CHRONIC BRIGHT'S DISEASE. 31 



soon be completely restored again. The speedy abatement of this 

 form of blindness argues against its dependence upon permanent 

 lesions. Somewhat more rarely, deafness and roaring in the ears 

 have been noticed in uraemia. 



COURSE. The course of chronic diffuse nephritis varies greatly. 

 In one class of cases the disease may last for ten or even for twenty 

 years, and may be so latent that the patient is scarcely aware that 

 he is ill, and so that a careless physician who neglects to examine 

 the urine can make but little out of his patient's persistent but 

 vague complaints of loss of strength and energy, of impaired appe- 

 tite and digestion. When the inflammatory process runs this slug- 

 gish course, the urinary tubules take but little part in the changes 

 which are going on in the interstitial connective tissue. There are 

 but slight and merely transient inflammatory exudations into the 

 tubules, whose epithelium suffers but little direct damage ; hence, in 

 such a case, but few^if any casts or other characteristic forms are 

 found in the urine. This languid process results merely in thicken- 

 ing of the renal connective tissue, followed by shrinking. It is this 

 grade of inflammation, according to our view, which marks the dis- 

 tinction, both anatomically and clinically, between the forms of 

 Bright's disease. Sometimes the disease maintains this insidious 

 character throughout its course. The patient then preserves a tol- 

 erable appearance of health for years. His urine, which is copious 

 and pale, shows but little albumen ; but late in the disease he gen- 

 erally presents signs of a hypertrophy of the heart. In such a case 

 death may take place suddenly in a uraemic convulsion, before there 

 has been any dropsy whatever. In other cases attacks of eclampsia 

 recur at irregular intervals. Still other patients die of apoplexy in 

 consequence of the hypertrophy of the left heart and of the accom- 

 panying disease of the arterial walls. 



In another and larger class the course of the disease is less slug- 

 gish and insidious. The inflammation is more active, and involves 

 the tubules directly, so that dropsy soon develops. In some instances, 

 which nevertheless are rare, the disease progresses steadily and 

 with unabated activity to the end, causing the death of the patient 

 in a few months by dropsy, secondary inflammations, or uraemia. 

 Much more commonly there are marked fluctuations in its intensity. 

 There will be periods, sometimes long ones, in which the urine re- 

 tains its normal volume, is but moderately albuminous, and shows 

 few casts or none at all. The dropsy abates and disappears ; in a 

 word, the symptoms of parenchymatous nephritis fade away or dis- 

 appear. But between these intervals come exacerbations, during 

 which, in spite of the most urgent and incessant efforts of the 



