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APPARENT ACUTE GLOMERULONEPHRITIS WITHOUT ALBUMINURIA
120 is that these readings, which proved to be so tricky without the use of control, were not like typical fading pseudo-reactions ; they were too circumscribed and their colour was too uniformly even. Yet against the control solution they proved to be pseudo-reactions. It is somewhat humiliating, after all these years, to realise that one can be caught napping by a quite atypical . form of pseudo and negative reaction ; but my experience may serve as a warning to others. I do not think that the value of my comparative experiments (already published) is likely to be in any way invalidated, as the pseudo error (not large) is applicable to all the groups which were under consideration. But for those desirous of finding out whether the powerful modern prophylactics are yielding a 95 % or a 99% conversion-rate, I cannot too strongly emphasise the necessity of using the control in all post-Schick tests. I have, as always, used the Wellcome brand of toxin and control in this investigation.
#danger
GUY BOUSFIELD.
London, S.E.5.
HEXOBARBITONE AND TUBARINE om,—An
excessive amount OLaodominai
experienced by
some
pain
nas oeen
patients when first regaining abdominal operation under light
consciousness after an anaesthesia and relaxation with ’Tubarine.’ I attributed this to : 1. Early restoration of consciousness and body function per se as compared with other methods of anaesthesia, allow-’ ing immediate postoperative abdominal discomfort to be at all. 2. The variable, but, I think, often excessive contraction of the gut following administration of tubarine. Gray and Halton1 commend on this and also show clearly the synergism that exists between curariform drugs and barbiturates.
experienced
,
It occurred to me, therefore, to try going back to the of hexobarbitone because of its more prolonged action, and particularly because of its pleasant postoperative effect of sustaining a light sleep for some hours. This change has been justified by results. Relaxation during operation has been prolonged and sustained up to one hour and less cyclopropane has been required ; but the chief benefit has been the postoperative comfort of the patient, who, having experienced much less pain, gets a pleasant sleep until the effects of the operation have worn off. I also think there is less intestinal r-..nt-.’J’1at.ir’ll’YB TT-r7t--T:T D. Tl Rpf}",{XT1B.TU" HUGH BROWNE. contraction. Memorial Hospital, Haywards Heath. use
APPARENT ACUTE GLOMERULONEPHRITIS WITHOUT ALBUMINURIA SIR,-The syndrome described last week by Dr. Crofton and Dr. Truelove vividly recalls to my memory experiences which during the first world war were puzzling many clinicians in Central Europe. Many victims of the so-called Kriegsnephritis had died of acute oedema of the lungs before admission to hospital because, in view of the absence of albuminuria, the combination of generalised oedema and bradycardia had led the doctors on the front to the erroneous diagnosis of Kriegsaedema. Unfortunately the leading symptom of I saw many cases severe dyspnoea was overlooked. of analbuminuric acute glomerulonephritis at Wenckebach’s First University Clinic in Vienna during 1917 and 1918. Apart from albuminuria they presented the full picture of acute glomerulonephritis-i.e., severe hypertension, oedema, and bradycardia. The skin capillaries revealed dermatoscopically the characteristic picture which I deseribed in 1920.2 The most striking sign, however, was acute or subacute oedema of the lungs, which was invariably present and was demonstrated by the cloudy appearance of the lung fields on screening." Under the then-prevalent Volhard’s "-fast-and-thirst regime the majority of cases recovered, albuminuria appearing on the third or fourth day. Necropsy of patients who had died of acute left ventricular failure showed typical acute glomerulitis with all histological details. The syndrome should preferably be termed " analbuminuric stage of acute diffuse glomerulonephritis " 1. Gray, T. C., Hatton, J. Proc. R. Soc. Med. 1946, 39, 400. 2. Hahn, L. Med. Klin. 1920, no. 40, p. 1039.
.
