in a few hours, or to long-standing disease of a very serious nature, from which there is no probability of recovery.

It has been said that small quantities of albumen may appear in the urine even of the healthy, and that the discharge persists for a time and then disappears. This undoubtedly happens occasionally, but for one such case I should say one meets with twenty in which, although for months there are no grave symptoms, sooner or later indications are afforded of more than mere temporary change. Eventually the existence of chronic disease is established, and the case, after some years, it may be, assumes a grave form and ends fatally. That "physiological albuminuria" may occur is possible, but I believe it to be one of the rarest of events. I am unable to understand what is meant by "insensible albuminuria," a condition which Dr. William Roberts compares with "insensible perspiration." The author seems to forget that what is called "insensible perspiration" can be demonstrated at any moment by allowing it to condense upon a piece of cold glass placed near the skin, when it becomes sensible enough; while the "insensible albuminuria" seems to be a mere assumption, or hypothesis, or conjecture, neither to be proved nor disproved. The suggestion is, I think, fraught with some danger; for while on the one hand there is no doubt that certain cases of albuminuria have been foolishly condemned to die a quarter of a century too soon, it is quite certain, on the other, that far too little importance has been attached to some serious cases, which in the commencement might have been adduced as examples of "physiological albuminuria," the merest traces only of albumen being occasionally present. Of course it is of the greatest consequence that the practitioner should do his utmost to avoid erring, either on the side of making too much of a case of temporary albuminuria, and thus, perhaps, ruin a career by needlessly stopping study at a critical period, and by unnecessarily insisting that the patient should winter in the South; or, on the other hand, by making too light of a case of a chronic disease in its early stage, lose the only chance of curing the patient or of greatly prolonging his life by recommending a judicious course of treatment.

I have seen many cases of slight albuminuria in young people, who in every other respect seemed perfectly healthy. The course of the malady, in the great majority of instances, rendered it quite certain, I regret to say, that the very slight traces discovered could not be due to temporary derangement or to physiological albuminuria, but depended upon the commencement of organic disease. I should certainly decline to recommend such cases of very slight albuminuria for life insurance, until at least one year had expired after the observation, the urine having been examined at intervals during this time, and invariably found free from albumen. I am aware that the most confident assurances have been given in cases of the kind, but I can call to mind several in which I believe great mistakes would have been made by practitioners who feel very certain of being able to arrive at a correct conclusion; cases in which a favorable opinion would have been given at any time during three or four years, although they ended fatally in five or six years from the commencement; cases which did well where a very unfavorable prognosis would have been made; cases, again, which seemed to completely recover for a period of more than a year, and then relapsed into ordinary chronic albuminuria, and died in the course of five or six years.

For my own part, I feel sure that the greatest caution, as regards committing ourselves to an opinion, ought to be exercised. The patient should be seen a few times, and several examinations of the urine taken at different times of the day and night. should be made. Taking into his consideration all the general and special points of the individual case, the physician will often be able to arrive at a correct conclusion and give advice that should be acted upon. But with all the care he may take, he will be led to make a mistake now and then, and regard the case as more serious or less serious than it turns out to be. I have no doubt that now and 'then a case which in the beginning was very obscure and concerning which I had been unable to give a positive opinion, has at a later period, when there could be no doubt as to its nature, come under the notice of another physician, who would then no doubt feel surprised that I had not expressed myself more decidedly as regards diagnosis.

case.

The significance of mere traces of albumen in the urine is a question which often comes before us in connection with life insurance. Decide we must, and it is needless to say how very important it is that we should arrive at a correct conclusion. There may well be conflicting opinions with regard to a definite One adviser, considering that a trace of albumen is of no consequence, recommends that the life be accepted by the office, while another considers it necessary to give an equally confident opinion, and holds that the trace of albumen is an indication of commencing disease, which will destroy life long before the ordinary period of life is reached, and regards the risk as too hazardous for the office to accept.

Sometimes very decided traces of albumen will be found towards evening or after unusual fatigue, while the water passed in the early morning will be quite free. There are cases in which albumen is found in the water almost constantly for a period extending over some years, and then ceases to be detected for several months and reappears, again disappears for a year or two, and then returns and persists till death occurs from chronic structural change in the kidney.

