John H. Talbott

RENAL FUNCTION IN PATIENTS WITH GOUT

There are several theories of the pathogenesis of urate 2 accumulation in patients with gout. A disturbance of elimination of this substance by the kidneys is probably the most popular. This has been challenged, however, in a previous communication from this laboratory (1), since it appears to be inconsistent with certain experimental data. Whether or not this theory is valid, it deserves serious consideration because urates as naturally occurring end-products of purine metabolism are disposed of by the body largely by excretion through the kidneys. If one pursues the hypothesis to a logical conclusion, any defect of elimination might be inherited or it might be an acquired phenomenon following damage to the functioning units of the kidneys. The accepted theory (2, 3) of renal physiology in man assumes that urates are present in glomerular urine as are other ultrafiltrable substances and reabsorbed in part by the cells lining the tubules. If the kidneys were primarily at fault in the gouty diathesis, accumulation of urate might be attributed either to (a) a reduction of the number of functioning glomeruli or (b) an increased reabsorption by the tubules. Both of these phenomena are partially susceptible of quantitative analysis now that improved methods for the study of kidney function are available. A presentation and discussion of kidney function data, as determined by five experimental procedures, are contained in this communication. These include tests for the excretion of substances normally present in the body such as urea, creatinine, urate, sodium and chloride and for the excretion of foreign substances introduced parenterally such as phenolsulphonphthalein, neo-iopax

RENAL BIOPSY STUDIES CORRELATED WITH RENAL CLEARANCE OBSERVATIONS IN HYPERTENSIVE PATIENTS TREATED BY RADICAL SYMPATHECTOMY

The morphologic changes in the kidneys of patients who have died from essential hypertension and its complications are well known. The structural pattern at death is informative, but it offers little clue as to the intervening degenerative processes responsible for the terminal picture. A noteworthy effort has been made in recent years to fill the void. Various investigators (1, 2, 3) have applied the ingenious renal clearance procedures devised by Smith (4) to hypertensive patients and have obtained consistent and definite data. Anatomical studies also have been pursued in living patients, and recently one of us (B. C.) reported a small series of renal biopsies, taken during life from patients with various degrees of essential hypertension (5). The specimens were obtained during operation for sympathectomy, and all showed diffuse vascular disease. Since this preliminary report the number of biopsies has been increased to more than 100.2 No attempt was made at that time to consider anatomic findings in relation to renal clearance data or to the clinical status. In the first portion of the present communication, such an attempt has been made, and the microscopic appearance of renal tissue from 20 living patients has been correlated with the function of the kidneys. The quantitative clearance procedures include measurement of rate of formation of glomerular filtrate, renal plasma flow, and maximal capacity of the tubules to excrete diodrast.3 The second portion of the paper deals

A record case of the tetralogy of Fallot, with comments on metabolic and pathologic studies☆

Abstract Clinical, metabolic, and pathologic studies of a patient with advanced morbus caeruleus (tetralogy of Fallot) are reported. The patient died at the age of 19, and had been cyanosed since the age of 2. He was proficient scholastically, and, until a year before death, suffered a minimum of handicap from his malady. He was thought to have had rheumatic fever at the age of 9 and subacute bacterial endocarditis during his last year of life. A colon bacillus abscess of the cerebrum was immediately responsible for death. The metabolic investigations revealed a profound variation from the normal in the acid-base equilibrium of the body, and changes in renal function. As much as 75 per cent of the blood in the cardiac chambers was thought to traverse a right-to-left shunt. The oxygen saturation of the arterial blood varied between 62 and 58 per cent. These are critical levels for human existence. The oxygen capacity was about 35 volumes per cent. The carbon dioxide content of the arterial blood was less than 33 volumes per cent. The arterial pH s was less than 7.29. A profound, uncompensated acidosis was attributed to the increased concentration of undetermined acids and failure of the respiratory center to maintain the usual balance between free and combined carbon dioxide. The functional insufficiency of the kidneys was attributed to anoxemia, venous congestion, and acidosis.

