What does the urinary excretion of albuminous bodies reveal as to the nature of the process on which orthotic albuminuria depends? Regarding it as nucleo-albumin, as clid von Leube, Obermeier and Keller, and regarding nucleo-albuminuria as the expression of degenerative changes of the renal epithelia ("Mauserung"), we have to infer from its appearance the presence of renal changes in orthotic albuminuria. This theory, however, which is held by Keller, is not free from objection even without calling to aid an exact investigation of the nucleo-albuminous nature of the proteid body. In the first place, the latter is absent in chronic affections of the kidney, although the large quantities of des quamated epithelia in the urine furnish unquestionable proof of degener ative processes. In the second place, it is often excreted through the urine for months or years, so that the renal epithelia would not be able to supply the necessary material. 'We unreservedly share von Leube's opin ion that it passes direct from the blood into the urine. Even though the correctness of Rost oski's opinion that this substance is of an easily diffusi ble nature, may be questioned, it nevertheless seems to be a fact that its excretion bears a different significance to that of ot her albuminous bodies, and the separation of that form of albuminuria to which alone it is con fined seems to be the most plausible proceeding (Raudnitz, F. Kraus).
The absolute quantity of the excreted albumin may, according to my experience, vary very widely. It may be "minimal," but it may also attain to the high values which occur in the most severe renal affections, amounting to as much as from 2 to 5 per mille. It varies in the same individual under apparently unchanged conclitions of life, and its inten sity depends upon factors as yet undiscovered.
1890 Heubner stated in his well-known work that orthotic albuminuria was of rather rare occurrence, but this opinion, to which he still adhered until 1897, may now be considered obsolete. All those who have a large juvenile material at their disposal upon which to make systematic observations agree that albuminuria is of frequent occurrence. This conviction originated in France, although a few French authors discredited it, Teissier for instance as tate as 1905. In a large number of cases Leroix found, in 1883, one case in every seventeen children. Langstein and Reyher, of the Royal Charity Hospital, found orthotic albuminuria in 12 per cent. of all admitted children. Martin found albuminuria in 86 out of 304 debilitated children, or 38 per cent., Jehle 39 per cent. in 223 carefully observed cases.
According to Heubner's statistics the frequency of the affection is distributed over the various periods of life as follows: From 0 to 15 years 22 eases, or 39 per cent.
From 16 to 20 years 21 cases, or 3S per cent.
From 21 to 30 years 10 cases, or 17.S6 per cent.
Over 30 years .... . 3 cases.
Schaps, who made investigations at the Breslau Clinic, found 94.12 per cent. between the ages of 5 and 15. All authors are agreed that the affection is exceedingly rare in early childhood and that its greatest fre quency sets in toward puberty. Schaps found only 1 case (2 per cent.) under 5 years; 15 cases (41 per cent.) from 5 to 10 years; 18 cases (53 per cent.) front 10 to 15 years; and only 1 case (2.9 per cent.) over 15 years.
Langstein saw 2 cases of 3 years, 3 of 4 years, 2 of 5 years and 5 of 6 years. It was only after 6 years that he observed increased frequency. In Jehle's statistics the frequency of the affection is tabulated as follows: From 0 to 6 years among 35 ca.ses 1, or 2.S per cent From 7 to 10 years among 111 cases 32, or 19.S per cent.
From 11 to 14 years among S4 cases 59, Of 64.2 per cent.
Opinions are divided as to the susceptibility of the sexes. Dubreu ille places the number of male patients at eight times larger than that of females; Oswald places the proportion of males to females at 4 to 3; IIeubner found that the female sex suffers to a vastly greater extent from orthotie albuminuria than the male. Klemperer and Schaps are of the same opinion and personally I must also share it, since there are 66 female eases in 87 0 observations. On the other hand, Jehle did not
observe any particular difference, finding 45 among 107 girls and 42 among 116 boys.
As a family affection orthotic albuminuria was first described by IIeubner, later by Rudolf, Hoxon, Schoen, Laeour, Schaps, Langstein and Jehle.
Symptomatology.—There is no need to further discuss the symptoms that dominate the clinical picture and gave the affection its name. The picture, however, has not yet been charactoized with the desirable degree of accuracy-, which is partly explained by the fact that the various authors had not immediately seized upon the correct conception of the disease. Thus, a number of investigators spoke of orthotic or cyclic albuminuria as an affection sui generis where, aside from albumin, hyaline casts, epithelial casts and renal epithelia were demonstrable in the urine (Keller and Stlidsberg). Although the value attributed at the time to the presence of casts in the urine for diagnosing renal affections has depreciated during the last few years, an important aid to differential diagnosis would be sacrificed, if the results of the examination of the sediment were to be ignored. It has certainly been established that the presence of a few isolated hyaline casts does not justify the diagnosis of a renal affection, but it would be well if even at the present time the presence of epithelial and granular casts, aside from that of renal epi thelia, were regarded as the expression of renal involvement, and the conception of orthotic albuminuria confined, in conformity with IIeubner, to such narrow limits as to refer to cases which show the typical behavior of albumin secretion to the exclusion of those whose urine contains casts and other renal elements. Jehle's recent investigations, to which I shall refer later in detail, seem to show that the presence of even large numbers of casts and other form elements does not justify the exclusion of a diag nosis of orthotic albuminuria. On the other hand, Goetzky's extremely careful, numerous examinations of the sediment of the urine of children with orthotic albuminuria have shown that this affection runs its course without the excretion of form elements, and casts in particular. Goetzky obtained on many successive days each portion of urine, both albuminous and non-albuminous, and examined the freshly prepared sediment. Where casts were present, even in sinall numbers, he also found other deviations in the urinary picture and anomalies in the albuminous excretion, which would render it doubtful whether there was true orthotic alburninuria. It would be wise, therefore, to take IIeubner's words to heart: "The presence of well develope.d hyaline casts, especially the cellular and granulated varieties, or of epithelia., should as a measure of pre caution always be looked upon, at least in children, as a sign of nephritis and not of orthotic alburninuria." A few cases are mentioned in the literature where from time to time the morning urine contained albumin. Although it is possible that this constitutes a different form of juvienile albuminuria, it should be con sidered that the cycle may have been disturbed from insufficient evacua tion of the evening urine and from children having urinated during the night. Otherwise the urine of true orthotic albuminuria does not present any noteworthy peculiarities. Its often turbid consistency is attributable to the presence of phosphates or oxalates, the latter being particularly frequent in some cases. The sediment contains but very few round cells, also some mucus or mucous cylindroids, the significance of which is open to doubt. Sometimes there are seminal threads in the urine of boys at the age of puberty or, as Heubner emphasizes, fragments of a substance which probably emanates from the prostate which might be mistaken for cast fragments. In girls nearing puberty the urinary sedi ment contains vt-ith great regularity numerous vaginal epithelia which point to desquamative vulvitis. They will, according to my experience, disappear with the first. menstruation.