Abnormal excretion has been accidentally discovered in children who felt absolutely healthy. In the great majority of Ca.':,CS, however, there are manifestations which point to a disturbance of the general condition. Heubtier characterizes these symptoms as follows: "There is considerable atony and lassitude which deprive the children of all joyfulness, alacrity and pleasure of work, or there is headache, articular pains and symptoms of weakness." Gillet distinguishes between three forms of the clinical picture. Some of the patients have no complaints whatever, others have widely varying functional disturbances (dyspepsia, neurasthenia, adolescent pains), while the third group has headache, transient cedetna and pains in the sacral region. It is an easy matter for me, too, to pick out three classes out of the number of cases I have observed: (1) Those with a pale complexion, tendency to fatigue, palpitation, anorexia, headache: complaints which are associated with chlorosis; (2) A smaller number of children looking flourishing, but complaining of headache, congestions to the head, occasional vomiting, colic, recurrent urticaria; (3) The third group having no pathological symptoms at all, where the presence of albutninuria was discovered by accident.
The objective findings of the albumin have long been neglected, with the exception of its periodical coming and going, more stress having only recently been placed upon them, notably upon the examination of the heart and vascular system. But these are the only points in which abnormal conditions have been observed. Schaps, for instance, reports having observed more or less pronounced pathological cardiae mani festations, such as palpitation, dierotia, strong apex beat, arrhythmia and noises, in 20 patients out of 35. He has also observed dilatation of the heart which affected either the right or the left side and repeatedly alternated. Generally speaking, the symptom-complex observed by Schaps in regard to the circulatory system, agrees with that described by Germain See under the name of "hypertrophie et dilatation de la croissance." Schaps having observed but one case with cardiac dilata tion, hesitates to describe its nature. Stridsberg positively demonstrated hypertrophy of the heart in 13 among 31 eases, the symptoms in the remaining cases being uncertain. Lommel, Krehl and Loeb have ob served about the same cardiac manifestations as Sehaps. Krehl sum marizes the cardiac changes under the term "cor juvenum." I have not been able, with the material at my disposal, to find such a large num ber of cardiac anomalies as Sehaps, although I have occasionally found increased frequency of pulse, arrhythmia and systolic noises at the apex. Considering that sotne authors, Striclsberg among others, have unques tionably included eases of renal affections, it may well be supposed that the results of cardiac observations are not yet ripe for comparison.
Reyher made orthodiagraphic examinations of the hearts of ehildren with orthotic albuminuria and found that in the great majority of cases there was arrest of heart development ("Tropfherz"). In one ease an electro-radiogram was taken by Heubncr which showed the presence of the infantile prong which is normally present in the first half of the period of childhood, while in adults it occurs in nervous, neurasthenic Patients. "These findings point to the continuance of a certain infantil ism in the region of the circulatory organs, a nervous disturbance of the cardiac function." Otherwise, signs of eardiac weakness could not be discovered in the diagram.
Matthes, like myself, has never observed any partieular tension of the pulse or elevated blood pressure. In a few cases the blood pressure was determined by Heubner with von Reeklingiftausen's apparatus, with the result that in patients in a reclining position the systolic pres sure was 110, 150 up to 160—figures which, although not pathologically high, were by no means unusually low. The pulse pressure was usually low-, because the diastolic pressure was high. The fundus of the eye was always found normal with the exception of the case I am about to report in detail.
In the majority of cases the hwmoglobin content was found normal, even in children with unusually pale complexions. The latter was there fore not the result of antemia, but of an abnormal distribution of the blood, or angiospasm.
Pathogenesis, Nature, and Etiology.—There is no dearth of theories to explain the presence of orthotic albuminuria, but in their totality they are more or less hypothetical. They may be conveniently divided into two groups: one regarding an affection of the kidney, with anatom ical structural changes, as> the etiological factor, the most prominent supporters of which are Johnston and Senator; and the other thinking that the affection has nothing to do with an impairment of the renal tissue, as supported by Heubner, Posner, Ibrahani, Neukireli and others. One of the reasons why this difference of opinion has lasted to the present day is that there was no autopsy ease on which to .study the pathological anatomy. I am fortunate enough to fill this gap by the study of a case which was observed by Heubner and myself from the beginning of the affection until its fatal termination and in which the kidneys were histo logically examined in the most painstaking manner. The course of the case appears so important for the ventilation of the whole question that its detailed communication at this place may be worth while.