THE MODERN TREATMENT of ANURIA and OLIGURIA by DAVID K

583 Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from

THE MODERN TREATMENT OF ANURIA AND OLIGURIA By DAVID K. BROOKS, M.B., B.S. Research Fellow Surgical Unit, St. Mary's Hospital, London, W.z2

There are few conditions which offer a greater operative procedures; bilateral renal calculi; challenge to the medical and nursing staff than carcinoma of the prostate and cervix; procidentia, that of acute renal failure. There are also few etc. conditions where the application of modern tech- (b) Dehydration and electrolyte depletion, e.g. niques and careful clinical biochemical assess- low salt syndrome. ment are more essential to the achievement of (c) Tubular necrosis such as follows: gross success. dehydration; prolonged hypertension; separation True or complete anuria rarely occurs except of placenta; abortion; crush syndrome; miss- where there is mechanical obstruction and, as matched blood transfusion; nephrotoxins, e.g. early recognition of oliguria is essential in acute mercuric chlorides, bismuth, sulphonamides. renal failure, it is important to define it in a (d) Acute nephritis. Protected by copyright. recognizable form. The history of a successfully treated case of The normal output of urine varies between one acute suppression of urine normally falls into four and two litres per day. On a mixed diet it is phases: obligatory to pass a minimum volume of approxi- (a) The precipitating condition or cause. mately 500 ml. in 24 hours (Gamble, I947). This (b) The anuric phase. entails good renal function and the ability to con- (c) The diuretic or pre-recovery phase. centrate fully to a maximum specific gravity of (d) The recovery phase. I.o35 (I,I55 m. osm./l.). Oliguria has been defined as less than 700 ml. in The Precipitating Condition or Cause 24 hours. Where good renal function is present Careful clinical assessment to elucidate the such urine will concentrate sufficiently to produce causation of anuria is important because of the a specific gravity of i.oi8 (595 m. osm./l.) or more. undesirability of prolonging an irreversible condi- Where renal damage is present, a low specific tion, and the need of remedying quickly, and to gravity of i.oo8 (265 m. osm./l.) to 1.o014 (460 m. the maximum, any condition that is immediately http://pmj.bmj.com/ osm./l.) is to be expected (Joekes, I957). Severe treatable. oliguria may be defined as a urine output of Dehydration, electrolyte imbalance, low blood 500 ml. or less in 24 hours. pressure are all easily treatable. Sulphonamide Where there is a urine output of 300 ml. or less, anuria usually responds to alkalis and increased such will be the inability of the kidneys to keep fluids. pace with the production of metabolites, the The onset of renal failure, following poisoning condition might well be called metabolic anuria. with bismuth or mercuric chloride, may be avoided The object of therapy in oliguria and anuria is by the early use of British anti-lewisite or calcium on September 28, 2021 by guest. to tide the patient over until the kidneys have time disodium versenate. These substances may be to recover their function. toxic, however, once anuria is established (Stock, At this time, it is probably true to say that 1952; Merrill, 1955). suppression of urine due to malignant hyperten- Care must be observed in the treatment of de- sion, chronic nephritis and polycystic kidneys hydration and electrolyte imbalance in case renal developing into oliguria, and the rare condition of damage has already occurred. bilateral cortical necrosis, is, in the main, not reversible. The Anuric Phase The reversible causes of acute renal suppression Three factors emerge as a consequence of the may be listed as: acute suppression of urine: (a) Mechanical-obstruction of the ureters, by: (a) The retention of water. 584 POSTGRADUATE MEDICAL JOURNAL November 1958Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from (b) The accumulation of the products of meta- this is clinically possible, is by no means contra- bolism, urea, uric ,acid, creatinine, phosphate, indicated. sulphate, etc. An accurate record of all additions to the patient (c) The metabolic upsets arising from the above, in the form of fluids, such as medicines, ion as yet little understood, but involving the shift of exchange resin, etc., and all losses in the form of electrolytes from the cells to the extra-cellular vomit, urine and faeces must be kept, in order for fluid compartments, and for want of a better term this assessment to be made. may be called the poisoned-cell phenomenon. The measured insensible loss of the average The consequences of fluid