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ANNOTATIONS

ACUTE NEPHRITIS IN CHILDHOOD

ANYONE who studies the terminology of acutenephritis in childhood must be left with a feeling ofbewilderment-W. W. Payne and R. S. Illingworth 1give a list of eighteen different terminological varie-ties-and with all this differentiation there is no

evidence of increased clarification. Payne and Illing-worth have tried to clear away a lot of unnecessaryclassification and they attack in particular thediagnosis of acute focal nephritis. The first detaileddescription of this type is usually attributed to Volhardand Fahr, who defined it as a symptomless hsematuriaarising at the height of an acute infection, withoutoedema, nitrogen retention, hypertension or reductionin urinary volume, and with a uniformly goodprognosis. This conception has been generallyaccepted by paediatricians in this country, but Paynebegan to have doubts about the simplicity of theclinical syndrome when he found that nitrogen reten-tion was often present. With Illingworth he hassearched the records of the Hospital for Sick Children,Great Ormond Street, and in their paper they discuss301 cases of acute nephritis seen there. It soon

became clear that many cases diagnosed as acute focalnephritis were accompanied by symptoms as severe asin those called acute diffuse nephritis. Thus vomiting,headache, frequency of micturition and abdominal painwere as common in cases without definite oedema asin those with oedema, among children admitted duringthe acute stage. This seems to dispose of the"symptomless hsematuria" definition of acute focalnephritis, but the matter is still further elucidated bythe demonstration that, accepting definite oedema asevidence of diffuse kidney damage, a high degree ofnitrogen retention was rather less frequent in cases

of acute nephritis with oedema than in those without.It is true that in many children with the simplest formsof acute nephritis the blood-nitrogen figures fallrapidly and after a few days are almost normal. Itmay be this which has led many authorities to speakof the absence of nitrogen retention in one form ofacute nephritis. It is perhaps of some significancethat the commonest symptom associated with highdegrees of nitrogen retention was vomiting, and itwould be fair to assume that Payne and Illingworthsatisfied themselves that the kidney lesion and not thevomiting is the main cause for the alteration in theblood chemistry. The whole value of the clinicaldiagnosis of acute focal nephritis lay in its goodprognosis, but even this is demolished by Payne andIllingworth. Classifying cases into those with no

oedema, those with no oedema other than puffiness ofthe eyelids, and those with definite oedema, they foundthe prognosis in the three groups was equally serious,the majority being not healed but in a latent stage ofdisease when re-examined from one to twelve yearsafter the acute attack. Essential in the diagnosis ofthis latent stage of nephritis is a careful microscopicalexamination of a centrifuged urinary deposit. It is

suggested that the uniformly good prognosis hithertogiven for cases called acute focal nephritis may partlybe due to a more superficial examination of the urine.Payne and Illingworth conclude that acute focalnephritis is not a clinical entity since there are nocriteria of any value in diagnosing it. If their viewsare accepted there seems to be no way of establishingduring an attack of acute nephritis in childhood whatis likely to happen.

1. Quart. J. Med. January, 1940, p. 37.

PSYCHOBIOLOGY

AMONG the criteria of fame, the creation of anadjective from one’s surname should rank high.Pauline purity and Shavian wit are not only memorialsbut useful descriptive epithets for which ’any languagemay be grateful. In psychology, the adjectivesFreudian, Jungian, and Adlerian, however, owe theirpersistence as much to the nebulousness of the ideasthey are intended to convey as to the fame of theirparents. The same cannot be said of Meyerian.Though the words of Adolf Meyer himself are notalways easy to follow-they often appear as Germantranslated into American-he has wisely trained up ageneration of psychiatrists who not only know whathe is talking about but can translate it into everydaylanguage. One of these is Dr. Wendell Muncie, andin his new book1 he has set out Meyerian psychobiologyand psychiatry in such a way that anyone with anI. Q. above 120 should have no difficulty in followinghim.

