SOCIETY FOR ENDOCRINOLOGY

22

deficiency could readily occur and was best prevented by allowing a liberal intake of potassium (e.g., as fruit) about two days after diuresis had been frankly established. Infection was an important cause of death in anuria and One dose hence penicillin should be given routinely. was . sufficient whilst the patient was anuric and unable to excrete the antibiotic. Similarly with the other antibiotics there was no need for continued dosage during

pelvic carcinomas sudden anuria might occur, and drainage of the ureters seemed indicated only when treatment of the carcinoma was possible. In the discussion -that followed, Mr. JOHN SOPHIAN the recent information that seemed to favour the operation of the Oxford shunt in the aetiology of some anurias and made a plea for surgical intervention to reverse this postulated mechanism. Dr. R. H. PARAMORE felt that spinal anaesthesia still merited consideration in the treatment of the anurias. Mr. A. W. BADENOCa referred to the possibility of renal function returning after an obstructive episode lasting longer than two weeks ; and the PRESIDENT referred to obstruction due to tuberculous stricture of the ureter. In summing up, Dr. BuLL referred to 36 cases, collected between the three opening speakers, in which anuria due to acute tubular necrosis had not been influenced by renal sympathetic block.

assembled

anuria, and with some of them there was the risk of toxic effects. For example, an anuric patient could get 2 g. of aureomycin initially and -then about 1 g. in divided doses until diuresis occurred. Mr. AsuTON MiLLER discussed surgical measures in the broad group of anurias. Renal decapsulation was unjustifiable as, in his experience, the capsule of the kidney was rarely tense in these conditions and the operation was only occasionally followed by diuresis. Such diuresis, from the natural history of the disease, was to be expected coincidentally in -some cases. Renal SOCIETY FOR ENDOCRINOLOGY decapsulation did not, by the way, lead to renal sympaHe also the of renal advised use thectomy. symagainst Posterior Pituitary Gland pathetic block in the established anurias. Turning to the THE 34th meeting of the Society for Endocrinology, obstructive anurias, Mr. Miller stated that ligation of a held in Cambridge on June 20, was devoted to a symureter led to short-lived loin pain and a non-functioning on the Posterior Pituitary Gland. Dr. G. W. kidney that was capable of functioning again if the posium HARRIS was in the chair. obstruction were relieved within fourteen days. The term " calculous anuria " should not be used for the terminal LOCALISATION OF OSMORECEPTORS stages of bilateral calculous disease but for cases where Mr. P. A. JEWELL and Prof. E. B. VERNEY, F.R.S., both ureters or the ureter of a sole functioning kidney said that intracarotid injection of hypertonic sodium Obstruction was commonest in the were obstructed. chloride solution has been found to inhibit water diuresis upper third of the ureter and normally led to colic and a by causing release of the antidiuretic hormone from the palpable tender kidney. Obstruction was rarely absolutely posterior pituitary. Investigation of the vascular bed complete. Usually there was X-ray evidence of the site of the internal carotid artery showed that this vessel of obstruction. In puzzling cases old surgical practices supplies the pituitary gland and the anterior hypoof operating on the side where pain was last felt or where thalamus, including the greater part of the supraoptic muscular rigidity persisted should not be forgotten. nucleus and paraventricular nucleus, as well as other In anuria it was always imperative to determine parts of the prosencephalon. Proof was given that the whether obstruction was present, and this usually receptive elements, the osmoreceptors, stimulated by involved ureteric catheterisation. Normally a rapid the administration of hypertonic saline do not lie in the return of renal function occurred after the obstruction pars nervosa of the pituitary. The findings in an animal was released. When a calculus had been pushed back in which one internal carotid artery was tied intradurally into the renal pelvis, operation should be deferred until suggest that the receptors lie in the prosencephalon. the general condition had improved following diuresis. RELEASE OF ANTIDIURETIC HORMONE Where a calculus could not be dislodged and the catheter Dr. MARY PICKFORD described the release of antiby-passed it, thus allowing drainage, then the catheter should be removed after twenty-four hours and open diuretic hormone from the posterior pituitary following operation performed. " Renex anuria " was a blunder- injections of acetylcholine, nicotine, morphine, and ’buss term that he did not favour, especially in the ferritin. Acetylcholine is rendered temporarily ineffective absence of any experimental evidence of renorenal in this respect after application of di-isopropylfluoroshunt. It had been used loosely, for example, where a phosphonate (D.F.P.) to the supraoptic nuclei. Intrastone blocked one ureter and function had failed in the carotid injection of adrenaline before an antidiuretic dose other kidney on account of severe dehydration or other of acetylcholine regularly annuls the action of the latter. circulatory disturbance. Sulphonamide obstructive Morphine is still effective in inhibiting a high rate of anurias were still common, especially in febrile dehydrated urine flow if applied directly to the supraoptic nervepatients. Sulphonamide crystals were rarely found, and cells, whether or not the cholinesterase of the cells has more commonly there was only a brown deposit of been disorganised by D.F.P. It appears that the cells epithelial cells and red blood-cells. In one patient of the supraoptic nuclei, like others in the body, can be removal of such debris was followed by diuresis, but the activated by different types of stimuli, some arriving urine-now fell off again and the secondary episode of by nervous pathways, some being directly chemical, and anuria had all the characteristics of acute tubular some being physical or physicochemical. Also like the necrosis. Recovery eventually followed with the use cells of other tissues, when the supraoptic nerve-cells of the Hammersmith regime. He felt that there was no are rendered unresponsive to one type of stimulus they sharp division between Sulphonamide obstructive anuria can still respond to another. and Sulphonamide tubular necrosis. Acute pyeloEXTRACTS OF NEURAL LOBE nephritis occasionally led to ureteric obstruction from Prof. H. B. VAN DYKE (New York) described work iii inflammatory products lodging in the lower end of the ureter even in the absence of treatment with sulphonwhich he and his colleagues1 extracted a protein from the pars nervosa of the pituitary with the biological amides. Obstruction from external pressure on the !activities of both principles ureter might occur, for example, after gynaecological (antidiuretic pressor and the seen in about the ratio as they are found-in same and was oxytocic) operations usually only by urologist 1the gland. Its molecular weight was about 30,000, and after a lapse of more than forty-eight hours. At this time pyelostomy was indicated as an emergency measure ;iits biological activity was found to be low (1unit = 61 later on, the lower end of the ureter could be exposed, ] 1. van Dyke, H. B., Chow, B. F., Greep, R. O., Rothen, A. and divided and reimplanted into- the bladder. In J. Pharmacol. 1942, 74, 190.

