Cough. Some years ago Dr. Noland MacKenzie--to whom we are indebted for the greater part of our knowledge of the subjectcalled the attention of the profession to cough as a physiological nasal reflex. He maintained, and I believe it is now accepted by all rhinologists, that there are certain areas in the nose which if irritated will culminate in a cough. The existence of such areas have also been demonstrated in the larynx and trachea. This area is more pronounced on the posterior third of the lower turbinal and the opposite septal wall.

In Diabetes one of the early symptoms is a dryness of the pharynx associated with a redness of tht mucous membrane. This dryness soon extends to the oral cavity and to the mucous membrane of the entire upper air passages.

Again, let us consider Rheumatism and its relation to diseases of the upper air passages. Take that form of uric acid diathesis known as lithemia, in which there is no excess of uric acid in the urine. In it we do not find any of the constitutional symptoms of rheumatism but the product of imperfect nitrogenous metabolism is retained in the system. This is manifest especially in the pharynx, in engorged blood vessels of a bluish cast and in an hypersecretion of a tenacious mucus which it attached to the membrane. This is due to an effort on the part of the membrane to excrete this excess that has not been thrown off by the kidneys. The condition is most frequently noticed in good livers, who neglect to take proper exercise.

An English army surgeon states, "that men who had varicose veins on the legs had also enlarged tonsils." He found that "in anesthetizing by the closed method, patients who were of a florid, full necked, healthy type suffered from cyanosis, labored breathing and excessive mucous secretion due to the reduction of the ingress of the air by the enlarged tonsils," and also, "that the chronic obstructions to free respiration and oxidation of the blood from which these patients suffer, produces a certain degree of chronic engorgement throughout the systemic veins, and this factor-that is, the enlarged tonsils-contributes to the gradual dilatation of the veins of the legs from which those patients suffer." He spoke of enlarged tonsils being a factor in hernia by causing forced breathing and abdominal exertion.

The size and shape of the nose has always-in both ancient and modern times-been considered an indication of the proportionate development of the generative organs. So intimately indeed was the nose supposed to be associated with the organs of generation that

among the Greeks the crime of adultery was punished by the cutting off the nose. That there is a direct influence upon the nose and throat due to the normal stimulation of the organs of generation is not to be doubted. The examination of the healthy nose and throat prior to the advent of puberty and that of the healthy nose in the adult presents marked differences, both in structure and secretion. The change in the tone and register of the voice, the growth of hair on the pubes and in the anterior nares are found to be associated or coincident with increase in the vascularity of the erectile tissue of the middle and lower turbinals. Frequently the female, after puberty, shows a turgescence of the nasal mucous membrane regularly with menstruation. In cases where the operation of oophorectomy or hysterectomy have been performed the nasal mucous membrane not infrequently returns to the infantile type and the anterior nares are found to be more capacious.

Masturbation in children in early years is found associated with a thickened condition of the nasal mucous membrane covering the turbinals and if the practice is continued after puberty we may find the reactionary stage, atrophic rhinitis with perversion of the sense of smell.

Kyle says, "the special causes of reflex nasal phenomena-as sneezing, dyspnea and epistaxia-when emanating from the sexua! organs, are continual abuse of their physiological function, pregnancy, menopause, chronic affections of the uterus and ovaries and a¦¦ abnormalities of menstruation." Coitus will occasionally cause nose bleed, on the other hand absolute continence is said to produce epistaxis. Under sexual excitement not only does the erectile tissue of the generative organs become engorged but the same structure in the nipples and nares is also stimulated and thus produces the symptoms of obstructed respiration. Of course this varies in degree. In the lower order of animals and especially in dogs this turgescence and stimulation of the tissues is noticeable under sexual excitement.

To sum up, I again quote:

First, "that turgescence of the nasal mucous membrane always occurs during the procreative act."

Second, "that there exists a marked degree of nasal hyperesthesia at such times."

Third, "that a more or less marked periodical engorgement of the nasal mucousa occurs in females coincident with menstruation." Fourth, "that this same engorgement occurs at times during pregnancy showing that it is not dependent upon the menstrual flow."

Fifth, "that operations which destroy the functions of the generative organs cause the nares to return to the state which existed prior to the advent of puberty."

Sixth, "that in the lower animals sexual excitement is always accompanied by occlusion of the nares."

Seventh, "that long continued hypernutrition from frequent and inordinate congestion will produce permanent tissue changes in the nose."

818 Rose Building.

POST OPERATIVE UREMIA.*

BY B. R. BURGNER, M. D., CLEVELAND, O.

The object of this paper is neither to present anything startlingly new nor is it my intention to burden you with a long analysis of the various theories of etiology, etc., but simply to present the subject to you for discussion.

Symptoms of renal insufficiency are not so frequent now as formerly, because of the free use of water before, after, and frequently during major operations. Consequently uremia, which is the climax of renal insufficiency is correspondingly infrequent. No doubt, the frequency of this complication will be lessened still more, as we become more familiar with its causes. When uremia does occur the onset is comparatively sudden, the symptoms acute and progressive, and death completes the drama unless strenuous methods are used to combat the toxemia.

