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SPLANCHNIC BLOCK FOR ANURIA
365
specialised profundities. If he really collaborated and his name appeared at the head of an article, it would not matter because he could be attacked by fellow experts. Dr. Harrison’s paper is typical of hundreds The of others. His experimental work is excellent. arithmetic of his statistical adviser is beyond reproach. But there is no logical cohesion between the two. He and his adviser have unwittingly misled each other. Neither is to blame. The fault lies in our cultural legacy of science split up into water-tight compartments. What is true of statistics is equally true of radiology, histology, I want to plead for clinical laboratory reports, &c. more whole-hearted collaboration. Experts must not lose touch with general medicine, and general medicine must learn from experts. Royal Society of Medicine.
DENYS JENNINGS.
SPLANCHNIC BLOCK FOR ANURIA SIR,-Your leading article of August 17 on the recent work of Trueta and his colleagues1 refers to the need for further trial of splanchnic block in anuria. The interesting and attractive explanation of oliguria made possible by their observations lends belief to the probable benefit from splanchnic block. Nevertheless, caution is needed in interpreting a diuresis which may follow this method of treatment. In the last two years, we have had 4 cases of severe oliguria after abortion, all treated conservatively without
hypertonic solutions, splanchnic block,
or
decapsulation,
and all had a spontaneous diuresis and recovered. Detailed biochemical studies were made, and are being reported elsewhere. If splanchnic block had been done towards the climax of their desperate illness, doubtless it would have been given the credit for their recovery. CASE I.-Single, aged 31. Abortion at 16th week, followed by 10 days oliguria with secretion of only 262 c.cm. urine. Blood-urea rose to 550 mg. per 100 c.cm. Excellent diuresis then occurred, and complete recovery. Well two years later. CASE 2.-Single, aged 37. Abortion at 16th week, followed by 14 days severe oliguria with a total secretion of 2360 c.cm. urine. Blood-urea rose to 350 mg. per 100 c.cm. Good diuresis then began and blood-urea returned to normal. Well 22 months later. CASE 3.-Married, aged 24. Two children. Incomplete
Obituary ARTHUR TUDOR EDWARDS M.A., M.D., M.CHIR. CAMB., F.R.C.S. Mr. A. Tudor Edwards, who died suddenly at St. Enodoc’s, Cornwall, on August 25, won a world reputation by his advancement of thoracic surgery. Born in 1890, Arthur Tudor Edwards was educated at Mill Hill School, at Cambridge University, and at the Middlesex Hospital where he was awarded the senior Broderip and university scholarships. From the first it was clear that his bent was surgery. At the Middlesex he worked under the late Sir John BlandSutton and Mr. (now Sir) Gordon Gordon-Taylor ; the surgery of mangled limbs he learned from the mechanical genius of Meurice Sinclair; and he gained a wide experience of traumatic and general surgery during the first world war, in which he served as a major with a casualty clearing station. After demobilisation he acquired an aptitude for treating the aftermath of operations on the gastro-intestinal tract that must have been the envy of his colleagues. The years of waiting were ended by his appointment to the Westminster Hospital and the Brompton Hospital. His way was not easy ; the attitude to thoracic surgery was at that time one of cautious, and indeed justified, reserve which was to be overcome only by proof that major procedures could be undertaken with safety. In his successes with the surgical treatment of bronchiectasis, bronchial and oesophageal carcinoma, and pulmonary tuberculosis, Tudor Edwards provided that proof; and to the Brompton he attracted visitors of all nations, eager to learn his methods. His reputation was established through his pioneer work in developing techniques which helped to advance thoracic surgery from the occasional reluctant, and always precarious, intervention to the status of an acknowledged specialty ranking with abdominal and other accepted branches of surgery. But he had further claims to recognition : he was a great operator and a teacher of distinction. Those that saw the easy grace of his technique in the difficult procedures that had previously defeated others realised that he was in the front rank of great operators ; his associates were perhaps most impressed by the courage and foresight with which he embarked on difficult cases, and by his sound clinical judgment. Really great success in major surgery comes not to the lone worker but to the man who can organise and inspire his colleagues, assistants, and nurses to form one harmonious unit, and in this again he set a great example. " My first meeting with Tudor Edwards," writes G. M., " was in the early nineteen-twenties, when I sought his help on behalf of a patient with bronchial carcinoma. That first contact made an impression which is still clear ; for even at that time he showed the characteristics which were to make him a leader and a pattern for the younger men in his specialty, both in this country and abroad. His manner was grave and courteous, he paid careful attention to my notes of history and clinical findings, to the reports of bronchoscopist and pathologist-and then he crosschecked them all1 Essential data must be verified if he did not know and trust those who had recorded them. We were not offended, for it was clear that his one object was the safety of the patient, and this he ensured by every resource he could command. Nothing second-rate would do. He was an outstanding organiser of team-work. Surgeon, _
