The examination of the seanty turbid wive, rich in salts, shows considerable acetone during, more often, before, and for a long time after the attacks. Indiean, albumin, acetic acid and oxybutyrie acid have also been shown to be present by several authors (Shaw, Vala gussa and others); still these are not constant findings, while great weight is laid on all sides on the presence of acetone.
After the acute attack is over, recovery occurs with surprising rapidity. The appetite returns at once and a definite convalescence is seareely observed.
Much uncertainty exists eoneerning the cause of this peculiar con dition. The fact that the disease has been observed for the most part in well-to-do circles, and that in the parents of the patient the symp toms of so-called uric acid diathesis is often present, has caused certain authors (Comby, Valagussa, notch, Holt and others), to look upon it as an expression of a hidden uric acid diathesis, particularly as pains in the joints are observed, and a variation of the relation of the urea to urie acid has been found, the latter being increased during a paroxysm (Holt).
Other writers depending upon the swelling of the liver, which some times is present, and the presence of ieterus at the conclusion of a par oxysm, assume an hepatic insufficiency of the liver as the cause, which leads to acetonuria in eonsequenee of the deficient function of this organ.
The majority of writers eonfine themselves to the rather vague hypothesis of a disturbance of the intermediate metabolism, acid in toxication (Edsall), ete. For the sake of curiosity, the view of Krot kow is mentioned, who assumes a pseudomening,itis produeed by disturbances of digestion.
All the observations are not uniform in character. There are, for example, cases described in which the paroxysm is ushered in by aeute illness of another kind as angina, measles, diphtheria, etc., so that many variations occur botb in the prodromata and the course of the disease. These facts have caused Hutinel, very properly, to assume two varieties of the disease, a primary and a secondary. In regard to the primary group, I would personally like to emphasize sharply and establish the hysterical character of the affection, as has been timidly suggested by others.
In addition to the fact that the disease appears almost exclusively among the better classes, and that a nervous heredity is often demon strable, I would point particularly to its occurrenee in brothers and sisters, as is repeatedly described (Hutinel and Malian). and that it is analogous with the psyehical contagion in chorea and similar dis orders. The sudden onset without recognizable cause, tile great inten sity of the symptoms, suggest, likewise, this explanation, as does also the subsidence of the disease in a definite time. The lack of pronounced stigmata does not niilitate against such an assumption, since infantile hysteria at this age is, as a rule, mono-symptomatic. Moreover, the sudden cessation and the almost momentary return to complete health are, according to my view, indications in this direction. The occurrence of the attacks after excitement, or at the conclusion of either mental Of bodily exhaustion, are in favor, likewise,. of this assumption. The demonstration of abnormal secretion of uric acid salts has been repeat edly shown to be true in hysterical attacks, and, finally, I would mention in favor of my bypothe.sis the surprising result of certain therapeutic measures, having no influence on the etiology of tbe disease, as, for example, the darkening of the room (Botch), the administration of a purge Valagussa), the subeutaneous salt infusion 1111arfan), which, according to the assertions of the writers mentioned, are able to shorten the attacks, all of which would favor an effect produced by suggestion.
It remains, however, to explain the acetovuria. For the most part, it has been shown to be present early in the course of the disease. It can, however. be a consequence of marked disturbanees of digestion, as acetone is found in the urine in other different affections of the digest il'e apparatus in childhood. When it is present at the beginning it is possibly the result of some disturbance of digestion from which the child has previously suffered, and is only- the expression of an exacer bation during the intereurrent attaek. In order to determine this, one must examine the urine more frequently and continuously for acetone, in a number of affections in childhood.