Minds That Came Back

At a time when discussions in connection with mental illness are being removed from the closets of prejudice and taboo, this book is a welcome commentary. It is written in an easy, clear, stimulating style. Technical terms are nicely defined for the benefit of the layman. The source material is indeed unique and unusual, but it portrays the conditions described perfectly. To take autobiographical material of people who were judged insane and weave a story from it is a scientific as well as a literary feat of considerable merit. The purpose of the book is to provide educational material to the millions of people whose families have been touched by mental illness. He not only succeeds in doing this but he also succeeds in underlining the hopefulness that people should and can have in many of these disease entities. This is a book which can be recommended to the medical

Electrolyte Balance of the Blood in Ménière's Disease

Mygind and Dederding 1 associated the pathogenesis of Ménières disease with a disturbance of water and salt equilibria. From their investigations they concluded that a dehydrating and an acid-forming diet was indicated in the treatment of this condition. Two years later Furstenberg, Lashmet and Lathrop 2 extended these observations, showed evidence which indicated that sodium was the offending ion and recommended a regime with a low sodium diet and intermittent periods of ammonium chloride ingestion. This regime, where employed, has been successful, 3 , 4 but we believe from our data that a lowering of the sodium content of the body fluids is not its mode of action. In this communication blood studies from 14 patients with Ménières disease are presented. The diagnosis was confirmed by one or more clinicians and satisfied most of the criteria discussed by Crowe. 5 In all of the patients the concentration of serum total base, sodium and potassium was determined and in 4 the concentration of serum protein and hydrogen ion also. Eight patients were seen during periods of acute symptoms and bloods were taken at such times. In 6 patients, bloods were taken after the institution of a low sodium regime or during periods of freedom from symptoms after admission to the hospital. The results are given in Table I. It is observed that the concentrations of serum sodium and total fixed base are within the range for normals. The average concentration of serum sodium is slightly less in the patients with acute symptoms than in those without acute symptoms. The concentration of potassium is somewhat higher in the patients with acute symptoms.

Medicine in Art: A Cultural History

Within the past few weeks two important books on art have appeared in this country— 20,000 Years of World Paintings , edited by Jaffe, and Medicine in Art , edited by Rousselot. The reproductions in each volume are delightful, the lithography is outstanding, and the prices are consistent with the quality. Medicine in Art is not an encyclopedic treatise, but it fills one void among several. Each of the principal contributors is European or European-oriented. Ilza Veith, formerly of the University of Chicago and now professor of the history of medicine at the University of California and the outstanding Western scholar of Oriental medicine, prepared the section on the Far East and the Middle East. Dusseldorf and Paris claim the other contributors. My interest in this book is directly related to the colored cover program forThe Journal, which was started more than three years ago. The weekly selection has required me

At the Bedside

MINDFUL of the honor bestowed upon me in delivering the Annual Discourse for 1967, I shall attempt to justify the breach of silence. With this remark my thoughts return to my professor of botany in...

Textbook of the Rheumatic Diseases

It is not customary to comment at length on each new edition of a standard text or monograph. Copemans treatise, however, is one of the exceptions because of the subject matter and the incidence of the diseases discussed. A complete rewriting every seven years is frequent enough to incorporate new items of significance and, at the same time, is less of a chore to the senior author than would be a more frequent revision. In this current edition Copeman was assisted by 24 of the best-informed and clinically wise physicians in the United Kingdom who concern themselves with bones and joints. We may mention a few, even at the expense of apparent favoritism: Lord Cohen of Liverpool, Bywaters of Taplow, Kellgren of Manchester, Kersley of Bath, and Sir Reginald Watson-Jones of London, all of them teachers, investigators, and clinicians who insure quality without compromise. The discussions will interest American physicians,

The Metabolism of Lead in Man in Health and Disease.

More than 35 years ago Aub and associates of Harvard published a monograph on lead poisoning, which was judged the definitive work in this field for a number of years. In the intervening time, Robert Kehoe of the Kettering Laboratory, the University of Cincinnati, has devoted essentially a professional lifetime to the same problem. Since lead is an important heavy metal in current economy and environment, it is imperative that this subject be continually surveyed as a major problem for investigation. The breadth of study must inevitably include normal and nontoxic levels of metabolism of lead in man, plants, and animals, as well as the exposure of man especially to toxic concentrations. And lastly, a comprehensive study must include the treatment of lead intoxication from excessive primary intake or secondarily from absorption by plants and animals. The Harben Lectures review the potential industrial hazards as well as lead inhalation from

Medical Department, United States Army, Internal Medicine in World War II. Vol. 1: Activities of Medical Consultants

The first of 3 volumes in the series on Internal Medicine in the U.S. Army history of the medical department concerns the activities of the medical consultants. Under the direction of Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to the Surgeon General, the available physicians of first-class talent in this specialty who had not already been assigned to general hospitals, station hospitals, or other armed forces activities, were recruited as consultants. In this category one notes, particularly: William S. Middleton, then of Madison; Benjamin M. Baker of Baltimore; Garfield G. Duncan of Philadelphia; Yale Kneeland, Jr., and Perrin Long of New York; and Walter Bauer, Dennette Adams, and Herrman L. Blumgart of Boston. Although I was never in the pyramid on the way up to a consultant assignment, I had occasion during the years 1942 to 1946 to confer with several consultants in the Zone of the Interior