retention rapidly be- adult is now accepted to be less than one litre in come apparent when unrestricted fluid intake is 24 hours and generally falls as the time from the allowed, or worse, when fluids are forced in the onset of anuria progresses, probably because of misguided attempt to invoke a diuresis. In either endogenous production of water from fat meta- case, cardiac failure, oedema, pulmonary conges- bolism (Swan and Merrill, I953). tion, hypertension, cerebral oedema and the symp- With this in view, and the probability that some toms of water intoxication will result. degree of overhydration may have occurred by the time the oliguric state has been recognized, as The most common cause of death within I4 little as 400 ml. in 24 hours can be recommended days of the onset of oliguria due to renal disease in the early stages of treatment, and a graaual loss is overhydration (Bull, Joekes and Lowe, I949). of weight, as food stores are used up, is to be Even when overhydration is not a factor, the re- desired (Merrill, I955). tained products of metabolism produce the gradual The accurate measurement of urine output is of onset of lethargy, coma, vomiting, pericarditis and paramount importance, not only for the assess- lowered resistance to infection. The rising con- ment of fluid replacement, but for the determina- centration of potassium in the body is reflected in tion of the progress of the patient, and the amount high plasma-potassium levels and is associated of urea and electrolytes excreted. Protected by copyright. with cardiac failure and muscle weakness. If necessary, therefore, a When the kidney begins to recover it secretes a self-retaining catheter dilute urine of low concentration, which, on reach- should be inserted into the bladder and, after ing a volume of a litre or more, begins to reduce emptying, a measured quantity of fluid, containing the blood urea. an antibiotic, passed back into the bladder through the catheter: 30 ml. of fluid containing ioo mg. of The kidney at this stage still has an impaired chloramphenical has been used successfully. This tubular function, unable to concentrate and to volume is deducted from the volume of urine differentiate between electrolytes. Thus, the pass- obtained on releasing the catheter. ing of a profuse dilute urine may soon lead to In order to avoid the oral complications asso- dehydration, and electrolyte imbalance and de- ciated with oliguria and its treatment, i.e. parotitis, pletion. thrush and ulceration, part of the fluid Within a variable period of time, usually six to intake eight weeks, full return of kidney function is to be should be taken by mouth. This regime should be expected, sometimes with no detectable abnor- reinforced by the sucking of pure glucose sweets, mality (Lowe, 1952; Oliver, 1953). followed by bland antiseptic mouth washes. http://pmj.bmj.com/ The Suppression of Harmful Metabolites The Regulation of Water The main metabolic consequences the anuric The fluid requirements in the anuric patient patient has to face arise from the metabolism of need to be assessed accurately each 24 hours so protein, producing a rising blood non-protein that the building up of a positive or negative im- nitrogen, cardiotoxic levels of plasma potassium, balance is avoided as time progresses. These re- and release of unexcretable fixed acid. quirements amount to the fluid loss through the Therapy is therefore directed towards a com- on September 28, 2021 by guest. skin, lungs, urine, vomit and faeces. pletely protein-free intake and the reduction of Although various formulae are available for the endogenous protein metabolism. Advantage is assessment of insensible loss through the skin and therefore taken of the protein-sparing effect of lungs, none can be applied with confidence to glucose and, owing to the necessity of restricting every patient. fluid intake, this entails the use of hypertonic The simplest and most accurate method is to solutions. Up to 50 per cent. glucose can be safely record the daily change in weight, the weighing injected into a large vein by means of a polythene being performed at the same time each day and on catheter (Bull, 1952). Although the procedure of the same scales, with the bladder empty. Ideally passing the catheter is simple, in the condition of this is done on a bed weighing machine, but anuria, where it may by necessity stay in situ for mobilization of the patient for weighing, where three weeks, maximum precautions for sterility November I958 BROOKS: The Modern Treatment of Anuria and Oliguria 585 Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from LLOYD-LUKE Books that enshrine profound thought