abortion at 16th week. Oliguria persisted for 13 days, and during this time she passed only 1350 c.cm. urine. Like the previous cases, she was extremely ill with vomiting and hiccough, and she became oedematous. Blood-urea rose to 400 mg. and the serum potassium to 42-5 mg.- per 100 c.cm. The heart became completely irregular and the electrocardiogram showed very large T-waves and absent P-waves. Spontaneous diuresis then occurred, and, although colpotomy was necessary for pelvic abscess, she made a satisfactory recovery, and was well three months later. CASE 4.-Single, aged 31. Admitted on account of bloodstained vomitus, but found to have an incomplete abortion. She had been losing for a week. The next five days a moderately severe oliguria was noted. Blood-urea rose to 365 mg. per 100 c.cm. A diuresis then began, and her blood chemistry returned to normal within two weeks. She was quite well 18 months later. As far as could be determined, these cases were not due to incompatible blood-transfusion, sulphonamide therapy, or ahortifacients. They may have begun as a reflex vascular spasm with cortical ischaeinia, and possibly progressed to thrombosis and cortical necrosis. In the obstetrical wards there has also been one fatal case of anuria from cortical necrosis of the kidnevs in a girl of 16 admitted at term with severe accidental concealed haemorrhage. She was delivered of a stillborn child and developed anuria and died on the third day. A splanchnic block with amethocaine hydrochloride was given on the second day, and repeated on the third day, but without any effect. About 1500 deliveries and 400 abortions are admitted annually at this hospital. In view of our experience it is surprising that only 19 cases of acute renal failure after abortion, and only a total of 52 associated with Dreenancv. have so far been Dublished.2 M. A. M. BIGBY. F. AVERY JONES. Central Milddlesex County Hospital, J. MACVINE. London, N.W.10. 1. Trueta, J., Barclay, A. E., Daniel, P., Franklin, K. J., Pritchard, M. M. L. Lancet, August 17, p. 237. 2. O’Sullivan, J. V., Spitzer, W. J. Obstet. Gynœc. 1946, 53, 158.
septic
,
physician, radiologist, pathologist, anaesthetist, physiotherapist, nursing staff, surgical assistant-all knew what was expected of them and gave of their best. The patient also was made fully aware of the nature of the
specialised profundities. If he really collaborated and his name appeared at the head of an article, it would not matter because he could be attacked by fellow experts. Dr. Harrison’s paper is typical of hundreds The of others. His experimental work is excellent. arithmetic of his statistical adviser is beyond reproach. But there is no logical cohesion between the two. He and his adviser have unwittingly misled each other. Neither is to blame. The fault lies in our cultural legacy of science split up into water-tight compartments. What is true of statistics is equally true of radiology, histology, I want to plead for clinical laboratory reports, &c. more whole-hearted collaboration. Experts must not lose touch with general medicine, and general medicine must learn from experts. Royal Society of Medicine.
DENYS JENNINGS.
SPLANCHNIC BLOCK FOR ANURIA SIR,-Your leading article of August 17 on the recent work of Trueta and his colleagues1 refers to the need for further trial of splanchnic block in anuria. The interesting and attractive explanation of oliguria made possible by their observations lends belief to the probable benefit from splanchnic block. Nevertheless, caution is needed in interpreting a diuresis which may follow this method of treatment. In the last two years, we have had 4 cases of severe oliguria after abortion, all treated conservatively without
hypertonic solutions, splanchnic block,
or
decapsulation,
and all had a spontaneous diuresis and recovered. Detailed biochemical studies were made, and are being reported elsewhere. If splanchnic block had been done towards the climax of their desperate illness, doubtless it would have been given the credit for their recovery. CASE I.-Single, aged 31. Abortion at 16th week, followed by 10 days oliguria with secretion of only 262 c.cm. urine. Blood-urea rose to 550 mg. per 100 c.cm. Excellent diuresis then occurred, and complete recovery. Well two years later. CASE 2.-Single, aged 37. Abortion at 16th week, followed by 14 days severe oliguria with a total secretion of 2360 c.cm. urine. Blood-urea rose to 350 mg. per 100 c.cm. Good diuresis then began and blood-urea returned to normal. Well 22 months later. CASE 3.-Married, aged 24. Two children. Incomplete