23

µ,g.). Although considerable evidence has been obtained oxytocic and antidiuretic activities are present in constant ratios and that the protein is homogeneous, the possibility of adsorption of highly active principles on to The an inert protein molecule has not been excluded. highly purified principles recently isolated by du that

‘

Vigneaud and his co-workers2 were discussed. These principles have been isolated in extremely active forms1 unit of the oxytocic principle being contained in 1-25 (.Lg., and 1 unit of the antidiuretic-vasopressor principle in 1.6 µ.g. The amino-acid content of these two principles has been investigated ; tyrosine, cystine, aspartic acid, glutamic acid, glycine, and proline are common to both, whereas arginine and phenylalanine characterise the oxytocic principle and leucine and isoleucine characterise the antidiuretic-vasopressor principle. Using these principles, various workers have established that neither the contraction of the isolated rat uterus nor the ejection of milk by the lactating mammary gland is a specific test for the oxytocic principle, whereas the depressor response of the fowl’s blood-pressure appears to meet this requirement provided that contamination by antidiuretic-vasopressor principle is not excessive. The extremely -sensitive antidiuretic test in the dog proved specific for the antidiuretic-vasopressor principle. It is not yet possible to decide whether the neurohypophysis secretes a large molecule containing both oxytocic and antidiuretic-vasopressor principles, or smaller molecules of highly active principles. The separate secretion of the latter has more teleological attraction. FATE

OF POSTERIOR PITUITARY PRINCIPLES

Prof. H. S. HELLER discussed the rapid inactivation of antidiuretic extracts by defibrinated blood, serum, and liver homogenate. When injected intravenously the antidiuretic activity of posterior pituitary extracts was found to disappear rapidly from the circulating blood. An antidiuretic substance appeared in the urine of animals after intravenous injection of large doses of such extracts. Recent unpublished experiments by Ginsburg and Heller have shown that the liver and kidney both play a part in the "clearance" of the antidiuretic principle : it would seem that in addition to excreting it, the kidney also removes it by another, as yet unknown, process. MILK EJECTION

Mr. B. A. CROSS described the evidence

underlying the

present concept of a milk-ejection reflex.3 The act of suckling stimulates a nervous reflex excitation of the posterior pituitary gland, and the secretion from this gland causes contraction of some element in the mammary gland and thus a positive ejection of milk from the mother to the young. Recent work, using du Vigneaud’s highly active oxytocic and antidiuretic extracts, indicates that the posterior pituitary principle underlying milk ejection is the oxytocic principle, and not a mixture of the two as had been previously suggested. Mr. Cross also discussed unpublished work in which it was found that previous administration of adrenaline, or stimulation of the posterior region of the hypothalamus with resultant sympathetic excitation, will inhibit the milkejection reflex. Since the same procedures inhibit the milk-ejection effect of posterior pituitary extract it is likely that the effect of adrenaline is, at least in part, on the mammary gland itself. _

SECRETION OF ANTIDIURETIC HORMONE

Dr. A. G. LEwIS produced evidence that after 18 hours’ dehydration a normal person had posterior pituitary 2.