GENERAL PATHOLOGY INTRODUCTION TO FLUID BALANCE 11tSURGERY IN SURGICAL PRACTICE (2nd Edited by D. H. PATEY (2nd edit.)

M.D., F.R.C.P., F.R.S. (1958) Cloth-bound 17s. 6d. net D.M.(Oxon.), F.R.C.S.(Eng.) (1958) 84s. net (1958) Paper-covered 9s. 6d. net (1957) 20s. net

RECENT TRENDS MEDICAL ETHICS IN CHRONIC BRONCHITIS A Guide to Students POSTURAL DRAINAGE Edited by NEVILLE C. OSWALD and Practitioners by E. WINIFRED THACKER T.D., M.D.(Cantab.), F.R.C.P.(Lond.) Edited by MAURICE DAVIDSON M.C.S.P. D.M.(Oxon.), F.R.C.P.(Lond.) (1956) 8s. 6d. net (1958)net3. ((I 957) 20s. net

OPHTHALMOLOGY THE RESPIRATORY MUSCLES

by P. D. TREVOR-ROPER BREATHING by V. KEATING M.B., B.Chir.(Camb.), F.R.C.S., by E. J. MORAN CAMPBELL M.B., B.Ch., D.A., F.F.A.R.C.S.(Eng.) D.O.M.S.(Eng.) M.D., Ph.D.(Lond.), M.R.C.P.(Lond.) (1956) 25s. net Protected by copyright. (1955) 75s. net (1958) 20s. net

Descriptive catalogue available on request LLOYD-LUKE (MEDICAL BOOKS) LTD., 49 Newman Street, W.I

should be enforced and complete sterility main- and pH, and raised phosphate and sulphate, are all tained at the changing of each bottle. found in the uraemic state. To each 500 ml. of glucose solution are added Lowered serum sodium may be due either to 2,500 units of heparin, and one unit of insulin is sodium depletion or more probably to dilution by added for every 3 g. of glucose. The slow infusion overhydration. The therapy for the latter is of not less than 200 g. of glucose which should be intense water restriction. The shift of sodium from

aimed at, can be achieved in only 400 ml. of water. the plasma into the cells, due to the poisoned cell http://pmj.bmj.com/ The advantages of this regime over the tube phenomenon, is also a possible factor. The ad- feeding of fat and glucose, such as has been administration of the sodium ion is to be avoided. If, vocated (Bull, Joekes and Lowe, 1949; Borst, however, sodium depletion is considered to have I948), are seen in the complete control obtained occurred, small quantities of sodium in the form of over fluid and calorie intake, the absence of any lactate, bicarbonate, or chloride can be adminis- stimulation to vomiting, and the possible greater tered. If clinical improvement results, further protein-sparing effect of glucose over that of fat quantities can be given until the deficit, as calcu- (Engle, I952). In addition, the urea and electro- lated from the plasma deficiency and total body on September 28, 2021 by guest. lyte content of vomit is such that it is often valuable water, has been made good. This quantity should as an excretory mechanism, and its return down never be exceeded.> the stomach tube in an attempt to maintain e.g. weight of patient = 70 kilo. balance is contra-indicated. Total body water estimated at 6o per cent. The use of testosterone proprionate to inhibit of body weight = 42 1. protein catabolism has not proved very successful, Plasma sodium 12o mEq./l. but the newer synthetic non-virilising compounds 42 X 20 = 840 mEq. of sodium are re- may be of value (McSwiney and Prunty, I947). quired to correct the observed deficit and bring the plasma sodium level to Electrolyte Imbalance I40 mEq./l. Lowered plasma sodium, calcium, bicarbonate, No marked clinical improvement is to be ex- 586 POSTGRADUATE MEDICAL JOURNAL November 1958 Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from pected from attempts to modify the acidosis than 25 per cent. The infusion of ioo ml. of io per resulting from the accumulation of fixed acids, cent. calcium gluconate every 24 hours will do no phosphate, sulphate, etc., by administration of harm and on physiological grounds may help to alkali in the form of bicarbonate or lactate mitigate the effects of hyperkalaemia (Meroney (Grollman, 1954; Merrill, I955). Also tetany, and Herndon, 1954). It may be added to hyper- due to a further lowering of the already decreased tonic glucose solutions. Hyperkalaemia is an level of plasma ionized calcium, may occur on the indication for dialysis. The rapid infusion of administration of alkali. hypertonic saline or of sodium bicarbonate will temporarily, for one or two hours, reverse the Treatment of Hyperkalaemia cardio-toxic effect of potassium (Merrill, 1955) and A complete potassium-free intake should be may be used, for example, prior to dialysis. instituted and maintained throughout the period of anuria. Milk, fruit, etc., are banned. Tea The Extra Renal Removal of Metabolites without milk may relieve the monotony of glucose When conservative treatment, as described drinks. above, is inadequate to control or maintain the A raised plasma potassium occurs mostly due patient until the pre-recovery stage develops, the to its release from protein catabolism and probably extra renal removal of metabolites becomes partly as an inherent metabolic consequence of essential. anuria. When toxic levels are reached, muscular This requires strict biochemical and physiologi- weakness, cardiac irregularities, absence of tendon cal control and a well-trained team. The indica- reflexes can be demonstrated. The E.C.G., when tions for this procedure, which should be regarded plasma levels of 7 or 8 mEq./l. are reached, shows as part of general therapy and not as a substitute high-peaked T waves, absent P waves, slurred for the regime described above, may be sum- widened Q.R.S. complexes. Cardiotoxic levels of marized as follows: potassium vary with each individual, age and (a) General clinical deterioration-' the uraemicProtected by copyright. duration of the disease. Rapid onset of potassium state.' No hard and fast rules can be laid down, intoxication is to be expected following major as individual tolerance to raised-plasma non- operative procedures and where gross tissue protein nitrogen levels appears to vary so much, damage has occurred (Bywaters, 1944). and are not necessarily in themselves indications Treatment for the control of potassium intoxica- for dialysis. A careful clinical assessment of the tion should be instituted early, before pathological rate of progress as manifested by drowsiness, peri- levels appear. Intravenous glucose tends to carditis, vomiting, muscular irritability, etc., must alleviate the condition by the uptake of potassium be made. in its metabolism (Bull, 1952). Ion exchange (b) Hyperkalaemia-cardiotoxic plasma potas- resins which exchange ammonia or sodium for sium levels of 7 mEq./l. or more as shown by potassium may be used (Elkington et al., I950; E.C.G. recordings. Knowles, I953; Milne and Yellow Lees, I953). (c) Acidosis-a plasma bicarbonate of less than Fifteen g. of resin given in 30 ml. of 5 or io per I 5 m. mo./l. cent. glucose water is well tolerated orally when (d) Gross overhydration. http://pmj.bmj.com/ given early in the disease, and can be given, if The therapeutic methods available are intestinal necessary, three times a day: 30 to 60 g. of ion irrigation, peritoneal lavage and dialysis. exchange resin can be given rectally in 2o0o ml. of Intestinal Irrigation. The perfusing of hyper- water or I per cent. methyl cellulose. It may be tonic fluids of varying composition through the necessary to administer a glycerine enema in order gut at a constant rate is difficult to perform and may to obtain return of the resin, as retained resin is of be associated with complications of intestinal limited value. The rectal route can be com- haemorrhage, perforation, ileus and pulmonary