Psychobiology is based on the conception that anaccurate and complete record of the events in a

person’s life from birth on enables one to understandbehaviour seen in any particular cross-section. Inother words, it relies on what we more humbly callthe patient’s personal history. What are consideredthe important events are put down chronologically ona somewhat illogically constructed torpedo-shapedchart, and the result is grandly known as a " psycho-biogram." From the psychobiogram of Mrs. A. G.we learn she was an obedient child when 3, hadmeasles at 4, learnt where babies come from at 15,developed endogenous depression at 37, and so on.The value of the method is its objectivity. Factsare recorded free from fanciful interpretations. Itsgreat disadvantage is its neglect of constitution asshown by the family history. Parents and relativesare dismissed in two or three lines. The unbiased

psychiatrist recognises that if the child is father tothe man, so equally is the father father to the child.The second criticism which Meyerian psychobiology

and psychiatry must face is its outlandish termin-ology. A glossary may help the uninitiated.

MEYERIAN

OligergasiasMinor pathergasiasMajor reactions or

holergasiasMerergasias

ThymergasiasPara-reactions

ParergasiasDysergasiasAnergasias

ENGLISHMental defectMinor psychoses-or neurosesMajor psychoses-or psychoses

properApparently the same as the minor

pathergasiasAffective reaction typesParanoid and schizophrenic statesSchizophrenic statesConfusional statesIrreversible organic psychoses

The embryo psychobiologist is advised to start byconstructing a psychobiogram of himself and of twoof his colleagues. While it is no doubt excellent forstudents to do their own blood-sugars and blood-ureas, the advisability of prolonged introspection isanother matter. It is not necessary to have lymph-adenoma to understand its pathology. A training inobjective unemotional observation is enough. Never-theless psychobiology is an eminently sane, scientific,and valuable approach to psychiatry. Occupationtherapy, hydrotherapy, the rational use of drugs, and

1. Psychobiology and Psychiatry. A textbook of normal andabnormal human behaviour. By Wendell Muncie, M.D.,associate professor of psychiatry, Johns Hopkins University.London: Henry Kimpton. 1939. Pp. 739. 40s.

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treatment by explanation, exhortation, and personalcontact all find a balanced place in the scheme. It

approaches the treatment of mental illness with ahopefulness which is in welcome contrast to our

English therapeutic nihilism.

CLEARANCE OF SODIUM EVIPAN

THE safety of continuous intravenous administra-tion of a drug such as sodium evipan depends on theway in which it is rendered inactive in the body. Theterm " clearance " is used to imply reduction in theamount of active drug in the body, and in the experi-ments undertaken there has been no attempt to deter-mine whether the drug is broken down or is merelydeviated by fixation by tissues other than the brain.Clearance may be exponential, a fixed proportion ofdrug being removed per unit of time, or constant,a fixed quantity of drug being removed per unit oftime. With drugs cleared in an exponential mannercumulation rises to a maximum, after which there isno further increase; with those cleared in the secondway there is no limit to cumulation, which can goon until death is produced. Das and Raventos ofEdinburgh examined the clearance of sodium evipanin rabbits, mice and monkeys (Maeacus rhesus). Twoexperimental methods were used. In the first a largeinitial dose was given intravenously and the rate ofinfusion to maintain a constant state of depression wasthen determined. In the second the times needed forrecovery after different doses were observed.The results of the first method indicate that inrabbits the rate of clearance is about 1/125 of theamount present in the body per minute, in mice 1/35 perminute and in monkeys 1/30 per minute. With rabbitsthe results of the second method agreed with the first,the rate of clearance being 1/22 per minute. With micethe second method gave the much slower rate of destruc-tion of 1/110 per minute. Das and Raventos did not

experiment with monkeys by the second method, butthey quote the results of Storm, who found by thismethod that the rate of clearance was 1/140 perminute. The reason for discrepancy between the twomethods is not known. All the experiments indicatethat the clearance of sodium evipan is approximatelyexponential-i.e., the amount cleared per minute isproportional to the amount injected. This evidencethat sodium evipan is cleared by the safer of the twoways of clearance bears out the clinical experiencethat it is safe to administer the drug by continuousintravenous infusion.

