It has already been explained by Senator that congestion of the kidney will lead to the excretion of albumin and casts, and Jellle tries to prove by a number of experiments that this is the exclusive pathogenic factor in orthotic albuminuria which, according to him, is identical with lordotic albuminuria. He obtained in both lordotic and normal children the identical urinary picture which is present in lordotic albuminuria, by compressing the inferior vena eava through the abdominal walls above the juncture of the renal veins; furthermore to eliminate albu minuria in pathological lordosis by preventing in some way a stasis in the region of the inferior vena cava, while albuminuria immediately occurred if both factors, stasis and lordosis, were present.
Jehle continues as follows: "Albuininuria strictly follows mechani cal laws and can only be explained on the ground of mechanical causes, and not by reflex processes alone. In the erect posture a stagnation occurs in the inferior vena cava froin the kidneys down, which in normal individuals is too slight to cause albuminuria. Nevertheless, there is some slight albuminous excretion after long standing, which would correspond to Senator's 'physiologic albuminuria.' Pathological lordosis increases the stagnation, causing pathological excretion of albumin which is thus merely the sign of exaggerated stasis to which the kidney, as a very sensitive organ, energetically reacts. For this reason artificially and correctly produced lordosis will cause albuminuria in normal individuals. For the same reason albuminuria may be prevented in lordotics by artificially avoiding stagnation. This may, for instance, be done by the upside down position which would prevent stagnation on the ground of hydrodynamic laws, or in the erect position by correct ing the lordosis. Finally, it is possible to cause albuminuria in lordosis in the horizontal or even upside-down position, if the slight stagnation which this position involves is incfeased by a mechanical impediment, such as exists in exaggerated lordosis. Again, albuntinuria can be produced in both normal and lordotic children by pressure upon the inferior vena cava above the juncture of the renal veins. Albutninuria is, therefore, induced by causing a mechanical renal stasis, and it is always absent when renal stasis is in some way- prevented. Albuminuria is,therefore, only seemingly dependent upon the position of the body, but simply and solely on the conditions 'of stagnation in the region of the inferior vena cava. Thus, I can induce albuminuria in the decubitus or prevent it in the orthostatic position according to whether I cause or prevent renal stasis by mechanical means."
There is no doubt that Jehle has proved by his ingenious experi ments that albuminuria may be caused by lordosis, which has been con firmed by those who have tested his findings, among whom are Binge], Bruck, Nothmann, Goetzky. critics should therefore not question the fact of the existence of lordotic albuminuria, but concern themselves with the following questions,— I. Is every case of orthotic albuminuria lordotic? 2. Does lorclosis of the upper pait of the lumbar spine always lead to albuminuria? 3. Is Jellle's explanation of the pathogenesis of lordotie albuminuria correct? The question whether all chiklren with orthotic albuminuria have the characteristic form of lordosis cannot bc answered without reserve at the present time, since this would require extensive investigation which at present has only just commenced. I have unquestionably seen eases of orthotic albuminuria without characteristic lordosis and Goetzky's inves tigations with the large material of the Berlin Children's Clinic have shown that not only are there children with characteristic lordosis and no albu minuria, but also eases of orthotic albuminuria without any trace of lordosis. However, it should be remembered that the clinical examination will only reveal one side of the vertebral column, while we have no knowledge whatever of the behavior of the ventral side, and it is upon this and its relation to the vena cava that Jellle's thcory chiefly depends.
As to the consistency of the 1111/IC, this may be identical in genuine orthotic albuminuria and in the artificially produced lordotic form, or it may be restricted to the presence of proteicl substances that can be pre cipitated by acetic acid. But the excretion of casts and red blood cor puscles does not belong to the picture of orthotic albuminuria, as has recently again been corroborated by a number of investigations by Goetzky which directly contradict the probability of that affection being present. In Jehle's experiments, however, casts and other form elements were unusually frequent components of the urine in lordotic albuminuria. We would, therefore, have to assume that the lordosis in genuine orthotic alburninuria is so slight as not to cause any material injury to the renal epithelia by whatever process. This, however, would be very remarkable since all degrees of lordosis are represented in orthotic albuminuria. For the present I cannot see any justification for identifying orthotic with lordotie albuminuria and for replacing the name of albuminuria orthotiea by albuminuria lordotica, as was proposed by Escherich some time ago.