only on September 28, 2021 by guest. bined with oral administration or used alone when oedema. the patient is vomiting or unable to swallow. It has not gained much popularity except on Attempts to make use of the low potassium con- the Continent. tent of stored packed cells have proved disappoint- Peritoneal Lavage. The use of the large peri- ing, but there is some recent evidence that ex- toneal surface for dialysing is, on physiological change transfusion may be of some benefit in this principles, sound and ofvalue clinically (Grollman, respect (Hughes, I958). 1954). It must be borne in mind, however, that trans- Slightly hypertonic sterile solutions, varied ac- fusions of blood or plasma are associated with cording to the biochemical needs of the patient, increased protein metabolism. Attempts to correct are perfused through the abdominal cavity. anaemia should be avoided for this reason unless In hyperkalaemia, for example, no potassium is found to be essential, i.e. an haematocrit of less added to the perfusing fluid and solution A would November I 958 BROOKS: The Modern Treatment of Anuria and Oliguria 587 Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from be found suitable. Where hyperkalaemia is not a The Diuretic or Pre-Recovery Phase factor, then a solution such as B would be With the production of urine volumes of I 1. indicated. or more, clinical improvement is to be expected and is reflected in falling N.P.N. plasma levels. Solution A A profuse dilute urine excretion soon leads to mEq./l. g./l. dehydration and electrolyte loss, so that daily Na.. .. i34 NaCl .. 6.26 weighing and plasma electrolyte recordings must Ca .. .. 4 NaHC03 .. 2.27 be maintained. Mg . ... I.I MgCl2 .. o.o5 As further recovery proceeds, intravenous HCO3 .. 27 CaCl2 .. 0.22 therapy may be abandoned and dietary restrictions C1 .. .. II2 Glucose .. 22 relaxed. Care should be taken, however, that each step taken towards a normal regime should be Solution B preceded by a careful biochemical assessment. mEq./l. g./l. Na... 132 NaCl .. 6.20 Discussion Ca .. . 3 NaHCO3 .. 2.I8 Although a large volume of literature exists on Mg.. . I. I MgClz .. 0.05 the subject of acute renal failure the condition K .. 4 CaC12 .. o.I7 often goes unrecognized and many cases of HCO3 .. 26 KC1 0. 3 uraemia still die due to the incautious administra- CI . .. II4 Glucose .. 21.6 tion of fluid in the early stages of oliguria and to the lack of precision in biochemical control. Total osmolarity 400 m. osm./l. Many patients still are not allowed the advantage of dialysis until their condition is such that re- In each case it is essential that the fluid be covery becomes improbable. hypertonic compared with the patient's plasma This paper is an attempt to interpret existingProtected by copyright. and it can be kept so by the addition of glucose. literature, much of which is in part controversial, The sterile fluid, to which streptomycin may be in the light of modern knowledge, and experience. added, is perfused at the rate of 2 to 3 litres per It is to be hoped that no case of acute renal hour for io to x6 hours though canulae passed suppression shall be considered hopeless until the through the abdominal wall under local anaes- cause has been shown to be irreversible. thesia. The canulae may be replaced by plastic catheters. A catheter is passed through the Summary lumen of each canula, and the canula withdrawn. The modern treatment of anuria and oliguria is Sedation is necessary, and the procedure best outlined. Stress is placed on the importance of performed on a weighing bed. Abdominal pain, restricting fluid intake, which should be carefully meteorism, intestinal haemorrhage, perforation of controlled by accurate daily weighing. bowel, peritonitis are some of the obvious compli- The early treatment of hyperkalaemia and cations of this procedure. caution in the elevation of a low plasma sodium, The Artificial Kidney. Whenever possible bicarbonate, and haemoglobin is urged. http://pmj.bmj.com/ extra renal removal of metabolites should be A method for giving a protein sparing high performed by the more effective and safer pro- calorie diet in small fluid volume is described. cedure of dialysis through an artificial kidney. Methods for the extra renal removal of meta- Various models for dialysis are in existence but bolites are mentioned, dialysis by the artificial the principles involved are the same (Kolff, 1947; kidney being recommended and the importance Skeggs and Leonards, 1948). of the correct timing of this procedure is Blood is pumped from an artery or vein through emphasized. one or more tubes of cellophane and back into the on September 28, 2021 by guest. patient through a large vein. The cellophane BIBLIOGRAPHY BORST, J. G. G. (1948), Lancet, i, 824. tubes are bathed in a circulating fluid of com- BULL, G. M., JOEKES, A. M., and LOWE, K. G. (I949), Lancet, position suitably adjusted to the needs of the ii, 229. patient. BULL, G. M. (1952), Proc. roy. Soc. Med., 45, 848. BYWATERS, E. G. L. (I944), J. Amer. med. Ass., 