REFLEX ANURIA.

1780

incising the deep fascia the brachial plexus was exposed consumer, and it is to such national societies as these, which lying on the glistening insertion of the scalenus medius. The have prepared and are circulating advice and information plexus was drawn inwards and the point of resistance, among the people, that the lot will fall of overcoming the noticed before the operation, was found to consist of last line of resistance to a purer milk-supply. On

the insertion of the scalenus into the rib. This insertio with the bone gave the sensation of a swelling, over which the plexus passed. The muscle was divided near its insertion and the bone exposed. There was no swelling on the rib, which was cut through with forceps at the insertion of the muscle and then removed piecemeal, the soft parts being protected with a blunt spatula. A smooth bed was left for the plexus when replaced. The deep fascia was sutured with catgut and the wound closed. The operation was completed at mid-day, and at 5 P.M. the patient drew attention to the fact that her hand was white and normal in colour, though it had been dusky-blue for three months. After a week she could close her hand perfectly. The symptoms disappeared and the pain did not return in spite of exertion such as typewriting in extremely cold weather, and A skiagram taken after the arm and hand regained power. the operation verified the fact that the first rib and not a supernumerary rib had been removed. The symptoms produced on exertion appeared to have been due to the rolling motion which the scalenus medius on contracting would cause in the already stretched plexus at the point where the nerve trunks passed over the prominence made by the insertion of the muscle into the bone. Dr. Murphy saw a case of operation for suspected cervical rib in London last year, in which no such rib was found. He suggests that the case was probably similar to his. An apparently normal first rib, it seems, may cause severe nerve symptoms, a fact which throws light on some hitherto obscure cases.

REFLEX ANURIA.

THE subject of reflex anuria is difficult and in need of further elucidation. In the Medical Revie,7v for December is related an instructive case, taken from the Archives of the Middlesex Hospital. A stout multipara, aged 49 years, was admitted under the care of Sir A. Pearce Gould on March lst, 1910. Six years previously she was seized with severe pain in the left lumbar region which lasted several hours. Similar attacks followed, the last on Feb. 18th. Attacks of pain also occurred in the right loin but were so frequent nor severe as on the left side. The pain was accompanied by vomiting and constipation and inability Before the attacks she noticed that the to pass urine. urine was dark, and she thought she had seen streaks In consequence of her stoutness abdoof blood in it. minal examination was difficult. Both lumbar regions was dulness in the left flank, were tender, and there which did not shift with her position. The urine varied in specific gravity from 1005 to 1012, was slightly alkaline, and always contained albumin and sometimes a little pus and blood. Skiagraphy showed three shadows in the left kidney but nothing in the right. As obesity rendered her an unfavourable subject for operation, and the symptoms were somewhat ambiguous, she was kept under observation. She complained of pain across the lower abdomen, and only with difficulty could it be found that she had more pain on the left than on the right side, and that there was more tenderness in the left flank than A CLEAN MILK CAMPAIGN. in the right. On March 14th the left kidney was exposed It was Ix order to consolidate public opinion in readiness for from the loin and found enlarged and mottled. the time when general legislation will be introduced for the incised and three irregular oxalate of lime calculi were purification of our milk, a joint committee of the National extracted from dilated pus-containing calyces. The League for Physical Education and Improvement and the section of the kidney was grey and yellow, and the organ National Health Society has prepared and issued three was obviously much diseased. A drainage-tube was inserted. leaflets, addressed to farmers and producers, to distributers After the operation the urine contained more pus, but was and retailers, and to housewives and all consumers of milk excreted in considerable quantity. She did well until respectively. They are brief, clear, and concise, and having April 9th, when she was quiet and almost apathetic. The been prepared by a committee, including representatives of total urine passed per urethram, which had averaged the medical, veterinary, and legal professions, of the Local 50 ounces, fell on the 8th to 15 ounces ; on the 9th and 10th Government Board, local authorities, and farmers and dairy- not a drop was excreted ; on the llth only half an ounce; men, the directions and advice given may be taken to be and on the 12th 1 ounce. From the wound only a little The urine was very turbid and contained both soundly scientific and practical. Much attention has pus was escaping. lately been directed to the purification of the milk-supply, and only 01 per cent. of urea. It was concluded that there was local authorities have obtained and are using powers to trace anuria from blocking of the right ureter by a calculus which to their source certain forms of milk contamination, notably had probably been the cause of the pain on that side and tuberculosis. In addition to these special powers all local was too small to be shown in a skiagram in so stout authorities have the power and duty of compelling cleanliness a woman. Operation on the right kidney was urged, in dairies, cowsheds, and milkshops, ensuring as far as but declined. Hypodermic injections of pilocarpine, diuretin, possible freedom from contamination until the milk is in the and saline enemata were repeatedly given and she sweated hands of the consumer. These measures often fail in their profusely. On the 12th she was very weak, but there were effect through lack of public opinion to support them, and no definite ummic symptoms and permission for an operation they are in many instances rendered futile by the ignorance was given. On exposing the right kidney from the loin a and carelessness of consumers. It is important to success small stone was found impacted in the neck of the ureter, that vendors should realise that the reputation for clean milk and a bougie was passed down into the bladder to make sure is essential to their own interests, and such admirable rules that there was no other calculus. Urine flowed from the as the suspension from duty for considerable periods without ureteral wound as soon as the stone was extracted. A loss of wages of dairymen in whose homes infectious diseases drainage-tube was inserted. She rapidly improved and on have arisen should lead the public to patronise those dairy the 15th passed 20 ounces of urine per urethram, and by the companies which make and keep them. Such a rule 19th the quantity had increased to 45 ounces. In May she is itself a guarantee that the other precautions necessary for had completely recovered except for a sinus in the left loin. obtaining uncontaminated milk are carried out in these Sir A. Pearce Gould explains the symptoms as follows. When establishments. When Bills have been passed, and super- the small calculus in the right kidney passed into the narrow vision of production and control of distribution have been neck of the ureter it not only prevented the passage of urine obtained, the problem will still remain of educating the but ariested the secretion of the opposite kidney by reflex

