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MANCHESTER MEDICAL SOCIETY
23
Reviews of Books
Medical Societies MANCHESTER MEDICAL SOCIETY Renal Function in Disease AT a meeting of this PLATT said that the
society on Dec. 3, Prof. ROBERT syndrome of renal failure was characterised by a steady deterioration in the power of the kidney to produce a concentrated urine. In the later stages the urine was pale, copious, and dilute, with a fixed specific gravity of about 1010. When the functional power of the kidney was insufficient for the excretory needs of the body the symptoms of uraemia developed. These were caused not only by retention of the wasteproducts of metabolism but by a general disturbance of electrolytes, including sodium, potassium, chloride, calcium, and phosphates. The symptoms of uraemiaweakness, anaemia, anorexia, vomiting, wasting, drowsiness, and coma-must be clearly distinguished from the more dramatic symptoms of hypertension (such as severe periodic headache, retinal disturbances, convulsions, and paralyses) which so often coexisted and confused the picture. As regards the loss of concentrating power in renal failure, the underlying pathology common to all cases was loss of nephrons ; and the lack of concentratingpower was usually ascribed to failure of the tubule cells in their function of elaborating a highly differentiated urine. This theory was unsatisfactory, however, because Rose Bradford showed fifty years ago that surgical removal of most of the kidney caused the remainder to secrete urine of the same type-copious, dilute, and of low specific gravity-and it was inconceivable that the remaining nephrons in the circumstances of this experiment should suddenly develop tubular failure. E. B. Verney and F. R. Winton had shown many years ago that an increase in glomerular pressure would also give rise to a urine of this type. More recent investigation by inulin and diodrast clearance tests had shown that the filtration fraction in chronic renal disease was high, which suggested that there was, in fact, a high glomerular pressure. Professor Platt suggested that if this was so, it was brought about simply by a large amount of blood perfusing a small number of nephrons. No humoral mechanism was involved, because renal failure might’exist in one kidney while the other kidney was secreting a normally concentrated urine. If it were accepted that a high glomerular pressure accounted for the character of the urine in renal failure, this did not rule out the possibility in some cases of coexisting tubular failure ; but failure of the tubule cells should give rise to glycosuria, which was never present in chronic renal disease. Moreover, the histology of chronic nephritis showed in general that in areas of tubular atrophy the glomeruli were non-functioning, whereas the few remaining glomeruli were surrounded by apparently active and dilated tubules. Considering the question of oedema in acute nephritis, Professor Platt said that this was not due to hypoproteinCurrent literature still aemia, nor to heart-failure. attributed it to increased capillary permeability; but this view, never satisfactory, was based on discredited observations on the protein content of the oedema fluid in acute nephritis. He suggested that low glomerular pressure would account for scanty urine of high specific gravity, which was typical of the early stage of acute nephritis and would lead to increased reabsorption in the tubules, giving rise to fluid retention and oedema. Inulin and diodrast clearance tests supported this hypothesis by Recent work in showing a low filtration fraction. Manchester and elsewhere suggested that there was haemodilution with a high blood volume in the early stages of acute nephritis-a condition which supported the theory that the kidney was primarily at fault and was strong evidence against the theory of capillary
permeability.
Finally, Professor Platt described the recent work of Trueta, Barclay, and others which had shown that the renal circulation could be largely, diverted from the cortex into the medulla ; and he discussed the bearing of these researches on such states as reflex anuria and cortical necrosis of the kidney.
Rheumatism and Soft Tissue Injuries JAMES CYRIAX, M.D. Camb., physician, department of physical medicine, St. Thomas’s Hospital. London : Hamish Hamilton. 1947. Pp. 410. 4is. THIS book deals with those obscure painful conditions of the limbs and back which are so common in general practice and yet so poorly understood by most of our profession. The difficulty arises from the patient’s failure to localise muscular and ligamentous- pain with accuracy, and his tendency to refer the pain over a segmental distribution. We still tend to look for disease at the place where the pain is felt rather than at its source of origin, and’we are not yet sufficiently aware of the frequency with which the source of pain lies altogether outside its distribution. Often an absence of gross pathological changes increases the difficulty of defining the source of pain, and we arrive at some sort of diagnosis by considering the features of the pain itself, together with the effect of procaine infiltration of its .suppased source. Dr. Cyriax describes a systematic method of clinical examination in which the segmental origin of a given pain is obtained by consulting the distribution of Foerster’s dermatomes. (This is not entirely satisfactory as deep pain is not usually referred to the skin.) The piece of tissue giving rise to the pain is then defined by a comprehensive examination of active and passive movements of the part, followed by systematic palpation for tender spots, and finally by infiltration of these with local anaesthetic. The subject is dealt with regionally, with chapters on shoulder pain, backache, and so on. Although the method appears logical enough, some of the conclusions reached are a little surprising. Thus under the heading of " radial perineuritis " we read of an epidemic disease characterised by pain extending from the scapula to the dorsum of the hand, with tenderness of the nerve behind the shaft’of the humerus. To this may be added an isolated paralysis of the medial and lateral heads of the triceps and anæsthesia of the dorsum of the distal phalanges of the index, and long fingers. " The diagnosis is confirmed by local anæsthesia" : but we are not told how. As the author blandly remarks, " the symptoms and signs of radial perineuritis and radial neuritis have nothing in common." In a later chapter we learn that " dural pain " is much the commonest cause of backache, and that lumbago is due to internal derangement of a lower lumbar joint. We are left with the feeling that a good idea has been developed somewhat uncritically. .