since albuminuria eventually appears after a few days unless the patient s,uccumbs to acute oedema of the lungs. It may be added that routine blood-pressure readings in patients with scarlatina often reveal a rise in blood-pressure before albuminuria attracts attention to the kidneys-a point of great interest in the pathogenesis of acute diffuse glornerulonephritis. LEO HAHN. Nuneaton. A TAX ON KNOWLEDGE !MR,—is there not an analogy with the legal profession as regards the use of books by doctors (referred to in your leading article last week) ? The position in respect of income-tax is controlled by a decision by Mr. Justice Rowlatt (Daphne v. Shaw [1926] 43 T.L.R. 45) in which he was unable to sav that the books of a solicitor or of a barrister or of a which were used in the sense of being consulted were plant." Discussing this point, the Solicitor (September, 1947, p. 195) observed : " That bases the decision, as it must be based, upon the actual words of the statute, which are really inapplicable to the occupation of a solicitor. Apparently some inspectors of taxes have taken a ’more practical view of the present conditions and have allowed members of the Bar an allowance for their books. Writers, too, receive an allowance for books purchased to meet the requirements of their work." It seemed to the Solicitor, however, as if iri the long run an amendment of the law may be necessary, and attention was drawn to the Australian Income-Tax Acts in which an allowance for libraries has -definite recognition. C. E. A. B. POSTURE AND PRESSURE SiR,-Your annotation of June 26 states that more than fifty years ago I demonstrated that four-legged animals would die from cerebral ansemia if kept upright for a few days. This is not correct. What I found was that big-bellied hutch rabbits when suspended, stretched out, in the vertical, head-up position quickly fainted from the blood sinking into the abdomen, and were at Tautonce restored by a bandage drawn round this. bellied wild rabbits did not faint. I also showed the International Physiological Congress at the Cambridge meeting, held so long ago, that when a snake was fixed on a board, drawn out full length, and put in the vertical position the blood ceased to fill the heart, standing in the veins just below it. On sinking the board and animal in a tall cylinder of water the heart filled, the pressure of water outside balancing that of the blood in the "
judge
animal.
-
LEONARD HILL.
Smallfield, Sturey.
SiR,—Hill did not show that the upright position would kill four-legged animals in " a few days," but referred to Solath42 who found that in the vertical feetdown position rabbits died in the course of 15 minutes to 2 hours. The effect of change of posture on the blood-pressure has been investigated many times. The largest series of controlled observations is that of Schneider and Truesdellwho reported results in 2000 normal adults. They found that there was a wide variation in the individual response. The pulse change on standing varied from a slowing by 15 beats per min. to an increase of 57 beats. In over 84 % of cases there was an increase of up to 30 beats. When the results were plotted as a histogram, a typical frequency distribution curve resulted. A similar variation was noted in the changes in blood-pressure. This variation is what would be expected of biological observations and was recorded by Hill and Barnard4 in dogs. The changes are necessary for two reasons : (1) the fall in cardiac output that takes place in the upright position, and (2) the change in the relative positions of the heart and the head. In the erect position energy has to be expended to raise the blood from the level of the heart to that of the head. The adjustment is a nervous one mediated by the carotidsinus mechanism, and if both carotid sinuses in man are denervated the mechanism fails and postural hypotension results.5 ,
1. Hill, L. J. Physiol. 1895, 18, 15. 2. Solathé (1877) quoted by Hill. 3. Schneider, E. C., Truesdell, D. Amer. J. Physiol. 4. Hill, L., Barnard, H. J. Physiol. 1897, 21, 324. 5. Capps, R. B., de Takats, G. J. clin. Invest. 1938,
1922, 61, 429. 17, 385.
#danger
GUY BOUSFIELD.
London, S.E.5.
HEXOBARBITONE AND TUBARINE om,—An
excessive amount OLaodominai
experienced by
some
pain
nas oeen
patients when first regaining abdominal operation under light
consciousness after an anaesthesia and relaxation with ’Tubarine.’ I attributed this to : 1. Early restoration of consciousness and body function per se as compared with other methods of anaesthesia, allow-’ ing immediate postoperative abdominal discomfort to be at all. 2. The variable, but, I think, often excessive contraction of the gut following administration of tubarine. Gray and Halton1 commend on this and also show clearly the synergism that exists between curariform drugs and barbiturates.
experienced
,
It occurred to me, therefore, to try going back to the of hexobarbitone because of its more prolonged action, and particularly because of its pleasant postoperative effect of sustaining a light sleep for some hours. This change has been justified by results. Relaxation during operation has been prolonged and sustained up to one hour and less cyclopropane has been required ; but the chief benefit has been the postoperative comfort of the patient, who, having experienced much less pain, gets a pleasant sleep until the effects of the operation have worn off. I also think there is less intestinal r-..nt-.’J’1at.ir’ll’YB TT-r7t--T:T D. Tl Rpf}",{XT1B.TU" HUGH BROWNE. contraction. Memorial Hospital, Haywards Heath. use
APPARENT ACUTE GLOMERULONEPHRITIS WITHOUT ALBUMINURIA SIR,-The syndrome described last week by Dr. Crofton and Dr. Truelove vividly recalls to my memory experiences which during the first world war were puzzling many clinicians in Central Europe. Many victims of the so-called Kriegsnephritis had died of acute oedema of the lungs before admission to hospital because, in view of the absence of albuminuria, the combination of generalised oedema and bradycardia had led the doctors on the front to the erroneous diagnosis of Kriegsaedema. Unfortunately the leading symptom of I saw many cases severe dyspnoea was overlooked. of analbuminuric acute glomerulonephritis at Wenckebach’s First University Clinic in Vienna during 1917 and 1918. Apart from albuminuria they presented the full picture of acute glomerulonephritis-i.e., severe hypertension, oedema, and bradycardia. The skin capillaries revealed dermatoscopically the characteristic picture which I deseribed in 1920.2 The most striking sign, however, was acute or subacute oedema of the lungs, which was invariably present and was demonstrated by the cloudy appearance of the lung fields on screening." Under the then-prevalent Volhard’s "-fast-and-thirst regime the majority of cases recovered, albuminuria appearing on the third or fourth day. Necropsy of patients who had died of acute left ventricular failure showed typical acute glomerulitis with all histological details. The syndrome should preferably be termed " analbuminuric stage of acute diffuse glomerulonephritis " 1. Gray, T. C., Hatton, J. Proc. R. Soc. Med. 1946, 39, 400. 2. Hahn, L. Med. Klin. 1920, no. 40, p. 1039.
