NEPHRITIS, ITS MODERN FRENCH

CONCEPTION.

L. W. LITTIG, A. M., M. D., Davenport, Ia.

The subject of this paper is introduced with a few lines by Herrick taken from Osler's Modern Medicine: "No serious, at least no successful attempt has been made to classify chronic nephritis from the standpoint of etiology; morbid anatomists and pathologists are far from unanimous in their description of the various types of this disease; physicians are not always able to make a differentiation that is satisfactory from the clinical point of view, or that holds good in the light of post mortem revelation." These words by Herrick come to us with a sort of humiliating force, and their truth will hardly be questioned.

The modern French classification of nephritis, as reported by Austin, and as presented by Widal and Castaigne, ignores any internal secretion the kidney may have, and regards this organ simply as a filter. Under normal conditions certain substances are permitted to escape with the urine, as albumen; other substances are retained, as urea and salt. The word urea" includes all the toxic substances eliminated by the kidney, whether ingested with food or elaborated within, and the word "uremia" is taken to mean the symptom complex due to the retention of these same toxic substances. This classification of nephritis is entirely physiological, and is based on this filter function of the kidney.

To ignore pathology strikes one as iconoclastic, but also reminds of the distinction once made between croup and diphtheria, a distinction based entirely on pathology, and of which the immortal Trousseau said: "Let them remain on their side of the Rhine with their notions of pathology, they but confuse our nosology; croup and diphtheria are one and the same disease," and, you know who was right. So let us not without a hearing, reject this modern French view of nephritis, although it does not do homage at the shrine of pathology.

In approaching the study of nephritis, we ask ourselves: "How is the kidney performing its function, is it permeable, and to what degree?" To stimulate interest in this study, and to indicate its solution according to Widal, Castaigne, and others of the modern French school, is the object of this effort. I shall consider only those procedures which Castaigne considers necessary and sufficient to appreciate the eliminating functions of the kidney.

With the discovery of albumen in the *Read before the M.S.M.V..Omaha, Sept., 19, 1913.

urine, accidentally or otherwise, every one of us immediately and mechanically takes the blood pressure, notes the apex beat, and compares the closing snap of the aortic valves. Castaigne is integrated in the same manner by the discovery of albumin, but this discovery promptly suggests a test of the filter function of the kidney. For this purpose, he prefers the deep injection into the buttock of one c.c. of a 5 per cent solution of chemically pure methyline blue. The urine is to be voided just before this injection is made, and the patient subsequently asked to void urine every thirty minutes until the blue appears in the urine. In a normal kidney, the blue or chromogen appears in the urine within thirty minutes, and if it does not appear within one hour permeability is minus, and elimination is retarded. During the day of the test a sample of urine is taken every hour, and thereafter every time the patient voids urine, until the blue and chromogen entirely disappear. Under normal conditions the blue should appear in the urine within from thirty minutes to one hour. The urine should be most highly colored from the fourth to the sixth hour, from which time the blue should gradually disappear. At the end of sixty hours the urine should not contain either blue or chromogen. If the blue appears in less than thirty minutes, and if it entirely disappear within from twenty to thirty hours, the kidney may be said to be "leaking," and functionating badly. If the urine continues to show blue or chromogen for five or six days, elimination is retarded. The elimination of the blue in the correct time does not prove that the kidney is normal, but a knowledge of this fact has an immense bearing in prognosis and treatment.

To

In addition, the urine is always examined for urea, not forgetting that there may be retention of urea in the blood with the urine showing a proper percentage. determine the presence of urea in the blood, ten c.c. of serum is secured by wet cupping, and the percentage of urea determined. Under occasional circumstances a spinal puncture is indicated, as when there are indications of severe uremic intoxication, and the spinal fluid used for the test; or the method recently proposed by McMaskey may be used. Any excess above one-half gram per liter is abnormal, although from one-half to one gram does not occasion alarm. From one to two grams of urea per liter suggests a serious condition, and from two to three grams per liter the patient usually will not live more than one year, and from three to four grams per liter

death may be expected in a few weeks. In estimating the significance of the per cent of urea, the diet must always be considered, as a higher per cent of urea is expected and is normal with a highly nitrogenous diet than when the patient is on a hyponitrogenous diet.

The results obtained by means of the methylene blue test agree so nearly with the results obtained by an examination of the blood for urea, that the latter examina tion may frequently be omitted, the methylene blue test being considered sufficient.

The most simple test of the elimination of chloride of sodium is that of Widal, who places the patient on a milk diet for several days. As each liter of milk contains 1.6 grams of sodium chloride, the amount of this salt ingested is readily determined, and knowing the amount ingested, it becomes a simple question for the chemist to determine whether the total quantity of salt ingested is elmininated or not.

With the thought that the chief function of the kidney is:

1. To prevent the escape of albumen; 2. to eliminate the excess chloride of sodium; 3. to eliminate the poisons which are ingested from without, or manufactured within, the study and classification of chronic nephritis becomes comparatively simple and most fascinating.