CURARE IN CONVULSION THERAPY

VARIOUS measures such as hyperextension of thespine and insulin premedication have been adoptedwith a view to reducing the risk of vertebral fracturesin the convulsion treatment of mental disorders, andwe have already mentioned in these columns the workof Bennett of Omaha on spinal anaesthesia in thisconnexion.2 Bennett now suggests the use of curarein combination with the convulsant drug on the linesproposed by Cole Ranyard West and others beforethem in the treatment of tetanus. He was led by hisresults in the treatment with curare of spastic paralysisin children to apply that drug to lessening the severityof the muscular contractions which follow the injectionof Metrazol. The varying composition of curare

makes it necessary to estimate the effective principlein each fresh supply. This is done by determining

1. Das, S. C. and Kaventós, J. Quart. J. exp. Physiol. 1939, 29,343.

2. See Lancet, Feb. 10, 1940, p. 275.3. Bennett, A. E. J. Amer. med. Ass. Jan. 27, 1940, p. 322.4. Cole, L. Lancet, 1934, 2, 475.5. West, R. Ibid, 1936, 1, 12.

the minimal lethal dose per kilogramme in mice. Theproblem of producing a safe commercial preparationis being undertaken by Prof. A. R. McIntyre ofNebraska and a safe commercial preparation shouldsoon be available. The drug is injected intravenouslyor intramuscularly, and the physiological effects beginimmediately after intravenous and fifteen minutesafter intramuscular injection. The patient developsptosis, nystagmus and strabismus with diplopia, weak-ness of the neck muscles, loss of facial expression, slowand hesitant speech and weakness of the throat andjaw muscles. Next the spinal muscles are affectedand lastly those of the arms and legs. When thepatient can no longer raise his head the convulsantdrug is given; the convulsion then comes on immedi-ately but with little tonic or clonic contraction. Theonly special precautions needed are to support thepatient’s head and to insert a tongue gag. Bennettadvises slightly larger doses of metrazol than usual,but he has not found that curare lessens the effective-ness of the treatment. The requisite dose of curareis between a quarter and a half of the calculatedhuman lethal dose. The only complication noted sofar has been a transient urticaria in some cases, butBennett advises that adrenaline and prostigminshould be at hand to be given in conjunction withartificial respiration if there are signs of respiratoryfailure. In tetanus Ranyard West found that withthe alkaloid curarine there was a real danger fromrespiratory spasm and Cole has lately noted that hehas abandoned curare in that disease. Until a largeseries of cases has proved that the administration ofrelatively large doses of curare does not mean thatone risk is substituted for another it is questionablewhether the practice should be widely followed. Theincidence of fractures in ordinary Cardiazol treatmentis still debated and their importance is as yet uncer-tain. The experience of psychiatrists who have usedconvulsion treatment with success and the recent find-ing of symptomless spinal fractures in epilepticssuggest that it is at least as urgent to inquire intothe significance of these injuries as to attempt drasticmeasures of prevention.

CHOICE OF A STETHOSCOPE

MOST of us choose our stethoscope on the adviceof the registrar or even of the maker and stick to itthrough life. At that stage in our evolution we haveno way of judging an instrument for ourselves-therustling of the hairs on the chest drowns all else-and later on we rightly refuse to change, for by thenwe have laid down that standard of normality whichis essential for successful auscultation. Nevertheless,there is much to be said for an efficient instrumentand it was high time that someone inquired into theacoustic properties of the multitude of types on

sale. This has now been done by Johnston andKline 7 of the University of Michigan. They producedartificial heart-sounds by means of a telephonereceiver driven by a variable-frequency oscillator.The receiver was placed inside the heart of a cadaverthrough an abdomino-diaphragmatic incision, leavingthe chest-wall intact. The chest-piece of the stetho-scope under test was then clamped to the prsecordiumand the ear-pieces were connected to a condensermicrophone with an output meter. Twenty-fourdifferent chest-pieces were compared as well as sixkinds of rubber tubing of different lengths. Theresults were expressed in decibels and compared withthose of a bell-type stethoscope which was adopted

6. Cole, Ibid, Jan. 27, 1940, p. 164.7. Johnston, F. D. and Kline, E. M. Arch. intern. Med. February,

1940, p. 328.