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The Independent Practitioner
LEADING ARTICLES
THE LANCET LONDON
The
6
JANUARY
Independent
1962
Practitioner
FOR many years we have been saying that the care people get from their own doctor at home is just as important as the care they get from hospital: we have urged that, in the National Health Service, general practice should have higher priority. But now a much more fundamental issue is arising. With society and medicine so different from what they were, is it still reasonable to have two kinds of doctors, practising separately in the hospital and in the home ? Do not the times demand an integrated service and an end to
independent general practice ? The general practitioner’s traditional separateness has been consolidated and emphasised by the health service, whose tripartite structure ensures his independence from hospital control. This was deliberate: the intention of the Act was not only to allow every patient his own doctor but also to give the doctor full professional responsibility for the patients he accepts. But, especially when winds of change are blowing, no mere legislation can ensure that either patient or doctor feels what he is meant to feel. In actual fact, many practitioners no longer see themselves as personally responsible for their patients through thick and thin, and many patients no longer expect them to take such responsibility. If the public are too often fascinated by the bright lights of the hospital, many practitioners likewise believe in their hearts that all that reallv matters in general practice is efficient screening of illness so that anything serious shall promptly reach the specialist. Important though such screening is, it will not in the long run justify retention of the independent practitioner. For in this country patients seldom live very far from a hospital; and, if their main requirement is accurate diagnosis, they are more likely to get it from a group working at or from a hospital, where specialists group may be able to offer the patient nearly everything that general practice can offer. The only thing it probably cannot do is to give him a doctor of his own, with whom he has a sense of personal contract: it cannot provide continuous care by one person-a medical friend who knows him at home and feels responsible for seeing that he gets the best out of modern medicine. As to how much this matters, opinions differ; but Foxhas argued that the independent practitioner, outside the hospital group, will survive only if he concentrates on what the hospital cannot do so well. He will survive as a " personal doctor " or not at all. Of those who accept the need to preserve and fortify are on
tap. Indeed, such
1.
Fox,
a
T. F. Lancet,
1960, i, 743.
29
the independent practitioner as the public’s ordinary and principal source of medical care, some want him to pay more attention to the psychological side of illness, while others would have him concentrate on prevention; and clearly practices will always vary with the practitioner’s character and interests. But, whatever his leanings may be, the personal doctor cannot be just a man who once knew some medicine but is now no more than the manager of a practice: the concept stands or falls by his being a real doctor, technically as well as personally. For the object of making him independent of the hospital group is to let him feel that he, and nobody else, is in charge of the patient; and plainly he ought not to be in charge unless his knowledge is up to date and his judgment is continually freshened and strengthened by the discussion of cases with colleagues. Unfortunately, in securing the independence of practitioners, the National Health Service has helped to isolate them from the medical life of hospitals, where everyday talk about patients provides the best of all instruction for both old and young. Many have passed since the Cohen Committee on years General Practice2 noted this isolation and said that general practitioners should be encouraged to take part-time work in hospitals; and now the Platt Committee,3for another reason, has made similar recommendations. We agree with them that it would often be useful if Dr. Jekyll, who in his own practice is entirely his own master, were to spend some of his time as a benign Mr. Hyde on the staff of a hospital consultant, And, quite apart from such part-time posts, a big step forward would be made if hospitals up and down the country were to start making the local practitioners associate members of their staff.! With this status, practitioners should have not only access to the wards but also the use of hospital libraries and common-rooms, which could become a local medical club-to the eventual advantage of patients as well as doctors. Such measures, however, are open to criticism on the ground that they do no more than patch a medical model which is plainly obsolete and ought to be scrapped. In his article on p. 36 Dr. LINDSEY BATTEN describes how the scope of general practice has narrowed within his own professional lifetime, and in the succeeding article Dr. ALWYN SMITH suggests that we cannot much longer expect any one person to offer responsible medical care to all sorts and conditions of men, as the family doctor does today. If their knowledge is not to be intolerably superficial, even personal doctors, ALWYN SMITH thinks, will have to confine themselves to certain groups of patients. But his comments on the present system go far deeper than that. He questions, very cogently, whether it is any longer realistic to separate domiciliary medicine from hospital medicine and to have a different organisation for each. After all, the distinction between illness at home and illness in
postgraduate
Report of a committee of the Central Health Services Council (Chairman, Lord Cohen), 1954. 3. Report of Joint Working Party on the Medical Staffing Structure in the Hospital Service (Chairman, Sir Robert Platt). H.M. Stationery Office, 1961. 2.
