ALBUMINURIA in children is frequently overlooked, especially in private practice, in cases presenting none of the well-known characteristic symptoms usually accompanying the disease. The oversight depends upon a lack of frequent and systematic urinary examinations. It is now axiomatic that the younger the child the less dominant the “old time” symptoms. The indications often point to involvement of organs remote from the kidney centre; for instance, a simple high fever may be present, or vomiting, purging, and collapse, or drowsiness and mild convulsive seizure, or simply anaemia.
The common cause of albuminuria in children is Bright’s disease as a sequela of the acute infections diseases so frequent in childhood. Again, Bright’s disease may exist without any apparent cause and practically without indicating symptoms in children even as young as six months or less. In these cases, when an urinary analysis is desired, the urine can be collected by keeping the child on pieces of well-boiled linen on a rubber pad for some hours. By this method sufficient urine can be wrong out to give the desired chemical and microscopic tests. A sterilized silk sponge can be used in the same way. If retention is present, a small catheter will secure the fluid. Pus, blood, or chyle ar rare causes of albumin in the urine of children.
Morbid growths resulting in pressure will also give rise to presence of albumin. The most interesting phase of the question of albuminuria in children is the so-called functional albuminuria. By this is meant a renal albuminuria with absence of casts and all characteristic signs of Bright’s disease or any other disease, the victim being to all intent and purpose in perfect health. The claim has been made that this condition is more frequent in boys than in girls. In cases of adolescence this seems to be established. It frequently accompanies the habit of masturbation. The amount albumin present varies greatly; sometimes it is quite large.
As a rule, it is limited, some in the morning, more at noon, and none at night; or, again, there may be none in the morning and quite marked at night; or, when the patient has been resting in bed, it may disappear altogether, remaining absent for some days after resuming the usual occupation of the day, and then from some apparently insufficient mental emotion or excitement a large quantity may reappear. The ingestion of food, or certain articles of food, like eggs, seem to cause it to return. Time and again the chemical urinary analyses show an entire absence of albumin in the morning urine, with a gradually increasing amount as the day advances, being highest in urine voided on retiring.
For this condition no attributable cause can be determined, exception the daily muscular activity of a child in contradistinction to the night’s repose, which gives a morning urine free from albumin. If exhaustive microscopical examinations fail to give evidence of Bright’s disease, such as tube casts, renal epithelium, etc., then the cause of the albuminuria becomes speculative and unsatisfactory. To many authorities the diagnosis of functional albuminuria, or albuminuria of adolescence, is sufficient while others fail to accept this comforting opinion and view with apprehension intermittent paroxysmal albuminuria, or the daily recurrence of a slight albuminuria as indicative of the existence of some unrecognized kidney lesion, or, at least, as the advance signal of the oncome of some form of Bright’s disease. I hold with the latter, and view sceptically the existence of a physiological albuminuria.
The diagnosis of these masked conditions is extremely interesting and vexatious. I recently came in contact with a case in a girl, aged 13, who had an attack of diphtheria, with secondary glandular involvement. She convalesced nicely. On the fourteenth day the temperature rose suddenly top 103 degree F., with albumin in a scanty urine, amounting to nearly one-half the amount of urine examined in test-tube. The temperature fell rapidly, the albumin diminishing in pace with the fill of temperature; the latter remaining stationery at 99 degree, and the urine containing a trace of albumin for four weeks, no tube-casts ever being present.
The following six weeks the urine was tested as follows: A morning, noon, and night sample, separately, every other day and a twenty- four hour sample every second day with negative results. The menstrual function was then established, and albumin appeared regularly for five days without casts. Then a period of six weeks passed without albumin, followed by a reappearance of albumin after a short period of nervous excitement, and so on. The question in this case arises: When was the albuminuria established?
In either event, there being no other symptoms but a high lever and a scanty urine at the time of the discovery of the albumin, the prognosis must be of the tentative or experimental type. The lesson to be drawn is the necessity of careful, exhaustive, and persistently-repeated examinations of the urine for casts, in order to establish a diagnosis and prognosis in the by means infrequent cases of albuminuria in children without symptoms.