,
The
Psycho -Analytical
Approach
to
Juvenile
Delinquency KATE
FRIEDLANDER,
M.D,
Berlin,
L.R.C.P.E.,
D.P.M.,
psychiatrist, Institute for the Scientific Treatment of Delinquency. London : Kegan Paul, Trench, Trubner. 1947. Pp. 296. 18s. Dr. Friedlander’s book is, and is meant to be, a contribution to Freudian literature. Reasonably enough, she uses a psychological definition of delinquency, and she is thus concerned with the Freudian approach to the delinquent character, which she carefully specifies. Roughly, this is the character which expresses the pleasure principle in the form of antisocial acts. The readers for whom the book is intended are probation officers, social workers, magistrates, psychiatrists, and education, health, and penal officers, and within the framework of the author’s intentions it is decidedly good. Written in language that can be understood by all, it recapitulates concisely the Freudian view of character development, and surveys the development of faulty character and delinquent character from the same angle. The treatment section, however, sketches a non-Freudian psychotherapeutic approach, in addition to the orthodox
psycho-analytical
one.
The final part of the book gives Dr. Friedlander her chance : every aspect of society’s attempt to deal with the delinquent is examined, criticised,assessed, and made. the subject of constructive suggestions. The ’difficulties-very great-of treating the delinquent in or out of prison, or even under the shadow of the law, are analysed. Much of this part is a blueprint of
Reviews of Books
Medical Societies MANCHESTER MEDICAL SOCIETY Renal Function in Disease AT a meeting of this PLATT said that the
society on Dec. 3, Prof. ROBERT syndrome of renal failure was characterised by a steady deterioration in the power of the kidney to produce a concentrated urine. In the later stages the urine was pale, copious, and dilute, with a fixed specific gravity of about 1010. When the functional power of the kidney was insufficient for the excretory needs of the body the symptoms of uraemia developed. These were caused not only by retention of the wasteproducts of metabolism but by a general disturbance of electrolytes, including sodium, potassium, chloride, calcium, and phosphates. The symptoms of uraemiaweakness, anaemia, anorexia, vomiting, wasting, drowsiness, and coma-must be clearly distinguished from the more dramatic symptoms of hypertension (such as severe periodic headache, retinal disturbances, convulsions, and paralyses) which so often coexisted and confused the picture. As regards the loss of concentrating power in renal failure, the underlying pathology common to all cases was loss of nephrons ; and the lack of concentratingpower was usually ascribed to failure of the tubule cells in their function of elaborating a highly differentiated urine. This theory was unsatisfactory, however, because Rose Bradford showed fifty years ago that surgical removal of most of the kidney caused the remainder to secrete urine of the same type-copious, dilute, and of low specific gravity-and it was inconceivable that the remaining nephrons in the circumstances of this experiment should suddenly develop tubular failure. E. B. Verney and F. R. Winton had shown many years ago that an increase in glomerular pressure would also give rise to a urine of this type. More recent investigation by inulin and diodrast clearance tests had shown that the filtration fraction in chronic renal disease was high, which suggested that there was, in fact, a high glomerular pressure. Professor Platt suggested that if this was so, it was brought about simply by a large amount of blood perfusing a small number of nephrons. No humoral mechanism was involved, because renal failure might’exist in one kidney while the other kidney was secreting a normally concentrated urine. If it were accepted that a high glomerular pressure accounted for the character of the urine in renal failure, this did not rule out the possibility in some cases of coexisting tubular failure ; but failure of the tubule cells should give rise to glycosuria, which was never present in chronic renal disease. Moreover, the histology of chronic nephritis showed in general that in areas of tubular atrophy the glomeruli were non-functioning, whereas the few remaining glomeruli were surrounded by apparently active and dilated tubules. Considering the question of oedema in acute nephritis, Professor Platt said that this was not due to hypoproteinCurrent literature still aemia, nor to heart-failure. attributed it to increased capillary permeability; but this view, never satisfactory, was based on discredited observations on the protein content of the oedema fluid in acute nephritis. He suggested that low glomerular pressure would account for scanty urine of high specific gravity, which was typical of the early stage of acute nephritis and would lead to increased reabsorption in the tubules, giving rise to fluid retention and oedema. Inulin and diodrast clearance tests supported this hypothesis by Recent work in showing a low filtration fraction. Manchester and elsewhere suggested that there was haemodilution with a high blood volume in the early stages of acute nephritis-a condition which supported the theory that the kidney was primarily at fault and was strong evidence against the theory of capillary
permeability.