30
hospital is artificial, since patients are always moving from one to the other. So he holds that, instead of being divided horizontally into general practice and hospital practice, each with its own kind of doctor, medicine would be better divided vertically according to the major specialties. In such a scheme, presumably, every child would be looked after by a pasdiatric department-whatever he needed and wherever he needed it. Some doctors in the department would work largely as domiciliary practitioners; others would be school doctors; others again would confine themselves to hospital paediatrics. But every kind of medical care for the child-whether he had wax in the ear, or behaviour problems, or some rare disease-would be given by members of a single department based on the hospital or hospitals. Similarly, the entire care of old people might be entrusted to the geriatric department; and the care of the pregnant, of course, to the obstetric department. This plan would fit in with the present tendency for hospital clinics to take more or less permanent charge of people with difficult diseases-hypertension, diabetes, coronary thrombosis, thyroid disorders, congenital abnormalities, epilepsy, disseminated sclerosis, and so on. And, especially where new and tricky methods of treatment are being introduced, this has obvious advantages. The more their regular care is specialised, the better chance patients have of being looked after by doctors who are knowledgeable about their particular
problem. To some extent, the vertical division of medicine has been adopted in Russian cities, where there are different clinics, and different doctors, for parents and children. But report says that, as a supplement to the official " scheme, the private " general practitioner is gaining ground among Russians who can afford him. If the vertical system meant in effect that patients were looked after by a department-even a series of departments-rather than a person, it might in the end give less satisfaction to the patient, and be less efficient, than continuous care by a family doctor with a view of the family situation as a whole. Ideally, the man in ordinary charge of a patient should be not a member of any specialty but an outsider capable of looking at all specialists with a certain detachment, knowing what they can and cannot do and therefore capable of protecting his patients against their expert enthusiasms. For every patient who ought to go to hospital there must be at least a score who need, year in year out, the aid of a medical adviser who can help them to avoid illness, who can put their various troubles and disabilities into perspective, and who can save them if need be from perfectionist medicine. Where a family doctor makes himself personally responsible for all this -shouldering the anxieties of patients and parents in time of trouble-he is doing something that no group is likely to do so well. On the other hand, it is certainly becoming harder and harder to insist that one kind of doctor should be free to practise all by himselfaccording to his own standards and his own judgment-
in complete independence of his colleagues in hospital. The fact that the independent practitioner has to rely on the hospital if anything goes wrong gives the hospital an interest in the way he goes about his work. And that interest will grow. Sooner or later an answer must be found to the underlying questions. In the coming years, should patients get their regular medical care, as formerly, from an individual practitioner; or should they get it from a unified service based on the hospitals? Has personal medicine of the old kind become an anachronism ; or is it more than ever necessary at a time when technology is losing touch with people ? Until these questions can be answered confidently, it would certainly be premature, in this country, to abandon the principles that everyone can have his own doctor, and that this doctor has professional independence. The case for the independent personal doctor may not be very tangible, but it is strong enough to deserve a great deal of thought before he is removed to a less responsible position in an integrated service based on the hospital rather than the home. All the same, though integration of hospital and domiciliary practice would at present be wrong, a closer association between practitioner and specialist has become a pressing necessity. For our part we hope it will be found that the practitioner can have an intimate relationship with hospital work-even spending several sessions a week as a part-time specialist -without being any the less a personal doctor in his own practice. But we cannot discount the possibility that such association with hospitals, with