Eye Changes.- Captain R.Graham Brown, R.A.M.C., kindly reported upon 35 consecutive cases. The fundus was normal in 29, while in 6 sight blurring of a portion of the disc margin or papilloedema was present. All these patients had facial oedema. The retinal change and the facial oedema appeared to clear up at the same time. No case was under observation at a sufficiently late stage for chronic changes to be manifest. Transient blindness occurred in 2 cases as one of several uraemic symptoms. Difficulty in reading was complained of by a few patients early in disease, and some of these had slight blurring of the disc; but it is doubtful whether this disability could not be explained by general causes.
Complications.- Only two serious complications were met with – bronchitis and uraemia. The importance of the former is very great, and its presence has a very adverse influence upon prognosis.
Uraemia is seen in about 8 per cent. of the cases. Its onset is usually early in the disease; it may afford the first manifestation. In only 2 cases of our 160 did it occur after the tenth day. The common manifestations of uraemia are torpor, severe headache, nausea, vomiting (always to be regarded as a danger – signal), and convulsions. Uraemic convulsions in this disease present several interesting features.
They come on with very little warning, they are very violent, they usually occur quite early in the course of the illness, and, paradoxical as it may seem, are to be regarded on clinical experience as of good prognosis provided they are not fatal within the first few hours. Our experience has been that those patients who have had severe uraemic convulsions calling for active measures and causing considerable alarm have, after a few days of semi – coma, passed on rapidly towards almost complete recovery; their albuminuria has ceased, the flow of urine has been re – established, and there has been a speedy return of a sense of well – being. Chronic uraemia, giving rise to a prolonged state of cheerful busy delirium bordering on mania, occurred in two cases who ultimately returned to apparently normal mental health. TREATMENT.
Treatment has been mainly expectant or aimed at the removal of complications as they arose. Diuretics were rarely used and seemed of no value. Diaphoretics were employed in a few cases, but it is doubtful whether they had any influence on the course of the disease. It is remarkable how these patients sweat without drug treatment. It is the exception to find the skin dry after the first few days. How packs were rarely used; they seemed of doubtful benefit and, by adding to risk of chill, a real danger.
Fluids were not restricted, but the patients were not encouraged to drink more than they desired. No attempt to wash out nitrogenous material by flushing the system was made. A reason for avoiding copious drinks is the effect which the intake of large quantities of fluid has upon the blood pressure. Purgation was used, but was never drastic. Calomel gr. iii. at night followed by a saline purge in the morning was the routine. Occasionally an enema was employed at the commencement of the treatment.
All cases were kept for three days at least on a rigid milk diet. Three pints per diem were allowed. After this time if the albumin showed signs of diminishing, if blood was no longer visible to the naked eye in the urine, if the quantity of urine was normal, if the blood pressure was not raise, an if headache was not troublesome, an increase in the diet was allowed – toast, biscuits, a flavoring of tea in the milk, rice – milk (a fluid form of rice pudding made without eggs). In no case did the patients condition for a return to strict milk diet.
While uraemic danger – signs were present the strict milk diet was enforced. The treatment of uraemia followed the usual lines – venesection, intravenous infusion of saline, and lumbar puncture. The last operation is of the greatest benefit; it is necessary to perform it under chloroform anaesthesia on account of the uncontrolled movement of the patient; the removal of six or seven drachms of fluid is followed by a striking improvement. The fluid is usually under slightly increased pressure, but it is possible that this is due to the anaesthesia.
Opium in the form of morphia or omnopon was given freely and with benefit in uraemic cases; its diaphoretic effect was very noticeable. In the chronic form of excitement bromide, even in large doses, had little or no effect; opium had to be substituted.
PROGNOSIS.
Our observation of these cases has been too short to allow any opinion as to their ultimate prognosis to be formed, but certain points bearing on their immediate prognosis have been noted. The coexistence of a severe degree of bronchitis is of bad omen; four cases died and the partial recovery of others was delayed greatly. The coexistence of sepsis did not seem to have any adverse influence. The presence of uraemic symptoms varied in significance. The cases that showed great sleepiness during the first few days did as well as those who did not show this sign.
Uraemic convulsions, as has already been noted, if not immediately fatal, were shown by experience of several cases of be of good prognosis. Persisting mental changes, which may be regarded as uraemic in origin, however, were associated with persistence of albuminuria and haematuria long after the normal date for their disappearance. The blood pressure in the early stages gave little guidance. Some patients with a systolic pressure of 180 mm. Hg. made as rapid a recovery as those in whom the pressure was not raised. As a herald of approaching uraemia sustained high blood pressure may be regarded as of importance.
Pressure – readings during or immediately after a convulsion are probably of little value, as they must be influenced by the muscular exertion involved in the seizure. As no patient was allowed to get up before his evacuation from his hospital no information is available as to the possible return of albuminuria in non – albuminous cases after apparent recovery and on the resumption of the erect posture. Temporary increase of the albumin occurs commonly in cases still confined to bed without change in general symptoms and appears to be independent of changes in the diet.
PATHOLOGY
The urine from 50 cases of war nephritis have been examined since February of this year. Concurrently with these, 44 urines, both from normal individuals and from men who were patients in hospital, have been examined as a control.
All cases of war nephritis showed casts in the urine. The casts were hyaline, granular, fatty and blood, the first two being the most common. As would be expected, the more definite the clinical symptoms the larger was the number of casts. Again, all cases of war nephritis showed the presence of many degenerate endothelial cells in pronounced distinction to urines obtained from men suffering with other illnesses where endothelial cells were few or absent. The presence of casts and of endothelial cells is, in our opinion, sufficient microscopical evidence on which to diagnose this form of nephritis. The endothelial cells are of all shapes and sizes, but are most commonly spherical, varying from about 10M. to 35 or 40M.
They show vacuoles, one or more nuclei, and are invariably granular in appearance. They are in all stages of degeneration. Occasionally one has been seen to bud, and it is common to find one bursting open and the intracellular protoplasm being distributed into the surrounding fluid. It seems to us that these cells may be similar to the “amoeba urinate granulata,” described by other writers.12 They have never shown any true amoeboid movement, however, and are exactly similar in appearance to endothelial cells from pleural effusions or to those found in the faeces in chronic cases of dysentery.
They stain well in moist preparations, especially if the urine sediment has previously been washed in distilled water. As has been said, their presence in the urine of cases of war nephritis is invariable, nor are they found in any number in other conditions. We had two cases, however, of injury in the loin, where although the kidney was not damaged microscopically endothelial cells were found in the urine. These were, no doubt, due to the fact that the kidney substance was disturbed by the force of the original wound shock or by toxin absorption from the wound. This was confirmed by microscopical examination in one case.
In mild cases of war nephritis a few only of such degenerate cells will be found in the centrifugalized deposit of the urine. In a serious case many may be found in each field of the microscope (objective 6 X eye – piece). One of our cases who at first showed no definite clinical signs gave no endothelial cells in the urine, but as his symptoms of nephritis developed the endothelial cells appeared. These bodies persist in the urine after the patient is apparently well – even when the urine shows no casts; and perhaps they may be of value not only in the diagnosis of a doubtful case, but also in determining whether a man has had war nephritis in the past. How long they persist we are at present unable to say.
