This communication is based upon the study of 250 cases of nephritis which have come under the personal treatment or supervision of one of us. (C.E.S.), and upon the pathological investigation of the last 50 of these (A.T.N.). The figures quoted below refer to 160 of those cases whose records are available.
It is proposed to deal with the subject under the headings of Clinical Aspects and Pathology, and to review the various work which has been done upon its etiology.
CLINICAL ASPECTS.
Seasonal Incidence.- Our own cases reached their maximum in the months of January and February. This is contrary to the observations of other writers and is probably to be explained by an increase in the military population form which this hospital draws its sick; during these months divisional units were “resting” in the neighborhood.
Age Incidence.- The average age of our last 160 patients was 31 years. The disease was commonest in the decade 25 to 35; 8 per cent. of the cases, in which a history of previous disease could be excluded, occurred over the age of 40.
Previous Renal Disease.- A history of this could rarely be obtained. Of 160 cases, 6 certainly and 2 probably has suffered from a previous attack o nephritis. Of these, 2 gave a history of nephritis while on active service, one six months, the other 12 months previously; 4 had had acute nephritis in civil life; 2 gave histories of scarlet fever with delayed convalescence within the preceding five years.
Nature of the Duties on Which the Patients Were Employed – Of our 160 cases 10 per cent. had never been in the front line; while the remainder had all served at the front, in many cases such services had been discontinued for a period of weeks or months before the onset of nephritis. Three of our 250 cases occurred in officers. The average stay in France of our last 80 cases was 72 months; 5 cases occurred before the fourth month.
Associated Conditions.- Some degree of bronchitis was a constant feature; it was often a serious complication, in tow of the fatal cases was responsible for death. Septic infection of the skin in the form of impetigo or a superficial wound was present in 12 of our cases. Trench – foot was present in two cases. Quinsy preceded the onset of nephritis by five days in one case. (Contrast Citron.6)
Type of Case.- There are all varieties in the severity of the disease, ranging from the slight attack with little or no oedema to the typical and fatal case. It seems possible that slight atypical or abortive cases, who suffer from an undiagnosed, malaise, may recover without admission to hospital.
Mode of Onset.- The appearance of the more striking symptoms is so impressive that it is only occasionally that the patient volunteers the statement that he had been indisposed for any time before he was compelled to “go sick.” Careful inquiry will, however, in large majority of instances, elicit the information that there has been some departure from the normal health for two or three days before the onset of the acute symptoms. Such slight prodromal symptoms include headache, backache, “a cold,” and a feeling of fatigue after slight exertion; some degree of bronchial catarrh is practically constant at this stage.
Alimentary symptoms are rarely mentioned, and it is unusual for complaint to be made of any alteration of urine or micturition during the prodromal period, but some patients speak of “scalding” as having occurred from the very commencement of the illness. The following symptoms and signs are found in every typical case: oedema, dyspnoea, headache. Very common, but not invariable, are backache, limp – pains, slight pyrexia, and scanty micturition. Probably if these patients came under observation at the earliest stage of the disease these symptoms would be more often evidence.
OEdema.- This always affects the face; it may be confined to this situation or involve the whole body. The positions in which it is found are, in order of frequency, face, feet, hands, lumbar region, scrotum, and abdominal wall. Ascites and pleural effusions are uncommon except in those patients in whom the disease tends to run a prolonged course. The duration of the oedema is very variable – usually it disappears rapidly; if the case if not seen during the first three or four days it may already be entirely absent; we have seen it disappear completely within 36 hours of the onset. Associated with the oedema an almost characteristic flush of the skin is often seen; it is not a cyanosis, but a red flush resembling early sunburn. In our experience this appearance has been most noticeable in patients suffering from capillary bronchitis.
Dyspnoea.- Some degree of respiratory distress is constant. Most of the patients describe the onset as quite sudden; the man may parade in full marching order without discomfort, and fall our a few minutes later, quite unable to march after the column has gone a few hundred yards. Many of the men, however, when closely questioned, state that they have noticed gradually increasing shortness of breath for two or three days before the occurrence of the dramatic attack. In a large proportion of cases this shortness of breath, slight and gradual or sudden and severe, may precede the appearance of facial oedema by several days.
When at rest the condition is one of hurried respiration rather than a true dyspnoea; it lasts for several days and may persist after the disappearance of oedema. Cheyne – Stokes respiration is not seen except in conditions of severe uraemia. Urgent respiratory distress while the patient is at rest may occur if the disease is complicated by severe bronchitis or as a manifestation of uraemia. Two of our seven deaths were due to sudden uraemic dyspnoea.
Headache.- All our patients suffered from dull headache, most commonly frontal, often occipital, rarely vertical. This is one of the earliest symptoms and is often of long duration. An increase in its severity has been noted as a herald of uraemia. We were unable to demonstrate a definite relationship between the degree of the headache and systolic blood pressure. Its disappearance is accompanied by a sense of well – being which cannot, in our opinion, be entirely due to the relief from a moderate though persistent pain.
Cough.- All our patients suffered to some extent from cough, often accompanied by a considerable of expectoration, the sputum being usually frothy and liquid, except in those cases which were complicated by purulent bronchitis.
Backache.- This is practically constant; rarely severe, it persists for several days. It is localized to the loin, and does not radiate; it is variously described as a dull ache, a weight or a load on the loins.
Abdominal pain is occasionally complained of; in our experience chiefly in those patients who suffer from uraemic symptoms. It is transient and variable in intensity and position.
Limb – pains.- These are common but transient. Nothing approaching in severity or persistence the “shin – pains” of trench fever has been met with. This point is of some clinical importance, for in many cases of trench fever albuminuria occurs during the first few days. The limb – pains of nephritis are present only in the early stage of the disease; they disappear with the return of the temperature to normal.
Urine.- In the first days oliguria of suppression is the rule this is usually of a few days duration only, and is frequently followed by polyuria which persists after all obvious oedema has disappeared. Frequency and scalding are not uncommon during the first few days. Incontinence of urine in non – comatose patients occurred in two cases in our series. This symptoms has been noted by a German observer. In 250 cases true dysuria with hypogastric and penile pain was present; these may have been “lower tract” affections as described by Abercrombie.8 They recovered without special medication.
Albuminuria is constant at first but may be remarkably transient; it has a tendency to vary from day to day irrespective of diet changes. No information as to its ultimate persistence is given by the cases of our series, for they were too short a time under observation.
Hematuria – Naked eye examination reveals the presence of blood in rather less than half the cases. Its amount is even more variable than the albumin, but it may be most persistent. The microscopical characters of the urine are described under the heading of “Pathology.”
Temperature.- Moderate pyrexia for a few days is the rule; its duration is brief and relapse uncommon. In the presence of associated disease, such as sepsis or severe bronchitis, the pyrexia is more definite and sustained; but with these exceptions war nephritis may, after the few days at the onset, be regarded as an afebrile disease.
Pulse.- The pulse – rate is little altered. It may rise to 90 or 100 and remain at this figure of a week or 10 days, but persistent tachycardia has been a very rare symptom. In two cases it occurred without any other apparent cause.
Blood – Pressure.- The haemodynamometer was not used in all cases, and experience has convinced us of the fallacy of relying upon digital impressions in estimating blood pressure. The highest record obtained was 210 mm.: this was met with in a uraemic case, in the presence of which complication readings of 150-180 were not uncommon. In mild and quiescent cases no striking rise of blood pressure was met with.