opportunities to transfer to consultant practice, will reveal that quite a lot of practitioners really prefer work in hospital to work in the home. From these, eventually, may come a demand for integration of domiciliary and hospital practice rather than loose association; and the demand may be supported by doctors who prefer to practise in large groups and might see positive advantages in the group moving to hospital premises. Perhaps most dangerous of all to the survival of the independent doctor is the fact that, to do the work that justifies his independence, he needs time; and the coming shortage of doctors is going to give him longer rather than shorter lists. Moreover, if he undertakes hospital sessions, he may be less than ever able to give unhurried personal attention to his patients at home. The most hopeful way of mitigating this scarcity is for doctors to delegate more of their work to ancillaries; and, provided the ancillaries can be found, this seems a probable development throughout the profession1 But delegation, though it saves medical manpower, is apt to weaken rather than strengthen the personal element in general practice. And if the personal element grows more dilute there will be less resistance to integration of home and hospital practice undertaken in the apparent interest of efficiency. For our part we hope that, in the national manner, a compromise will be found that will concede what is proper to specialist organisation yet will enable the independent practitioner to survive as a responsible
31
doctor. But at a time when the nation seems somewhat apathetic about the remarkably civilised ideas embodied in the National Health Service, we should point out that there is one possible fate for the personal doctor which would be even worse than his elimination through integration. This is that he should come to regard personal care of the patient as something separable from the rest of the practice-something which has to be paid for as an extra and for which a charge can suitably be made. The kind of personal care we have been talking about is not an extra, not a frill, not an amenity. It is the essence of the independent practitioner’s work-the reason, ultimately, for his existence. Our own feeling is that nothing is more necessary for British medicine, in the year now opening, than that the giving of such care should be encouraged and
personal
promoted. Obstructive
Nephropathy
rough-and-ready guide to renal function in patients with obstruction of the urinary tract, the bloodurea level gives help in such practical questions as the choice between slow and rapid decompression of the urinary tract, and the advisability of preoperative dialysis on the artificial kidney to make operation safer. But the blood-urea level gives a far from comprehensive picture As
a
of the state of renal function. The level may be distorted by prerenal factors, such as a low rate of urea production or a low-protein diet, or by an enhanced rate of urea production when the breakdown of tissue protein is increased by infection or trauma. Even when such sources of confusion are absent, the blood-urea gives information only on the excretory aspect of renal function, and tells us little or nothing of the homoeostatic or regulatory aspects, on which the maintenance of fluid balance depends. In patients with obstructive disease of the urinary tract retention of fluid is to be expected, and they may indeed become oedematous if attempts are made to induce a saline diuresis; and the possibility of urinary obstruction has to be kept in mind in patients presenting with acute renal failure.1 There may, however, be less obvious alterations in renal regulatory function, including a water-losing state 2-which seems paradoxical in obstructive disease. Defective control of fluid balance, with abnormal losses of electrolytes and water,appears more commonly after obstruction has been relieved. These clinical indications of defective renal homoeostasis suggest the need for a more thorough exploration of renal function, using specific tests of urinary concentrating and acidifying power; and such a study has now been reported by BERLYNE4 in seven adults with chronic
hydronephrosis. Obstructive nephropathy, like ascending pyelonephritis,5 might be expected to affect predominantly the distal part of the nephron, which includes not only the 1. Parsons, F. M., McCracken, B. H. Brit. med. J. 1959, i, 740. 2. Roussak, N. J., Oleesky, S. Quart. J. Med. 1954, 23, 147. 3. Bricker, N. S., Shwayri, E. I., Reardan, J. B., Kellog, D., Merrill, J. P., Holmes, J. H. Amer. J. Med. 1957, 23, 554. 4. Berlyne, G. M. Quart. J. Med. 1961, 30, 339. 5. Kleeman, C. R., Hewitt, W. L., Guze, L. B. Medicine, Baltimore, 1960, 39, 55.