.
since albuminuria eventually appears after a few days unless the patient s,uccumbs to acute oedema of the lungs. It may be added that routine blood-pressure readings in patients with scarlatina often reveal a rise in blood-pressure before albuminuria attracts attention to the kidneys-a point of great interest in the pathogenesis of acute diffuse glornerulonephritis. LEO HAHN. Nuneaton. A TAX ON KNOWLEDGE !MR,—is there not an analogy with the legal profession as regards the use of books by doctors (referred to in your leading article last week) ? The position in respect of income-tax is controlled by a decision by Mr. Justice Rowlatt (Daphne v. Shaw [1926] 43 T.L.R. 45) in which he was unable to sav that the books of a solicitor or of a barrister or of a which were used in the sense of being consulted were plant." Discussing this point, the Solicitor (September, 1947, p. 195) observed : " That bases the decision, as it must be based, upon the actual words of the statute, which are really inapplicable to the occupation of a solicitor. Apparently some inspectors of taxes have taken a ’more practical view of the present conditions and have allowed members of the Bar an allowance for their books. Writers, too, receive an allowance for books purchased to meet the requirements of their work." It seemed to the Solicitor, however, as if iri the long run an amendment of the law may be necessary, and attention was drawn to the Australian Income-Tax Acts in which an allowance for libraries has -definite recognition. C. E. A. B. POSTURE AND PRESSURE SiR,-Your annotation of June 26 states that more than fifty years ago I demonstrated that four-legged animals would die from cerebral ansemia if kept upright for a few days. This is not correct. What I found was that big-bellied hutch rabbits when suspended, stretched out, in the vertical, head-up position quickly fainted from the blood sinking into the abdomen, and were at Tautonce restored by a bandage drawn round this. bellied wild rabbits did not faint. I also showed the International Physiological Congress at the Cambridge meeting, held so long ago, that when a snake was fixed on a board, drawn out full length, and put in the vertical position the blood ceased to fill the heart, standing in the veins just below it. On sinking the board and animal in a tall cylinder of water the heart filled, the pressure of water outside balancing that of the blood in the "
judge
animal.
-
LEONARD HILL.
Smallfield, Sturey.
SiR,—Hill did not show that the upright position would kill four-legged animals in " a few days," but referred to Solath42 who found that in the vertical feetdown position rabbits died in the course of 15 minutes to 2 hours. The effect of change of posture on the blood-pressure has been investigated many times. The largest series of controlled observations is that of Schneider and Truesdellwho reported results in 2000 normal adults. They found that there was a wide variation in the individual response. The pulse change on standing varied from a slowing by 15 beats per min. to an increase of 57 beats. In over 84 % of cases there was an increase of up to 30 beats. When the results were plotted as a histogram, a typical frequency distribution curve resulted. A similar variation was noted in the changes in blood-pressure. This variation is what would be expected of biological observations and was recorded by Hill and Barnard4 in dogs. The changes are necessary for two reasons : (1) the fall in cardiac output that takes place in the upright position, and (2) the change in the relative positions of the heart and the head. In the erect position energy has to be expended to raise the blood from the level of the heart to that of the head. The adjustment is a nervous one mediated by the carotidsinus mechanism, and if both carotid sinuses in man are denervated the mechanism fails and postural hypotension results.5 ,
1. Hill, L. J. Physiol. 1895, 18, 15. 2. Solathé (1877) quoted by Hill. 3. Schneider, E. C., Truesdell, D. Amer. J. Physiol. 4. Hill, L., Barnard, H. J. Physiol. 1897, 21, 324. 5. Capps, R. B., de Takats, G. J. clin. Invest. 1938,
1922, 61, 429. 17, 385.