Uremia usually occurs during the first week following an operation, but has been known to occur as late as the third week. The immediate cause is the retention in the general circulation not of urine, but of substances which should have become urine. Ammonium and potassium salts have attracted the most attention as causes of uremia. The theory that pathological changes in the liver are frequent causes of uremia is worthy of consideration. The liver makes urea out of ammonium salts; so anything that interferes with the normal performance of this function allows the ammonium salts to remain in the general circulation as such. Experiment shows that the injection of ammonium salts into the circulation causes symptoms similar to those of uremia. We know that chloroform or ether, espe

Read at the December meeting of the Cleveland Homeopathic Medical Society.

cially chloroform, has a tendency to produce pathological changes in the cells of the liver, kidneys and heart, and that the liver is the organ most frequently and seriously affected. To me, this seems to account for those cases of uremia following protracted anesthesias, even though careful and frequent examinations have revealed no disease of the kidneys prior to the operation.

Under ordinary circumstances the diagnosis is comparatively easy, for the changes in the urine with the resulting symptoms paint the picture very clearly. One of the most characteristic symptoms is that the quantity of the urine is greatly diminished, while specific gravity instead of being increased remains about normal or more frequently below normal, showing a great decrease in the amount of solids, principally urea, excreted. Other changes are the presence of casts and a high percentage of albumin. The elimination from the blood by the skin and lungs of these products which should have been urine causes the ammoniacal odor that surrounds the patient and the urinous odor of the breath. The toxins affect especially the central nervous system, therefore we always have nervous symptoms which vary from slight tremors to convulsions; from somnolence, low muttering delirious, and mental stupor to profound coma; from slight visual disturbances to complete amaurosis. The temperature is variable and therefore is of no use in the diagnosis. The arterial tension is slightly increased for a short time, but is not so marked in postoperative uremia as in uremia under other circumstances. The pulse soon becomes weak and rapid. The skin is dry and of a dirty gray hue. Other symtoms fairly constant and persistent are vomiting and dyspnoea.

When the physician is confronted with such a set of symptoms it is high time that he be up and doing. Tomorrow will not do, for the chances are that there will be no tomorrow for the patient if something is not done. There is no condition to which the old adage, "an ounce of prevention is worth a pound of cure" is more apropos than to this condition. That it can be prevented very many times is readily shown by comparing the results of modern methods of preparing the patient for operation with those of earlier days. Water should be given freely and methodically for two days prior to the operation, for the purpose of washing out the skin and kidneys and stimulating the bowels. Baths should be given to free the skin so that the glands can perform their functions. Copious purgation is a method of the past. Instead of saline cathartics something mild should be used and just enough should be given to produce a soft but not a watery stool. An enema should be given the preceding night

and another in the morning about two hours prior to the time of the operation. Certain drugs which have an irritating action on the kidneys, such as bichloride of mercury and carbolic acid should be used with great care, especially where there is susceptibility or where there is a chronic nephritis. The least possible amount of anaesthetic should be given to produce relaxation and insensibility and the work in hand should be done with the greatest decrease in proportion to the amount of anesthetic given and the length of time the patient is under the anesthetic. The surgery is no place for levity or for wasting time. The surface of the patient should not be unnecessarily exposed during the operation, the patient being especially susceptible to draughts while under the influence of an anesthetic, and chilling of the surface may bring on a congestion of the kidneys or stir up a latent or chronic nephritis which may be very hard to overcome. After a long operation and while the patient is on the table, we believe it to be good practice to inject a quart of normal salt solution into the bowel. This increases the arterial tension, thereby lessening the danger of shock. It also acts as a diuretic, thereby overcoming to a certain extent the direct effect upon the kidneys of the anesthetic, which as we all know, retards the excretion of urine. When the patient is taken to his room, the room should be warm, the bed warm and the patient should be placed between blankets and kept between them until convalescence is well established.

The amount of urine should be recorded and an examination of it should be made once a day for at least a week and thereafter as often as it is deemed necessary. The amount of urine is usually decreased after an operation, for 24 to 48 hours. This is due to shock, lack of water ingested and to the anesthetic. The urine frequently contains albumin and casts which are usually transitory. This period while short may be lessened by giving saline enemas every three hours in addition to the enema mentioned above. The amount usually given is from 6 to 8 ounces. If this condition instead of improving increases in severity and the amount of solids is greatly diminished,. we soon have the general symptoms of uremia.

The object of the treatment should be first to eliminate the toxins as far as possible, second to decrease the toxicity of the materials remaining in the blood, third to prevent the further formation of toxins, fourth to support the patient. Elimination takes place through the skin, kidneys, bowels and lungs. The agents used to produce an increase in elimination are called diaphoretics, diuretics and purgatives. The one great remedy that we have to produce sweating and diuresis, and one that stands out prominent