Maurice B. Strauss

“WATER DIURESIS” PRODUCED DURING RECUMBENCY BY THE INTRAVENOUS INFUSION OF ISOTONIC SALINE SOLUTION

Control of renal excretion of water in man is largely vested in the supra-optico-hypophyseal system. Whenthe tonicity of the blood plasma and extracellular fluid rises, an increased secretion of antidiuretic hormone (ADH) leads to the conservation of water inasmuch as urinary solutes are excreted with a minimum of water. Conversely, when tonicity falls, a diminution of ADHoutput permits the excretion of a large volume of dilute urine. In both instances homeostasis is served. Many stimuli, in addition to hypertonicity, increase ADHproduction, including certain anaesthetic (1) and narcotic drugs (2), barbiturates (3), smoking (4, 5) and nicotine (6, 7), acetylcholine (8), exercise (9), emotion (9), syncope ( 10), pain ( 11 ) and conditioned reflexes ( 11 ), as well as the direct electrical (12) or acetylcholine (13) stimulation of nerve cells and fibers connected with the pars nervosa of the pituitary gland. Removal of amounts of blood insufficient to alter blood pressure significantly may nevertheless lead to increased ADH activity (9). There is also suggestive evidence that there may at times be increased ADH activity in patients with cirrhosis of the liver (14, 15). In contrast to the many factors which may lead to increased antidiuretic activity few other than destructive lesions involving the supra-optico-hypophyseal system and hypotonicity of the plasma and extracellular fluid have been reported to cause a decline in ADH activity. These are hypnotic suggestion (1), alcohol administration (16-18), and exposure to cold (19).

The effect of alcohol on the renal excretion of water and electrolyte.

That the ingestion of alcohol-containing beverages provokes an increased flow of urine was no doubt a matter of common observation even before Shakespeare commented upon it (1). However, the diuretic effect of alcohol is dismissed in recent textbooks (2, 3) with the statement that the increase in urinary output is largely due to the quantity of fluid imbibed with the alcohol. Although Simanowsky (4) in 1886 reported that a liter of beer provoked a greater diuretic response than a similar quantity of water, Raphael failed to confirm this a decade later (5). The matter then rested until 1910 when Mendel and Hilditch (6) administered a standardized daily diet to two volunteers and following several days of observation gave 16 ml. of 95 per cent alcohol with each meal and also at 10:30 a.m., 3:30 p.m. and 10:00 p.m., in each instance the alcohol being mixed with milk or water. There was no greater urine output on the alcohol than the control days. However, Miles (7) clearly demonstrated in 1922 that a single dose of 27.5 gm. of alcohol in 100 ml. of fluid definitely increased the flow of urine and similar observations are recorded in a number of studies reviewed in 1940 by Bruger (8). The diuresis has in general been ascribed to a direct action of alcohol on the kidney or its circulation. In 1938 Nicholson and Taylor (9) performed the first experiments in which excretion of electrolyte was studied in detail. They employed 136 to 161 gm. of alcohol ingested during a period of eight hours. The authors state that during the

Acute Renal Insufficiency Due to Lower-Nephron Nephrosis

ACUTE renal insufficiency due to the disorder now known as lower-nephron nephrosis1 or hemoglobinuric nephrosis2 occurs in association with a large variety of conditions, including intravascular he...

Alcoholic "Polyneuritis: Dietary Deficiency as a Factor in its Production.

S FROM CURRENT MEDICAL

OBSERVATIONS ON THE ETIOLOGIC RELATIONSHIP OF ACHYLIA GASTRICA TO PERNICIOUS ANEMIA.: IV. A BIOLOGIC ASSAY OF THE GASTRIC SECRETION OF PATIENTS WITH PERNICIOUS ANEMIA HAVING FREE HYDROCHLORIC ACID AND THAT OF PATIENTS WITHOUT ANEMIA OR WITH HYPOCHROMIC ANEMIA HAVING NO FREE HYDROCHLORIC ACID, AND OF THE RÔLE OF INTESTINAL IMPERMEABILITY TO HEMATO-POIETIC SUBSTANCES IN PERNICIOUS ANEMIA

Este artículo clásico hace referencia a la X observación, dentro de una serie de experimentos realizados por William Bosworth Castle (fig. 1). Castle, siendo joven estudiante de Medicina de la Universidad de Harvard, y posteriormente alumno interno del departamento de Medicina Interna del Boston City Hospital, elucida a través de sus observaciones y a lo largo de su trayectoria profesional, la patogénesis de la anemia perniciosa. Hasta entonces se sabía que la anemia que aparecía en el curso de una gastritis atrófica era conocida como anemia perniciosa, denominación que fue hecha por Addison en 1855 y posteriormente corroborada por Biermer en 1872. En aquella época esta enfermedad evidenciaba un mal pronóstico pero todavía no se conocía su causa. El concepto clásico descrito por Addison de anemia perniciosa era:

FACTORS INFLUENCING THE DIURETIC RESPONSE OF SEATED SUBJECTS TO THE INGESTION OF ISOTONIC SALINE SOLUTION

The ingestion of isotonic saline solution, long considered to have little or no immediate effect on urine flow (1), has recently been shown by Blomhert (2) to be followed by brisk water diuresis. Further, several investigators have demonstrated that similar diuresis may result from intravenous infusion of isotonic saline solution (2, 3, 4). Examination of the latter experiments reveals at least three factors which appear to be of importance in determining whether water diuresis ensues: hydration, posture and time of day. Thus Ladd (3) found that diuresis following saline infusion occurred only if the subjects had been prehydrated eight to thirteen hours before the infusion was given. A previous study from this laboratory (4) showed that diuresis occurred in recumbent subjects but not in those quietly seated in a chair. Blomhert (2) did not observe diuresis when infusion was accomplished at night, although it occurred regularly under the same conditions during the day. Since Blomherts studies were made only on recumbent subjects and no mention of posture is to be found in other reports concerning the response to ingested saline, it was deemed worthwhile to ascertain whether diuresis might be induced, and if so, under what circumstances, following saline ingestion by seated subjects.

Amount of Material Effective in Pernicious Anemia Present in Dog Liver

Conclusions 1. Extracts made from normal dog livers produce on intramuscular injection typical remissions in patients with Addisonian pernicious anemia. 2. The content of potent material in canine liver appears to be only about one-fifth that of hog liver. 3. This fact may possibly be correlated with the contradictory findings concerning the amount of the specific intrinsic factor in canine gastric juice.

The unsolved problem: obtaining personal health care.

Seventy years ago personal health care was a privilege; today, it is considered a right. Then the physicians premedical education was often limited to high school and may not have included even an...

Medical Education for Tomorrow

Abstract Government, which increasingly supports all medical education, will exert financial leverage so that the medical needs of the public are satisfied. Although the total number of physicians required in the future is controversial, the proportion of specialists will decline in favor of physicians trained to provide primary care. To train such physicians, medical schools must not sacrifice quality or try to turn out two classes of physicians. Rather, students must continue to be educated in the scientific method, but they should also have a clinical indoctrination oriented to the care of ambulatory rather than hospitalized patients. Thus, on graduation, they will be equipped to enter either postgraduate training programs for primary physicians or programs for specialists as determined by the needs of the public. (N Engl J Med 291:553–556, 1974)