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factor may be an anemia of varying degree, usually, in the early stages only slight, but, in women I have seen it severe enough, even in this stage, to prematurely precipitate the menopause.

The next most constant symptom or condition to herald the oncoming renal condition is a history of more or less constant stomach trouble covering a period of many months, which yields very poorly, if at all, to treatment, even to careful dieting. Such a history, in the non-alcoholic at middle age, is always suspicious. In fact a history in a patient carrying a pulse of 90 or more, with either a slight polyuria or even a scanty secretion of urine of a low specific gravity, warrants, in my belief, a diagnosis of probable Bright's, even if urinary findings are negative. Other symptoms that may be present, either singly or conjointly, to complete the picture, are: Indefinite nervous attacks, headaches without apparent cause, varying degrees of insomnia, attacks of dizziness and failing vision, especially by artificial light. In fact it is no unusual thing for the oculist to be the first to suspect renal insufficiency. Two other symptoms I have noticed in a few cases are, neuralgic attacks and repeated attacks of bronchial cough without any other evidence of the patient having a cold.

As for the urinary finding, the value of the presence or absence of albumen as a diagnostic sign, has, long since, been refuted. Albuminuria leads one to suspect Bright's but its absence is of no significance whatever. By far the most frequent form of chronic nephritis we meet is the interstitial variety, which only occasionally shows faint traces of albumen and then only in the last stages. Recently, a patient of mine died of uremia, whose urine during the uremic state and just a few days before death showed absolutely no albumen.

Aside from casts, the most valuable urinary finding, in my experience, is the output of total solids covering a period of 24 hours with the patient on a mixed diet. To estimate this, one must know the total amount passed in 24 hours and have a sample of this mixture. One may estimate the solids separately and then sum them up or he may make a fair estimate of the total solids from the specific gravity and Hager's coefficient. I believe this gives a better estimate by far of the renal efficiency or inefficiency than the total urea output alone. Of course, it is unncessary to mention the value of the presence of the various forms of casts or persistent presence of renal epithelium or blood cells. Such evidence is uncontrovertable. I have refrained from differentiating between the various forms of chronic Bright's-that is another story and a long one an

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it is here only that the presence or absence of albumen is of real value, as in the large white kidney albumen is always present and usually in good quantities.

To sum up this evidence, we have:

1. Persistent pulse rate of 90 or more as the patient approaches middle life, not accounted for by valvular disease or chronic lung disease;

2. Anemia;

3. A history of persistent digestive disorders;

4. Insomnia;

5. Headaches, without apparent cause;

6. Nervousness and unwonted irritability;

7. Dizziness;

8. Failing vision;

As clinical evidence and from the urinary examination we have: 1. Persistent polyuria with deficiency of total solids or,

2. Persistent scanty urine of low specific gravity with or without albumen;

3. Albuminuria when accompanied by casts in the absence of blood or large quantities of pus;

4. Casts, with or without blood cells and of renal epithelium.

DISEASES OF THE NOSE AND THROAT IN CONNECTION WTH DISEASED CONDITIONS OF OTHER

ORGANS OF THE BODY.*

BY GEORGE H. QUAY, M. D., CLEVELAND, O.

It is a well known fact that diseases of the nose and throat cause general systemic disturbances, and also that certain diseased conditions of other organs of the body cause nasal and pharyngeal disturbances. In this day of the specialist we are apt to become too narrow minded if we confine our attention to one branch of our profession to the exclusion of all the others. Because a man wishes to become a gynecologist is no reason why he should overlook rhinology and laryngology, and the reverse hold true also. No man can be a specialist in the truest sense who neglects all departments but his own. He should be a good general practitioner and not be regarded as a thing separate and apart, a kind of appendage, but he should take

* Written expressly for the CLEVELAND MEDICAL AND SURGICAL REPORTER.

an active part in all the problems with the solution of which general medicine is concerned. The general practitioner may fail to recognize special symptoms which might have been of the greatest importance to him in the recognition and treatment of his cases. Likewise the specialist, in confining his work to but one part of the body is apt to lose sight of the fact of the importance of constitutional symptoms.

That diseases of the nose and throat have an important bearing on many systemic diseases is a well known fact. Their true origin is sometimes masked. Conversely, it is true that many diseases having their origin in other organs of the body manifest themselves by symptoms referable to the nose and throat. For example, a patient goes to a physician for stomach trouble, who, in spite of well directed efforts, finds that he cannot cure the condition by directing his treatment to the stomach alone, he must take into consideration the totality of the symptoms. In his case the disorder may be due to a suppurating sinusitis, or, possibly to an over abundant secretion of mucous in the posterior nares. In such cases there is apt to be present a pale swelling of the inferior turbinates acompanied by a profuse muco-purulent discharge. Associated with the dyspepsia there is probably constipation. These must first be relieved before the stomach disorder can be cured.