distal convoluted tubules but also the collecting-duct system. Moreover, any mechanical distortion of the pyramids might well affect the spatial arrangement of the counter-current system, comprising the loops of Henle and the vasa recta, on whose anatomical juxtaposition the formation of a concentrated urine largely depends.s BERLYNE’S investigation was therefore centred on the ability to form a urine of low pH and high ammonia7 content after a standard dose of ammonium chloride (acidification of the urine being largely carried out in the distal tubule) and on the concentrating ability under the influence of vasopressin and mannitol diuresis 8-this depending both on distal tubule function and on the integrity of the counter-current system. The causes of hydronephrosis included prostatic hypertrophy, bladderneck obstruction, periureteric fibrosis, and aberrant renal vessels;four of the seven patients gave a history suggesting urinary infection, but this had been treated, and in all patients urea-splitting organisms were absent at the time of the investigations. All had some reduction in glomerular filtration-rate, the clearances of creatinine or inulin ranging from 9 to 64 ml. per minute. In six acidification of the urine was impaired, the pH ranging from 5-46 to 7.04; in only one was a normal pH level (5-10) attained. The excretion of ammonia and of titratable acid was reduced. In two patients some improvement in these functions followed relief of the obstruction; one patient, whose minimal pH before operation was 6.10, had a pH of 5-01 a month after prostatectomy. In the six patients whose urine was not acidified normally, concentration of urine under stress was also impaired. In three the maximal urinary was well below that of the plasma, bringing osmolality them into the category of acquired " nephrogenic diabetes insipidus ". All six patients with abnormal acidification and concentration had a raised blood-urea; while the patient in whom these tests were normal had a normal blood-urea of 22 mg. per 100 ml., although his creatinine clearance was reduced to 64 ml. per minute. Failure of the urinary pH to fall to the normal extent is not, however, a common feature in general renal failure7; nor is hyposthenuria (as opposed to isosthenuria). Discussing the hypothesis that the functional changes could be due simply to a reduced number of effective nephrons,9 BERLYNE accepts this explanation for the reduction of ammonia excretion and for the moderate failure of concentration in three of the patients; but he cannot account on this basis for the absence of normal acidification in six patients, nor for the hyposthenuria in three
patients. findings, besides their theoretical interest, have bearing on the management of patients with urinary-tract obstruction. Two patients in this small series had a metabolic acidosis before operation; and a third had water depletion, with a serum-sodium of 158 mEq. per litre, despite an intake of several litres a day. When his intake was increased to 7 litres a day, the water These
some
6. 7. 8.
Lamdin, E. Arch. intern. Med. 1959, 103, 644. Wrong, O., Davies, H. E. F. Quart. J. med. 1959, 28, 259. Cohen, S. I., Fitzgerald, M. G., Fourman, P., Griffiths, W. J., de Wardener, H. E. ibid. 1957, 26, 423. 9. Platt, R. Brit. med. J. 1952, i, 1313, 1372.
THE LANCET LONDON
The
6
JANUARY
Independent
1962
Practitioner
FOR many years we have been saying that the care people get from their own doctor at home is just as important as the care they get from hospital: we have urged that, in the National Health Service, general practice should have higher priority. But now a much more fundamental issue is arising. With society and medicine so different from what they were, is it still reasonable to have two kinds of doctors, practising separately in the hospital and in the home ? Do not the times demand an integrated service and an end to
independent general practice ? The general practitioner’s traditional separateness has been consolidated and emphasised by the health service, whose tripartite structure ensures his independence from hospital control. This was deliberate: the intention of the Act was not only to allow every patient his own doctor but also to give the doctor full professional responsibility for the patients he accepts. But, especially when winds of change are blowing, no mere legislation can ensure that either patient or doctor feels what he is meant to feel. In actual fact, many practitioners no longer see themselves as personally responsible for their patients through thick and thin, and many patients no longer expect them to take such responsibility. If the public are too often fascinated by the bright lights of the hospital, many practitioners likewise believe in their hearts that all that reallv matters in general practice is efficient screening of illness so that anything serious shall promptly reach the specialist. Important though such screening is, it will not in the long run justify retention of the independent practitioner. For in this country patients seldom live very far from a hospital; and, if their main requirement is accurate diagnosis, they are more likely to get it from a group working at or from a hospital, where specialists group may be able to offer the patient nearly everything that general practice can offer. The only thing it probably cannot do is to give him a doctor of his own, with whom he has a sense of personal contract: it cannot provide continuous care by one person-a medical friend who knows him at home and feels responsible for seeing that he gets the best out of modern medicine. As to how much this matters, opinions differ; but Foxhas argued that the independent practitioner, outside the hospital group, will survive only if he concentrates on what the hospital cannot do so well. He will survive as a " personal doctor " or not at all. Of those who accept the need to preserve and fortify are on
tap. Indeed, such
1.
Fox,
a
T. F. Lancet,
1960, i, 743.
