SYMPTOMS - ACUTE EXUADATIVE NEPHRITIS.
1. There are cases of acute nephritis of so mild a character that they may easily be overlooked. I think that these mild cases occur more frequently than is commonly supposed. The patients are hardy sick enough to go to bed. They have a little headache, per haps some aching in the back and limbs, loss of appetite, a little Eau sea, and the feeling of general malaise. They often think that they have taken cold. These indefinite symptoms last for one or two weeks, disappear, and the patient is well again. If the urine is not examined it is not known that the patient has been suffering from a mild nephritis. If the urine is examined it is found that the quantity is somewhat diminished, the specific gravity is not lowered, an ap preciable quantity of albumin is present, with hyaline, granular, and epithelial casts, sometimes with red and white blood-cells. If the number of blood-cells is sufficient to color the urine, the patient's at tention is attracted by the change in color; the diminished quantity he is apt not to notice. These changes in the urine last for four or five weeks and then disappear.
2. The ordinary cases of acute exudative nephritis vary indeed in their severity, but all give characteristic symptoms. The only dis eases with which they can be confounded are acute productive ne phritis, and exacerbations of a chronic nephritis. If any person seems to have several attacks of acute nephritis, it regularly means that he has a chronic nephritis with exacerbations.
The quantity of urine is diminished at the onset of the nephritis and continues small until the activity of the inflammation has sub sided; then the quantity increases from day to day and may even ex ceed the normal. The quantity of the urine must be in proportion to the quantity of blood which passes through the kidneys, so that this quantity gives us a measure of the intensity of the congestion which is arresting the circulation of the blood through the kidney. Complete suppression of urine is a serious symptom, both because it denotes an intense nephritis and because it is of itself a cause of death. The production of only a few ounces of urine in each twenty four hours is the rule in a great number of cases, and is not neces sarily of serious import. If it lasts only a few days the patients do
perfectly well. If the scanty excretion of urine is kept up for a num ber of days, opinions vary as to the results. Some believe that the diminished quantity of urine is the cause of the dropsy. Some think that the deficient excretion of excrementitious substances causes the convulsions. Some believe that the principal effect of a diminished excretion of urine is to cause bodily feebleness.
Unquestionably the production of urine may be very small for a number of days and yet the patients do well. Dr. Whitelaw (Lancet, Sept. 29, 1877) reports a case of anuria lasting for twenty-five days. The patient was a boy eight years old. The suppression of urine began twelve weeks after the beginning of a scarlet fever. With the exception of two ounces passed on the thirteenth day, there was com plete anuria for twenty-five days. Except for slight. headaches and later slight cedema, there were no urfemic or dropsical symptoms throughout. There was no albuminuria and no fever. The boy was watched night and day. He recovered entirely.
The specific gravity of the urine remains normal or is higher while the quantity is small ; when the quantity is increased the speci fic gravity falls a little.
The appearance of the urine is turbid, or smoke-colored, or bloody.
Albumin is present in very large quantities. Casts are numerous— hyaline, granular, nucleated, epithelial, and blood. There are also red and white blood-cells, and epithelial cells from the kidneys and from the bladder. As a rule the quantity of albumin and the number of casts are in proportion to the severity of the nephritis, but this is not always the case. Large quantities of albumin, numerous casts, and many red and white blood-cells may be found in the urine of kidneys which, after death, show no structural changes except in the glomeruli ; while, on the other hand, small quantities of albumin and a few hyaline casts are compatible with a severe ne phritis. Still further, the number of.casts found in the urine during life is not always in proportion to the number of casts found in the correspcinding kidneys after death.