THE LOW SALT SYNDROMES
Authors: T S DANOWSKI, E B GERGUS, F M MATEER
Journal: Annals of Internal Medicine (1955)

Article1 October 1955THE LOW SALT SYNDROMEST. S. DANOWSKI, F.A.C.P., E. B. FERGUS, F. M. MATEERT. S. DANOWSKI, F.A.C.P., E. B. FERGUS, F. M. MATEERAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-43-4-643 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptSome of the earlier workers noted the presence of low levels of serum sodium or serum total base in pneumonia, diabetes mellitus, eclampsia, uremia, congestive heart failure, cirrhosis and miscellaneous other conditions.1a, bSchroeder's clinical report in which the phrase "low salt syndrome" was first used pointed out the concurrence of hyponatremia, azotemia and clinical deterioration in edematous patients maintained on low sodium regimens with or without excessive administration of water.1cIn keeping with Schroeder's original description, the term "low salt syndrome" has become in subsequent usage a general phrase for all instances of low serum sodium levels. In the...Bibliography1. AtchleyLoebBenedictPalmer DWRFEMWW(a) : Physical and chemical studies of human blood serum, Arch. Int. Med. 31: 616, 1923. (b) Atchley, D. W., and Benedict, E. M.: Serum electrolyte studies in normal and pathological conditions: pneumonia, renal edema, cardiac edema, uremic and diabetic acidosis, J. Clin. Investigation 9: 265, 1930. (c) Schroeder, H. A.: Renal failure associated with low extracellular sodium chloride. The low salt syndrome, J. A. M. A. 141: 117, 1949. CrossrefGoogle Scholar2. Kerpel-Fronius E(a) : Ueber die Beziehungen zwischen Salz- und Wasserhaushalt bei experimentellen Wasserverlusten, Ztschr. f. Kinderh. 57: 489, 1935. (b) Kerpel-Fronius, E.: Durstexsikkose und Salzmangelexsikkose, Acta pædiat. 22: 143, 1937. (c) McCance, R. A.: Experimental sodium chloride deficiency in man, Proc. Roy. Soc. London 119: 245, 1936. (d) McCance, R. A.: The effect of salt deficiency in man on the volume of the extracellular fluids, and on the composition of sweat, saliva, gastric juice and cerebrospinal fluid, J. Physiol. 92: 208, 1938. (e) Nadal, J. W., Pedersen, S., and Maddock, W. G.: A comparison between dehydration from salt loss and from water deprivation, J. Clin. Investigation 20: 691, 1941. (f) Elkinton, J. R., Danowski, T. S., and Winkler, A. W.: Hemodynamic changes in salt depletion and dehydration, J. Clin. Investigation 25: 120, 1946. (g) Hopper, J., Jr., Elkinton, J. R., and Winkler, A. W.: Plasma volume of dogs in dehydration, with and without salt loss, J. Clin. Investigation 23: 111, 1944. (h) Flanagan, J. B., Davis, A. K., and Overman, R. R.: Mechanism of extracellular sodium and chloride depletion in adrenalectomized dog, Am. J. Physiol. 160: 89, 1950. (i) Bristol, W. R.: Relation of sodium chloride depletion to urine excretion and water intoxication, Am. J. M. Sc. 221: 412, 1951. (j) Tank, G. W., and Herrin, R. C.: Effect of NaCl deficiency on kidney function in dogs, Am. J. Physiol. 167: 831, 1951. (k) Remington, J. W., Remington, R. E., and Caddell, H. M.: Production of circulatory failure by electrolyte depletion, Am. J. Physiol. 170: 564, 1952. (l) Schechter, A. J., Cary, M. K., Carpentieri, A. L., and Darrow, D. C.: Changes in composition of fluids injected into the peritoneal cavity, Am. J. Dis. Child. 