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fislulae, no cicatricial contractions about the neck, no injuries to the rectum, no loss of sexual power." My paper is not a plea for catheter life as opposed 820 MEDICAL RECORD. [Nov. 24, 1906 to prostatectomy, for bare conservatism as against bare radicalism. It is submitted as an argument for discriminate intervention as against indiscrimi- nate operating ; for finer distinctions in tlie field of indications, and for a rational application of all the known methods and means of treatment in such pro- portions as shall gain the maximum results for each individual patient suffering from the condition known by the Buy Cheap Trileptal generic term, prostatic enlargement. 20 East Forty-sixth Street. SOME IMENTAL SYMPTOMS DUE TO DIS- EASE OF NASAL ACCESSORY SINUSES.* By J. A. STUCKY, M.D.. LEXINGTON, KY. That acute or Buy Trileptal Online chronic disease of the nasal accessory sinuses frequently gives rise to serious forms of mental Trileptal 135 Mg disturbance is very evident from the number of Trileptal 150 cases of melancholia and suicide which are re- ported Trileptal 150 Mg as being due to grippe or influenza. A few cases noted in my own experience in which the mental symptom was sufficiently pronounced to de- serve record, especially in chronic suppuration of the accessory sinuses, leads me Cheap Trileptal to bring the subject before this society for discussion. I shall report only one case in detail ; in the others only Trileptal Acne the mental symptoms will be given with the pathological findings as result of operation. All of these cases gave every evidence of chronicity, having existed for a long time. All gave the promi- nent characteristic symptoms of suppuration and were submitted to the usual diagnostic tests. All were operated upon Tegretol Vs Trileptal after the Killian method, of entering the frontal sinus, removing the floor of the sinus, or enlarging the infundibulum, as well as removing the middle turbinate and the anterior eth- moid cells, and as many of the posterior cells as could be found which gave evidence of being in- volved in the suppurative process. In two cases, in addition to invasion of the frontal and ethmoid, the sphenoid was involved ; in eight other cases, the maxillary sinus was also involved in the suppurative process. The case which I shall report presented unusual and interesting neurological symptoms, and was seen by Dr. G. P. Sprague in consultation. Dr. Sprague's notes are given in detail, followed Order Trileptal by notes of my examination, as well as the operation which followed. Case I. White, male, age 44, consulted me on account of pain over right eye. The left eye turned in; he had double vision when looking with both eyes ; slight ptosis of left lid ; pain over eye was worse at night and on arising in the morning and was aggravated by exercise or stooping over. Dis- charge of yellowish fluid from nose gave relief for several hours. The following are the notes of the examination taken by Dr. Sprague: "Patient ex- amined August 3, 1906; he said that in November, 1904, having been in good health, he suddenly be- came deaf in the right ear, soon after which it seemed as though there was a lump the size of a man's fist in the right nasal region, in which all sounds accumulated, and became confused or lost. He had no other symptom until late in December, 1905, when he suddenly began to have a sharp pain — which has never since spontaneously ceased — over the entire right half of the brain ; the worst pain being over the parietal protuberance. About _ *Read at the thirty-second annual meeting of the Missis- sippi Valley Medical Association at Hot Springs, .A.rk.. November 6-8, 1906. six weeks after the pain began he suddenly began to see double and found that the left eye had an internal squint ; both eyes have failed considerably, and the pain extends all over the right eyeball. With the beginning of the strabismus, the breath became vile, the tongue heavily coated, and there was a slimy taste, with lack of appreciation of the dif- ference in the taste of foods. Upon examination, the skin of the entire right side of scalp and right side of face, exclusive of the external ear, and fol- lowing a line near the insertion of the lower teeth to the middle line of the chin, is lacking in sensa- tion, although not wholly anesthetic. The right pupil is enlarged and stellate ; left pupil is smaller than right, and both react very slightly Trileptal Generic Name and slowly to both light and distance. Tongue is without tremor, but sharply deviates to the right. Knee jerks are normal; there is no ankle clonus. Shuf- fles in walking, and leans forward, with head ex- tended. Right eyelid droops very little. Grip of both hands normal. Has no aphasia. His family physician says that his mind is more sluggish, that Trileptal Cost he is more religious than formerly, that he occa- sionally 'preaches' in a wild manner about himself, and that he talks differently than when well, and uses wrong words at times, unless he talks slovvfly. His digestion is good and his bowels regular." My examination — ophthalmoscopic — is negative