Chronic Brights Disease

quantity, skin, passed, urine, elasticity, time, secretion, child and kidneys

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When the kidney is the seat of amyloid degeneration there is no neces sary albuminuria, and even increased secretion of urine is not an invariable symptom. Dr. M. Litten has published the details of four cases which place the truth of this statement beyOnd a doubt. In a case which was under my own care—a little girl seven years of age—general oedema had been present for two years, succeeding to an attack of scarlatina. The child suffered from angular curvature of the spine of some standing. Her liver and spleen were much enlarged, and felt very dense and resisting. Enlarged mesen teric glands could be detected in the abdomen on deep pressure. The aver age quantity of water passed in the twenty-fou• hours was twelve ounces.

It had a copious deposit of lithates. There was never any albumen, nor could any casts be discovered under the microscope. Its density varied from 1.020 to 1.025.

In this case, where the liver and spleen were evidently the seat of amy loid degeneration with probable enlargement of the same kind in the mesen teric glands, it is difficult to suppose that the kidneys had entirely escaped any participation in the disease. Probably only an early stage of the degen eration is characterised by absence of albuminuria and a scanty secretion of urine. As the disease becomes more advanced, the quantity of water secreted is more copious ; it contains albumen—at first in small quantities, afterwards in considerable amount, and the specific gravity of the fluid is high. Renal epithelium with hyaline, granular, and often fatty casts, may be seen by the microscope in the deposit.

There is a form of renal disease from which children of various ages are prone to suffer, which appears to be in many cases a temporary ailment, but which produces very definite symptoms. The disorder is indicated by pal lor, weakness, wasting, constipation, sometimes by sickness, and in every case by a remarkable absence of the natural elasticity of the skin. This loss of elasticity is a very characteristic symptom. 'When the skin of the abdomen is pinched up, it remains wrinkled, or only slowly recovers its smoothness. On examining the water no albumen is found, but the quantity is small and its specific gravity is low. Evidently sufficient solids are not discharged by the kidneys ; and the retention of effete matters in the system, owing to this renal inadequacy, is apparently the cause of the symptoms. A case has been already" referred to in the- chapter on enteric fever, in which a child convalescent from that disease passed for many days no more than eight or ten ounces of urine in the twenty-four hours, with a specific gravity of 1.015. He was excessively feeble, stupid, and lethargic ; his skin was markedly inelastic ; and it was only after the secretion of water had increased, and its density had risen, that his physical and mental weakness passed off, and the normal elasticity of his skin was restored. It was calculated that this boy

secreted by the kidneys, in the twenty-four hours, no more than two and three-quarter grains of solid matters for every pound of his weight—a quantity which is of course considerably below the average amount.

The quantity of urea passed daily in childhood is proportionately greater than it is in adult life. In the East London Children's Hospital I caused the urine of thirteen selected cases, in which kidney disease could be ex cluded, to be collected for the twenty-four hours ; and calculating roughly from the specific gravity, it appeared that the average quantity of solid mat ters passed from the kidneys in this time was five grains for every pound of the child's weight. The ages of the children were between four and ten years. In the adult the daily quantity has been estimated by Dr. Parkes to be three and a half grains per pound weight. My experiment was of course a rough one, making no pretensions to mathematical accuracy ; but the conclusion arrived at was, no doubt, sufficiently near the truth to be useful as a guide in practice.

I believe quite young children sometimes suffer from a temporary de ficiency in the secretion of urea, although, as it is impossible to collect the whole quantity of urine passed, I can bring forward no positive evidence. in support of this statement. Some time ago I saw a male infant seven weeks old, who was brought up at the breast of a very healthy mother. He had been perfectly well for the first four weeks after his birth. He had then begun to vomit sour fluid and curd, and at the same time his bowels had become obstinately confined. This state of things had con tinned for three weeks, the infant becoming thinner, and his bowels only acting after an aperient or enema. On the morning of the visit he had just been relieved after five days' constipation. The child was thin but did not look ill. No sign of disease could be observed about any part of his body, and the belly was not retracted. The skin was excessively inelastic. It lay on the abdomen in loose wrinkles, and when pinched up, the folds remained exactly as they were,left without smoothing ont. No urine could be obtained for examination. An aperient powder was given, and small closes of the infusion of senna with glycerine were ordered three times a clay. After two months the elasticity of the skin had partially returned, and eventually it was perfectly restored. The return of elasticity in the skin was accompanied by progressive improvement in the condition of the child. The vomiting ceased soon after treatment was begun ; but the costive state of the bowels remained a trouble for a considerable time.

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