46: 1015, 1933. (m) Elkinton, J. R., Winkler, A. W., and Danowski, T. S.: The importance of volume and of tonicity of the body fluids in salt depletion shock, J. Clin. Investigation 26: 1002, 1947. (n) Mateer, F. M., and Danowski, T. S.: Changes in undetermined acid following electrolyte depletion by vivodialysis, Federation Proc. 13: 96, 1954. CrossrefGoogle Scholar3. Darrow DC(a) : The importance of deficit of sodium and chloride in dehydration, J. Pediat. 13: 670, 1938. (b) Taylor, F. W.: Electrolyte loss by postoperative nasal-gastric suction, Arch. Surg. 66: 538, 1953. (c) Hutchinson, D. L., and Plentl, A. A.: Acute sodium deficiency in postpartum preeclamptic patient: report of case, Am. J. Obst. and Gynec. 66: 891, 1954. CrossrefGoogle Scholar4. DanowskiWinklerElkinton TSAWJR(a) : Biochemical and hemodynamic changes following the subcutaneous injection of glucose solution, J. Clin. Investigation 26: 887, 1947. (b) Mateer, F. M., Garver, K. L., Sakol, M. J., and Danowski, T. S.: Hyaluronidase and the subcutaneous administration of electrolyte-free glucose solution, Am. J. M. Sc. 226: 139, 1953. (c) Abbott, W. E., Levey, S., Foreman, R. C., Krieger, H., and Holden, W. D.: The danger of administering parenteral fluids by hypodermoclysis, Surgery 32: 305, 1952. (d) Editorial: Hyaluronidase and hypodermoclysis, J. A. M. A. 151: 644, 1953. CrossrefMedlineGoogle Scholar5. LoebAtchleyParson RFDWW(a) : Significance of certain chemical abnormalities found in blood in Addison's disease, Tr. A. Am. Physicians 52: 228, 1937. (b) Thorn, G. W., Forsham, P. H., and Emerson, K., Jr.: Diagnosis and treatment of adrenal insufficiency, 2nd Ed., 1951, Charles C Thomas, Springfield, Illinois. (c) Fraser, C. G., Preuss, F. S., and Bigford, W. D.: Adrenal atrophy and irreversible shock associated with cortisone therapy, J. A. M. A. 149: 1542, 1952. Google Scholar6. ThornKoeffClinton GWGFM(a) : Renal failure simulating adrenocortical insufficiency, New England J. Med. 231: 76, 1944. (b) Sawyer, W. H., and Solez, C.: Salt-losing nephritis simulating adrenocortical insufficiency, New England J. Med. 240: 210, 1949. (c) Murphy, R. V., Coffman, E. W., Pringle, B. H., and Iseri, L. T.: Studies of sodium and potassium metabolism in salt-losing nephritis, Arch. Int. Med. 90: 750, 1952. (d) Joiner, C. L., and Thorne, M. G.: Salt-losing nephritis, Lancet 2: 454, 1952. (e) Nussbaum, H. E., Bernhard, W. G., and Mattia, V. D.: Chronic pyelonephritis simulating adrenocortical insufficiency, New England J. Med. 246: 289, 1952. (f) Bull, G. M., Joekes, A. M., and Lowe, K. G.: Renal function studies in acute tubular necrosis, Clin. Sc. 9: 379, 1950. (g) Ravin, I. S., Aronson, P. R., and Yules, J. H.: Complications of the diuretic phase of lower-nephron nephrosis, New England J. Med. 244: 830, 1951. (h) Hunter, R. B., and Muirhead, E. E.: Prolonged renal salt wastage in "lower nephron nephrosis," Ann. Int. Med. 36: 1297, 1952. CrossrefGoogle Scholar7. JungmannMeyer JE(a) : Experimentelle Untersuchungen über die Abhangigkeit der Nierenfunktion von Nervensystem, Arch. f. exper. Path. u Pharmakol. 