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tween the attacks, the patient lying in a condition of profound insensibility from which he cannot be roused. The following symptoms are characteristic 50mg viagra cialis of uraemic coma: The pupils will not react to light. There is a urinous odor from the surface of the body. The respirations are irregular, sometimes rapid and sometimes slow; they are always of a peculiar hissing character. The temperature is elevated at first, but later slowly falls. The pupils are as a rule irregular, and albuminuric retinitis is almost always present. The face is pale. The pulse in a large number of cases is incompressible, and rigid arteries are found. The phenomena of an epileptic attack closely simulate uraemic convulsions, and it is some- times very difficult to distinguish between them. The convulsive movements in epilepsy are generally uni- lateral; both sides are equally affected in uraemia. The initial cry and great pallor of the face preceding the attack is peculiar to epilepsy. The temperature is not elevated in epilepsy and reflex sensibility continues all through the paroxysm. After an at- tack of uraemic convulsions the patient passes into deep buy viagra best coma. Following an epileptic seizure there buy viagra best is only a deep sleep, from which the patient can be roused. An examination of the urine will generally determine the nature of the case. In apoplexy the coma always precedes the convulsions. There is con- jugate deviation of the eyes, facial paralysis, and hemiplegia. In opium poisoning the pupils are sym- metrically contracted, even down to a pin point in size. The respirations are exceedingly slow, even as 922 MEDICAL RECORD. [June 27, 1896 few as five per minute. The pulse is strong, full, and readily compressible. The patient is not absolutely comatose, and can therefore be partially aroused. Acute alcoholic poisoning is a very common cause of coma. The respirations are hurried, and expiration quickly follows inspiration. The pulse is quick and strong and the patient can be partially aroused, but returns to a drunken consciousness. His answers are not rational, the words are not well articulated ; he is irritated by interference and buy viagra best often uses profane lan- guage. There is another variety of coma due to con- cussion of the brain from blows or falls on the head, and it is of great importance to distinguish this form, as it is frequently due to criminal assault. There is something very characteristic in this form 50mg viagra cialis of coma, for the control of the brain over the spinal cord is withdrawn; hence the reflexes of the spinal cord are set free and ever}' external impression leads to twitch- ing of the muscles, sometimes great enough to produce a movement of the whole limb. Hence, 50mg viagra cialis whenever there is jactitation it points to some injury of this kind to the head, and is very significant. Treatment. This should consist of, first, measures taken to prevent further structural changes in buy viagra best the kid- neys, to remove as quickly as possible all inflammatory products that may obstruct 50mg viagra cialis the buy viagra best smaller renal tubules, to facilitate the elimination of urea, and to remove or palliate certain 50mg viagra cialis symptoms, such as dropsy, anaemia, etc. The cause of the disease must be sought for and removed if possible. If the chronic abuse of alcohol is a cause, it must be stopped. Prolonged exposure to very severe weather must be avoided. It will be found in many cases of continued suppuration, caries, necrosis, chronic cystitis, and stricture of the urethra that renal degeneration has already taken place. This should be borne in mind by the surgeon, and should have great influence in deciding upon an operation. The diet should be light and of the highest nutritive value. Milk as a rule agrees very well indeed. It is best given with equal parts of lime water. Alco- holic liquors are badly borne and should be withheld. If alcohol is absolutely required, one or two 50mg viagra cialis glasses of red wine may be taken during the day with food. The patient should wear flannel next to the skin, and moderate exercise in the open air should be indulged in. Many writers lay great stress on keeping up a constant flow of water through the kidneys, thus endeavoring to wash clear the 50mg viagra cialis renal tubules of all the buy viagra best cellular mate- rials that they may contain, and using such remedies .is the sweet spirit of nitre and other diuretics for this purpose. I approve of the regular administration of cathartics, and for th ; s purpose twenty grains of the compound jalap powder given three or four times a week is very useful. It is also important that the function of the skin should be kept in action, and for this purpose the warm bath is very useful. The pa- tient can be placed in a bath of the temperature of ioo F., and hot water may be gradually added to it 50mg viagra cialis until the temperature reaches 104" or 106 F. The patient is kept in the bath for about half an hour, and is then removed and wrapped in warm blankets for three or four hours, during which time great perspira- tion takes place. The hot-air buy viagra best bath is another method employed to induce diaphoresis. The patient should be stripped and placed upon a chair, under which a lighted alcoholic lamp is placed. A blanket closely pinned around the neck and reaching to buy viagra best the floor con- tines the heated air to the surface of the body. If the patient is too weak to sit up, the hot air may be intro- 50mg viagra cialis duced underneath the bedclothes, which can be ele- vated so as to form a tent or cradle. In using diaphoretics as eliminatives, it must be remembered that the skin is an eliminative organ only to a small extent, and acts as such only when the other eliminative organs fail. Therefore, whenever the skin is to be used for this purpose, it should be always prepared for this vicarious action. Any exist- ing tension found in it must be removed; for when the