CLINIOAL AND PATHOLOGIOAL NOTES ON TRENOH NEPHRITIS By W. H. TYTLER AND J. A. RYLE With Plates 1-4 THE condition known as 'trench nephritis' or 'war nephritis' has been the subject of so much investigation, and of so many contributions to the medical literature, that the mere routine clinical and pathological examination of a series of cases, carried out under the conditions of work at a Casualty Clearing Station, cannot be expected to add much that is new to the knowledge of the disease. The present paper makes no pretensions to a solution of the main problems of the subject, but has the object only of presenting the clinical features in a considerable number of cases observed during the early stages, and of putting on record the results of pathological examination in a series of cases which terminated fatally within the first three weeks of the disease. The clinical notes are based on a series of 150 cases, all of which were under the direct care of one of us (J. A. R.). They represent the cases of this type of nephritis admitted to one Casualty Clearing Station during the early months of 1916 'and the entire winter of 1916-17. They were all cases presenting con­ stitutional symptoms as well as albuminuria, no cases being included of the prevalent albuminuria without indisposition, and none of the so-called' lower tract ' cases. The fatal cases on which the autopsies reported were performed were collected from several Casualty Clearing Stations and field ambulances. For the opportunity of examining them we are indebted to the medical officers who had charge of them, Their names are too numerous to permit of individual acknowledgement. We have adhered throughout the paper to the term' trench nephritis' as being the one in most common use, although it is not completely accurate, since the condition is by no means confined to trench troops. Olinical Notes. Etiological factors. All the patients were necessarily males of military age, and within these limits were about equally distributed. All were employed in the forward area and the great majority actually in the trenches. There was commonly no history of any predisposing illness, nor were there any concurrent \Q. J. M••Jan.•1918.) CLINICAL AND PATHOLOGICAL NOTES ON TRENCH NEPHRITIS 113 epidemics, such as scarlet fever or tonsillitis, which could be considered to bear on the etiology of the disease. The seasonal incidence showed a marked increase during the winter months. As noted above, the cases described in this paper were observed during the early part of 1916 and the entire following winter. During the summer months of 1916 the cases were so occasional that consistent records of them were not kept. The following chart shows the admissi.on rate during the winter of 1916-17: Monthly Admissions of Trench Nephritis to iYO. - Casualty Clearing Station from October 1, 1916, to March 31, 1917. October. 8 December 30 February.. 22 November. 23 January... 18 March. 12 During the winter of 1916-17 the cases were derived from five divisions, each of which occupied the same position throughout these months. One division yielded 40 per cent. of the cases, the next highest 20 per cent., while the remaining three gave approximately equal numbers. There was nothing to indicate whether the high incidence in one division was due to geographical or to epidemic factors. Olinical features. Onset. The history was usually of an onset from two or three days to two weeks previous to admission. The almost constant complaint was of shortness of breath on exertion, while swelling of the extremities and face was also very frequently noted. A history of cough and of a general feeling of unfitness was common. The history of onset did not suggest an acute febrile or septicaemic attack. Olinical picture. On admission, and indeed throughout the early course of the disease, the most striking characters were pallor, oedema, and dyspnoea. Of the more severe cases, comprisi.ng between 20 and 25 per cent. of the whole number observed, the following is a general presentation: The patients were pale and puffy, with oedema of the eyelids, face, feet and hands, and, after a short time in bed, of the back and flanks, which might show deep creases due to the pressure of folds in the bed-clothes. The abdomen, on palpation, was full and tense. The spleen, though often enlarged post mortem, was never palpable during life. The respirations were short and rapid, and the dyspnoea increased on the slightest exertion. There was impaired resonance and air entry at the bases, with or without moist sounds. The wore, eases showed cyanosis of the lips and ears. Nearly all required a bed-rest to give them relief, while continuous administration of oxygen was sometimes n.ecessary. Except as a terminal event expectoration was not commonly profuse. One case had a large bilateral pleural effusion, but in the remainder