Cases are from time to time met with in which it is probable that the albumen of the chyle finds its way into the urinary passages and becomes mixed with the urine. Chyle itself obtains ent rance in those rare and remarkable cases known as chylous urine (see page 47), and it is probable that in a far greater number of cases the serum of the chyle, from time to time, somehow filters through the walls of lacteal vessels which have become temporarily obstructed, and may at last find its way by a circuitous path into the urinary passages, and escape with the water. A substance nearly allied to albumen is probably formed, under certain circumstances, upon the surface of mucous membranes, and may perhaps be correctly regarded as a modification of the material of which the outer part of epithelial cells is composed, but in a less perfectly formed state than the substance ordinarily produced. Possibly in some cases the albuminous substance present is due to the action of the epithelial cells, or rather to the bioplasm of the epithelium. So many modifica

tions of albumen are discovered that there can be no doubt that some forms are variously altered and modified during their formation, while every form is not produced in the same way.

Disturbances in the nervous system by reflex action may cause contraction of the muscular fibres of vessels, and in consequence the transudation of a small quantity of albumen through the capillaries may occur.

Small quantities of albumen in the urine sometimes appear in. cases where there is unusual excitement of the testicles. In some of these cases the albumen is due to slight hemorrhage, but it cannot always be accounted for in this way, as no blood corpuscles can be found. It may, therefore, be discharged with the semen or find its way into the vesiculæ seminales.

The presence of albumen may be due to temporary or permanent changes in some part of the urinary apparatus; to serious structural changes of the gland structure or some part of the mucous membrane, or to mere temporary derangement. It may depend upon transudation of the serum of the blood in a diluted state, or it may be due to the escape of a little blood from the capillaries of the secreting structures of the kidney, or from the mucous membrane of the pelvis of the kidney, ureters, bladder, or urethra. Just as hemorrhage occasionally takes place from the capillaries of the mucous membrane of the nose or mouth without there being any definite disease, so bleeding may occasionally take place in some part of the urinary tract without being due to any actual lesion or leading to any definite morbid change.

Among the most important of the circumstances which determine the presence of albumen in the urine, are the following: Pressure upon the large veins, particularly the renal veins and the inferior vena cava ; Passive congestion of the capillaries of the kidney; Alterations in the blood; The escape of blood into the urinary passages; The presence of cancerous growths; In females the menstrual discharge; Affections of the mucous membrane of the urethra, bladder, or pelvis of the kidney; Stone in the kidney, ureter, or bladder; Acute or chronic, functional or structural, temporary or permanent changes in the kidney itself.

ALBUMEN IN THE URINE FROM PRESSURE UPON THE LARGE

VEINS.

Wherever any physical impediment to the return of blood in the emulgent veins or inferior cava exists, and in some cases of obstructed portal circulation, as in cirrhosis of the liver, traces of albumen may be detected in the urine. No casts, or at most only a few transparent mucous casts, are to be found in the deposit, and for the detection of albumen we must rely on chemical tests. In some instances a tumor may be distinctly felt, and then the nature of the case is at once demonstrated, but when it is situated in the posterior mediastinum or behind the liver, the diagnosis is often extremely difficult. The pressure of the gravid uterus may occasion the albuminous urine in some cases of pregnancy, but the presence of albumen cannot always be referred to this cause, for it is not unfrequently found at an early period of pregnancy, when the uterus is too small to exert sufficient pressure. Dr. Tyler Smith considers that in some cases in which there was no organic disease, the albumen might be accounted for by some influence exerted upon the nerves. Out of 112 specimens of urine from pregnant women, Dr. H. Van Arsdale and Dr. Elliott only found albumen present in two instances ("New York Journal of Medicine," 1856), but in England it has been found by some physicians in a much higher percentage. Regarded from a clinical point of view albumen in the urine during pregnancy is of less serious import than under other circumstances, seeing that the great majority of such cases completely recover after the birth of the child.

In some cases of ascites albuminous urine seems to be due to the pressure upon the veins, for after tapping, the albumen ceases, while it reappears with the reaccumulation of the ascitic fluid. In forms of cardiac disease albumen in the urine seems to be due to impeded venous circulation.

It has been suggested that spasm of the minute arteries caused by reflex nervous actions excited by poison in the blood may occasion such disturbance in the circulation in the kidney as to lead in some cases to the escape of serum. In cases in which the albumen in the urine depends upon obstructed venous circu