COURSE OF THE DISEASE - CHRONIC PRODUCTIVE NEPHRITIS WITHOUT It is characteristic of the chronic productive inflammations of the lungs, the heart, the arteries, the liver, and the kidneys that, while they often exist as serious and fatal diseases, they may also exist as lesions and yet do not interfere with long life and apparent good health. This seems to depend, at least in part, on the rapidity with which the inflammatory changes in these different parts of the body are developed. If the development is slow enough, the functions of the organ continue to be performed in spite of the new growth of con nective tissue.
We have to admit that in all cases of chronic non-exudative ne phritis a period of weeks, or months, or years elapses during which the changes in the kidney are slowly going on, and yet the patients seem well and are not aware that they have any disease. How far the nephritis can advance and how many years it can exist before the symptoms of it appear, it is difficult to say. We see a great many different stages in the development of the nephritis in persons who die from other diseases and have never given any renal symptoms.
The nephritis is of slow development, gradually altering the structure of the kidney more and more, so that we should expect that the symptoms of the nephritis would also be developed gradually. This is very often the case, but quite as often the nephritis will ad vance without symptoms up to a certain point and then the patient suddenly becomes ill.
A. Cases with Slow Development of Symptoms.—Of the patients in whom the symptoms are gradually developed we may distinguish : 1. Patients who gradually develop hypertrophy of the left ventri cle of the heart, with a lowering of the specific gravity of the urine, and a pulse that is easily made too tense, otherwise their health is good. We often watch these persons for many years, expecting other renal symptoms. But the symptoms do not come, and the patients die of some other disease.
2. Patients who have digestive disturbances, and gradual loss of flesh and strength. The urine is of low specific gravity and increased quantity, or the specific gravity and quantity remain almost normal; often from time to time there are traces of albumin and a few hyaline casts. These patients are often very puzzling. From year to year
they slowly get more feeble and more emaciated; the digestive dis turbances are sometimes better and sometimes worse. Occasionally there is an interval of great improvement so that the patients think they have entirely recovered. As the disease lasts a long time the patients are apt to see a number of physicians and get a number of opinions, for the diagnosis is really a difficult one. Some of the pa tients die from intercurrent diseases, but others go on and die simply exhausted with nothing but the chronic nephritis.
3. Patients who for months or years have attacks of spasmodic dyspncea and between these attacks are comparatively well. The pa tients are usually over forty years old. The attacks of clyspncea are apt to come on in the early morning and go off later in the day. Often chronic arteritis, or chronic endocarditis, exists at the same time. For a while the attacks of dyspncea can be relieved, and the pa tients are capable of mental and physical exertion and feel quite con fident of recovery. But as the attacks of clyspncea recur they last longer and are harder to relieve. Finally comes the time when the dyspncea cannot be relieved. It lasts day and night, the patients cannot lie down, the scrotum and legs become oedematous, and death hardly comes soon enough to relieve their distress.
4. Patients who have symptoms progressing for several years. At first vomiting, or headache, or neuralgic pains. Then dyspncea, a little dropsy of the legs, and loss of flesh and strength. Finally death from exhaustion, or with an attack of convulsions, or in coma.
5. Patients in whom the symptoms come on in attacks, each at tack worse than the preceding, and the general health more and more impaired between the attacks. During the attacks there are head ache, sleeplessness, delirium, stupor, coma, convulsions, dyspnoea, vomiting—sometimes one, sometimes another the prominent symp tom. The tension of the pulse is considerably increased. The urine is of low specific gravity and often contains a little albumin. Be tween the attacks the patients at first seem to be fairly well, but later they gradually lose flesh and strength. The urine between the attacks is of low specific gravity and contains little or no albumin. The pa tients finally die in one of the attacks.