The 'bloody Moloch': Osler and van Helmont on bloodletting.

In a passage on the treatment of pneumonia, Osler quoted van Helmont's remark that 'a bloody Moloch presides in the chairs of medicine'. This paper explores Helmont's use of 'Moloch' as a term of abuse against the bloodletting of traditional Galenist physicians and his vigorous opposition to the use of bleeding in treating diseases. The possible reasons for Helmont's opposition to the practice of bloodletting are discussed, leading to the conclusion that it arose from his theories of the origin of diseases, reinforced by some observations of its malign effects on a patient who had been bled excessively. The question of whether Helmont knew of Harvey's discovery of the circulation of the blood is explored and the conclusion reached that, if he did, he ignored it completely. Helmont believed that 'pure' and 'impure' blood coexisted in disease and could be affected selectively by bloodletting which, in effect, concentrated the 'impure' at the expense of the 'pure' blood to the great detriment of the patient.

Magnetic resonance imaging targeted transperineal prostate biopsy: a local anaesthetic approach.

BACKGROUND: Despite high rates of disease misclassification and sepsis, the use of transrectal biopsy remains commonplace. Transperineal mapping biopsies mitigate these problems but carry increased cost and patient burden. Local anaesthetic, multiparametric magnetic resonance imaging (MRI)-targeted transperineal biopsy may offer an alternative. Here, we aim to determine the feasibility, tolerability and detection rates of clinically significant prostate cancer using a local anaesthetic, transperineal, MRI-targeted biopsy technique. METHODS: Tertiary referral centre in which 181 consecutive men underwent local anaesthetic, transperineal MRI-targeted prostate biopsy (September 2014 to January 2016). A standardized local anaesthetic technique was used to obtain targeted biopsies using visual estimation with the number of targeted cores determined by each of a number of users. We assessed adverse events, patient visual analogue pain scores and detection rates of clinically significant cancer (defined by University College London (UCL) definitions one and two and separately by the presence of dominant and non-dominant Gleason pattern 4). We secondarily assessed detection of any cancer, rates of detection by MRI (Likert) score and by presenting PSA. Differences were assessed using Chi-squared tests (P<0.05). RESULTS: One hundred eighty-one men with 243 lesions were included. There were no episodes of sepsis or re-admissions and one procedure was abandoned owing to patient discomfort. Twenty-three out of 25 (92%) men would recommend the procedure to another. Median visual analogue pain score was 1.0 (interquartile range: 0.0-2.4). A total 104/181 (57%) had UCL definition 1 disease (Gleason ⩾4+3 and/or maximum cancer length ⩾6 mm) and 129/181 (71%) had UCL definition 2 cancer (Gleason ⩾3+4 and/or maximum cancer length ⩾4 mm). Fifty-four out of 181 (30%) and 124/181 (69%) had dominant and non-dominant pattern 4 disease or greater (irrespective of cancer length). Any cancer was detected in 142/181 (78%). Significant disease was more likely in higher MRI-scoring lesions and in men with PSAs ⩾10 ng ml-1. CONCLUSIONS: This approach to prostate biopsy is feasible, tolerable and can be performed in ambulatory settings.

van Helmont's proposal for a randomised comparison of treating fevers with or without bloodletting and purging.

Around the year 1643, Joan Baptista van Helmont, a Flemish chemist, alchemist and physician who had devised what he claimed to be a new form of medicine, proposed a 'challenge' to traditional Galenic physicians to compare treatment of fever by traditional methods and by a regime which did not involve bloodletting and purging. Two groups of patients were to be treated and 'casting of lots' was to be used - in some way not specified in detail - to decide who received which treatment. This 'challenge' has been regarded as the first proposal for the use of randomisation in a clinical trial. This paper explains the background to the challenge and discusses what can be deduced from Helmont's text about the details of how he proposed that the 'trial' was to be carried out. It concludes that internal evidence in Helmont's writings makes it certain that no such 'trial' was ever conducted. It seems that the 'challenge' was probably a rhetorical device to support Helmont's vehement criticism of traditional Galenic medicine and its practitioners, and, in particular, toemphasise his absolute opposition to the use of bloodletting as a medicaltreatment. An appendix includes a short summary of Helmont's theories of the origins of disease and transcriptions of the passages of Helmont's Latin text translated in the article.

[Focal therapy for prostate cancer: German version]. / Fokale Therapie des Prostatakarzinoms : Deutsche Version.

Focal therapy is a treatment strategy for men with localized prostate cancer that may serve as an alternative option to radical therapy. A number of minimally invasive ablative technologies are available to deliver treatment, and the energies most commonly used include high-intensity focused ultrasound and cryotherapy. The benefit of a tissue-preserving approach is the limitation of damage to key structures such as the neurovascular bundles, external urinary sphincter, rectal mucosa and bladder neck. This in turn minimizes side effects typically associated with radical therapies whilst also aiming to maintain oncological control. Over 30 single-centre studies of focal therapy have been published to date reporting excellent continence rates, good potency rates and acceptable short-term oncological outcomes. However, there are a number of controversial aspects associated with focal therapy including the index lesion hypothesis, patient selection criteria, assessment of treatment effect and the lack of medium- and long-term oncological outcomes. In the process of the adoption of new technology, there is a limited window of opportunity to provide this evidence in well-designed prospective trials. Men should be allowed to benefit from the potential advantages of this novel treatment whilst under close surveillance. An English version of this article is available under dx.doi.org/10.1007/s00120-014-3734-7.

Peter Lowe: information and misinformation about a Scots surgeon of the sixteenth century.

The paper reviews what is known of Peter Lowe's surgical education, practice and activities before he obtained the Royal Charter in the last year of the sixteenth century, founding what became the Royal College of Physicians and Surgeons of Glasgow. It attempts to separate probable fact from accumulated fiction then discusses briefly Lowe's possible contributions to the contents of the Charter.

Intact neurological outcome after neurointerventional treatment for intracranial venous thrombosis with straight sinus involvement.

The role of neurointerventional treatment, including local thrombolysis, for intracranial venous thrombosis (ICVT) currently remains uncertain. We describe a case of postpartum ICVT involving the straight sinus, with rapid neurological deterioration and progressive thrombosis, despite anticoagulation. She underwent multimodality neurointerventional treatment involving attempted mechanical clot disruption, microcatheter suction, intrathrombus thrombolysis and microballoon disruption and clot retrieval. The patient achieved a full clinical recovery, with radiological evidence of recanalisation at follow-up.