Finally, Professor Platt described the recent work of Trueta, Barclay, and others which had shown that the renal circulation could be largely, diverted from the cortex into the medulla ; and he discussed the bearing of these researches on such states as reflex anuria and cortical necrosis of the kidney.
Rheumatism and Soft Tissue Injuries JAMES CYRIAX, M.D. Camb., physician, department of physical medicine, St. Thomas’s Hospital. London : Hamish Hamilton. 1947. Pp. 410. 4is. THIS book deals with those obscure painful conditions of the limbs and back which are so common in general practice and yet so poorly understood by most of our profession. The difficulty arises from the patient’s failure to localise muscular and ligamentous- pain with accuracy, and his tendency to refer the pain over a segmental distribution. We still tend to look for disease at the place where the pain is felt rather than at its source of origin, and’we are not yet sufficiently aware of the frequency with which the source of pain lies altogether outside its distribution. Often an absence of gross pathological changes increases the difficulty of defining the source of pain, and we arrive at some sort of diagnosis by considering the features of the pain itself, together with the effect of procaine infiltration of its .suppased source. Dr. Cyriax describes a systematic method of clinical examination in which the segmental origin of a given pain is obtained by consulting the distribution of Foerster’s dermatomes. (This is not entirely satisfactory as deep pain is not usually referred to the skin.) The piece of tissue giving rise to the pain is then defined by a comprehensive examination of active and passive movements of the part, followed by systematic palpation for tender spots, and finally by infiltration of these with local anaesthetic. The subject is dealt with regionally, with chapters on shoulder pain, backache, and so on. Although the method appears logical enough, some of the conclusions reached are a little surprising. Thus under the heading of " radial perineuritis " we read of an epidemic disease characterised by pain extending from the scapula to the dorsum of the hand, with tenderness of the nerve behind the shaft’of the humerus. To this may be added an isolated paralysis of the medial and lateral heads of the triceps and anæsthesia of the dorsum of the distal phalanges of the index, and long fingers. " The diagnosis is confirmed by local anæsthesia" : but we are not told how. As the author blandly remarks, " the symptoms and signs of radial perineuritis and radial neuritis have nothing in common." In a later chapter we learn that " dural pain " is much the commonest cause of backache, and that lumbago is due to internal derangement of a lower lumbar joint. We are left with the feeling that a good idea has been developed somewhat uncritically. .
,
The
Psycho -Analytical
Approach
to
Juvenile
Delinquency KATE
FRIEDLANDER,
M.D,
Berlin,
L.R.C.P.E.,
D.P.M.,
psychiatrist, Institute for the Scientific Treatment of Delinquency. London : Kegan Paul, Trench, Trubner. 1947. Pp. 296. 18s. Dr. Friedlander’s book is, and is meant to be, a contribution to Freudian literature. Reasonably enough, she uses a psychological definition of delinquency, and she is thus concerned with the Freudian approach to the delinquent character, which she carefully specifies. Roughly, this is the character which expresses the pleasure principle in the form of antisocial acts. The readers for whom the book is intended are probation officers, social workers, magistrates, psychiatrists, and education, health, and penal officers, and within the framework of the author’s intentions it is decidedly good. Written in language that can be understood by all, it recapitulates concisely the Freudian view of character development, and surveys the development of faulty character and delinquent character from the same angle. The treatment section, however, sketches a non-Freudian psychotherapeutic approach, in addition to the orthodox
psycho-analytical
one.
The final part of the book gives Dr. Friedlander her chance : every aspect of society’s attempt to deal with the delinquent is examined, criticised,assessed, and made. the subject of constructive suggestions. The ’difficulties-very great-of treating the delinquent in or out of prison, or even under the shadow of the law, are analysed. Much of this part is a blueprint of