SYMPTOMS.—It is sometimes impossible to tell which of the varieties of chronic nephritis exists in a given patient, but in other cases the diagnosis can be made. If, however, we correct our clinical diagnosis by post-mortem observations, we find that we may be mistaken about even the (apparently) most characteristic cases. There is more difference in the earlier stages of these cases than in the later ones. In hospitals, where the patients come to die, all the cases of chronic diffuse nephritis are a good deal alike.
The atrophied kidneys present us with a very great variety of clinical histories. It is impossible to describe all the different ways in which the disease may begin and run its course, but we may enumerate some of them:
1. Persons may have atrophied kidneys for a number of years without any renal symptoms; they die from accident or from some other disease, and at the autopsy the kidneys are found to be far advanced in disease.
2. The disease of the kidneys exists, but it gives no symptoms until the patient suffers from some severe accident or is attacked by some acute disease, and then the renal symptoms are suddenly developed.
3. The patient will very slowly lose flesh and strength, the appetite will be capricious, either mental or bodily exertion is an effort, but there are no positive symptoms, except that the urine is of rather low specific gravity, and in the evening urine there will be occasionally a trace of albumen. In this condition these patients may continue for years. They may improve very much under treatment, and finally die from some other disease without ever developing any renal symptoms. Other cases, however, do after a time develop all the characteristic symptoms.
4. For several months the patients do not feel well: the appetite is lost, there is nausea and occasional vomiting, they become pale and anæmic, do not sleep well at night, are irritable and easily worried, are troubled with headache. The urine continues normal or is of low specific gravity or contains a little albumen. Then they suddenly become worse and the regular symptoms are developed.
5. In other cases headache or sleeplessness or dyspnoea or loss of vision may precede all the other symptoms by several weeks.
6. Severe neuralgic pains in different parts of the body, coming on in attacks and very rebellious to treatment, may precede the other symptoms for months.
7. The very first symptoms may be an attack of convulsions. The patient may have been apparently in good health, and while sitting quietly in a room or lying in bed will be seized with a general convulsion. In some of these cases the convulsions are repeated; between them the patient remains partly or completely unconscious, and dies in a few days. In other cases one or two convulsions are followed by the development of the other symptoms of the disease.
8. With valvular disease of the heart and atrophied kidneys we may get the same combination of symptoms which I have described in the section on chronic congestion of the kidneys.