73: 49, 1913. (b) Peters, J. P., Welt, L. G., Sims, E. A. H., Orloff, J., and Needham, J.: A salt-wasting syndrome associated with cerebral disease, Tr. A. Am. Physicians 63: 57, 1950. (c) Welt, L. G., Seldin, D. W., Nelson, W. P., German, W. J., and Peters, J. P.: Role of the central nervous system in metabolism of electrolytes and water, Arch. Int. Med. 90: 355, 1952. (d) Cooper, I. S.: Disorders of electrolyte and water metabolism following brain surgery, J. Neurosurg. 10: 389, 1953. (e) Cort, J. H.: Cerebral salt wasting, Lancet 1: 752, 1954. (f) Anthonisen, P., Hilden, T., and Thomsen, A. C.: Electrolyte disturbances in cerebral lesions, Acta med. Scandinav. 150: 355, 1954. CrossrefGoogle Scholar8. MegibowBookmanSirota RSJFJH(a) : Mechanisms of blood pressure depression following sodium depletion, Am. J. Med. 8: 395, 1950. (b) Lesser, G. T., Dunning, M. F., Epstein, F. H., and Berger, E. Y.: Electrolyte losses in edematous individuals following organic mercurials, Federation Proc. 10: 81, 1951. (c) Wiggins, W. S., Manry, C. H., Lyons, R. H., and Pitts, R. F.: The effect of salt loading and salt depletion on renal function and electrolyte excretion in man, Circulation 3: 275, 1951. (d) McLester, J. S., and Holley, H. L.: Salt depletion syndrome with increasing edema occurring during mercurial diuretic therapy, Ann. Int. Med. 36: 562, 1952. (e) Preedy, J. R. K., and Russell, D. S.: Acute salt depletion associated with nephrotic syndrome developing during treatment with mercurial diuretic, Lancet 2: 1181, 1953. CrossrefGoogle Scholar9. Danowski TS(a) : Studies in diabetic coma and acidosis. Interrelationships of urinary potassium, sodium and chloride, J. Lancet 73: 224, 1953. (b) Knowles, H. C., Jr., and Guest, G. M.: Changes of tissue electrolytes in diabetic acidosis, J. Clin. Investigation 32: 580, 1953. MedlineGoogle Scholar10. DanowskiAustinGowMateerWeigandPetersGreenman TSACRCFMFAJHL(a) : Electrolyte and nitrogen balance studies in infants following cessation of vomiting, Pediatrics 5: 57, 1950. (b) Gamble, J. L., and McIver, M. A.: Body fluid changes due to continued loss of the external secretion of the pancreas, J. Exper. Med. 48: 859, 1928. (c) Falconer, M. A., Murray, A., Osterberg, A. E., and Bargen, J. A.: Intestinal obstruction in man: alterations in the serum bases and their significance, Arch. Surg. 38: 869, 1939. (d) Darrow, D. C.: Retention of electrolyte during recovery from severe dehydration due to diarrhea, J. Pediat. 28: 515, 1946. (e) Gamble, J. L.: Deficits in diarrhea, J. Pediat. 30: 488, 1947. (f) Seneca, H., and Henderson, E.: Extrarenal azotemia in cholera, Am. J. Trop. Med. 30: 855, 1950. (g) Catanzaro, F. J., Ostfeld, A. M., and Bergner, G. E.: Occurrence of low salt syndrome during treatment with chloramphenicol, J. A. M. A. 149: 571, 1952. MedlineGoogle Scholar11. GreenmanShalerDanowski LJBTS: Biochemical disturbances and clinical symptoms during prolonged exchange resin therapy in congestive heart failure, Am. J. Med. 14: 391, 1953. CrossrefMedlineGoogle Scholar12. CookePrattDarrow REELDC(a) : The metabolic response of infants to heat stress, Yale J. Biol. and Med. 22: 227, 1950. (b) Di Sant'Agnese, P. A., Darling, R. C., Perera, G. A., and Shea, E.: Abnormal electrolyte composition of sweat in cystic fibrosis of pancreas. Clinical significance and relationship to disease, Pediatrics 12: 549, 