SYMPTOMS - CHRONIC PRODUCTIVE OR DIFFUSE NEPHRITIS WITH The urine varies in quantity at different times in the course of the disease. In the earlier periods the urine is often scanty or even sup pressed. If the disease goes on rapidly the quantity of urine may continue small; if it goes on slowly the quantity is often increased. In some of the worst cases, with general dropsy, the patients will pass more than 100 ounces of urine a day.
The specific gravity and the proportion of urea to the ounce of urine slowly diminish as the disease progresses. This is the rule, but there are exceptions to it. In cases which improve, the quantity of urea, after being much diminished, may increase until the patient excretes the full normal quantity for the twenty-four hours.
In the cases of shorter duration the specific gravity is apt to run between 1.012 and 1.020. In the very chronic cases it will be be tween 1.001 and 1.005. A very low specific gravity indicates a large growth of connective tissue in the stroma of the cortex, or waxy de generation of the capillaries of the glomeruli and of the arteries of the kidney. Many persons who think that they have kidney disease get into the habit of drinking large quantities of mineral waters. This, of course, gives them urine of low specific gravity. In all doubtful cases it is necessary to determine the quantity of the whole excretion of urea for the twenty-four hours. There are patients in whom the quantity of urea is the principal factor in enabling one to decide between albuminuria without nephritis and chronic nephritis with exudation.
The urine regularly contains albumin and casts. During the active periods of the disease the quantity of albumin is very large; in the slow, prolonged cases the quantity is much smaller and at times it may disappear altogether. Generally speaking, with large quanti ties of albumin the patients are dropsical and anwmic; with small quantities of albumin they are anaemic but not dropsical. There seems to be a common cause for the exudation of serum from the blood-vessels throughout the entire body, the serum infiltrating the tissues, accumulating in the serous cavities, and mixing with the urine.
The number of casts is regularly in proportion to the quantity of albumin, but there are exceptions to this rule.
A peculiar pallor of the skin and white color of the sclerotic is seldom absent. This gives to the patient a face very characteristic of chronic nephritis. In making a diagnosis in doubtful cases a good deal of importance is to be attached to the presence or absence of this appearance of the face. The change in the color corresponds to a diminution in the quantity of haemoglobin and in the number of red blood-cells. These changes in the blood are often not far advanced, but sometimes they are, and some patients even die with the symp toms of pernicious anaemia.
Dropsy may be considered almost a constant symptom of chronic exudative nephritis. There is an infiltration of the subcutaneous connective tissue with serum and an accumulation of serum in the serous cavities. The position of the fluid varies with that of the pa tient, accumulating in the dependent portion of the body. There is much variety as to the extent of the dropsy. In some patients there is never anything more than a moderate of the legs, while in others a marked general dropsy is the most prominent symptom of the disease. There is also a variety as to the time of appearance and the duration of the dropsy. It may be one of the first symptoms of the nephritis, or it may not occur until late in the disease. When it is once established it may never leave the patient, or it may appear and disappear at irregular intervals.
Many of the patients are troubled with headache and sleeplessness. In some of them these symptoms exist only when the pulse is of high tension and disappear when the pulse becomes soft. In others, how ever, the headache and sleeplessness persist with a soft pulse. It must not be forgotten that these symptoms may also depend on di gestive disturbances and not on the disease of the kidneys.