During the later stages cases differ widely in their course. In the mild eases the condition of the urine which has just been described, in which the quantity will hardly sink lower than 400 c.c. (131 oz.) lasts without much aggravation for one to two weeks.
Gradually the urine becomes clearer and more plentiful. The albumin and sediment noticeably disappear, but not simultaneously, since the presence of sediment may still be demonstrable after tlac most delicate tests for albumin fail to produce any precipitation.
In serious cases the symptoms are increased and new ones are added to the picture. The kidneys are enlarged and painful to press ure, while the spontaneous pain, generally located in the abdominal region, is comparatively slight. The attacks of colic described by Israel have never been observed by Heubner.
The dropsy increases ancl gives the patient, who is generally extremely pale, a characteristic appearance. It is at first limited to the face, particularly the eyelids, but by degrees it spreads over the extremities, the genitals, and in the end becomes a general anasarca. Serious cases almost always show dropsy of the cavities, ascites, hydro thorax, hydropericardium. CEdema of the mucous membranes may be absent where the cedema of the skin is intense, but may be present if this should be moderate.
The effect of the (edema depends upon its location; cudema of the skin causes painful tension and interferes witb free movement; accu mulation of water in the serous sac gives rise to dyspncea, cough, and cardiac weakness. (Edema of the glottis may be a complication which seriously threatens life. A high grade of dropsy, without alburninuria, has been observed not very rarely after cases of scarlet fever (Ham ilton, Bartels, Henoch). In the eases of Bartels and Henoch the amount of urine passed was extraordinarily small. We must not forget that in addition to the renal and vascular changes, a third component may contribute to the development of (edema in the course of nephritis scarlatinosa. This is an extraordinarily early involvement of the hei_rt. We may say almost without reservation that a clinical and probably an anatomical change in the heart is demonstrable first of all in scar latina] nephritis, more frequently than in any other form of acute Bright's disease. This was well known to both Bomberger and Wagner
but Friedlander studied it more carefully. He found dilatation, gener ally of the left ventricle, either alone or combined with hypertrophy. The weight of the heart exceeded the normal average by nearly 40 per cent. Silbermann often observed that the changes in the heart began even in the first week. In addition to cederna, the clinical symptoms of cardiac insufficiency are small and frequent pulse, precordial pain, severe dyspncea, which renders the condition very distressing.
Among the prominent symptoms of nephritis the physician has to give special attention to orromic symptoms. These are generally ushered in by a conspicuous decrease in the quantity of urine, to 200, 100 c.c. (7-31 oz.) or less. Even complete suppression is not rare, but there are exceptions to this rule, in which the dreaded syndrome appears without any decrease in the quantity of urine. Headache, vomiting. jactitations, increased restlessness and nervousness in the child, serious lack of appetite, the appearance of a thick fur on the tongue, ammoniacal fctor of the breath, should prepare us for the appearance of eclamptic paroxysms. Occasionally, in the midst of apparent good health, the dangerous condition arises without these forerunners. The uraunic convulsions are epileptiform in character; sometimes restricted to single groups; sometimes involving the whole body. They may repeat themselves, or they may be repeated at short intervals, during which the patient either lies deeply comatose, or else exhibits the greatest restlessness or the most violent excitement. During this period the child may die suddenly, without regaining con sciousnes.s, or there may be only one or two convulsions, which are quickly followed by recovery. The secretion of urine is restored, and the urine, at first deeply tinged with blood, gradually becomes paler, and within a few; weeks the renal inflammation 15 entirely healed.