Granular pharyngitis accompanied by a sensation of extreme dryness in the throat is frequently found in connection with a dirty coated tongue. Hyperesthesia, and more especially paraesthesia, of the pharynx is more frequently due to disorders of the digestion than to any other cause. In children stomach disorders and loss of appetite are often due to swallowing the abundant muco-purulent discharge associated with adenoids. Again, infra-orbital pain of a violent character may be due to the discharge from an abscess in the antrum becoming dammed. We are all familiar with the intense brow pain that may be present in acute rhinitis, due to blocking of the frontal sinuses. As a result of necrosing ethmoiditis we frequently get a degree of mental excitibility, maybe flushing of the face, on the other hand symptoms of depression, lassitude, inability to work, a mental state bordering on melancholia, and many of the so-called neurasthenic symptoms which are really due to pyaemic absorption from the infected cavity.

In infants and young children the chief cause of nasal obstruction is a catarrhal condition of the nasal mucous membrane. This may be due to infection during birth to the child, being permitted to lie in wet napkins and being allowed to crawl on cold

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floors which are generally covered with dusty carpets. Again, in many of these cases adenoid growths are the cause of the obstruction.

The results of nasal obstructions can be classed under two heads: First, the effect on the general health and development of the child; second, the effect on other organs and parts.

The most serious is the arrested development of the lungs and chest. The lower part of the chest is apt to become contracted, the so-called pigeon-breast. The child breaths with its mouth open, there is not infrequently some degree of deafness and often acute otitis followed by otorrhoea. The child does not get along well in school. He is languid, or may be restless, a poor sleeper, his speech not clear nor distinct. As a result of occluded nostrils not infrequently you will find chronic pharyngitis, laryngitis, bronchitis and asthma. In fact Bosworth goes so far as to claim that over 90% of cases of asthma can be cured by attention to the nose. In confirmation of this I believe every rhinologist can cite numerous cases of asthma cured or greatly benefited by removing pathological conditions in the nose.

The distressed and labored sleep of the mouth breather causes him to rise in the morning heavy and unrefreshed. This lack of rest must necessarily affect the general health of the sufferer. The person who sleeps all night with open mouth and goes about through the day in the same condition shows such evidences of air starvation as anemia, relaxed muscles and flabby tissues. The face and the person's actions indicate his physical inertia. Circulation is depressed, the activity of the digestive organs is lessened. These persons are irritable, anemic, not disposed to exertion, and are usually fussy about their eating. The voice is comonly hoarse and tires easily, in fact, the person's general condition is far below par. In many of these cases it is surprising how quickly the patient will gain weight, sleep better and show a buoyancy of spirit when proper nasal breathing space is secured.

Again, take for example Epistaxis. Consider the great vascularity of the mucous membrane of the nasal passages, its spongy or cavernous structure and the correlation of its blood vessels with other vascular tracts in remote portions of the body, and it is not surprising that nose bleed is a symptom of many pathologic conditions in other organs of the body. We may have overfilling of the capillaries due to overaction of the heart in certain organic diseasel conditions of that organ. Anything that tends to retard the flow of blood to the heart, that increases vascular tension or lessens the re

sistance of the vessel walls predisposes to nasal bleeding. This is true not only in organic heart disease but in hyperaemia of the lungs, liver, kidneys, etc. Nose bleed may at times be the forerunner of extravasation of blood into the brain and of retinal apoplexy in connection with renal lesions. Whenever we meet with hemorrhage from the nose in a middle aged person, there being no obvious ulcerative process to account for it, our suspicions should be aroused and we should seek for evidences of high arterial tension and vascular degeneration.

As stated, nose bleed is a frequent concomitant of cardiac disease without compensation. It is most common in venous stases due to failure of compensation in mitral disease and in aortic insurficiency. We are all familiar with nose bleed, the result of hemor rhagic diathesis. At times overvexation of the mental faculties anxiety or violent emotions will also cause the condition. Likewise it is common in the plethoric and in those addicted to the use of stimulants.

Epistaxis occurs as a symptom in many acute conditions as, for example, typhoid fever, scarlet fever and diphtheria. It is not in frequently an accompaniment of impoverished conditions of the blood as in chlorosis, leucocythemia, tuberculosis, syphilis and malarial fever and in congestion of the liver and spleen. It may also occur from the suppression of a cutaneous eruption, from sudden cessation of a normal flow of the menses when we get the well known vicarious discharge from the nose. At times the sudden disappearance of a hemorrhoidal flow will be followed by nose bleed. Cases are on record where it has followed the stoppage of hemorrhage from varicose veins of the leg. At the age of puberty, especially in boys, nose bleed is not infrequently seen. Hemorrhage from the nose, also enlargement of the turbinals is frequently met with during pregnancy This may be due to vicarious action or, possibly, to the pressure of the enlarged uterus upon the abdominal veins. It has also been reported as occurring after the removal of the uterus and its appendages. It may be symptomatic of irritation from the gastrintestinal tract. There are numerous instances on record where the bleeding seems to arise from psychical impressions conveyed through the sense of smell, from various articles of food, etc. Many peculiar cases also are recorded. One, for example, where every time the patient heard a bell ring it produced epistaxis. When the tendency to nose bleed occurs late in life it can be explained by the degenerative changes taking place in the vascular system which accompanies old age.

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