123, 103. A well-trained team, a weighing bed to detect ELKINGTON, S. R., CLARK, S. K., SQUIRES, R. D., for BLUEMLE, L. W., and CULSLEY, A. P. (1950), Amer. J. changes in circulating blood volume, facilities med. Sci., 220, 547. quick electrolyte determination, are essential for ENGLE, F. L. (1952), Endocrinology, o50, 62. the successful outcome. Blood pressure and GAMBLE, J. L. (1946-47), Harvey Lect., 247. GROLLMAN, A. (I954), 'Acute Renal Failure,' Thomas, Spring- E.C.G. recordings must be taken at short intervals. field, Illinois. The patient may be dialysed for 8 to I0o hours HUGHES (I958), Lancet, i, 323. using frequent changes of fluid. Bibliography continued on page 596 596 POSTGRADUATE MEDICAL JOURNAL - November I9-58 Postgrad Med J: first published as 10.1136/pgmj.34.397.583 on 1 November 1958. Downloaded from Summary L.E. cells are not found in all patients with the All the cases described had features which led disease. In all the cases L.E. cells were found in to the presumptive diagnosis being made clinically, the peripheral blood and we felt that the test, and in every case L.E. cells were demonstrated taken in conjunction with the clinical findings, is in the peripheral blood. In one case the diagnosis of the greatest value. was confirmed at autopsy. Regarding the management of cases, the con- High fever, loss of appetite and weight, painful sensus of opinion at present favours the use of swollen joints and pleural involvement were com- conservative measures in milder cases. In the mon to all. Splenic enlargement and ulceration of acute stages bed rest is essential with the necessary the mucous membrane of the mouth was noted in symptomatic treatment. The joint manifestations one case and peripheral vascular phenomena and may be helped by suitable splintage and salicylate hepatic enlargement in another. The characteristic therapy. Pneumonic episodes should first be butterfly rash on the face occurred only once. treated with appropriate antibiotics. In this series Other interesting features have been discussed in all cases were acutely ill and it was felt that steroid the footnote to each case. Although widespread therapy was indicated. Apart from the case which joint involvement was common, X-ray failed to lived only a short while after admission, all re- demonstrate any lesions in the affected joints. sponded to large doses of steroids and were able to Examination of the blood showed mild to moderate be discharged on a reduced dosage under out- hypochromic anaemia and a leucocyte count rang- patient supervision. An exacerbation of symptoms ing from 4,00ooo to 5,ooo per c.mm. The B.S.R. was occurring in case 5 while on maintenance therapy raised in all cases, ranging from 63 to 105 mm. was controlled by increasing the steroid dosage. (Westergren one-hour reading). Plasma proteins As symptoms abated it was found possible to once were raised (7 to io g./Ioo ml.), with the rise more reduce the dosage. mainly in the globulin fraction, a finding in keeping While steroids have undoubtedly been life- with reported series. In those cases in which saving in the acute exacerbations, no evidence hasProtected by copyright. plasma proteins were repeated they were found to been found of alteration in the underlying patho- be uninfluenced by steroid therapy. logical processes. Since the L.E. cell phenomena was first demon- We wish to thank Drs. R. M. Fulton and J. D. strated by Hargraves et al. (I948) several new tech- Allan for their kindness in allowing us to see their niques have been introduced. The test is now patients and use the case notes, and we are being widely used and there are a number of con- especially grateful to Dr. Fulton for his advice and ditions other than systemic lupus where it is found encouragement. to be positive. Positive L.E. cell tests have recently been described in rheumatoid arthritis by Fried- of our which is not REFERENCES man et al. (1957). One cases, BROWN, C. H., SHIRLEY, E. K., and HASERICK, J. B. (I957), described here, had painful deformity of the small Gastroenterology, 3I, 649. joints of the hands of six years' duration. She had a DUBOIS, E. L. (I956), Ann. intern. Med., 45, I63. ELLMAN, P., and CUDKOWICZ, L. (i954), Thorax, 9,46. mild hypochromic anaemia, but no other visceral FRIEDMAN, A. I., et al. (xI957), Ann intern. Med., 46, "II 3. manifestations were noted. L.E. cells were found GLASER, G. H. (I952), Arch. Neurol. and Psychiat, 67, 745. HARGRAVES, M. M., RICHMOND, H., and MORTON, R. http://pmj.bmj.com/ in the peripheral blood. She is still under observa- (I948), Proc. Mayo Clin., 23, 25. tion, but is at present considered to be a case of HILL, L. C. (xI957), Brit. med. Y., 2; 726. rheumatoid arthritis. JOSKE, R. A. (I956), Proc. roy. Soc. Med., 49, 329. MUEHRCKE, et al. (I956), Proc. roy. Soc. Med., 49, 327. Dubois (I956) states, on the other hand, that, OSLER, W. (I885), Lancet, i, 415, 459, 504. despite recently introduced refinements of tests, OSLER, W. (I895), Amer. J. Med. Sci., IIo, 629. on September 28, 2021 by guest.

