Chronic Brights Disease

urine, time, water, temperature, normal, albumen, acute, granular and headache

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On examination of the body the lower part of the right lung was found to be consolidated. The left kidney was absent. The right measured three inches in length by two and three-quarters in breadth. The capsule was adherent, and on removing it small portions of renal substance were torn away with it. The surface of the organ was very granular and irreg ular. On section the tint was paler than natural ; the pyramids were less red than in the healthy subject, and the cortex was thinned. The whole kidney felt very dense, and its substance seemed .unusually tough. Un fortunately, the organ was not examined microscopically, but there can be little doubt that this was a case of granular kidney, and that it was of some standing, although in so young a child.

Sometimes the only sign of the chronic disease may be the marked pallor of the complexion, with frequent attacks of headache and vomiting, lasting for several days, or a week or more at a time. Sometimes, as in the adult, the sight becomes affected from albuminous retinitis. Such cases, without a careful examination of the urine, may be mistaken for cerebral tumour. Indeed, a history of frequent attacks of headache and vertigo, accompanied by vomiting, and of gradual failure of the sight, is very suspicious of a tumour of the brain. In all such cases, therefore, it is very important to make a careful examination of the water for albumen, and to search the deposit frequently for casts of tubes. The skin is gen erally dry and rough, and is often markedly inelastic, so that when pinched up into folds it remains wrinkled, and does not smooth out quickly, as a healthy skin would do. This is especially the case in infants and the younger children. Purpura is sometimes found to he an accompaniment of the renal mischief ; but whether it is excited by the nephritis, or, as Dr. Gee suggests, arises with it as a consequence of some bodily condition common to both, is uncertain. Purpuric patches may be seen on the skin, and blood may be passed with the urine and stools.

Usually, acute exacerbations occur from time to time. These mostly follow a and are accompanied by scanty secretion of urine, puffiness of the face, and oedema of the limbs. The water is then albuminous, and may be smoky, or even red, from admixture with blood. The headache is often severe, vomiting may be distressing, the dropsy may be marked, and convulsions may occur, with drowsiness or coma. Sometimes the attack is complicated with pericarditis or pleurisy, as it is in the adult. When the acute symptoms subside, the amount of albumen gradually diminishes, and after a time may quite disappear from the urine. There may be then little left to show that the kidneys are not healthy, but re peated examinations of the urine will perhaps disclose a slight deposit, with fragments of granular or hyaline casts.

In cases of acute renal dropsy, it is common enough to hear that the child had had scarlatina some months or years previously, followed by dropsy ; that he had completely recovered to all appearance ; but that lately, having been exposed to cold, he had begun to vomit and the oedema had reappeared. In such a case it is reasonable to conclude that the restora tion of the kidneys was not so complete as had been supposed. Some times the acute exacerbation is preceded by pallor, wasting, vomiting, gen eral weariness, and a look of ill-health. The child passes water much more frequently than natural in the day, and at night may wet his bed.

A boy, aged fourteen, was in the East London, Children's Hospital, under the care of my colleague, Dr. Donkin. The patient had had mea sles and scarlatina. He was said to be very dull at his lessons. His se cretion of urine was large, and be seemed to have a difficulty in holding it. A. month before his admission the boy had had a rash over the body which had lasted a fortnight. He had then begun to vomit his food, complained of pain all over, looked pallid and weakly, and was manifestly losing flesh.

When admitted, he was pale and thin ; seemed very fretful, and looked ill. His temperature was normal. His urine was acid, had a specific gravity of 1.015, and contained no albumen or sugar. The boy coughed a little, but nothing positive was noted about his chest. There was no sign of peeling of the skin.

After being in the hospital for about three weeks, during which time he had decidedly improved and had gained flesh, the lad was allowed to go out into the garden. The same evening his face looked puffy, and his legs were found to pit on pressure. His temperature that night was normal. On the following day the oedema was marked. He vomited several times ; complained of severe headache, and seemed very stupid and stubborn. His temperature rose that evening to 100°. His water was smoky, con tained a sixth of albumen, and had a flocculent deposit which showed under the microscope many granular casts. On the third day his tem perature was 101.8° both morning and evening, and he had a series of con vulsive fits, followed by drowsiness which lasted for twenty-four hours. His temperature then became normal again, and the cedema began to de cline. His water was discoloured with blood for several days, and the al bumen and casts only slowly disappeared ; but before the boy's discharge, his urine, except for a slight haziness with the cold nitric acid test, had again become normal.

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