of the series pleural effusion was uncommon, and when present not of large amount, as borne out also by the autopsy findings. During the months of December 1916 and January and February 1917, bronchitis was an almost constant complication. At this season it was extremely 114 QUARTERLY JOURNAL OF MEDICINE prevalent among all troops in the region, as were also laryngitis and tracheitis, and there was also a small epidemic of acute purulent bronchitis, due in part to the influenza bacillus, and showing a relatively high mortality. The bronchitis, as a complication of the nephritis, was usually present on admission, and was undoubtedly a prominent cause of the severe respiratory symptoms. Also, in the fatal cases, it would seem to have been an important determining factor. The dyspnoea was in our cases frequently urgent and distressingly obvious. So predominant were the respiratory signs that, until the condition became more generally recognized in the field ambulances, cases were not uncommonly sent down with a diagnosis of acute bronchitis or of pneumonia. From clinical evidence we consider the dyspnoea to be primarily due to pulmonary oedema, and this view was substantiated by the autopsy findings. Bronchitis was undoubtedly a great contributory factor, and swelling of the abdomen and of the tissues of the abdominal wall probably played a part. We have frequently remarked a striking resemblance between the respiratory symptoms in trench nephritis and those seen in cases of gas-poisoning: particularly those due to phosgene. The pulse, in nearly all cases, was full and bounding, and the blood-pressure was generally above 140 mm. of mercury. One case showed subconjunctival haemorrhages. Pyrexia was not the rule save in relation to the bronchitis. A small group of cases, however, without apparent bronchitis, showed temperatures ranging from 1000 to 1040 F. during the first week of the disease. Another small group of cases showed the respiratory picture described above, with the addition of prolonged expiration and the general symptoms of severe asthma, but with complete absence of external oedema. The presence of albumin and casts in the urine, and the relatively small amount of expectoration, served to distinguish this group from the cases of simple capillary bronchitis which were so numerous during the winter. In spite of the anasarca and the pulmonary oedema the patients usually passed a quantity of urine not much below the normal amount. The figure in most cases was between 30 and 50 ounces. None of the cases with respiratory symptoms and oedema showed evidence of uraemia, and, indeed, there was only one case of this latter type in our series. This case showed no respiratory dis­ tress, and there was a marked diminution of urine. Our experience does not represent the true proportion of respiratory to uraemic cases, since during the same period other clearing stations had a relatively much greater number of cases with cerebral symptoms. Also we examined at autopsy several cases of sudden death with little or no previous illness which, we concluded, belonged to the class of trench nephritis. Mortality and prognosis. In the fatal cases death usually occurred during the second week, as closely as could be determined. In such cases the terminal picture showed increased cyanosis, and very severe dyspnoea with profuse frothy CLINICAL AND PATHOLOGICAL NOTES ON TRENCH NEPHRITIS 115 expectoration. Death in all the fatal cases in our series was apparently due to respiratory failure. The mortality among cases of nephritis admitted to this Casualty Clearing Station during the winter of 1916-17 was 4 per cent. All of these fatal cases were of the respiratory type, and in all but one there was associated bronchitis. The immediate prognosis, then, in the absence of this very common complication, may be said to be good in the dyspnoeic form of the disease. The uraemic type, from the experience of those who have seen more of it, shows a higher mortality rate. Treatment. As always, the first essential in successful treatment is early diagnosis. Cases which had been first recognized late in the disease were in general slower in their reaction to treatment. We would suggest that during the periods of high incidence of the condition an increased watchfulness for incipient pallor and dyspnoea would lead to better results ill treatment. Warmth and rest in bed with good nursing and the administration of saline purgatives, produced a rapid change in the condition of all cases of moderate severity. Postural treatment for the dyspnoea, and oxygen when necessary-given preferably by the continuous intranasal method-gave much relief. Hot packs were often beneficial, but seemed to be definitely contra­ indicated in cases with pyrexia or severe bronchitis. The diet was customarily fluid, sometimes with the addition of light farinaceous foods.