As necessary steps in arriving at a classification, diagnosis and treatment, (1) the methylene blue test must be made; (2) the ratio between the salt intake and output must be established; (3) the blood must be examined for urea, with due regard to protein intake, and (4) the arterial tension must be noted. This series of tests places the patient in one of the four groups of Castaigne's classification:

1. Chronic albuminuric nephritis.

2. Hydropigenous nephritis (chloremic nephritis of Widal).

3. Hyduric nephritis (uremic nephritis of Widal).

4. Chronic hypertension, or cardiovascular nephritis.

These terms at first seem new and somewhat irrelevant, but in taking them up little more at length, they at once become simple, natural, and most expressive.

The first group, chronic albuminuric nephritis, is characterized by a permanent albuminuria; the elimination of methylene blue begins and ends within the proper time; there is no retention of nitrogenous products; there is no retention of chloride of sodium; the arterial tension is normal, and there is no exaggeration of the snap of the aortic semilunar valve. These pa

tients may remain well for years and years, or they may succumb to some acute intercurrent infection, or to some acute intoxi. cation, or ultimately progress to a more serious type of nephritis.

The practical conclusion drawn by Castaigne from the study of this group applies especially to treatment. A milk diet is not required, and a normal amount of salt, or a normal nitrogenous diet, is not injurious. But the patient must be kept under observation, the blood pressure must be noted from time to time, and the function of the kidney occasionally tested.

The second group is the hydropigenous nephritis of Castaigne, or the chloremic nephritis of Widal. Both of these terms are apt. This is our old acquaintance, chronic parenchymatous nephritis, which we know to be "hydrogpigenous," or dropsy producing. Widal, thinking more of the retention of sodium chloride and, perhaps, the uremic" results of such retention, elects the term "chloremic." Since this classification is based especially on the dominant symptoms, the term coined by Castaigne "hydropigenous" seems preferable. Hydropigenous nephritis is characterized by an abundance of albumin in the urine, by marked edemas, and possibly by transudations into the serous cavities. Arterial tension is not increased, there is no exaggeration of the snap of the arotic semilunar, methylene blue is eliminated in schedule time, and there is no retention of urea. But there is retarded elimination and retention of chloride of sodium, and in this chronic hydropigenous or chloremic nephritis, the blood deposits sodium chloride in the interstitial and cellular tissues, where it is tolerated only when diluted to a cer. tain point. To secure this dilution water is attracted and edema is the result. It is this deposit of sodium chloride in the tis sues that accounts for edema. It also explains visceral edemas which are in turn responsible for headache, vomiting, gastric disturbances, etc. With increased salt intake all these symptoms are decidedly aggravated, according to Castaigne, Widal, Lemmierre, and Javal. On the other hand, a strictly salt-free diet is followed by immediate improvement in all of the symptoms in his group. In order that the prognosis and treatment may be intelligent, it is absolutely indispensable," says Castaigne, "to test the function of the kidney (inject methylene blue) to test the blood for urea, to establish the balance between salt intake and output, and to note the blood pressure. A patient is suffering from chloremic nephritis when hypertension is

These patients may be comfortable for a long time with a proper diet, or they may progress to hypertension. They are benefited by a milk diet, as milk contains but 1.6 gram of salt per liter, but it must not be forgotten that a milk diet adds a large quantity of fluid to tissues already overburdened. They may have meat, fresh water fish, eggs, dry leguminous vegetables, cereals, fruits, fresh cheese, etc. Of course these articles are to be served without salt. After several weeks of salt free diet, two or three grams of salt daily are permitted, used as the patient elects.

The third type of Widal, reluctantly accepted by Castaigne as a type of nephritis, is the cardio-vascular, in which hypertension is the feature and the accidents of which are cardio-vascular. In these patients we find the kidney-heart, and in them cardio-vascular accidents dominate the closing scenes. They have a certain quantity of albumen in the urine, but there is no retention of salt or of urea. They are usually beyond the age of 40, they have occasional headaches, occasional attacks of vertigo. They are the men whom we regard with a certain anxiety, and to whom we caution moderation in all things, and whose blood pressure and urine require watching.

The fourth type of nephritis is the hyduric of Castaigne, so named because these patients void a large quantity of urine of low specific gravity, resembling water. It is named uremic by Widal because these patients always have nitrogenous retention, and uremia is apt to give the most striking tone to the closing picture. Both terms are fitting, but that selected by Castaigne is more in keeping with the basic idea of the classification. These patients always have increased arterial tension, with a corresponding exaggeration of the aortic semilunar snap. This description easily remind us of our old acquaintance, chronic interstitial nephritis. But this type is rarely pure in its later stages. While its normal termination is uremic, it may be chloremic or cardio-vascular, or a combination of the three.

Taking up the subject of uremia, the "normal termination" of hyduric nephritis, Castaigne tells us of a "chloremic" type and of a "uremic type, and treats of both under the one heading, uremia.

