Three eases of intermittent albumi nuria which occurred in the same family. As often as six times. based upon as many observations. attention has been called to the family character of this disease. In the family of the children mentioned above gout is hereditary: a very important fact as regards the eti ology of the disease. Lacour (Lyon Med., No. 25, '97).
Albuminuria, particularly cyclical or irregular albuminuria, may be frequently due to gastrointestinal autointoxication. Case in which hydatid cysts of the liver caused marked constipation and icterus and distinct albuminuria; latter disap peared after operation upon the cysts and recovery from disturbed condition of di gestive organs. The function of the liver and of thyroid gland is particularly im portant in such albuminuria, since dis turbance of either organ may lead to production of toxic substances which cause albuminuria. A. Praetorias (Ber liner kiln. Woch., Apr. 4, 11, '98).
The diagnosis of physiological albu minuria ought not to be made except in cases when persons presenting no other symptom of disease excrete, constantly or intermittently, a urine containing a scanty quantity of albumin, but no morphotic elements and especially no casts. The centrifugal apparatus, now coming into general use, will certainly contribute to restrain the number of these cases.
Even when no casts can be found, albuminuria ought never be regarded as absolutely inoffensive. Although a cyclical albuminuria continuing years may be compatible with perfect health, still many authors (Johnson, Greenfield, Bull, etc.) are of the opinion that it sig nifies the first stage of the evolution of granular atrophy of the kidneys. The albuminuria often found in parturient women (Aufrecht saw it in 56 per cent. of all cases) must also be regarded as physiological.
Protest against the indiscriminate re jection of candidates for assurance on account of albuminuria: that is, after a merely chemical examination of the urine. In every ease in which albumin is found microscopical examination of the sediment obtained by centrifugali zation is essential for the avoidance of unnecessary rejections. There are two fundamentally distinct forms of albu minuria, the renal and the extrarenal. The latter is indicative merely of a functional or organic lesion of the gen ito-renal tract, which is not necessarily or even usually dangerous to life. Ex t tarenal albuminuria is characterized by its transitory and intermittent nature. Since, however, some forms of renal albuminuria are equally transitory and intermittent, the final distinction be tween the two is based on the micro scopieal examination of the sediment. The presence of blood, pus-cells, epi thelium from the mucosa of the urinary tract, spermatozoa, and shreds of mucus, in the absence of renal elements, is decisive of an extrarenal origin. Prob ably in many eases of so-called physi ological albuminuria the origin of the albumin is extrarenal. Zechnisen found albumin in the urine of 21 out of 144 ophthalmic patients; in 60 per cent. the presence of blood, vesical or urethral epithelium, pus, or spermatozoa pointed to an extrarenal origin. Von Noorden
found albumin in the urine of 154 ap parently healthy soldiers, which in 10fi originated extrarena Hy. Flensburg ex amined the urine of those soldiers in which Ile had unexpectedly found albu min at the end of their two years' service: in the majority every trace of albumin had disappeared, and in the remainder there was no single symptom of nephritis. In every ease of albunii nuria the presence of blood should be excluded, for traces of blood too minute to be detected by Heller's or the spectro scopic test will nevertheless give the reactions of albumin. In extrarenal al buminuria nucleo-albutnins preponder ate. In doubtful cases the urine should lie obtainea by eatheterism, so that every source of contamination may be avoided. Albuminuria of renal origin may be either temporary or permanent, functional or organic. Organic lesions are characterized by persistence. But persistence is not an absolute bar to acceptance, for cases occur, though rarely, in which albuminuria with renal casts continues indefinitely without any disturbance of health. If, however, there are polyuria, casts, cardiac hyper trophy, or dilatation. arteriosclerosis, retinitis, uremia, and wdenta, nephritis is obviously present. Every case should be judged on its merits. Even without albuminuria, endarteritis, or any one of the above-mentioned symptoms, com bined with persistently-increased diu resis and a specific gravity between 1.010 and 1.012, is extremely suggestive of an organic renal lesion. The functional form of renal albmninuria is transitory or intermittent, and is principally due to intoxication or autointoxication. The toxic symptoms produced must de cide in each case whether the applicant should he accepted. The most impor tant variety is that which occurs after exercise, and which points to a meta bolic instability which may possibly be come dangerous. Renal albmninuria which persists during convalescence from infectious diseases is of no more significance as a sequel than slight bron chitis; if there are no cardiovascular changes the candidate may be passed. Some of the most difficult problems are connected with cases of ascending infec tion from the bladder. If the process is tuberculous, the candidate should clearly be rejected. In other cases the question whether the kidney is involved will be decided by the effect produced and the condition of the heart and ar teries. Many eases of functional al buminuria are due to circulatory dis turbances. Of this nature is probably that form known as "cyclical," or "pos 1 tural," in which there is usually some circulatory disturbance, as evidenced by cardiac dilatation, tachycardia, palpita tion. or anmnia, though doubtless hered ity and other factors are involved. It is the rule to reject these applicants; but, as the prognosis is usually excel lent, there is no reason why they should not be accepted after a period of pro bation. This form of albuminuria is practically identical with the albumi nuria of cardiac disease. Stokvis (Brit. Med. Jour.; from Wiener med. Woch., May 3 and 10, 1902).