i neither

1781 stimulation of the vaso-constrictor nerves and inhibition After its removal, while the of the secretory nerves. urine from the right kidney was escaping through the drainage-tube, urine quickly appeared in the bladder, mostly, if not wholly, from the left kidney. Further evidence of the influence of the impacted stone upon the secretion of the opposite kidney is the fact that urea in the urine passed after the operation rose to over 1 per cent. in contrast to the 0’1 per cent. before. This reflex arrest of secretion in a diseased kidney by impaction of a calculus in the opposite ureter is analogous to the anuria occasionally caused by a urethral operation when the kidneys are diseased. It is an interesting example of the fact that reflex effects depend partly on the condition of the part to which the efferent impulse is sent. Indeed, it is believed that calculous occlusion of one ureter never causes fatal anuria if the opposite kidney and ureter are healthy.

Atlantic ; but,

on

the other

hand,

it cannot be denied that

opposite direction, for draughty corridors, ice-cold bedrooms, and chilly living-rooms claim their quota of victims each succeeding winter. The happy medium in this country would seem to be an employment of the two methods, utilising the ventilating powers of the open fire as well as the equable heat given out by the steam radiator, but only a few of our more modern dwellings as yet offer such

we,

II

here,

err

in the

a combination. THE

-

ULTIMATE RESULTS OF ENTEROSTOMY.

