Chronic Brights Disease

albumen, acid, urine, time, boy, sand, uric, trace and casts

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In this case the history and the previous symptoms, as well as the rapidity with which the renal phenomena followed the chill, pointed to some chronic affection of the kidneys, although no albumen was found in the urine on the lad's admission into the hospital. Perhaps in many of these cases careful and repeated examination of the water would be more successful in finding albumen. A great deal depends, too, on the way in which the examination is conducted. Boiling the urine and afterwards adding a few drops of nitric acid is a very coarse test ; and if the propor tion of albumen is small, it may easily escape detection by this means. A far more delicate test is that of floating cold urine from a pipette upon the surface of strong nitric acid placed in the bottom of a test-tube. Albumen should never be excluded until the urine has been tested by this process, and allowed to stand for a quarter of an hour in order to give the light, cloudy disk of albumen time to form upon the top of the acid. Still, it cannot be denied that, however carefully the examination may have been conducted, it will often be impossible to discover the presence of even a trace of albumen between the attacks of acute disease. The child, how ever, is not well. He often remains pale and thin, loses all appetite, and is nervous and excitable. His dislike to eating is a source of great anx iety to his parents, and, indeed, it is often most difficult to persuade him to take even a minimum quantity of food.

The water may be secreted in fair amount, often, indeed, is copious ; but its specific gravity is low. It is usually very acid, and sometimes uric acid sand is seen at the bottom of the chamber-pan. Perhaps on this ac count there is often a difficulty in holding the water, especially at night. There can belittle doubt that, although giving rise to no very characteris tic symptoms, the kidneys are not healthy, and that their depurative func tions are imperfectly performed.

A case which I saw some time ago, in consultation with 3Ir. E. Stanley Smith, affords a good example of the insidious progress of granular kid ney disease in the child.

A little boy, aged nine years, of excitable, nervous temperament, in heriting a tendency to epilepsy on his father's side, and to phthisis on his mother's, was said to have been poorly for eighteen months. His indis position had begun with an attack of "fever" in which the temperature rose every night to or ; he had severe headache, and was at times slightly delirious. He was ill for a week. Since that time he had had similar attacks, but milder in character. He was said often to look pasty and sallow in the face, and to seem languid and inclined to mope, although when pretty well in health he was lively and active, and his spirits were high. When poorly, his urine would contain a trace of albumen ; it was

always very acid, and often contained large quantities of uric acid sand. No casts were ever seen at that time. The boy was wasting slowly, al though his appetite was good. He slept badly, and was always restless at night. His bowels were usually costive, and after an aperient he passed much mucus. He stammered at times, and the muscles of his face would often twitch. The specimen of his urine shown to me was very acid and of specific gravity 1.024. It contained no trace of albumen ; but there was a copious deposit of uric acid sand. After I had seen the boy he did not improve. The albumen became more frequent, and granular casts and blood-corpuscles began to be discovered. On one occasion, a hyaline cast was seen. There was never any trace of oedema, and his heart and pulse were normal.

In this case the feverish attacks were no doubt attacks of acute gastric catarrh. Apart from this symptom, which may have been only an acci dental feature in the case, and had probably no other influence than that of the tendency to flatulence and acidity, there can be little doubt that the boy was suffering from granular kidney. It seems prob able that there is a connection between the passage of red sand and the kidney degeneration, for I have noticed the association in other instances. Certainly, in a case where a child habitually passes large quantities of uric acid crystals, I should be disposed to fear the occurrence of Bright's disease ; and the occasional presence of a trace of albumen would add strength. to my apprehensions. • The after-course of this boy's case is interesting. He was sent to the south of France, and passed a considerable time at Cannes. Dr. G. C. Bright, under whose care the boy was placed, informs me that on arriving at Cannes the urine contained one-eighth of albumen, and that its sediment showed numerous granular casts and much renal epithelium. After a stay of nine months the water had ceased to contain albumen or casts, although there was still an occasional deposit of uric acid sand. Its density was habitually 1.025.

In this boy there was no hypertrophy of the heart ; and no abnormal tension of the pulse was ever noticed. Although the albumen ceased for a time to be present in the urine, it is impossible to suppose that all structural lesion of the kidneys had disappeared. This is no doubt another instance of renal disease without albuminuria, or rather, with intermittent albuminuria, for that albumen and casts will eventually reappear can scarcely be doubted. It is curious that a sister of the patient suffered from similar symptoms.

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