RANGE OF FLIGHT OF MUSCA DOMESTICA.

1585 In the second volume of

my

book, "

" Surgical

ureter

or

kidney

in which it is situated is the

Diseases of the Kidney and Ureter (pp. 84-86of pain in the kidney of the opposite side. With reference to Mr. Moore’s remarks and 455), I have made it sufficiently clear that I

cause

on

the

stone after a previous I should like to add that if he will examine the cases tabulated in the first four tables appended to my Hunterian lectures (1898) he will find mention of several cases in which calculi were formed at intervals varying from some months to ten years after a previous operation on the involved kidney. I am, Sir, yours faithfully, HENRY MORRIS. Cavendish-square, W., Nov. 22nd, 1913.

recognise reno-renal reflex pain as well as a rarity of variety of other reflex pains, which I there describe, removal,

recurrence

of

due to renal and ureteral calculus. But my opinion to-day with regard to the occurrence of pain in a healthy kidney of one side, and nowhere ,else, as a result of the presence of a calculus in the kidney or ureter of the opposite side is the same So far as my own as when I wrote in 1900. experience and researches go, there is not a single case which affords satisfactory evidence of symptoms on one side only being caused by a stone in the kidney of the other side (p. 84, Vol. II., THE DIAGNOSIS OF SYPHILIS. op. cit.). To the Editor of THE LANCET. I have recently had under observation a patient who, though free of pain on the left side but with SIR,-The public health committee of the Chelsea three calculi in the left renal pelvis, had a sharp borough council has made arrangements with the attack of pain in the region of the right kidney; Lister Institute of Preventive Medicine for the this pain disappeared entirely after the discharge carrying out of the Wassermann blood reaction free of a small concretion not larger than half a raisin- of charge for medical practitioners attending the pip from the right organ. Had this minute calculus, poorer class of patients residing in Chelsea. Outtoo small to have given an appreciable shadow in a fits can be obtained at the Lister Institute, and skiagram, not been detected in the urine, or had it samples of blood may be sent either to establish a not come away, but had continued to give rise to diagnosis in suspected cases or during the treatment pain, the calculi which are still present in the left of cases to ascertain the efficacy of treatment. The kidney might have been regarded as the sole cause name and address of the person from whom the of the right renal pain, and the case might have blood is taken must be included in the particulars been described as a typical instance of the theory required of the case, for the information of the of reno-renal reflex. medical officer of health as to the status of the Mr. Moore, with scientific candour, points out patient and his being a resident in the borough. that the issue in his case was obscured, "as the Such information will be treated in the strictest pain might have been due to pyelitis produced by confidence, and no use whatever will be made of it the colon bacillus." Still, the reno-renal reflex pain to the detriment of the patient. on the right side induced him to resort to the It does not seem feasible at the present time to of both and arrange for the microscopical (dark ground illutransperitoneal manipulation kidneys ureters, notwithstanding the presence of " a mination method) examination of discharge or markedly tender spot just internal to the left material from chancrous sores, as it would seem anterior superior iliac spine," to the detection by desirable that such material should be taken direct skiagrams of a small shadow in this situation, and from the patient by the expert who makes the microto the fact that though pain was felt more in the scopical examination, owing to possible errors in colright loin it occurred simultaneously in the left lecting material by less practised persons, and the effects of drying or other changes upon such material loin also. This reno-renal reflex theory was used by in transit to a laboratory for examination. Negative Knowsley Thornton as an argument in favour of results in the determination of spirochætæ under "abdomino-lumbar nephrolithotomy "-an operation such circumstances might give rise to unfortunate whereby the peritoneal cavity is opened along the conclusions. No doubt this is a matter which will semilunar line and the calculus removed through receive early consideration by the Royal Commission a stab wound in the loin. The theory was urged i now sitting.-I am, Sir, yours faithfully, LOUIS C. PARKES, M.D. Lond., D.P.H., by him as a reason for preferring that operation ’, Medical Officer of Health, Metropolitan Borough to lumbar retroperitoneal nephrolithotomy whereby Nov. 22nd, 1913. of Chelsea. the opposite kidney could not, of course, be examined. I have pointed out in my book just referred RANGE OF FLIGHT OF MUSCA to (Vol. II., pp. 196-8) the absence of confirmaDOMESTICA. tion of the theory itself and the fallacies to To the Editor of THE LANCET. which its adoption in practice leads. There are many pathological states of the kidney and SiR,-Recent elaborate experiments recorded in the renal cannot which calculus, ureter, including reports on flies as carriers of infection issued possibly be detected by manipulating these organs by the Local Government Board fully bear out the in situ. natural observations I have made from time to time I have on several occasions been able to demon- in field-work epidemiology as to the range of night strate to others that renal calculi weighing 30 or of Musca domestica being dependent upon the 40 grains or more, to say nothing of smaller con- environment of the breeding-places. In a special report upon epidemic diarrhoea in cretions, escape every form of examination by digital compression until an incision has been Southend in the year 1904 I introduced a " spot made into the renal parenchyma. Thus the mere map which showed that fatal cases of epidemic inspection and tactile examination of the kidney diarrhcea and excessive prevalence of flies occurred from within the abdomen do not afford a sufficient in houses grouped round a brickfield in which was guarantee that the organ is normal within; nor an immense collection of house refuse (hundreds is such an examination sufficient to justify the tons), not only from the town, but from parts of inference that a calculus quiescent as regards the London. In my annual report on the health of the

as

"