GASTRO-

GASTRO-ENTEROSTOMY has for some years enjoyed a high reputation in the treatment of many disorders of the stomach, both obvious and obscure, and although its reputation is not quite what it was, yet it is still employed frequently This is not surprising, for in by many surgeons. most cases the temporary results, at least, are very good, THE OVER-HEATING OF HOUSES. while the patient is in bed in hospital and is judiciously THE excessive humidity which has characterised the dieted. The permanent results, too, in some cases are truly weather during the year now drawing to a close, and more wonderful. Patients who have been in a state of chronic particularly throughout the month of November, has re- invalidism for 10 or 20 years have, as it were, regained directed attention to the much-debated question as to the their youth and the health and freedom from gastric methods of heating best adapted in this country for comfort disturbance so characteristic of the young. Many as well as health. We are often accused of being old- physicians, however, have seen no small number of fashioned, especially by Americans, and nothing surprises patients who have suffered from a return of the our professional brethren from the other side more, used as symptoms after having undergone the operation of gastrothey are to hot air or steam heat even in private houses, than enterostomy, and it occurred to Dr. Otto May, when he the open fire-places still found in many of our hospitals. was medical registrar to the Middlesex Hospital, that it That their more "up-to-date" " methods are not free from would be of interest and value to trace the after-history of defects is, however, being gradually forced upon the patients on whom the operation of gastro-enterostomy had American nation, and it is not without significance, there- been performed at that hospital. He excluded all malignant fore, to find that the Boston Medical and Surgical Jozcrnal cases, for obviously they could afford no information of value. of Nov. 17th has been inveighing against them in no He selected the three years 1906, 1907, and 1908, so that uncertain terms. According to this authority, the average sufficient time might have elapsed between the performance temperature of the American furnace-heated home is of the operation and the date of investigation. Of the 90 76° F., as contrasted with 60° F. in England. But it patients upon whom the operation had been performed he is in the comparative humidity that the most striking was able to obtain information as to the results in 65. In difference lies. We are not afraid of moist air ; it is order to arrange the results statistically he divided the cases lesponsible for the clear complexions, and absence of into four groups. In the first are those in whom the result is wrinkles, characteristic of us, although, it is true, it entirely satisfactory ; they can do their usual work without renders us more liable to rheumatoid affections unless care- discomfort, provided they use reasonable care in their fully regulated. The average humidity in the United dietary. In the second class he puts those where occasional States and Canada is very much less than in this country, attacks of pain or vomiting occur in spite of ordinary care, but the Canadian and American take care to reduce the but where considerable improvement has resulted. In the proportion still more by their customary methods of heating. third class are those in whom slight improvement has Indeed, to such a degree is this carried out that the occurred, but the gastric conditions are sufficiently troublehumidity often falls as low as 16, according to the article some to interfere seriously with the capacity for work. In from which we are quoting, which is about half the humidity the last class Dr. May puts those cases in whom no definite of the Desert of the Sahara, the mean humidity of which is improvement can be found. As to the results, rather less stated to be 30. The consequences of this extraordinary than half (46 per cent.) were "cured," while another dryness in the atmosphere of the home are not without mani- 20 per cent. were greatly relieved, but in 23 per cent. of the The surface moisture of the body is eagerly whole the operation had to be described as a total failure, and festation. absorbed by the parched air, the mucous membranes of the only slight benefit had occurred in the remaining 11 per cent. throat, nose, and pharynx become dry, congested, and The cases which gave almost uniformly good results belonged liable to any prevalent infection, and the heat-regulating to two classes: (1) dilatation of the stomach caused by mechanism of the body fails to react when its owner has to go pyloric obstruction ; and (2) duodenal ulcer. Apparently, also, out into the cold. As a result the ‘° great American cold " of some cases of gastric ulcer without pyloric obstruction Elizabeth Robins, the " fall cold " of the lay papers, and the received much benefit. Dr. May comes to the conclusion that "chronic American naso-pharyngeal catarrh " of the medical gastro-enterostomy is contra-indicated in that fairly large press has the nation in its grip every succeeding winter, and class of women who suffer from pain and flatulence, but in the "one-night-cough-cure"" quacks, the numerous, much whom no definite evidence of organic trouble can be found. advertised ’’ anti-catarrh" remedies, and the makers of He suggests that the fundamental indication for the operation "cuspidors"reap a plentiful harvest, while extra labour is is marked delay in the emptying of the stomach after a simple also thrown upon the medical profession. The Boston Medica test meal, and he thinks that the skiagraphic method is the and Surgical Journal roundly states that the super-heatec most trustworthy one for this determination. We might also American house is "a medical barbarism and an anachronisrr mention that although the numbers of men and women in this age of enlightened progress." Many English medica patients in the series were almost equal, 34 of the men have had the same view when sojourning across thE ! patients being men and 31 women, yet of the men 22