Taking up first the chloremic type, permit me to again call attention to the fact that the deposition of salt in the subcutane

very patent edema; and that a similar accumulation of fluid in the lungs, digestive tract, or nervous system is much less evident, but far more serious and is due to the deposition of salt in these structures resulting in local accumulations of fluid, and to this local accumulation of salt and fluid in the viscera Widal, Javal, and their pupils apply the term "chloremia." If this accumulation of fluid be in the lungs, there will be attacks of bronchitis due to edema and congestion, with attacks of dyspnea and coughing. If in the digestive tract, the patients have repeated attacks of vomiting with watery diarrhea, the vomit and stools containing a large amount of sodium chloride, an effort on the part of nature to throw off the salt. Nephritics that do not have hypertention or retention of the urea may suffer from intense headaches, convulsions, deliriums, coma, Cheyne-Stokes respiration, sudden, blindness, etc., all due to local deposition of salt and resulting local edemas. All of these symptoms are aggravated by an increased intake of salt, and promptly relieved by a salt free diet. I am sure that some of us have heretofore considered some of these symptoms as due to urea (broad sense), with no thought of salt as the efficient and sufficient provoking agent. A therapeutic test that suggests itself is to stop the intake of chloride of sodium, or to increase it, and this might suffice were it not for the fact that nitrogen retention is often associated with this chloremic uremia; hence the importance of the blood examination for urea.

Clinically, the uremic type is evidenced by entirely different symptoms, the first of which is a loss of appetite amounting to repugnance to food, with possibly vomiting, and a serosanguinolent diarrhea. Itching of the skin is a common symptom with a general depression, somnolence, or complete coma. The patient understands the questions put to him, but his stupor is such that he answers by signs only. Uremic intoxication is often associated with chloremia, and in these cases the examination. of the blood serum for urea is especially necessary.

In the treatment of nephritis, with this French conceptition of the disease, diet naturally assumes a very important place.

Castaigne does not subscribe to the idea that with a nephritic it is "milk or death," but he reserves milk for certain definite indications, as follows: A milk diet (two and one-half liters daily) must always be imposed during the acute stage of nephritis. In hyduric nephritis (our chronic intersti

tial), during the period of compensation, an exclusive milk diet for three or four days each month is of great value, unless the patients dislike milk, when a three or fourday water, or fruit cure is substituted. This three or four day-milk cure or water cure is called a "disintoxication cure.' Milk diet is of value in the acute accidents of hyduric (chronic interstitial) nephritis, as increased albuminuria, hematuria tendency to uremia, etc. In hydropigenous nephritis, with its edemas, a salt free diet is much better than a milk diet. In simple chronic albuminuric nephritis, without chloride or nitrogenous retention, milk is unnecessary, and may actually be injurious if used to excess. Castaigne concludes: "An absolute milk diet must be considered as an exceptional diet, reserved for special cases, and for a limited period. If continued too long, its deficiency in hydrocarbons makes it injurious."

In cases of hydropigenous nephritis, a salt free diet is of prime importance, especially when there is no nitrogenous retention. A salt free diet if continued for some time may cause apathy, digestive disturbances as manifested by a distended abdomen and retarded digestion and fermentations or diarrhea, symptoms which promptly disappear if two or three grams of salt be given the patient daily. The nitrogen in a salt free diet may, if the patient suffers from nitrogen retention, favor the development of uremia. To this class of patients Castaigne gives a salt-free plus hyponitrogenous diet.

A salt-free diet is useless to patients without chloride retention, and to patients suffering from hyduric (chronic interstitial) nephritis it is dangerous because insufficient, these patients requiring restriction of the nitrogen intake. Castaigne confines a patient with chloride retentior to a salt-free diet for from fifteen days to one month. At the expiration of this time, if edemas, be still present, two or three grams of salt are given to the patient daily, to use as he elects.

When there is marked retention of urea, the hyponitrogenous treatment is imposed, and in three steps, as it were: (1) the water cure, (2) the grape cure, and (3) the hypoThe water cure is an nitrogenous diet. exceptional diet to be reserved for uremia. only, and it consists of from two to three quarts of water, and about three ounces of milk sugar daily for four days. During this time the patient may be given some active purge. This water cure is followed

by a grape cure, which is very easily carried out everywhere even in winter, when

grape juice is remembered. The water diet and the grape diet are but temporary, to be followed by the hyponitrogenous diet, in which starches and sugars are all important. Potato with butter, rice with sugar, tapicoa, sago, herbaceous vegetables, endive, spinach, turnips, carrots, leeks, well ripened fruit, milk in small quantites. Meat, fish and dried leguminous vegetables are to be prohibited.

Before closing should like to add that in the treament of acute uremia, Castaigne urges bleeding, lumbar puncture, and the water diet. He considers lumbar puncture and the removal of fifteen to thirty c.c. of fluid as of great benefit in the treatment of the nervous symptom of uremia, as headaches, ocular disturbances, convulsions, etc. He urges lumbar puncture in all cases of uremia where the nervous system is compromised.

In closing, I believe that this modern French classification of nephritis presents something tangible, refreshing, and stimulating, and that it makes it possible to approach nephritis with a clearer conception of what is to be done.

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