of

1586 of Southend for the year 1906quote from second special report published that year, that of some 70 deaths from epidemic diarrhoea that season in the whole borough 30 deaths were within a few hundred yards of the brickfields ; 14 more were in a neighbourhood where a large number of stables, provision shops, and chicken-runs had recently come into existence, and flies were in superabundance in all the affected dwellings. In the same special report I referred to a goodclass house inhabited by decent people who kept servants, and which stood by itself some distance from other buildings. When I visited this house it proved to be the most fly-plagued house I ever was in-the ceilings and walls were simply black with flies, and no food could be prepared in the house without flies falling in; three flies were noticed in the baby’s bottle. Two young children had suffered from epidemic diarrhoea (the baby died), and the family had fled the house. Less than a quarter of a mile away was a large collection (several tons) of house refuse, and the house was also midway between four farms-a most typical " " (as I termed it in my contriplace of arrestment " bution on House Flies as Carriers of Disease" in the Journal of Hygiene, 1909), because of its relative position to the breeding-place of the flies. Again and again have I made the observation that flies escaping from a breeding-place are held up by the nearest occupied houses, and this almost irrespectiveof the direction from which the wind blows or the cleanliness of the house. Recently I was visiting a village in Norfolk where one of a terrace of houses in the main street was occupied by a rag and bone and skin dealer who also kept a horse, and incidentally a considerable collection of stable manure. On investigating the prevalence of flies in this street the difference between the numbers in the dwellings on one side of the street and the other as remarkable-the terrace of houses on the side of the street nearest the fly breedingplace having effected a considerable arrestment of flies, when compared with the opposite terrace. The conclusion I have arrived at from natural field work observation is that flies do not readily leave a house in which they find protection, warmth, and abundance of food. Such houses near breedingplaces suffer from a plague not realised by the occupants of houses even in the next street further away, and though fly-papers may show a daily suicide (unintentional) of several hundreds of fiies, there are just as many more to be found 24 hours later if the windows are left open and the weather is warm. Of course, some flies in warm weather, if dry, pass from house to house in terraces and streets, and these may carry infection. Where houses are numerous, flies decrease in numbers in inverse proportion to the distance Inof the houses from the breeding-place. versely flies fly further when places of arrestment in the shape of houses are few or far off. Where houses are fairly numerous few flies will be found much beyond a quarter to half a mile radius from the breeding-place. Where houses are few flies will travel further afield, and many more will be found half a mile from the breeding-place than where houses are many. There is no reason why solitary flies should not in time cover a mile or more, especially in the open country. Environment is the chief determining factor in the range of flight of house flies.-I am, Sir, yours faithfully,

borough a

J. T. C.

NASH, M.D. Edin.,

Chief Medical Officer for Norfolk. The Shirehall, Norwich, Nov. 22nd, 1913.

THE EFFECTS

OF THE DUCTLESS GLANDS UPON DEVELOPMENT.

To the Editor of THE L A N SIR,-There is in THE LANCET of

C E T.

Sept. 6th last title which this Mr. Gilford with Hastings paper by I have read with much interest. I should like, Sir, to refer to the following passage in this paper (p. 719) : " In a case of ateleiosis fully described by Arnold Paltauf there was a tumour of the pituitary body. On the other hand, in Schaaffhausen’s case, in a skeleton in the Royal College of Surgeons of Edinburgh, and in a case upon which I myself made a post-mortem examination, there was no gross evidence of pituitary tumour or insufficiency." I submit that the published accounts of these cases in the originals afford no indication whatever that the pituitary body was examined in any case; that the above is not a statement of facts, but a statement of inferences. In Paltauf’s account of his case he states that the sella turcica was very large in all dimensions, not only as compared with that of a child of the same stature, but that the measurements were considerably greater than the average of those of several adults of normal growth. But he makes no mention of pituitary body at all in his account. It may be correct to infer that there was a tumour of the pituitary in this case, since the sella turcica was so much enlarged; but I submit that it is only an inference, not a fact; and Paltauf goes on to state that both the sphenoid and the basilar portion of the occipital bone showed measurements markedly smaller than those of a child of the same height, that the foramen magnum in its antero-posterior diameter was, on the contrary, very large. Is it justifiable to infer from this that structures passing through it were enlarged ? Or is it a fact that they were so enlarged ? Schaaffhausen makes no mention of the pituitary in his post-mortem account. And the account of the exhumed skeleton written about 14 years later teaches nothing about it. The same applies to the skeleton in the Royal College of Surgeons, Edinburgh, in spite of the additional facts (concerning the sella turcica) stated in Mr. Hastings Gilford’s letter to THE LANCET of Sept. 13th. It is not necessary for cretinism that thyroid insufficiency be accompanied by a tumour; and one would ask why it should be in the case of pituitary insufficiency ? There remains Mr. Hastings Gilford’s post-mortem examination of his own case, and one cannot learn from the account of it that the pituitary was examined microscopically or even macroscopically. It seems probable that the pituitary gland was not in mind when these necropsies were made. Schaaffhausen’s account was published in 1868, Paltauf’s in 1891, and Mr. Hastings Gilford’s in 1903, before the pituitary gland had attracted the amount of attention in relation to growth that it now receives. Paltauf, in his case, states that " the thyroid gland was small and pale red," and one might suspect that it was the thyroid that he looked upon with suspicion, not the pituitary. He did not know how to differentiate his case from cretinism (this is clear from the discussion of it), nor, apparently, did anyone else until Mr. Hastings Gilford took up the study of this condition. I submit, Sir, that although it may seem probable that abnormality of the pituitary gland is the cause (either the sole cause or by association with other, possibly glandular, abnormality) of ateleiosis, yet there is no knowledge that the pituitary was a