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Chronic Brights Disease

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disease, both in the acute and chronic stage, is seen in the child_ The acute form is, however, the more generally met with on account of the frequency with which scarlatina occurs in early life, and the tendency of this specific fever to be complicated by acute renal disease and dropsy.

Causation.—It is no doubt to scarlet fever that the large proportion of cases of acute Bright's disease in the young child must be referred. Still, it is not very uncommon to meet with acute renal dropsy in children who are without any history of scarlatina, who show no signs of desquamation of the skin, and in whom no cause for the symptoms but recent exposure to cold can be detected. The practice of short-coating infants of a few months old, regardless of the state of the weather, which prevails in this country, is no doubt often answerable for this as for other catarrhal dis orders in early life. A child of a few months old, who has been recently short-coated, is taken out on a cold damp day almost naked from his waist downwards ; for his scanty skirts afford little protection to the lower part of his body. A day or two afterwards he is noticed to be pale and puffy looking about the face ; he vomits, and his belly and legs begin to swell. At the same time his urine is scanty, high-coloured, perhaps smoky, and throws down a precipitate of albumen on boiling. This is not a rare in stance, but occurs sufficiently often to be a not unfamiliar experience to most medical practitioners. It has been suggested that there is a connec tion between eczema and kidney disease in children ; and eczema of the genitals has been said to be often followed by fatal renal symptoms ; but I cannot corroborate this statement by my own experience.

The form of Bright's disease met with during the first two or three years of life is generally the acute variety. Tnfants, however, as well as older children, may suffer from the disease in a chronic form ; but no doubt this is in many cases a relic of a previous acute attack. Certain diseases may lay the foundation of chronic renal mischief, viz., scarlatina, measles. small pox, scrofulous disease of bone and of other tissues causing prOlonged suppuration, ague, diphtheria, and (in infants) intestinal catarrh.

Either the contracted granular kidney (interstitial nephritis), the large fatty kidney (chronic parenchymatous nephritis), or the amyloid kidney may be met with in early life ; but the first is rare at this age, although it appears to be sometimes set up by obstruction to the escape of urine, either from impacted calculus or some other cause ; and the fibroid interstitial growth may then be profuse.

The large fatty kidney is more commonly met with than the preceding. This lesion is usually the result of acute Bright's disease, and commonly dates from an attack of scarlatina. It may, however, be chronic from the first and arise as a consequence of long-standing suppuration.

The amyloid kidney is far from rare. Children, especially those who are subjects of the scrofulous cachexia, are very liable to suffer from pro fuse purulent discharges. If the discharge is continued for a long time together, it will often lead to amyloid degeneration of organs in which the kidneys as well as the liver and spleen are involved.

Morbid Anatomy.—It is unnecessary in a special treatise, such as the present, to enter minutely into the pathological changes to be met with in the kidney in cases of chronic Bright's disease. The changes are the same in the child as they are in the adult, and are described at length in all the text-books. It may be sufficient to recall to the reader's memory the principal points connected with each of these three varieties.

The contracted granular kidney is, as its name implies, considerably re duced in size. Its capsule is thickened and adherent ; its surface is nodu lar, and its colour a deep red. On section we find the cortex thin ; the medulla atrophied, and the substance dense. The essence of the disease consists in a great hyperplasia of the connective tissue of the organ. This fibroid overgrowth passes inwards from the surface along the course of the intertubular vessels, and involves more or less regularly the whole depth of the cortex. It thickens the Malpighian capsules, and compresses the capillary tufts and the convoluted tubes. The small arteries are thickened and their calibre reduced. As the increase of fibrous tissue is not evenly distributed, but is much greater in some spots than it is in others, the amount of injury to the kidney substance varies ; and while some tubes are much atrophied and shrunken, others escape almost entirely. The convolut ed tubes are often denuded of their epithelial lining, and are sometimes seen under the microscope to be stuffed with fatty debris or with hyaline casts. In some places the denuded tubules dilate here and there into cysts ; in other places they atrophy and may be converted into mere threads. The straight tubes in the pyramids are comparatively little altered. The shrinking of the kidney and its granular appearance are late changes, and are due to the contraction of the new fibroid material.

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