TREATMENT OF PYLORIC STENOSIS

1272

clearly than phlebography. Finally, these workers haveclearly shown that surgery has much to offer in casesof superior vena caval occlusion where the underlyingcause is non-progressive and the symptoms are disabling.

7. Katz, S., Hussey, H. H., Veal, J. R. Amer. J. med. Sci. 1947,214, 7.

8. Kramer, P. New Engl. J. Med. 1954, 251, 600.9. Golden, R. Radiological Examination of the Small Intestine.

Philadelphia, 1945.10. Glazebrook, A. J. Lancet, 1952, i, 895.11. Macphee, I. W. Ibid, 1953, i, 678.12. Falle, E. De C., Gill, A. M., Post, H. W. A. Postgrad, med. J.

1954. 30, 532.13. Gill, A. M., Falle, E. de C. Lancet, 1952, ii, 356.

TREATMENT OF PYLORIC STENOSIS

THE results of medical treatment in chronic pepticulceration give us no cause for self-congratulation.Relapse-rates are very high ; and such treatment iEdoomed to failure in cases of pyloric stenosis, hour-glassdeformity of the stomach, giant ulcers, and deeplypenetrating ulcers.With regard to pyloric stenosis, it has been said that

three factors are operating-namely, spasm, oedema, andfibrosis-and that, of these, spasm and oedema can berelieved medically. This may be so ; but unfortunatelybenefits are short-lived, and many believe that relapseis inevitable. Now Kramer 8 has found radiographicallythat the administration of belladonna alkaloids mayworsen rather than relieve benign pyloric stenosis ; forthis drug further slowed the passage of barium from thestomach. Probably this is due to the coincident decreasein gastric motility, which may also account partly forthe relief of symptoms.Thus it seems that in patients with peptic ulcer and

pyloric stenosis medical treatment may be positivelyharmful. It is therefore important to decide certainlywhether pyloric stenosis is present. There is no bettertest than the time-honoured one of giving the patientcharcoal biscuits last thing at night, and in the morningaspirating the resting gastric juice. If this containscharcoal, it is probably best to call in a surgeon.

THE DISORDERED SMALL BOWEL

IT is an appalling commentary on our capacity as

healers that the consultant investigating the case of apatient with abdominal symptoms is usually relieved anddelighted to find a sufficient organic cause. Treatmentthen follows diagnosis in orderly sequence, and theencounter leaves him with a satisfying sense of complete-ness. Nothing disturbs him more than failure to find aclear reason for abdominal discomfort : a hauntingsuspicion that organic disease is being overlooked urgeshim on to a succession of time-consuming and expensiveinvestigations ; and all too often these leave him with afeeling of hopelessness and uncertainty which readilytransmits itself to his unhappy patient.

It is, of course, well known that the effect of mind overmatter is nowhere more evident that in the gastro-intestinal tract. The reactions of the distal bowel todramatic happenings must have been experienced byalmost everyone. But the disordered workings of thesmall gut are less clearly and less widely understood.In recent years studies have been made of the abnormalbarium patterns in the small gut, but usually only in thepresence of arresting symptoms due to steatorrhoea or

some other nutritional deficiency 9 after gastrectomy.1o 11Dr. Falle and her colleagues,12 in continuance of

work reported two years ago,13 have now described

significant radiographic findings in a group of patientswho were believed to have what they call " chronicdisturbances of small and large bowel function." Someabnormality was evident in almost half the patients whowere examined radiographically, although the deviationfrom normal was very slight in half of these. The com-monest disorder was clumping of the barium, which wasbest seen in a film taken at Pf2 hours ; changes in toneof the ileum or jejunum, and signs of accelerated passage

of the meal, were also evident. That such radiographicfindings were probably significant was suggested bycomplete failure to demonstrate them in patients whohad no symptoms. Falle et al. suggest that all of theseradiographic changes can reasonably be attributed topsychological tension, the existence of which was

established without difficulty in most of their cases.It is highly likely that, when the function of the large

intestine is disturbed, upper abdominal symptoms aredue to a similar disorder in the jejunum and ileum. Buteven if we learn confidently to interpret the radiographicchanges, the diagnosis of intestinal dysfunction mustremain a clinical one, to be made only after carefulexclusion of other causes. Patient and careful investiga-tion of the history is essential not only to diagnosis butalso to the first stage in therapy, in which reassuranceis more valuable than medication.l4We are all so conscious of the frequency of functional"

abdominal symptoms that we should not, be surprisedthat Dr. Falle and her colleagues put a third of all thenew cases at their gastric unit in this category. But weshould take note that by diligent and patient manage-ment they achieved complete remission of symptomsin well over half of their patients, and considerableimprovement in another quarter.

14. Haves, D. W. Amer. Practit. 1954, 5, 787.15. See Lancet, 1951, i, 333 ; Ibid, 1952, i, 913.16. Control of Rats and Mice. Vols. and 2 : 1 Rats. Edited by

DEXNIS CHITTY. Vol. 3: House Mice. Edited by H. N.SOUTHERN. London : Oxford University Press. Pp. 532(1 and 2) and 225. £5 5s. a set.

CONTROL OF RATS AND MICESTANDARD methods of rat and mouse destruction,

devised during the 1939-45 war,15 were largely based onwork at the Oxford Bureau of Animal Population, a fullaccount of which has now appeared.16 The species studiedwere the common " brown" rat of Europe, Rattus

norvegicus Berkenhout ; the even less appropriatelynamed " black " rat, R. rattus L. ; and the house mouse,Mus musculus L. The magnitude and difficulty of theresearch on these species can now be appreciated. Theconditions in which these rodents live are exceedinglydiverse ; their habits make them most elusive- (no doubtthis is a result of natural selection in man-madeenvironments) ; and control methods must be both simpleand economical.The Oxford work was based on extensive observation

of behaviour and population changes in natural conditions.The common rat was found to develop, in a stableenvironment, regular movements on well-defined path-ways. The appearance of an unfamiliar object, such asa trap or a pile of bait, leads to avoidance of the placewhere this has been put. But familiarity breeds contempt:the regular placing of harmless bait over several daysleads to acceptance of the bait even when poison is

eventually added. This familiar "prebaiting " obviatesthe remarkable tendency of this species to refuse foodswhich have previously caused illness-for example, poisonbait of which only a small sample has been taken. Theother species of this genus, R. rattus, has been less closelystudied, but it behaves in a generally similar way. Thehouse mouse does not develop specific poison shyness;but its behaviour is so variable from day to day that itis at least as difficult to poison.The important work on feeding behaviour was paralleled

by studies of the effects of poisons. Toxicological studiesshowed that the old standby poisons-barium carbonateand red squill-have rather low toxicities. Red squillmay be quite ineffective, unless the consignment is

carefully selected. Today, the main strong poisons ofchoice are zinc phosphide, arsenic, and antu (alphanaph-thylthiourea)-all after prebaiting-but antu is unsuitablefor use against R. rattus. The Oxford workers are

properly sceptical of the value of ’ 1080’ (sodiummonofluoroacetate) despite the enthusiasm with which itwas first received, especially in the U.S.A. : it is exceed-