1953. MedlineGoogle Scholar13. KellyDeming JJQB(a) : Low sodium syndrome and hyperpotassemia induced in edematous patients by mechanical removal of body fluid, Am. J. Med. 10: 766, 1951. (b) Nelson, W. P., III, Rosenbaum, J. D., and Strauss, M. B.: Hyponatremia in hepatic cirrhosis following paracentesis, J. Clin. Investigation 30: 738, 1951. (c) Holley, H. L., and McLester, J. S.: Salt depletion syndrome associated with decompensated cirrhosis of the liver, J. A. M. A. 145: 392, 1951. (d) Levinsky, W. J., and Kern, R. A.: Fluid, electrolyte, and protein depletion secondary to the bronchorrhea of pulmonary adenomatosis: a complication heretofore unreported, Am. J. M. Sc. 223: 512, 1952. CrossrefGoogle Scholar14. DanowskiWinklerElkinton TSAWJR: The treatment of shock due to salt depletion; comparison of the hemodynamic effects of isotonic saline, of hypertonic saline, and of isotonic glucose solutions, J. Clin. Investigation 25: 130, 1946. CrossrefGoogle Scholar15. WinklerCrankshaw AWOF(a) : Chloride depletion in conditions other than Addison's disease, J. Clin. Investigation 17: 1, 1938. (b) Westwater, J. O., Steven, D., and Garry, R. C.: A note on the serum Na level in patients suffering from tuberculosis, Clin. Sc. 4: 73, 1939. (c) Sims, E. A. H., Welt, L. G., Orloff, J., and Needham, J. W.: Asymptomatic hyponatremia in pulmonary tuberculosis, J. Clin. Investigation 29: 1545, 1950. (d) Rapoport, S., West, C. D., and Brodsky, W. A.: Salt losing conditions; the renal defect in tuberculous meningitis, J. Lab. and Clin. Med. 37: 550, 1951. (e) Harrison, H. E., Finberg, L., and Fleishman, E.: Disturbances of ionic equilibrium of intracellular and extracellular electrolytes in patients with tuberculous meningitis, J. Clin. Investigation 31: 300, 1952. (f) Amatuzio, D. S., Breitenbucher, R. C., Falk, A., and Stutzman, F. L.: Hypopotassemia and hyponatremia in pulmonary tuberculosis during treatment with streptomycin and para-aminosalicylic acid, Am. Rev. Tuberc. 66: 357, 1952. CrossrefMedlineGoogle Scholar16. ElkintonWinklerDanowski JRAWTS(a) : Inactive cell base and the measurement of changes in cell water, Yale J. Biol. and Med. 17: 383, 1944. (b) Elkinton, J. R., Winkler, A. W., and Danowski, T. S.: Transfers of cell sodium and potassium in experimental and clinical conditions, J. Clin. Investigation 27: 74, 1948. (c) Srikantia, S. G., Venkatachalam, P. S., and Gopalan, C.: Electrolyte studies in nutritional edema, Metabolism 2: 521, 1953. MedlineGoogle Scholar17. DanowskiElkinton TSJR: Exchanges of potassium related to organs and systems, Pharmacol. Rev. 3: 42, 1951. MedlineGoogle Scholar18. Laragh JN: Effect of potassium chloride on hyponatremia, J. Clin. Investigation 33: 807, 1954. CrossrefMedlineGoogle Scholar19. WeirLarsonRowntree JFEELG(a) : Studies in diabetes insipidus; water balance and water intoxication, Arch. Int. Med. 29: 306, 1922. (b) Helwig, F. C., Schutz, C. B., and Curry, D. E.: Water intoxication; report of fatal human case, with clinical, pathologic and experimental studies, J. A. M. A. 104: 1569, 1935. (c) Talbot, N. B., Crawford, J. D., and Butler, A. M.: Homeostatic limits to safe parenteral fluid therapy, New England J. Med. 248: 1100, 1953. (d) LeQuesne, L., and Lewis, A. A. G.: Postoperative water and sodium retention, Lancet 1: 153, 1953. (e) Kerrigan, G. A., Crawford, J. D., Sceery, R. T., Heeley, A., Terry, M., and Talbot, N. B.: Concerning the importance of the homeostatic systems in the recovery of patients requiring parenteral fluid therapy, Am. J. Dis. Child. 