14

morphia for a patient with diarrhoea we must askourselves whether it will really help to mix it withchloroform, hydrocyanic acid, capsicum, cannabis,peppermint, glycerin and alcohol. Simplificationmust be the first step towards economical prescribing,and it will lead to a fuller realisation of the trueaction of drugs and of how much can be done with howfew. Above all, let us turn to the B.P. before the com-mercial circular. Not only drugs but druggists as wellare scarce, let alone bottles and wrapping materials, sowe must be sure before we write any prescription thatthere is in fact a need for medicine in this case. Place-bos are very well in peace-time, and a bottle of medi-cine combined with reassurance may be as sound

psychotherapy as any, but now we must sometimesomit the bottle and rely on the reassurance. If we doorder a placebo at least let us be sure that its contentsare not being brought from the ends of the earth.

In February the Ministry of Health announced thecomposition of a committee to draw up a war-timeformulary, and its labours should be nearing com-pletion. Publication of the formulary will greatly easethe task of the conscientious prescriber, and hospitalshave naturally awaited its appearance instead of

drawing up emergency pharmacopoeias of their own.The War Formulary (W.F.) will no doubt immediatelyreplace the National Formulary for N.H.I. prescribing,and the insurance doctor who ignores it will find him-self surcharged in the ordinary way. In addition itshould replace all hospital formularies, and thereare already indications that the Services and localauthorities will give it their blessing. In drawing up.the W.F. the committee have been aiming at

making the best use of available drugs and not atoffering inferior substitutes, and the private practi-tioner will be doing the best for his patient as well assaving himself and his dispenser trouble if he uses it inhis everyday work. When prescriptions are writtenoutside the W.F. there should be some way of keepingthe M.R.C. lists in the doctor’s memory, or perhapsin his pocket. It could be made a rule that a chemistor hospital dispenser would make up a mixture con-taining something in list B only if that something wasinitialled by the prescriber. The unessential drugs ingroup C are presumably no longer imported and willslowly disappear from the market. There remainsthe question of proprietary medicines. Their manu-facturers may deserve some reward for their foresightin laying in stores, but the Ministry of Supply cannotexpect wholehearted support from doctors for savingon drugs while the M.R.C. lists are ignored bycommercial firms.

A RARE SPIRITAs WILFRED TROTTER would have been the first

to remind us, it is not while grief is still poignant thatan author’s rank is fairly appraised. That thoughtmay deter some who rereading his collected papers 1and recalling the gracious personality of their authorare moved to prophesy that the slender volume willlive on the accessible shelf which holds " ReligioMedici," ALLBUTT’S FitzPatrick lectures and a

selection of OsLER’s essays, perhaps also HILTON onRest and Pain, and SUTTON’S lectures on MedicalPathology. Certainly, like the authors named,TROTTER could " write." He is speaking of " the1. The Collected Papers of Wilfred Trotter, F.R.S. London :

Humphrey Milford, Oxford University Press. Pp. 194. 10s. 6d.

case," the patient upon whom a pioneer operationwas done on Nov. 25, 1884:-

" The heresy of admitting that at the centre of thisevent there was a human being is possibly condoned byhis short appearance before us not being without a certaintragic dignity. He was young, intelligent, courageous,and he was to die. I owe to the impeccable memory ofa contemporary witness the knowledge that this youngman’s name was Henderson and that he was a native ofDumfries. I record this with pious satisfaction in beingable to add a name to the exiguous roll of those by whosemisfortune or endurance the world has directly gained.It is a strange defect in medical history to have kept sofew of the names of these benefactors and to have leftit to accident that we still know there existed suchhumble but significant people as little James Phippsand Sarah Nelmes or Alexis St. Martin. To the highprofessional spirit treasuring such names may seem trivialand even a little ludicrous. Let us not forget, however, thatthey are the names-of those who have borne more substan-tial witness than has yet been produced by any philosopheror any theologian that all suffering is not in vain."That TROTTER felt that emotion explains why he wasbeloved ; that he could so express it will explain whyhe will be loved by those who never even saw him.