Bibliography continuedfrom page 587-David K. Brooks, M.B., B.S. JOEKES, A. M. (I957), Proc. roy. Soc. Med., 50, 496. McSWINEY, P. R., and PRUNTY, F. T. G. (I957), J. Endocr., KNOWLES, H. C., and KAPLAN, S. A. (x953), Arch. intern. Med., x6, 28. 92, I 89. MERONEY, W. H., and HERNDON (I954), J. Amer. med. Ass., I55, 877. KOLFF, W. J., and BERK, H. T. J. (x944), 'Artificial Kidney, MERRILL, J. P. (I955), 'The Treatment of Renal Failure,' Grune Dialyser with Great Area,' Geneesk, Gids., Vol. 2I. and Statton, New York. KOLFF, W. J. (I947), 'New Ways of Treating Uraemia,' J. and A. MILNE, M. D., and YELLOW LEES, H. (I953), Lancet, ii, 791. Churchill Ltd., London. OLIVER, J. (r953), Amer. J. Med., 15, 535. LOWE, K. G. (1952), Lancet, i, Io86. SKEGGS, L., and LEONARDS, J. R. (I948), Science, Io8, 212. MATHE, G., and HAMBURGER, J., 'Ciba Foundation Sym- STOCK, R. J. (I952), Bull. N.Y. Acad. Med., 28, 507. posium on the Kidney.' SWAN, R. C., and MERRILL, J. P. (I953), Medicine, 32, 215.