86: 622, 1953. CrossrefGoogle Scholar20. WestonHanensonGrossmanBorunWolfmanLeiter REIBJERML(a) : Water retention and hyponatremia produced in edematous cardiac patients by Pitressin tannate administration, Federation Proc. 12: 153, 1953. (b) Chalmers, T. M., Lewis, A. A. G., and Pawan, G. L. S.: Effect of posterior pituitary extracts on renal excretion of sodium and chloride in man, J. Physiol. 112: 238, 1951. (c) Leaf, A., and Mamby, A. R.: Antidiuretic mechanism not regulated by extracellular fluid tonicity, J. Clin. Investigation 31: 60, 1952. Google Scholar21. AlbrinkHaldMan MJPMEB: Water content of hyperlipemic serum, J. Clin. Investigation 33: 914, 1954. Google Scholar22. ElkintonSquires JRRD(a) : The distribution of body fluids in congestive heart failure. I. Theoretic considerations, Circulation 4: 679, 1951. (b) Squires, R. D., Singer, R. B., Moffitt, G. R., Jr., and Elkinton, J. R.: The distribution of body fluids in congestive heart failure. II. Abnormalities in serum electrolyte concentration and in acid-base equilibrium, Circulation 4: 697, 1951. (c) Black, A. B., and Litchfield, J. A.: Uraemia complicating low salt treatment of heart failure, Quart. J. Med. 20: 149, 1951. (d) Sanderson, K. V.: Salt depletion and mercury poisoning: potential dangers in treatment of failing heart, M. J. Australia 1: 662, 1950. (e) Squires, R. D., and Elkinton, J. R.: The significance of hyponatremia in congestive heart failure, J. Clin. Investigation 30: 675, 1951. (f) Citron, D., Bercu, B., Lemmer, R., and Massie, E.: Congestive heart failure and hyponatremia: untoward effects of mercurial diuresis, Ann. Int. Med. 34: 872, 1951. (g) Weston, R. E., Grossman, J., Escher, J. W., Mokotoff, R. L., and Leiter, L.: Pathogenesis and treatment of salt and water retention in congestive failure, M. Clin. North America 5: 61, 1950. (h) Iseri, L. T., McCaughey, R. S., Alexander, L., Boyle, A. J., and Myers, G. B.: Plasma sodium and potassium; concentrations in congestive heart failure: relationship to pathogenesis of failure, Am. J. M. Sc. 224: 135, 1952. (i) Farber, S. J., and Soberman, R. J.: The relative amounts of body sodium and water in patients with heart, renal or hepatic disease, J. Clin. Investigation 32: 566, 1953. (j) Uricchio, J. F., and Calenda, D. G.: Failure of hypertonic saline in treatment of hyponatremia and edema in congestive heart failure, Ann. Int. Med. 39: 1288, 1953. CrossrefMedlineGoogle Scholar23. Elkinton JR(a) : Unpublished data. (b) Danowski, T. S.: Unpublished data. Google Scholar24. WhiteKurtzRubin AGMG(a) : Comparative renal responses to water and antidiuretic hormone in diabetes insipidus and in chronic renal disease, Am. J. Med. 16: 220, 1954. (b) Welt, L. G.: Edema and hyponatremia, Arch. Int. Med. 89: 931, 1952. (c) White, A. G., Kurtz, M., and Rubin, G.: Impaired renal response to antidiuretic hormone in chronic renal disease, J. Clin. Investigation 32: 611, 1953. (d) White, A. G., Rubin, G., and Leiter, L.: Studies in edema. III. Effect