These papers cover a wide range of topics but areinformed by a common purpose. It is to show thatthe great, the ideal doctor should understand theharmony of art (in the Hippocratic sense), science(in the laboratory sense) and philosophy (in Galen’ssense) not confounding the persons nor dividing thesubstance of the trinity. Other great doctors beforeTROTTER have written memorably on the first theme.ARISTOTLE himself, so very long ago, remarked thatsomething more than knowledge was needed forhealing. Nobody has written so well on the psycho-logical aspects of clinical medicine :-

-

" The attitude of the patient approaching his doctormust always be tinged-for the most part unconsciously-with distaste and dread ; its deepest desire will tendto be comfort and relief rather than cure, and its faithand expectation will be directed towards some magicalexhibition of these boons. Do not let yourselves believethat however smoothly concealed by education, by reasonand by confidential frankness these strong elements maybe, they are ever in any circumstances altogether absent."

,

Great investigators before TROTTER have realisedthat pompous general principles impede scientific

progress, as HARVEY’S comment on BACON-" Hewrites philosophy like a Lord Chancellor "-showed.They might not have explicitly admitted whatTROTTER made plain-viz., that " in general, discoveryhas been the result of action rather than thought "or drawn this conclusion :-

" The historian is apt to be indignant at the obstaclesto new knowledge offered by the censure of theologiansand the persecution of ecclesiastics. Theologian andecclesiastic have no doubt done their best, but the effectof their utmost zeal has been insignificant in comparisonwith that resulting from the conscientious use of therational mind."

Yet the history of medicine, as TROTTER showed,bears out this diagnosis. Nobody now reads GALEN ;none of his works which once gave law to the medicalworld will bear reading. But there are some essays,like TROTTER’S, perhaps addresses to students or

practitioners, neither too long nor too steeped inwholly obsolete technicality to be unreadable. One,on the proposition that the best doctor is also a

philosopher, exemplifies the defect of Greek and stillmore of Hellenistic science. GALEN did believe inscientific research but he had a still stronger faith inprinciples and abstractions. His order of importance

15

is the logical, the physical, the ethical ; of him it wasplainly true that :-

" Now facts unfortunately are not the natural diet ofthe mind. They are laborious and often undignified tocollect; they are apt to be formless, ugly, and evennasty ; they dirty the fingers, they smell, and sometimesbite. How different from the noble, shapely, and aboveall well-behaved conceptions of the mind, which are somanifestly of a higher order of reality."That this was true of GALEN and that GALEN could" write " bad disastrous consequences for the growthof medicine. But it does not lead TROTTER to

conclude that the" theoretical, speculative andrational element in the pursuit of medicine " shouldbe rooted out. On the contrary, he remarks that"

experience seems to show that a branch of knowledgestrictly limited to experiment and without any kindof speculative admixture tends in time to lose its

inspiration and drift into a dry and rigid orthodoxy.Some such decline was perceptible in the physicalsciences towards the end of the 19th century andthere can be little doubt that a strict reliance on

experiment alone would in the long run have a similardeadening effect on scientific medicine."In the last of his papers, which was printed a few

months before his death, TROTTER approaches thisproblem. We admit, he says in effect, that reason,the intellectus agens of the scholastics, has in factoften produced disastrous results (indeed a modernmathematician said that ARISTOTLE, from whosecreative reason the scholastics evolved their intellectusagens, was one of the greatest misfortunes whichhappened to mankind). But we must also admit

(a) that purely experimental science tends to ultimatesterility, (b) that large tracts of human interests, forinstance social institutions, are not directly open toexperimental study and that without the applicationof reason " it seems probable that the ominous

fatuity and confusion that mark our social and politicalaffairs must continue to increase." How then can wefree the use of reason from its defects and retain itsvalue ? TROTTER was already a sick man when heposed this question and his answer is partial. Withhis usual modesty he would have said that he couldnot answer it, but he has indicated the direction inwhich a solution may be found.

"

" We must get rid of the disastrous belief that thereis any activity of the mind corresponding with the con-ception of pure reason. The mind has no such function.All processes of reasoning, however abstract, are par-ticipated in and influenced by feeling. We cannotseparate off the reasoning process as such and set it towork in an emotional vacuum. What we can do is tosuspect the grosser cases of the effect of feeling and tomake an appropriate correction."

