(b) Both Forms of Acute Nephritis. In children suffering from acute nephritis convulsions are of quite frequent occurrence, even when the disease is not of severe type. So many children recover after one or more convulsions that they are not grave symptoms. In adults convulsions do not occur nearly as often as in children, but the patients are much more likely to die. In children general blood letting can very seldom be practised; in adults there are a few cases in which it is appropriate. In most of the patients the drugs which dilate the arteries give altogether the best results.
(c) Chronic Nephritis with Exudation. The convulsions belong to the advanced cases of the disease, to the patients who are dropsical, anaemic, and apparently thoroughly poisoned with excrementitious substances. The heart's action and the pulse are feeble. In these patients it is difficult, or impossible, to control the convulsions. The most efficient plan seems to be the daily sweating with the hot pack.
There are cases of chronic nephritis with exudation in which an exacerbation of the inflammation takes place, and the patients then behave much as if they had an acute nephritis.
(d) Chronic Nephritis without Exudation. Convulsions are of frequent occurrence early in the disease as well as late; indeed, in many persons the attack of convulsions is the first symptom of the nephritis. Many of the patients have hypertrophy of the left ven tricle of the heart and chronic endarteritis in addition to the ne phritis. Common as these attacks are, their causation is most ob scure, for there can be no question that the liability to the convul sions is not at all in proportion to the failure of the functions of the kidneys. Certainly a marked increase in arterial tension is the rule with these attacks, and the control of the convulsions is in propor tion to the success in dilating the arteries. But there are cases in which we are not able either to dilate the arteries or to control the con vulsions; and there are cases in which the convulsions continue al though the pulse becomes rapid and feeble. It is for the convulsions with this form of nephritis that hypodermics of morphine are of so much efficacy for a time. It must be admitted that when a patient with chronic nephritis begins to have convulsions death is not far off.
5. Contractions of Groups of —These are of common occur rence in the severe forms of acute and chronic nephritis and in puer peral eclampsia. Very often they merely precede an attack of general convulsions. They are best marked and of longest continuance in the advanced cases of chronic nephritis with exudation.
6. Delirium and Coma.—They come on suddenly in attacks, either associated with convulsions or by themselves; or they are developed slowly and gradually and continue for a considerable length of time. The attacks belong to the severe cases of acute nephritis, to the ex acerbations of chronic. nephritis with exudation, and to the ordinary cases of chronic nephritis without exudation. The gradual develop ment of delirium and coma is apt to continue, although sometimes with intervals of improvement, up to the time of the patient's death. They are very often seen in the advanced stages of both forms of chronic nephritis.
7. Vomitiny is seen in many cases of nephritis. It is evidently due to a number of different causes. In acute nephritis the vomiting seems to be of the same character as that which may occur with an acute inflammation of any part of the body. In chronic nephritis the vomiting may be due to chronic gastritis; or the stomach, like the intestine, gets rid of some of the accumulated urea and serum.
Besides these forms of vomiting there is a special and aggravated form which belongs regularly to the cases of chronic nephritis with out exudation. It is usually accompanied by a marked increase of arterial tension. The vomiting is frequent, distressing, and may con tinue for days. The most efficient means of controlling it are chloral hydrate by the rectum in twenty-grain doses, or hypodermic injections of morphine.
8. A Rise of Temperature.—In acute nephritis, as in any other acute inflammation, there may be a febrile movement. As a rule the temperature is not high and falls to the normal within a week. But in children temperatures of 104° or 105° F. may be reached.
In chronic nephritis the severe attacks of cerebral symptoms— headache, convulsions, delirium, coma, hemiplegia—are not infre quently accompanied with a considerable rise of temperature. I have seen it as high as 109° F., and yet the autopsies show no reason for the febrile movement.