(a) Chronic Bright's Disease (Second Stage, Large White Kidney) This variety seems to be the least frequent in infancy. Its course and pathology resemble in general the disease as ReCII adults. The characteristics of the disease are scanty urinc, high percentage of albu min, a plentiful sediment of all sorts of cylinders, fatty cells, renal epi thelium and leucocytes.
For the pathology we refer to the kidney shown in Plates -19-50, which comes from a thirteen-year-old boy who (lied of this affection. The thickened cortex is opaque. yellow in color, upon a light transparent back-ground, especially between the medullary sheathes of Bertini—a symptom of the high-grade degeneration of the parenchyma.
As in most of the described eases, the etiology in this ease was obscure. In some there seems to have been demonstrated a connection with previous infectioms diseases.
The prognosis is generally unfavorable—death takes place after months or years. , Treatment will be considered in connection with the other forms of chronic nephritis.
(b) Contracted Kidney (Granular Atrophy) Heubner is of the opinion that most of the contracted kidneys which have been observed in older children are of the seeonclary type. It appears that the condition is not so rare as was formerly supposed. Even in 1897 Heubner was able to use for his comparative study 30 eases which had come to autopsy.
Amongst the etiological factors already mentioned, syphilis and scarlet fever, and heredity have been emphasized. In the majority of the cases, the exact causal factor cannot be proved with certainty.
The urine is abundant, of low specific gravity, light in color, and contains a small percentage of albumin, which disappears from time to tin-le. The sediment, which is small in amount, contains hyaline casts.
The disease leads to retarded development, and the children feel weak and faint. Baginsky observed excessive emaciation and dryness of the skin; Forster, serious nervous symptoms, tremor and psychical depression. After a fairly long time the characteristic alteration in the vascular system (hypertrophy of the ventricle and tension of the radial artery) develop. The ophthalmoscope often leads to a diagnosis by revealing the characteristic changes in the fundus.
In its pathological anatomy the disorder does not differ from that of adults. The contraction of the kidney may- be extreme. Most eases result in death during childhood; usually after a duration of three to four years. The patients seldom attain a more advanced age. Death occurs with symptoms of uramia, of apoplexy, or from the hamor rhagic diathesis. Therapeutic measures are without value.
(c) Chronic Hamorrhagic Nephritis ThiS form, according to Wagner, is characterized by the absence of (edema, and by the occurrence of acute exacerbations, during whieh greater or smaller quantities of blood will be s.eereted with the urine, which eontains albumin and casts. The quantity of urine diminishes with the appearance of blood in the urine. The prognosis is relatively favorable. Of six cases observed by Wagner, four recovered. It seems worth mentioning that in a series of eases the eausal factor was ton sillitis (see the remarks about nephritis following tonsillitis).
(d) Doubtful Forms This name was chosen by Heubner because in these, eases the symptomatology does not permit them to be classed with the other forms of nephritis already described, and because the termination seems to be uncertain. All the cases continued beyond the age of infancy. Of these doubtful forms, the larger number seemed to belong to the nephritis of older children.
found amongst 35 cases the most frequent cause, to be the infectious diseases (most often scarlet fever and then diphtheria, measles, influenza, and tonsillitis).
symptoms bear slight resemblance to a renal disease. As a rule we find general weakness, a pale skin, the child easily tired, mentally and physicially, .e., the symptoms we are ac quainted with as occurring in orthotic albuntinuria. These disturbances decrease as the child grows older. Headache, vomiting, inclination to diarrhosa, are seldom observed. Heubner was not able in a single case to demonstrate dropsy, retinitis, hypertrophy of the heart, or excessive tension of the vessels. The quantity and the specific gravity of the urine is nearly normal. The daily quantity of albumin secreted is seldom higher than 1 per cent., and generally remains far below this. The sediment very scanty in quantity, contains hardly anything except hyaline casts, though there are sometimes granular, epithelial and waxy easts. Fatty cells and red blood corpuscles are absent, while the leucocytes arc sometimes found in groups resembling casts. The albuminuria is often of the orthotic type. The differential diagnosis from orthotic albuminuria may be very difficult, and is frequently to be established only from the results of sedimentation. Heubner gives no information as to the cause of his eases. He refers to the observa tion of Aufrecht, Dixon Mann, Slawyk, who saw death occur between the ages of twenty and thirty with symptoms of uramia in certain patients who suffered with this form of nephritis.