I agree with this enumeration, except to express a doubt in regard to albuminuria of puberty. Ill my experience I have found this to be essentially different to orthotic albuminuria, as there were always the typical method of albuminous secretions and the general conditions associated with chlorosis, without casts in the urine. The affection often disappears as soon as the organism is completely developed, in young women immediately after the first menstruation.
Of much greater importance is the differential diagnosis with nephritis and non-renal affections which are associated with albuminuria, such as cardiac disorders and chronic febrile affections. Cystitis as a cause of albuminuria can be excluded by examination of the sediment, while chronic nephritis may give rise to considerable difficulties, because in this affection the albuminous excretion may present the orthotic type. The investigation of orthotic albuminuria has not yet advanced far enough to admit of a judgment as to whether the chemical composi tion of the urine may be a factor in the differential diagnosis. ille'ry's statements in this respect are based upon the urological cycle and are entirely, hypothetical. Nor will it be permissible to draw conclusions from the daily quantities of excreted albumin. The method of excretion may possibly be of importance, as will easily be understood from the previous remarks on this subject. Even though alternating excretion of albuminous and non-alburninous urine is an important faetor in the diagnosis, it should not be overlooked that some forms of true nephritis may be associated with this symptom. "These forms consequently can not be excluded until an extensive investigation into the presence of nephritis has established a negative result." Hypertrophy of the left ventricle, elevated blood pressure, or increased pulse tension exclude the diagnosis of orthotic albuminuria. Examination of the fundus of the cye should iu case be omitted, since retinitis albutninurica may be an early symptom of nephritis. Headache, vertigo and vomiting may not at once be taken as uremic signs., as these symptoms may also occur in pure orthotic albuminuria. In regard to urinary casts I have already stated my opinion to the effect that their presence would under any cir cumstances bar the diagnosis of essential albuminuria.
"But if all these findings are in favor of orthotic albuminuria, I want to observe all these cases for at least a year or more, and repeatedly convince myself during that time of the absence of any and every symp tom pointing to nephritis, before I make my diagnosis positive." Hettbner suggests to facilitate the diagnostic prelinainaries by showing the rela tives how to make an exact test for albumin with freshly voided urine.
The tests should be made four or five times a day for an initial period of one to two weeks, the results being chronicled in tabular form. In doing so, it is important that, before retiring for the night, the child should not urinate into the night vessel, and the same rule holds good for the first morning urine. The urine voided while lying down, should be free from albumin. The total quantity of day urine is collected and examined in all directions, and if there should be any sediment, it should contain no morphological components. These examinations should be continued for a year every two or three months, and during that time the child should receive no treatment whatever, living exactly like a healthy child. Then it will be possible to make a correct diagnosis.
Course. —The course may be distinctly chronic. The condition has been observed for twenty years and longer (Headmen, Posener), as reported in the literature. The albuminous excretion may be inter rupted for days, weeks or months (intermittent albuminuriaL which will render a decision exceedingly difficult as to whether the albuminuria has come to a definite standstill or not.
Prognosis.—The prognosis of the affection as .such is absolutely favorable in the great majority of ca,:es. Heuhner holds the same view-, although he has reported a few isolated cases in which orthotic albu minuria developed into infantile nephritis after it had persisted for years. Personally I consider the transition of true orthotic albuminuria into nephritis unproven. Probably the cases which are supposed to prove it, were front the first nephritis of an extremely insidious character and had nothing more in common with orthotic albuminuria than the periodicity of albuminous excretion. Von Leube looks upon the form of the affection which may develop into nephritis, as albuminuria of puberty, which he regards as a group of its own. lie says: "In cases where cardiac insufficiency and ann.mia dominate the pathological picture, parenchymatous nephritis may set in owing to persistent, thoug,h light stagnation, and to bad nutrition of the renal parenchyma which may render the epithelia less resistant to renal irritation which under ordinary circumstances would not give rise to nephritis." It is a noteworthy fact that, in individuals with orthotic albliminuria, nephritis does not occur in the course of an infectious disease any more frequently than otherwise; indeed, cases have been reported in which the albuminous excretion was arrested after the infection was cured.