Agnes K., ten years old, was admitted to the Berlin University Children's Clinic on March 10, 1903. A noteworthy point in the history is that the mother has aborted ten times. The child knew nothing of a syphilitic affection, and any guiding point in this respect could at first not be obtained. One sister died of tuberculosis, one of scarlet fever, while one brother is healthy. Had measles at the age of six months, the case being attended by, a physician; at the age of seven there was bronchitis; at the age of eight chickenpox. In July, 1903, she contracted a cough which improved after a stay at Pyrniont, but afterwards recurred. The Pyrmont physician could find nothing wrong with the child who came to the clinic owing to her cough and a slight glandular swelling of the neck.
Examination revealed nothing particularly abnormal but for a few palpable cervical glands. They were from pea to bean size. She had a flourishing complexion, red conjunctiva, and MUCOUS membranes, was intelligent and active. There were a few crepitant riles over the right lung, the heart was not pathologically changed and the urine 1N-as free from albumin. Hydropathic measures improved the bronchitis after a slight febrile exacerbation; the glandular swellings receded upon mercury inunetion and iodine treatment. During the entire time of observation there WaS no albumin present in the urine, until, on May 24, 1904, the child again visited the clinic owing to headache and vomiting. The urine was then found to contain the unusually- large quantity of almost 4 per mille of albumin, in which the substance precipitable by acetic acid predominated. Careful clinical observation during the next few days, together with the quantitative analysis of the various portions of urine, showed that this was a typical ease of orthotic albuminuria, in which the excreted albuminous quantities varied from day to day. Psychic excitement was found to lead to considerable increase of the albumin. In spite of repeated thorough examinations no casts could be found.
Owing to its considerable interest, the case was admitted into the clinic, where clinical observation established the fact that the case was one of orthotie albuminuria. Metabolic experiments, made for over a week, elicited the fact that the quantity of uric acid was abnormally large in proportion to the excreted nitrogen and the daily- excreted quantity of oxalic acitl was between 50 and 70 mg. Crystals of the latter were found in the sediment. When the child was discharged, the sus picion of nephritis was excluded.
I had not seen the child until the beginning of November, 1004, when she was sent to me by an ophthalmologist with the diagnosis of retinitis albruninurica, associated with nephritis, and I frankly confess that I was not particularly pleased with the position of affairs. The child having complained about glittering before the eyes, the mother had obtained an oculist's advice. There was headache anti vomiting.
upon thorough examination I found no symptom to induce me to agree with the diagnosis of the oculist. Heart and vessels were normal. The daily urine certainly contained large quantities of albumin, but no casts. Ophthalmoscopieal exaniination revealed pronounced choketl disc and perivascular choroiditic foci at the periphery of the fundus. No doubt this picture could simulate retinitis alburninurica, but as the child's appetite was excellent in spite of vomiting, and dyspeptic disturbances which belong to the picture of unemia were completely absent, I refused to accept the diagnosis of nephritis with urtemic symptoms. Von Michel gave an opinion of bilateral choked disc with ehoroiditie foci at the Periphery of a luetic nat ure. A provisional diagnosis was mad& of cerebral tumor, possibly of a syphilitic nature, and orthotic albuminuria. The further course confirmed the diagnosis of tumor, but antisyphilitic treatment was unsuccessful. Ataxia of the extremities and blindness followed next. Then came paralysis of the ocular muscles, spasms of the extremities, a pronomiced alteration in the shape of the head, hydro cephalus rapi,tly developing which rendered an exact topographical diagnosis of the tumor impossible. While the patient remained in the dorsal decubitus, the urine was always free from albumin which, however, appeared even during the last few months whenever she sat erect out side the bed. Casts were never found. Gradually there was periodical unconsciousness alternating with epileptic paroxysms, ending in death on October 10, 1005, during an epileptic attack.
Autopsy revealed a cerebellar tumor, gliosarconia of the left hemi sphere, and a considerable hydrocephalus. There were tuberculous foci in both apices of the lung, the heart was quite normal, and the abdominal organs were extremely plethoric. The kidneys were not enlarged, the capsule was easily detached, the surface thoroughly smooth but for a contraction the size of it pea. at the surface of one of the kidneys. Macro scopically, the renal section was absolutely normal. The most pains taking tnicroscopical examination (Heubner) established absence of any inflammatory or degenerative changes. The loops of the glomeruli were perfectly tender, transparent, in several places well filled with blood corpuscles and free from atiy exudates whatever. "Sections 5 rum. thick showed that there could be no question of a nuclear increase either of the capsule, glomerular epithelium or capillaries. Neither WaS there any exaggerated number of leueocytes in the capillaries." The contrac ture was occasioned by a relatively fresh infarct, probably owing to a marantic thrombosis of a small vessel which had recently developed. A few epithelia of the uriniferous ducts in this region showed slight fatt.y degeneration.