Obituary ARTHUR TUDOR EDWARDS M.A., M.D., M.CHIR. CAMB., F.R.C.S. Mr. A. Tudor Edwards, who died suddenly at St. Enodoc’s, Cornwall, on August 25, won a world reputation by his advancement of thoracic surgery. Born in 1890, Arthur Tudor Edwards was educated at Mill Hill School, at Cambridge University, and at the Middlesex Hospital where he was awarded the senior Broderip and university scholarships. From the first it was clear that his bent was surgery. At the Middlesex he worked under the late Sir John BlandSutton and Mr. (now Sir) Gordon Gordon-Taylor ; the surgery of mangled limbs he learned from the mechanical genius of Meurice Sinclair; and he gained a wide experience of traumatic and general surgery during the first world war, in which he served as a major with a casualty clearing station. After demobilisation he acquired an aptitude for treating the aftermath of operations on the gastro-intestinal tract that must have been the envy of his colleagues. The years of waiting were ended by his appointment to the Westminster Hospital and the Brompton Hospital. His way was not easy ; the attitude to thoracic surgery was at that time one of cautious, and indeed justified, reserve which was to be overcome only by proof that major procedures could be undertaken with safety. In his successes with the surgical treatment of bronchiectasis, bronchial and oesophageal carcinoma, and pulmonary tuberculosis, Tudor Edwards provided that proof; and to the Brompton he attracted visitors of all nations, eager to learn his methods. His reputation was established through his pioneer work in developing techniques which helped to advance thoracic surgery from the occasional reluctant, and always precarious, intervention to the status of an acknowledged specialty ranking with abdominal and other accepted branches of surgery. But he had further claims to recognition : he was a great operator and a teacher of distinction. Those that saw the easy grace of his technique in the difficult procedures that had previously defeated others realised that he was in the front rank of great operators ; his associates were perhaps most impressed by the courage and foresight with which he embarked on difficult cases, and by his sound clinical judgment. Really great success in major surgery comes not to the lone worker but to the man who can organise and inspire his colleagues, assistants, and nurses to form one harmonious unit, and in this again he set a great example. " My first meeting with Tudor Edwards," writes G. M., " was in the early nineteen-twenties, when I sought his help on behalf of a patient with bronchial carcinoma. That first contact made an impression which is still clear ; for even at that time he showed the characteristics which were to make him a leader and a pattern for the younger men in his specialty, both in this country and abroad. His manner was grave and courteous, he paid careful attention to my notes of history and clinical findings, to the reports of bronchoscopist and pathologist-and then he crosschecked them all1 Essential data must be verified if he did not know and trust those who had recorded them. We were not offended, for it was clear that his one object was the safety of the patient, and this he ensured by every resource he could command. Nothing second-rate would do. He was an outstanding organiser of team-work. Surgeon, _
abortion at 16th week. Oliguria persisted for 13 days, and during this time she passed only 1350 c.cm. urine. Like the previous cases, she was extremely ill with vomiting and hiccough, and she became oedematous. Blood-urea rose to 400 mg. and the serum potassium to 42-5 mg.- per 100 c.cm. The heart became completely irregular and the electrocardiogram showed very large T-waves and absent P-waves. Spontaneous diuresis then occurred, and, although colpotomy was necessary for pelvic abscess, she made a satisfactory recovery, and was well three months later. CASE 4.-Single, aged 31. Admitted on account of bloodstained vomitus, but found to have an incomplete abortion. She had been losing for a week. The next five days a moderately severe oliguria was noted. Blood-urea rose to 365 mg. per 100 c.cm. A diuresis then began, and her blood chemistry returned to normal within two weeks. She was quite well 18 months later. As far as could be determined, these cases were not due to incompatible blood-transfusion, sulphonamide therapy, or ahortifacients. They may have begun as a reflex vascular spasm with cortical ischaeinia, and possibly progressed to thrombosis and cortical necrosis. In the obstetrical wards there has also been one fatal case of anuria from cortical necrosis of the kidnevs in a girl of 16 admitted at term with severe accidental concealed haemorrhage. She was delivered of a stillborn child and developed anuria and died on the third day. A splanchnic block with amethocaine hydrochloride was given on the second day, and repeated on the third day, but without any effect. About 1500 deliveries and 400 abortions are admitted annually at this hospital. In view of our experience it is surprising that only 19 cases of acute renal failure after abortion, and only a total of 52 associated with Dreenancv. have so far been Dublished.2 M. A. M. BIGBY. F. AVERY JONES. Central Milddlesex County Hospital, J. MACVINE. London, N.W.10. 1. Trueta, J., Barclay, A. E., Daniel, P., Franklin, K. J., Pritchard, M. M. L. Lancet, August 17, p. 237. 2. O’Sullivan, J. V., Spitzer, W. J. Obstet. Gynœc. 1946, 53, 158.
septic
,
physician, radiologist, pathologist, anaesthetist, physiotherapist, nursing staff, surgical assistant-all knew what was expected of them and gave of their best. The patient also was made fully aware of the nature of the