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Almost Constant Complaint Was Frequently Noted. a History of Cough asthma, but with absence of external edema. The CLINICAL AND PATHOLOGIC NOTES ON complete presence of albumin and casts in the urine, and the relatively TRENCH NEPHRITIS small amount of expectoration, served to distinguish this group from the cases of simple capillary bronchitis which W. H. TYTLER AND J. A. RYLE were so numerous during the winter. In spite of the anasarca (Abstract from the Quarterly Journal of Medicine, London, 1918, and the pulmonary edema the patients usually passed a 11, p. 112) quantity of urine not much below the normal amount. None These British officers describe the clinical features in 150 of the cases with respiratory symptoms and edema showed evidence of uremia. cases of trench nephritis observed during the early stages in a casualty clearing station. They also record the results of In the fatal cases death usually occurred during the second week. In such cases pathologic examination of cases which terminated fatally the terminal picture showed increased within the first three weeks of the disease. They were all cyanosis, and very severe dyspnea with profuse frothy expec- toration. Death cases presenting constitutional symptoms as well as albu- in all the fatal cases was apparently due to failure. minuria, no cases being included of the prevalent albuminuria respiratory without indisposition, and none of the so-called "lower tract" PROGNOSIS cases. All the patients were employed in the forward area The mortality among cases of nephritis admitted to this and the great majority actually in the trenches. There was casualty clearing station during the winter of 1916-1917 was commonly no history of any predisposing illness, nor were 4 per cent. All of these fatal cases were of the respiratory there any concurrent epidemics, such as scarlet fever or ton- type, and in all but one there was associated bronchitis. sillitis, which could be considered to bear on the etiology of "The immediate prognosis, then, in the absence of this very the disease. The seasonal incidence showed a marked increase common complication, may be said to be good in the dyspneic during the winter months. form of the disease. The uremic type, from the experience of those who have seen more of it, shows a higher mortality SYMPTOMATOLOGY rate." The cases were observed during the early part of 1916, and TREATMENT the entire following winter. The history was usually of an The authors emphasize that "the first essential in success- onset from two or three weeks to admission. The previous ful treatment is early diagnosis. Cases which had been first almost constant complaint was of shortness of breath on recognized late in the disease were in general slower in their exertion, while swelling of the extremities and face was also reaction to treatment." Warmth and rest in bed with good frequently noted. A history of cough and of a general feel- nursing and the administration of saline purgatives, pro- ing of unfitness was common. The history of onset did not duced a rapid change in the condition of all cases of moderate suggest an acute febrile or septicemia attack. On admission, severity. Postural treatment of the dyspnea, and oxygen and throughout the course of the the most early disease, when necessary—given preferably by the continuous intra- striking symptoms were pallor, edema and dyspnea. Of the nasal method—gave much relief. Hot packs were often bene- more severe cases, comprising between 20 and 25 per cent, of ficial, but seemed to be definitely contraindicated in cases the whole number observed, the following description is given : with pyrexia or severe bronchitis. The diet was customarily "The patients were pale and puffy, with edema of the eye- fluid, sometimes with the addition of light farinaceous foods. lids, face, feet and hands, and, after a short time in bed, of "So far as possible patients were not evacuated until the the back and flanks, which show creases due to might deep symptoms had largely disappeared. In uremic cases bleeding the of folds in the bedclothes. The on pressure abdomen, and lumbar puncture may give relief, the former." palpation, was full and tense. The spleen, though often particularly enlarged postmortem, was never palpable during life. The URINE EXAMINATION respirations were short and rapid, and the dyspnea increased The urine showed a on the slightest exertion. There was impaired resonance and nearly always large amount of albumin air entry at the bases, with or without moist sounds. The on admission, the amount being roughly proportional to the worst cases showed cyanosis of the lips and ears. Nearly severity of the symptoms. Specific gravity varied between all required a bedrest to give them relief, while continuous 1.012 and 1.018, with an average of 1.015. Of the entire series administration of oxygen was sometimes necessary. Except of cases only about 2 per cent, showed macroscopic hematuria. as a terminal was not event, expectoration