29
the independent practitioner as the public’s ordinary and principal source of medical care, some want him to pay more attention to the psychological side of illness, while others would have him concentrate on prevention; and clearly practices will always vary with the practitioner’s character and interests. But, whatever his leanings may be, the personal doctor cannot be just a man who once knew some medicine but is now no more than the manager of a practice: the concept stands or falls by his being a real doctor, technically as well as personally. For the object of making him independent of the hospital group is to let him feel that he, and nobody else, is in charge of the patient; and plainly he ought not to be in charge unless his knowledge is up to date and his judgment is continually freshened and strengthened by the discussion of cases with colleagues. Unfortunately, in securing the independence of practitioners, the National Health Service has helped to isolate them from the medical life of hospitals, where everyday talk about patients provides the best of all instruction for both old and young. Many have passed since the Cohen Committee on years General Practice2 noted this isolation and said that general practitioners should be encouraged to take part-time work in hospitals; and now the Platt Committee,3for another reason, has made similar recommendations. We agree with them that it would often be useful if Dr. Jekyll, who in his own practice is entirely his own master, were to spend some of his time as a benign Mr. Hyde on the staff of a hospital consultant, And, quite apart from such part-time posts, a big step forward would be made if hospitals up and down the country were to start making the local practitioners associate members of their staff.! With this status, practitioners should have not only access to the wards but also the use of hospital libraries and common-rooms, which could become a local medical club-to the eventual advantage of patients as well as doctors. Such measures, however, are open to criticism on the ground that they do no more than patch a medical model which is plainly obsolete and ought to be scrapped. In his article on p. 36 Dr. LINDSEY BATTEN describes how the scope of general practice has narrowed within his own professional lifetime, and in the succeeding article Dr. ALWYN SMITH suggests that we cannot much longer expect any one person to offer responsible medical care to all sorts and conditions of men, as the family doctor does today. If their knowledge is not to be intolerably superficial, even personal doctors, ALWYN SMITH thinks, will have to confine themselves to certain groups of patients. But his comments on the present system go far deeper than that. He questions, very cogently, whether it is any longer realistic to separate domiciliary medicine from hospital medicine and to have a different organisation for each. After all, the distinction between illness at home and illness in
postgraduate
Report of a committee of the Central Health Services Council (Chairman, Lord Cohen), 1954. 3. Report of Joint Working Party on the Medical Staffing Structure in the Hospital Service (Chairman, Sir Robert Platt). H.M. Stationery Office, 1961. 2.
30
hospital is artificial, since patients are always moving from one to the other. So he holds that, instead of being divided horizontally into general practice and hospital practice, each with its own kind of doctor, medicine would be better divided vertically according to the major specialties. In such a scheme, presumably, every child would be looked after by a pasdiatric department-whatever he needed and wherever he needed it. Some doctors in the department would work largely as domiciliary practitioners; others would be school doctors; others again would confine themselves to hospital paediatrics. But every kind of medical care for the child-whether he had wax in the ear, or behaviour problems, or some rare disease-would be given by members of a single department based on the hospital or hospitals. Similarly, the entire care of old people might be entrusted to the geriatric department; and the care of the pregnant, of course, to the obstetric department. This plan would fit in with the present tendency for hospital clinics to take more or less permanent charge of people with difficult diseases-hypertension, diabetes, coronary thrombosis, thyroid disorders, congenital abnormalities, epilepsy, disseminated sclerosis, and so on. And, especially where new and tricky methods of treatment are being introduced, this has obvious advantages. The more their regular care is specialised, the better chance patients have of being looked after by doctors who are knowledgeable about their particular