Livermore,

A. H., du Vigneaud, V. J. biol. Chem. 1949, 180, Pierce, J. G., du Vigneaud, V. Ibid, 1950, 182, 359 ; Ibid, 1950, 186, 77. Turner, R. A., Pierce, J. G., du Vigneaud, V. Ibid, 1951, 191, 21. 3. Cross, B. A., Harris, G. W. Nature, Lond. 1950, 166, 994 ; J. Endocrinol. 1952, 8, 148. Andersson, B. Acta physiol. scand. 1951, 23, 1.

365.

hormone in the circulation with an antidiuretic activity equal to approximately 20 milli-unitsPitressin.’ It seems unlikely that the 5 milli-units per ml. of antidiuretic substance which has been detected by rat assay of human serum has any physiological action. Direct assay in man has shown that human serum contains less than 0-1 milli-unit per ml. after 12 hours’ dehydration. Emotional stimuli, intravenous infusion of acetylcholine, hypertonic saline, nicotine, or morphine, anaesthesia and surgical operations, and syncope may all produce large releases of the antidiuretic hormone in man. DIABETES

INSIPIDUS

Dr. J. E. CArES described the results of investigation, in collaboration with Dr. 0. Garrod, on fifteen patients Pitressin tests separate the with diabetes insipidus. rare pitressin-resistant cases. Water deprivation gives and Hare’s test with hypervariable results. Hickey tonic saline may be nullified by an osmotic diuresis. Nicotine intravenously causes little or no antidiuresis when given in doses large enough to cause antidiuresis in normal persons; larger doses usually The effect of nicotine in clinical cause some antidiuresis. diabetes insipidus supports the belief that nicotine stimulates the secretion of the antidiuretic hormone. The response to large doses suggests that the lesion of the supraopticohypophysial system is often not complete.

Reviews of Books Psychiatry

in General Practice

C. A. H. WATTS, M.D. Durh.; B. M. WATTS, M.B. Durh. London : J. & A. Churchill. 1952. Pp. 228. 12s. 6d. Dr. and Mrs. Watts have written an original and stimulating book showing, with many illustrative cases, how the generally accepted principles and techniques of psychiatry have been applied to the problems of a busy general practice in a mining district of LeicesterDr. C. A. H. Watts appears to have had the shire. advantage of learning and practising psychiatric methods in the war-time school of the South African Medical Corps, perhaps thus escaping the formidable task of devising them ab initio in the surroundings of an established practice ; but this book shows clearly that, with - a sufficiency of knowledge and the will and patience to use it, a general practitioner can make of psychiatry the kind of specialty another may make of obstetrics or paediatrics. The authors divide psychotherapy into three grades. Major psychotherapy, like major surgery, is for the specialist ; elementary first-aid psychotherapy is an inescapable part of every doctor’s task; while the intermediate field should belong to the general practitioner but too often goes uncultivated from real or supposed lack of time, from lack of knowledge or imagination, or from plain dislike. The book explores this intermediate field, section by section, showing the problems which commonly present themselves, the guise in which they appear, and how their solution may be attempted. The unsuccessful or half-successful case is not omitted, and the limitations of psychotherapy are clearly indicated ; the authors do not for a moment pretend that it can relieve a practice of every troublesome psychopath or neuropath, but they do maintain that to tackle emotional problems on their own ground and not merely to treat their physical symptoms will in the end save time, and will restore many patients, if Preventive not to full health, at least to working capacity. psychotherapy, especially in childhood and before marriage, is fully considered ; and there are interesting reflections on mental hospitals and on the limited usefulness of voluntary ’ admission. The book ends with a reasoned plea for mental wings in general hospitals-for the diagnosis and treatment, as distinct from the segregation and maintenance, of the mentally sick-and for a multiplication of general-practitioner .

psychiatrists. Practitioners will find much here to stimulate and and teachers could deduce from these pages what kind of psychiatric instruction the future practitioner needs and ought to have.

help them,