515

series undoubtedly died as a result of aspiration suggeststhat greater care is needed in posturing and feedingthose who are very ill. Gardner believes that aspirationof vomit or food is too often the coup-de-grace-ratherthan an agonal phenomenon-in an ill patient who mightotherwise recover. He suggests that the standard hos-

pital feeding cup, which is designed to facilitate feeding inrecumbency, should be abolished as its style contributesto aspiration. Not only does the shape of the spoutenable fluid to be poured into the trachea, but the hoodedtop ensures that the patient is taken unawares. The

patient should either sit up and drink out of an ordinarycup or glass or lie on his side and drink through a straw.If neither is practicable, feeding should be through atube directly into the stomach. The danger associatedwith vomiting can be offset only by the adoption of aprone or semiprone position.

1. Spiller, W. G. J. nerv. ment. Dis. 1909, 36, 601.2. Peterman, A. E., Yoss, R. E., Corbin, K. B. Proc. Mayo Clin. 1958,

33, 31.3. Woollam, D. H. M., Millen, J. W. Proc. R. Soc. Med. 1958, 51,

540-550.4. Feeney, J. F., Watterson, R. L. J. Morph. 1946, 78, 231.

OCCLUSION OF ANTERIOR SPINAL ARTERY

THE syndrome of occlusion of the anterior spinalartery is of interest because of the striking clinical picture.It was first recorded in life by Spiller,1 who called thedisorder syphilitic acute anterior poliomyelitis, havingrecognised the distinctive involvement of anterior horncells at the level of the lesion. This description of thenecropsy findings is excellent. For many years the condi-tion continued to be regarded as a manifestation of

syphilitic vascular disease; but it is now clear that manypatients show no evidence of neurosyphilis; indeed thecerebrospinal fluid is often normal.Ten cases seen at the Mayo Clinic since 1949 have been

described by Peterman et al. In three the lesion involvedthe lower cervical region, and in seven the thoracic regionof the spinal cord. The onset is usually abrupt and theclinical picture is fully developed within a few hours.In the lower limbs, there is sudden loss of power oftenwith pain across the shoulders; bladder and bowels areparalysed; and appreciation of pain and temperature islost below the level of the lesion. The posterior columns,subserving joint-position sense, touch, and vibration

sensibility are spared. In the cervical cases there are totallower-motor-neurone lesions of the muscles supplied bythe segments involved-usually c7, c8, and Tl. There

may therefore be very severe permanent disability dueto bilateral disruption of function of the upper limbs,particularly the hands. In addition there may be seg-mental sensory loss, presumably due to ischxmia in thecentral grey matter of the cord. Symptoms and signsare usually symmetrical. The association of an anterior-horn-cell disorder at the level of the lesion with sparing ofthe posterior columns points to the diagnosis.The outlook for the lower limbs is fair. In all but one

of the ten Mayo Clinic cases the patient could walk aftera few weeks; and control of bladder and bowels wasregained. Wasted muscles do not recover. The anteriorhorn cells, which seem to be extremely vulnerable toanoxia, are permanently affected.Woollam and Millen 3 agree with Feeney and Watter-

son that the nervous system has been developed to thelimit of the’vascular supply: hence the havoc broughtabout by occlusion of the anterior spinal artery. Radicular

arteries from vessels adjoining the vertebral column varfrom two to seventeen; and two of these (ontcervical and one lumbar) contribute largely to theanterior spinal artery, which is formed by the fusion ojtwo longitudinal chains. The artery supplies the wholtof the grey matter except part of the dorsal horn, and iipartly supplies the anterior columns of white matter. Thelower cervical region and the lower thoracic region aremost usually involved. The reasons for this are not clearIt is believed that blood flows through the anterioi

spinal artery, from both above and below, towards thethoracic region, and the sites of election may be water-sheds. Another possibility is indicated by clinical con-siderations. Some patients with occlusion of this arteryshow no evidence of generalised vascular disease or o:

disease of the vertebral column. Some seem to hav(

engaged previously in physical work involving thtshoulders and back, or to have suffered exposure. Tht

dependence of the anterior spinal artery on radicula]contributions suggests that vasodilation in the thoracicmuscles may lead to ischsemia in the spinal cord. Théconverse situation has been described in which theanterior spinal artery participated in the anastomosis

consequent on coarctation of the aorta at the level of theductus arteriosus.5

In other conditions associated with vascular lesions ofthe cord, such as syphilis, vertebral fracture, aorticocclusion during operation, dissecting aneurysm of theaorta, and the aortic-arch syndrome, there are obviouspathological reasons for cord involvement. In many cases ofocclusion of the anterior spinal artery this is not so: it is noteven clear whether hypertension and atherosclerosis areimportant in this disorder. The description of well-documented cases is still of great interest.

5. Blackwood, W. Proc. R. Soc. Med. 1958, 51, 540-550.6 Boshell, B. R. Sanford, J. P. Ann. intern. Med. 1958, 48, 1040.

"CLEAN" VERSUS CATHETER SPECIMENSOF URINE

IT is widely accepted that specimens of urine for

bacteriological investigation from female patients shouldbe obtained by catheterisation. Besides causing incon-venience and occasionally embarrassment, this pro-cedure carries a moderate risk of introducing fresh

infection, and in fact it is often carelessly performed with-out regard for asepsis. It has been suggested that tech-nical perfection necessitates the presence of two nurses-one to separate the labia and clean the meatus, and theother to insert the catheter.

Wishing to avoid the hazard of introducing infectionBoshell and Sanford advocate the examination of " clean "

freshly voided specimens as an alternative, and claim thatthese specimens compare favourably in a bacteriologicalsense with those obtained by catheter. The suggestedprocedure consists in thorough cleaning of the peri-urethral area in a Sitz chair filled with green soap solution,followed by gentle scrubbing with pads containingZephiran’ (1% solution of benzalkonium chloride).The patient then voids, holding the labia apart, anda mid-stream specimen is collected for culture. Theresults in 67 cases corresponded closely with thosefrom subsequent catheter specimens, and the technique isrecommended as a screening method to reduce the needfor instrumentation. It may be questionable, however,how far such arrangements are appropriate in a busyoutpatient clinic or hospital ward.