Some on reading this will murmur " Freud " ; somewill recall a teacher even greater than FREUD whodefined the conditions of entrance into the kingdomof heaven. There is the soul of TROTTER’S teaching,intellectual humility : " The fault, dear Brutus, isnot in our stars but in ourselves." We are not to

throw away the instrument of reason but we are toroot out the deadly sin of intellectual arrogance, thefatal pride of the intelligentsia. But this train of

thought carries us beyond the bounds of our pro-fession. We say hail and farewell to a beloved con-temporary, sure that his influence will work uponthose to come after us, when these times are but amemory of old, unhappy, far-off things.

Annotations

NERVOUS CONTROL OF THE COLON

DURING the past two years White, Verlot and Ehren-theil,l at the Massachusetts General Hospital, Boston,have made a series of observations on the pressurechanges in the rectum and lower colon in patients withdisease, injury or operative lesions of the brain, spinalcord or pelvic nerves. The method used was to infuseinto the rectum water at the rate of about a litre in tenminutes and observe the pressures by a manometer whilerecording the patient’s sensation of wind, desire todefsecate or cramp-like pain. Normally the maximalcomfortable capacity of the colon is 1500-2000 c.cm. ;there is a basic tone which gradually relaxes with

increasing amounts and this is interrupted by peristalticcontractions which last a few seconds and send the

pressure up. A sense of fullness is reached in the normalcolon, as in the bladder, when the pressure reaches30 cm. of water ; a contraction which raises the pressureabove 50 cm. is distinctly uncomfortable. The basictone rises steeply as the normal capacity is approachedand peristaltic waves occur with increasing frequencyuntil a state of tetanic contraction is reached ; at this

point fluid usually escapes round the catheter. If aweak barium suspension is used and the bowel observedwith X rays, the contraction peaks are seen to correspondwith mass peristaltic waves. Haustral segmentationmovements produce no visible change in the manometer.From their cases these workers conclude that the cerebralcortex normally has an inhibiting effect on the spinalreflex activity of the colon, thus increasing its storagecapacity. Lesions situated in the cortex or brain-stem

frequently remove this inhibitory action and result inhypertonicity. In spinal-cord injuries the stage of

spinal shock passes relatively quickly, and a remarkablehypertonia of the colon appears soon after high injuriesto the spinal cord. Destruction of the cauda equina orof the sacral segments in the spinal cord produces a stateof the colon in which the peristaltic rush movements areabsent though haustral segmentation continues. At thesame time loss of sensation-of the feeling of fullness-inthe lower half of the colon is complete. In taboparesisand syphilis of the cord the colon shows low basic toneand feeble peristalsis and an increased capacity (3000c.cm.) with greatly reduced sensation. The results arecomparable with those of T. R. Elliott 2 on the nervouscontrol of the bladder.White and his colleagues early observed during ithe

passage of a barium meal that the movements of thedistal colon were quite different from those in its proximalpart. In the proximal colon there is a gradual filling ofthe caecum and ascending colon with ingesta passing outof the small intestine, and this goes on until the colon isfilled to beyond the hepatic flexure. Haustral contrac-tions change only the contour of the contents ; at inter-vals, however, a great peristaltic wave occurs whichsweeps the contents of the proximal colon into the

sigmoid and upper rectum, and to the exterior if the analsphincter relaxes or is out of control. With training,inhibition of defecation occurs by voluntary contractionof the anal sphincter, and this voluntary effort is absentin infancy, in unconsciousness, in disease or injury of thebrain and in states of shock. Further work on the linesthese workers have laid down may show that in some

patients with excessive sphincter action, with relaxed ’

tone of bowel musculature, or with a combination of thesearising from the persistent neglect of the defaecation call,there is an altered nervous control of the lower bowelaccounting for the delay now described as dyschezia.1. White, J. C., Verlot, M. C. and Ehrentheil, O. Trans. Amer. surg.

Ass. 1940, 58, 608 ; Ann. Surg. 1940, 112, 1042.2. J. Physiol. 1907, 35, 367.