commonly profuse. Microscopically, the centrifugalized urine showed numerous One case had a bilateral large pleural effusion, but in the tube casts, red blood cells and leukocytes. The number of remainder of the series pleural effusion was uncommon, and casts, however, was smaller than in severe acute when present not of large amount." usually nephritis as seen in civil life. The bronchitis, as a complication of the nephritis, was THE BLOOD usually present on admission, "and was undoubtedly a promi- nent cause of the severe respiratory symptoms." The dyspnea Urea in the blood varied from 0.05 to 0.15 per cent., with was frequently urgent and distressingly obvious. So pre- an average of 0.08 per cent. The amount did not seem to dominant were the respiratory signs that, until the condition bear any constant relation to the amount of urea in the became more generally recognized in the field ambulances, urine. Leukocytes in a small series of cases were not cases were not commonly sent down with a diagnosis of acute definitely increased, the usual figure being between 8,000 and bronchitis or of pneumonia. From clinical evidence the 10,000. Higher counts were not observed save with authors consider the dyspnea "to be primarily due to pul- severe bronchitis. monary edema, and this view was substantiated by the PATHOLOGY necropsy findings. Bronchitis was undoubtedly a great con- The morbid anatomy in trench nephritis is based on a tributory factor, and swelling of the abdomen and of the series of twenty-five necropsies. The most constant gross tissues of the abdominal wall probably played a part." A changes observed were those seen in the lungs and- spleen, striking resemblance was frequently noted between the consisting, briefly, "in an extensive pulmonary edema, often respiratory symptoms in trench nephritis and those seen in of rather characteristic nature and usually accompanied by cases of gas poisoning. a purulent bronchitis, and in the presence of characteristic The pulse, in nearly all cases, was full and bounding, and hemorrhages throughout the spleen. The kidneys constantly the blood pressure was generally above 140 mm. of mercury. showed to the naked eye only the most slight and indefinite One patient showed subconjunctival hemorrhages. Pyrexia changes. "It was seldom that one could attempt even a was not the rule save in relation to the bronchitis. A small guess at the nature of the disease from the gross examina- group of cases, however, without apparent bronchitis, showed tion of the kidneys alone." They were seldom enlarged, and temperatures ranging from 100 to 104 F., during the first the only change suggesting disease was a slight pallor and week of the disease. Another small group of cases showed opacity of the cortical tissue. The cortex was seldom swollen the respiratory picture described above, with the addition of or wider than natural. A few of the kidneys showed some prolonged expiration and the general symptoms of severe congestion so that the cortical vessels stood out as red Downloaded From: http://jama.jamanetwork.com/ by a West Virginia University Library User on 06/20/2015 streaks against a pale background. In some cases swelling associated with severe bronchitis, the latter being regarded of the gloaieruli, causing them to stand out from the cut as secondary. The characteristic changes were found in the surface like minute glistening drops, was observed. This lungs, the spleen and the kidney, in all of which capillary change, however, was not constant. Hemorrhagic lesions thromboses were present, most marked, however, in the lungs were not infrequently seen elsewhere than in the spleen. and in the kidney associated with acute glomerulitis. The Several cases showed petechial hemorrhages in the renal most marked changes were found in the lung. There was a pelves. Two cases showed numerous subepicardial, and one diffuse edema with some fibrinous and cellular exúdate, the case numerous subpleural petechiae. Two cases showed large condition being really one of pneumonitis rather than edema cerebral hemorrhage, one central and one superficial. The in the usual sense, and associated therewith was a bronchitis heart was often considerably dilated when the lung involve- which the authors regard as secondary. Bacteria were not ment was extreme, and such cases showed venous engorge- found in the lungs except in the bronchi, in which were ment of the abdominal viscera. In most cases congested streptococci of the mouth type. Beside the thromboses in lymph nodes were found at the roots of the lungs, and often the spleen there were many small hemorrhages, and hemor- in the mesentery. The brain in some cases showed moderate rhages were also found in the serous membranes and in two 'subarachnoid edema. cases in the brain. The changes in the kidney were less ETIOLOGY marked than expected from the symptoms, being principally Bactériologie examination was carried out on material from inflammatory changes in the glomeruli.
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