METABOLISM IN NEPHRITIS 393 



exception may not prove the rule, but it is very probable that Chace and 

 Myers are correct in supposing that the determining factor in bringing 

 about death from renal insufficiency in many instances is. an acidosis at- 

 tendant upon the inability of the kidney to excrete acid phosphates. 



A disturbed water metabolism may be a distinct contributing factor 

 towards producing renal insufficiency. This may be brought about in a 

 number of ways. It has been previously mentioned that the sudden ex- 

 cretion of large volumes of fluid in edematous patients may bring about 

 a harmful degree of blood and tissue concentration. Foster and Davis 

 have shown that in the severer cases of nephritis in which the power to 

 concentrate solids in the urine is much diminished there is a considerable 

 increase in non-protein nitrogenous constituents of the blood where the 

 water intake was curtailed. Mosenthal(a) had demonstrated in experi- 

 mental nephritis in dogs that a part at least of the increase of non-protein 

 nitrogen in the blood must be attributed to inspissation ; the kidney, with 

 its polyuric tendency, in these conditions acts like a suction cup that drains 

 the body of every available drop of water. That the signs of renal insuffi- 

 ciency may be marked if there is not enough water available to form 

 urine is possibly best illustrated by the constantly quoted fact that in 

 cholera, when the intestines deplete the body of fluid, anuria results even 

 though the kidneys are anatomically intact. 



It is a well known fact that animals deprived of water will not live 

 as long while starving as those that are allowed to drink (ISTothwang, 

 Landauer). Desiccation will hasten a fatal outcome, as any one who has 

 seen many cases of diabetes mellitus and nephritis must appreciate. It 

 is almost a clinical proverb, not without its exceptions to be sure, that a 

 diabetic patient will not die if he exhibits some sign of edema. Besides 

 the above well founded bedside impression, there is one fact that has been 

 experimentally established, on both man and animals, which must have 

 a bearing in this connection : there is a distinct increase in protein catab- 

 olism when the fluid intake is excessively curtailed (Denning, Landauer, 

 Straub(6)). 



It may be readily gathered, from all the factors mentioned above, which 

 may be ascribed to an inadequate water drinking: increased tissue and 

 blood concentration, diminished excretion of urine, and an acceleration 

 of protein catabolism, that water deprivation may in many instances be 

 a distinct contributing factor, and at times the main cause for the occur- 

 rence of the symptoms of a marked renal insufficiency. 



Protein destruction as a possible cause of the intoxication following 

 renal insufficiency has already been discussed under the heading of "pro- 

 tein destruction in nephritis." The conclusion arrived at was that this 

 phenomenon was a state accompanying renal insufficiency of a very marked 

 degree, being a symptom, but not a causative factor of the "uremic poison- 

 ing." 