problem. To some extent, the vertical division of medicine has been adopted in Russian cities, where there are different clinics, and different doctors, for parents and children. But report says that, as a supplement to the official " scheme, the private " general practitioner is gaining ground among Russians who can afford him. If the vertical system meant in effect that patients were looked after by a department-even a series of departments-rather than a person, it might in the end give less satisfaction to the patient, and be less efficient, than continuous care by a family doctor with a view of the family situation as a whole. Ideally, the man in ordinary charge of a patient should be not a member of any specialty but an outsider capable of looking at all specialists with a certain detachment, knowing what they can and cannot do and therefore capable of protecting his patients against their expert enthusiasms. For every patient who ought to go to hospital there must be at least a score who need, year in year out, the aid of a medical adviser who can help them to avoid illness, who can put their various troubles and disabilities into perspective, and who can save them if need be from perfectionist medicine. Where a family doctor makes himself personally responsible for all this -shouldering the anxieties of patients and parents in time of trouble-he is doing something that no group is likely to do so well. On the other hand, it is certainly becoming harder and harder to insist that one kind of doctor should be free to practise all by himselfaccording to his own standards and his own judgment-
in complete independence of his colleagues in hospital. The fact that the independent practitioner has to rely on the hospital if anything goes wrong gives the hospital an interest in the way he goes about his work. And that interest will grow. Sooner or later an answer must be found to the underlying questions. In the coming years, should patients get their regular medical care, as formerly, from an individual practitioner; or should they get it from a unified service based on the hospitals? Has personal medicine of the old kind become an anachronism ; or is it more than ever necessary at a time when technology is losing touch with people ? Until these questions can be answered confidently, it would certainly be premature, in this country, to abandon the principles that everyone can have his own doctor, and that this doctor has professional independence. The case for the independent personal doctor may not be very tangible, but it is strong enough to deserve a great deal of thought before he is removed to a less responsible position in an integrated service based on the hospital rather than the home. All the same, though integration of hospital and domiciliary practice would at present be wrong, a closer association between practitioner and specialist has become a pressing necessity. For our part we hope it will be found that the practitioner can have an intimate relationship with hospital work-even spending several sessions a week as a part-time specialist -without being any the less a personal doctor in his own practice. But we cannot discount the possibility that such association with hospitals, with opportunities to transfer to consultant practice, will reveal that quite a lot of practitioners really prefer work in hospital to work in the home. From these, eventually, may come a demand for integration of domiciliary and hospital practice rather than loose association; and the demand may be supported by doctors who prefer to practise in large groups and might see positive advantages in the group moving to hospital premises. Perhaps most dangerous of all to the survival of the independent doctor is the fact that, to do the work that justifies his independence, he needs time; and the coming shortage of doctors is going to give him longer rather than shorter lists. Moreover, if he undertakes hospital sessions, he may be less than ever able to give unhurried personal attention to his patients at home. The most hopeful way of mitigating this scarcity is for doctors to delegate more of their work to ancillaries; and, provided the ancillaries can be found, this seems a probable development throughout the profession1 But delegation, though it saves medical manpower, is apt to weaken rather than strengthen the personal element in general practice. And if the personal element grows more dilute there will be less resistance to integration of home and hospital practice undertaken in the apparent interest of efficiency. For our part we hope that, in the national manner, a compromise will be found that will concede what is proper to specialist organisation yet will enable the independent practitioner to survive as a responsible
31
doctor. But at a time when the nation seems somewhat apathetic about the remarkably civilised ideas embodied in the National Health Service, we should point out that there is one possible fate for the personal doctor which would be even worse than his elimination through integration. This is that he should come to regard personal care of the patient as something separable from the rest of the practice-something which has to be paid for as an extra and for which a charge can suitably be made. The kind of personal care we have been talking about is not an extra, not a frill, not an amenity. It is the essence of the independent practitioner’s work-the reason, ultimately, for his existence. Our own feeling is that nothing is more necessary for British medicine, in the year now opening, than that the giving of such care should be encouraged and
personal
promoted. Obstructive
Nephropathy
rough-and-ready guide to renal function in patients with obstruction of the urinary tract, the bloodurea level gives help in such practical questions as the choice between slow and rapid decompression of the urinary tract, and the advisability of preoperative dialysis on the artificial kidney to make operation safer. But the blood-urea level gives a far from comprehensive picture As
