupil of Willis, studied the anatomyof the heart (1669) and left some accurate drawingsshowing the spiral arrangement of the muscular fibres,a fact almost forgotten until its revival by Pettigrew.Robert Hooke, of Christ Church (1635-1702), whowas not only a skilled microscopist but an archi-tect of no mean talents (he built the new buildingsof Bethlehem Hospital in 1675), was the first to recordthat the blue colour in a peacock’s tail has no realexistence, but is due to " a texture visible under themicroscope "-i.e., is due to interference, though,

1 Early Medical and Biological Science ; extracted fromEarly Science in Oxford, by R. T. Gunther, M.A., LL.D. OxfordUniversity Press, Humphrey Milford. 1926. Pp. 246. 7s. 6d.

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- of course, he did not know the reason. These quota-tions may suffice to indicate the interest of Mr.Gunther’s book. Of the series of postcards issuingfrom the same press,2 two especially are worthy ofTiote ; the one (dated 1631) shows the Castle of Healthattacked by flying evils, an early forecast of microbialinvasion ; the other (dated 1660) is an amputationscene from a window in the Bodleian. The patientis seated in a chair placidly regarding the operator,who is removing his leg with a hack-saw, no preliminaryincision of the soft parts having apparently beeninade.

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THE ACTION OF PITUITARY EXTRACT ONTHE UTERUS.

IN 1924 Dixon and Marshall showed the existenceof a relation between the cyclic activity of the ovaryand the pituitary gland, and stated that the amountof pituitary secretion discharged into the cerebro-spinal fluid depends largely upon whether corporalutea are present or absent. They came to the con-clusion that as the corpus luteum is supposed toundergo retrogression shortly before the close ofpregnancy, the revival of the ovarian secretion causesa sudden increase of pituitary secretion, which by itsaction on the more irritable uterine muscle bringsabout labour. According to this theory the increaseof pituitary secretion is an important factor instarting parturition. Subsequent observers, instudying the conduction of contractions in uterinemuscle, found that there are distinct changes in themechanism of this muscle at different stages of theoestrous cycle. It was also found that remarkablechanges take place under the action of pituitary extract,which seems to induce the same effect in the uterusat the dioestrous period as that which occurs naturallyat oestrus and during early pregnancy. In order totest the view that a steady or sudden increase ofpituitary secretion at the end of pregnancy finallybrings about labour, H. H. Knaus4 has now reportedon his further results obtained from injecting stan-dardised - pituitary extract into doe rabbits at variousstages -of pregnancy. The duration of pregnancy inthese animals is 31-32 days. It was found possibleto induce parturition by injecting a certain quantityof pituitary- at any time after the twenty-ninth dayof pregnancy. In experiments during the time fromthe eighteenth to the twenty-eighth day of pregnancyno quantity of pituitary was found sufficient to induceabortion on the day on which the experiment wascarried out, but as a result of prolonged pituitaryaction-nine injections of pituitary were given athourly intervals-the foetuses were killed inside theuterus, and were cast some days afterwards. In agroup of experiments covering the period from thefirst to the seventeenth day of pregnancy, no matterwhat (reasonable) quantity of pituitary extract wasinjected, it was never found possible to disturbpregnancy. Knaus considers that his results show that

.

considerable changes occur in the relation betweenthe hypophysis and the uterine muscle during preg-nancy. An interpretation of the results might applyto one of these organs or to both of them. Heconcludes that there is no increase of irritability orsensitivity of the uterus during pregnancy, but that,corresponding to the growth of each muscle cell, thereis a regular rise of contractility of the muscle. Thelarger the muscle cell the greater is its ability toshorten itself, and that is why the effect of pituitaryextract upon the muscle increases steadily andpregnancy advances. By the twenty-ninth day ofpregnancy the uterine muscle cells have grown so largethat their maximum contraction, caused by pituitary,results in delivery of the young, while in the last fewdays of pregnancy the uterus keeps on growing andincreasing its contractility, so that eventually a

maximum contraction is no longer needed to producethe young.

2 Old Ashmolean Postcards : Oxford Science Series. Fivecards, one in colour, 6d. Oxford University Press.

3 Journal of Physiology, lix., 276.4 Ibid., June, 1926.

RESPIRATORY ARCHIVES.

THE first number of a new journal entitled ArchivesMédico-Chirurgicales de l’ Appareil Respiratoire hasjust reached us, founded by Emile Sergent and Th.Tuffier, its object being to collate the work of physio-logists, physicians, and surgeons in its bearing on thepathology of the respiratory system. The foundershold that recent knowledge of the physiology of thechest and precision in technique have given a fruitfulstimulus to the clinical study of respiratory diseasesand have contributed largely to the developmentof new clinical methods. Artificial pneumothorax,phrenicectomy, and extrapleural thoracoplasty enablethe physician to-day to contend against lesionsthought, until recently, to be almost incurable.Excision and destruction by cautery of lobes of thelung involved by suppurations or by tuberculosisare no longer considered in the light of forlorn hopes.Each number of the journal (about 100 pages) is tocomprise three parts, the first to be reserved fororiginal contributions, the second for critical reviews,and the third for a digest of the principalpapers published in France or abroad. The Archiveswill appear at two-monthly intervals, the cost inEngland per volume of six numbers being130 francs. The publishers are Gaston Doin et Cie,Paris.The first number opens with an article by E.

Sergent on the interpretation of respiratory murmurs,in which he pleads for recognition of the fact that apathological breath sound is not something adventi-tious or superimposed, as are rales and friction sounds,but is none other than the physiological laryngo-tracheal sound, transmitted by some pathologicalcause beyond those regions over which it is normallyperceived and modified in its acoustic properties bythe physical conditions associated with the patho-logical cause. In the second original article Th.Tuffier, to whom every credit is due for the originationof this method, deals with extrapleural pneumolysiswhich he has himself carried out 57 times in 55 sub-jects, 44 of whom were suffering from pulmonarytuberculosis. He used fat grafts in 33 cases, paraffinin 8 cases. At first sight his results appear happierthan those obtained by other surgeons, but manyof his observations are of short duration. For example,while one case was seen eight years and another twoyears after operation, and both had done well, in11 other cases of pulmonary tuberculosis reportedas satisfactory an opinion was based on examinationsmade less than five months after operation. Theresults in cases other than tubercle were less satis-factory. Phrenicectomy is the subject chosen forcritical review. F. Bordet discusses the resultsobtained in cases (1) of pulmonary tuberculosis,(2) of bronchiectasis, (3) of chronic basal suppurations.In the first group the scope of the operation as acurative measure is very limited, although in Germany,Italy, and America improvement has been claimed ina number of cases. As a preliminary to thoracoplasty,and in association with artificial pneumothorax,phrenicectomy is gaining adherents. The curativevalue of phrenicectomy as the sole procedure in thetreatment of bronchiectasis is regarded as doubtful,though there have been exceptional cases. A.Baumgartner and P. Alary deal with the possiblevariations in origin and course of the phrenic andaccessory phrenic nerves. They favour the operationof evulsion (exeresis) over the radical operation ofGoetze, except in cases where difficulties arise, andparticularly when there is pleural effusion. Theydo not discuss the difficulties caused by pain andtransmitted pulsation during evulsion, which are

very real to those who have had experience of theoperation. It is surely optimistic to state

" When onehas resected 7 or 8 cm. of the phrenic at the base ofthe neck one can consider that the anastomoses havebeen destroyed."The journal has been modelled on the well-known

Journal de Chirurgie, and the idea and its execution