of Pitressin on renal excretion of water and electrolytes in patients with and without liver disease, J. Clin. Investigation 30: 1287, 1951. (e) Stein, M., Schwartz, R., and Mirsky, I. A.: Antidiuretic activity of plasma of patients with hepatic cirrhosis, congestive heart failure, hypertension and other clinical disorders, J. Clin. Investigation 33: 77, 1954. (f) Brown, H., Iliya, A. A., Price, P. B., and Rambo, O. N., Jr.: Effect of acute renal failure on the plasma volume and volume of packed red cells in the dog, J. Lab. and Clin. Med. 45: 102, 1955. CrossrefMedlineGoogle Scholar25. Klinghoffer KA: Dehydration from diuretics, Internat. Clin. 1: 221, 1941. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Pittsburgh, Pennsylvania*Presented at the Annual Session of the American College of Physicians, Philadelphia, Pennsylvania, April 25, 1955.From the Department of Research Medicine, Children's and Presbyterian Hospitals of Pittsburgh, University of Pittsburgh School of Medicine.†Established Investigator of the American Heart Association. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byThe Flame Photometer as Engine of Nephrology: A BiographyTranscellular Movement and Intracellular Concentration of Sodium in Erythrocytes After Surgery and in Seriously III PatientsEntstehung und Korrektur von Störungen im Wasser-Elektrolyt- und Säuren-Basen-Haushalt bei Erkrankungen des Herz-Kreislauf-SystemsBrain Damage and Brain DeathSick Cells and HyponatræmiaInappropriate Renal Sodium Loss Reverted by Vena Cava ObstructionHENRY O. HEINEMANN, M.D., JOHN H. LARAGH, M.D., F.A.C.P.Adrenocortical insufficiencyMineralsSome Effects of High and Low Sodium Intakes during Pregnancy in the RatSome Effects of High and Low Sodium Intakes during Pregnancy in the RatDie Grundstoffe der NahrungThe pathogenesis of hyponatremia in congestive heart failure�ber Hyponatri�mie-Syndrome und ihre Analyse durch Elektrolytbestimmung in ErythrocytenHYPONATRÆMIA AND IMPAIRED RENAL TUBULAR FUNCTION WITH CARCINOMA OF BRONCHUSThe low salt syndromeSt�rungen des Wasser- und Elektrolythaushalts bei diuretischer TherapieSymptoms and signs in disorders of body fluidPathophysiologie der HerzinsuffizienzMineralstoffwechsel und KreislaufMineralstoffwechsel und KreislaufClinical and Experimental Interrelations of Sodium and the Central Nervous System*Diuretische und saluretische Wirkungen von Chlorothiazid unter normalen und pathologischen BedingungenThe alkali metal ions in the organismAllgemeine Nebenwirkungen der diuretischen TherapieElectrolytes and NutritionACTH Treatment for Novurit-Resistant Cardiac EdemaTHE OSMOTIC BEHAVIOUR OF THE BODY CELLS IN MANThe breakdown of the water equilibrium in diseaseThe Natural History of the Eccrine Miliarias: A Study in Human EcologyTherapy of acute and chronic glomerulonephritisEditorialDiseases of Medical ProgressTreatment of the Low-Salt Syndrome in Congestive Heart Failure by the Controlled Use of Mercurial Diuretics 1 October 1955Volume 43, Issue 4Page: 643-657KeywordsCirrhosisEclampsiaHeartHeart failureHospital medicineHyponatremiaIntoxicationPneumoniaSaltsSodium ePublished: 1 December 2008 Issue Published: 1 October 1955 Copyright & PermissionsCopyright ©, 1955, by The American College of PhysiciansPDF downloadLoading ...