a
of the state of renal function. The level may be distorted by prerenal factors, such as a low rate of urea production or a low-protein diet, or by an enhanced rate of urea production when the breakdown of tissue protein is increased by infection or trauma. Even when such sources of confusion are absent, the blood-urea gives information only on the excretory aspect of renal function, and tells us little or nothing of the homoeostatic or regulatory aspects, on which the maintenance of fluid balance depends. In patients with obstructive disease of the urinary tract retention of fluid is to be expected, and they may indeed become oedematous if attempts are made to induce a saline diuresis; and the possibility of urinary obstruction has to be kept in mind in patients presenting with acute renal failure.1 There may, however, be less obvious alterations in renal regulatory function, including a water-losing state 2-which seems paradoxical in obstructive disease. Defective control of fluid balance, with abnormal losses of electrolytes and water,appears more commonly after obstruction has been relieved. These clinical indications of defective renal homoeostasis suggest the need for a more thorough exploration of renal function, using specific tests of urinary concentrating and acidifying power; and such a study has now been reported by BERLYNE4 in seven adults with chronic
hydronephrosis. Obstructive nephropathy, like ascending pyelonephritis,5 might be expected to affect predominantly the distal part of the nephron, which includes not only the 1. Parsons, F. M., McCracken, B. H. Brit. med. J. 1959, i, 740. 2. Roussak, N. J., Oleesky, S. Quart. J. Med. 1954, 23, 147. 3. Bricker, N. S., Shwayri, E. I., Reardan, J. B., Kellog, D., Merrill, J. P., Holmes, J. H. Amer. J. Med. 1957, 23, 554. 4. Berlyne, G. M. Quart. J. Med. 1961, 30, 339. 5. Kleeman, C. R., Hewitt, W. L., Guze, L. B. Medicine, Baltimore, 1960, 39, 55.
distal convoluted tubules but also the collecting-duct system. Moreover, any mechanical distortion of the pyramids might well affect the spatial arrangement of the counter-current system, comprising the loops of Henle and the vasa recta, on whose anatomical juxtaposition the formation of a concentrated urine largely depends.s BERLYNE’S investigation was therefore centred on the ability to form a urine of low pH and high ammonia7 content after a standard dose of ammonium chloride (acidification of the urine being largely carried out in the distal tubule) and on the concentrating ability under the influence of vasopressin and mannitol diuresis 8-this depending both on distal tubule function and on the integrity of the counter-current system. The causes of hydronephrosis included prostatic hypertrophy, bladderneck obstruction, periureteric fibrosis, and aberrant renal vessels;four of the seven patients gave a history suggesting urinary infection, but this had been treated, and in all patients urea-splitting organisms were absent at the time of the investigations. All had some reduction in glomerular filtration-rate, the clearances of creatinine or inulin ranging from 9 to 64 ml. per minute. In six acidification of the urine was impaired, the pH ranging from 5-46 to 7.04; in only one was a normal pH level (5-10) attained. The excretion of ammonia and of titratable acid was reduced. In two patients some improvement in these functions followed relief of the obstruction; one patient, whose minimal pH before operation was 6.10, had a pH of 5-01 a month after prostatectomy. In the six patients whose urine was not acidified normally, concentration of urine under stress was also impaired. In three the maximal urinary was well below that of the plasma, bringing osmolality them into the category of acquired " nephrogenic diabetes insipidus ". All six patients with abnormal acidification and concentration had a raised blood-urea; while the patient in whom these tests were normal had a normal blood-urea of 22 mg. per 100 ml., although his creatinine clearance was reduced to 64 ml. per minute. Failure of the urinary pH to fall to the normal extent is not, however, a common feature in general renal failure7; nor is hyposthenuria (as opposed to isosthenuria). Discussing the hypothesis that the functional changes could be due simply to a reduced number of effective nephrons,9 BERLYNE accepts this explanation for the reduction of ammonia excretion and for the moderate failure of concentration in three of the patients; but he cannot account on this basis for the absence of normal acidification in six patients, nor for the hyposthenuria in three
patients. findings, besides their theoretical interest, have bearing on the management of patients with urinary-tract obstruction. Two patients in this small series had a metabolic acidosis before operation; and a third had water depletion, with a serum-sodium of 158 mEq. per litre, despite an intake of several litres a day. When his intake was increased to 7 litres a day, the water These
some
6. 7. 8.
Lamdin, E. Arch. intern. Med. 1959, 103, 644. Wrong, O., Davies, H. E. F. Quart. J. med. 1959, 28, 259. Cohen, S. I., Fitzgerald, M. G., Fourman, P., Griffiths, W. J., de Wardener, H. E. ibid. 1957, 26, 423. 9. Platt, R. Brit. med. J. 1952, i, 1313, 1372.