The importance of this case requires no comment. Had tbe mother contented herself with the oculist's diagnosis it would have been impossible to observe all the details of the case to the end, and the case would have served as a support for the opinion of those who would derive orthotic albuminuria from an atiection of the renal tissue. Tbis autopsy has brought out, the fact that there is no such connection and that true orthotic albuminuria may occur independently of any anatomical change of the kidneys.
Among the theories which primarily inclined to t.his view, the cardio vascular 01le will probably have the most, supporters. Sehaps' opinion that the anomalies of the circulatory organs leading to orthotic albumi nuria belong to the group of "hypertropbie et dilatation de la croissanee " has recently found a IleW supporter in Loeb, who studied the behavior of Korany's quotient, Tead in individuals with orthotic albuminuria and concluded from his investigations that orthotic albuminuria is of a circulatory nature. According to korany the increase of the quotient admits of the conclusion that there is diminished speed of the blood cur rent of the glomeruli and consequently the kidneys, while a decrease of the quotient proved increased blood circulation in the vessels. It may be taken that this idea has been pretty generally accepted as correct. Loeb found in his patients that with the onset of albuminuria there was always a decrease of urine and nearly always increased concentration. In all cases, however, there was an increase in the quotient. Nephritic patients did not react in the same way. Those with good cardiac func tion went, through the experiment of rising without any considerable increase in the quotient, while those with cardiac insufficiency WOTO affected like patients with othotic albuminuria. Moreover, experiments made by- Knecht with cardiac insufficiency showed that "not the affec tions themselves, but cardiac insufficiency causes the result in the experi ment of rising from the decubitus." In this way Loeb comes to agree with Ede] in making orthotic albuminuria exclusively dependent upon circulatory disturbances of the blood current. On the other hand Leube had preciously explained that it is impossible to ignore the assumption of indicidual degrees of congenital permeability of the renal filtration metnbrane. He believes that the renal filter is not equally permeable in all indiciduals, and in illustration for his hypothesis cites the family occurrence of orthotic albuminuria. According to von Leube
the human race is divided into 3 groups: (1) those with an absolutely permeable renal filter who excrete albumin under normal conditions; (2) those with a relatively permeable filter who excrete albumin under the influence of physiological conditions of life; (3) those with a rela tively impermeable filter who will not react with albuminuria to the conditions referred to.
Another theory, which is supported by Sutherland, 3losny and Goublain, is that orthotic albuminuria is not dependent upon circulatory disturbances of the blood current, but upon those of the renal vessels, laying stress upon the connection between this affection and floating kidney. But as this is a very remote coincidence, the theory can for this reason alone have no general validity.
The oft-repeated assertion that there is a connection between ortho tic albtuninuria and previous infectious disease does not seem quite clear. The idea is that these diseases should have resulted in a "weaken ing " of the renal vessels, thereby leading to the occurrence of the anomaly. This, however, is refuted by the fact that this connection is absent in a number of cases and that there is no proof whether the cases cited in support of this. theory did not have ty-pical orthotic albuminuria precious to the contraction of the infectious disease, and furthermore, that prob ably the majority of cases in which nephritis occurred after an infectious disease, were simply in the last phases of nephritis which must be rigor ously- separated from those Of essential orthotic alburninuria.
Neukirch supports the nerve theory, holding disturbances of the renal innervation responsible for orthotic albuminuria. Teissier blames the destruction of red blood corpuscles following hepatic functional disturbances as the causative factor. Rolfe, too, inclines to this opinion, having observed orthotic albuminuria in individuals who had preciously suffered from paroxysmal hemoglobinuria. According to another hypo thesis t here is a connection between albuminuria and exaggerated demand upon the cells of the marrow, while von Noordert believes that there is a general metabolic disturbance which is as yet unexplained. I have myself inclined to the latter opinion, having found unusually large quantities of oxalic acid in the urine of SOUK' MSC'S, but inasmuch as the latter is not restricted to orthotic albuminuria, the assumption of a metabolic irregu larity can no longer be held to support this contention.