so far as fundus is concerned, except for slight swelling of edges of disk. Right pupil irregularly dilated ; no evidence of iritis or synechia ; media clear ; vision 20/40 when looking with one eye, 20/50 when looking with both ; lens do not improve vis- ion. Hearing noraial ; no evidence of disease of drum head or middle ear. Examination right an- terior nares shows a contracted and degenerated middle turbinate closely adhering to antral wall, completely occluding the middle meatus at its lower border ; a thin yellowish discharge without odor oozes from upper part of middle meatus; when wiped off with cotton quickly returns on bending head downward. Left anterior nares normal. Post rhinoscopic examination showed right side blocked with bluish mass covered with yellow pus and mucus ; left side was normal. Tenderness on per- cussion over right frontal sinus, more marked on deep pressure, especially under the orbital ridge and at the inner canthus. Transillumination of the sinuses is negative, ex- cept the right frontal, which is decidedly positive. Order Trileptal Online A diagnosis of disease of the frontal ethmoid and sphenoid sinus was made and an exploratory opera- tion advised, which was consented to. Under local anesthesia, the right middle turbinate was separated from the antral wall and removed with scissors and snare ; this was followed by flow of pus from eth- moid cells, which were found in a degenerating condition. The post nasal obstruction proved to be of tough tissue, resembling exteriorly a mulberry and was adherent to the anterior inferior wall of the sphenoidal sinus. This was with some difficulty removed with the- cold wire snare and was larger than an average sized chestnut. After the removal of this mass, the sphenoid sinus could be easily en- tered with a probe, and found to be filled with soft granulations which were removed with the curette, this operation gave prompt and pronounced relief. On the following day, August 5, the patient was etherized for the modified Killian operation. The posterior nares was tamponed to prevent blood from filling the pharynx, and an incision beginning be- low the median line of the base of the nose on the ■ight side and extending to the supraorbital notch along the upper edge of the eyebrow and as deep Nov. 24, 1906] MEDICAL RECORD. 821 as the frontal bone. The periosteum was carefully elevated and retracted and the sinus opened with chisel near the median line and above the orbital ridge, the opening was enlarged with rongeurs suf- ficiently to admit thorough insf>ection. The lining of the sinus was greatly thickened, was soft and edematous and of a dark blue color, and filled with dark serous Huid; the infundibulum was blocked by firm granulations. These were removed with cu- rette; the ethmoid cells were probed and found to have undergone polypoid degeneration Cost Of Trileptal ; the bony opening was Trileptal Vs Tegretol e.xtended down below the junction of the nasal bones, which gave free access to the an- terior ethmoid cells. These were removed with curette. After removing all morbid material, the bone edge was beveled and the frontal sinus was lightly packed with selvage gauze extending down into the nose. The incision was closed with the exception of a small (Opening for drainage at the inferior angle. The packing was Trileptal Coupon removed the sec- ond da\-, and the nose and sinus irrigated with warm saline and alphozone solution (i to 2,ooo)tvvice daily. The stitches were removed the fourth day, and the entire wound closed by the ninth day. The patient was up and walking around the hospital on the fifth day after the operation. The pain did not cease completely after the operation, but was so much relieved that he expressed himself as feeling like a new man, and although he had acquired Trileptal Tablets the morphine habit, having taken it twice daily for some weeks, was enabled to do without it after the first day. The nervous symptoms and religious hi.jster- ousness rapidly improved, and at this time are scarcely noticeable. His gait is steady, pupils nor- mal ; he does not see double though he says he is sensitive to bright light ; there is little or no ten- dency to squint, but he still has a heavy feeling on the right side of his head. His conversation, facial expression and general condition is that of another man. This case is one of the most unique in my series, and some of the Trileptal 60 Mg symptoms I am unable to account for. There is no evidence of syphilis and his well- nourished condition does not suggest tubercular or intestinal trouble. He was on anti-syphilitic treat- ment for some months before being brought to me, and both the iodides and mercury pushed to the point of toleration, with only the result Trileptal 450 Mg of increas- ing rather than diminishing the intensity of his symptoms. In the series of cases which follow, only the prom- inent mental symptoms are given. Practically the same operation was done and the same results ob- tained, only the results were more marked and rapid. All were of the chronic suppurative variety. Case H. Male, white, age si.xty-nine. Disease of nose for thirty years. Last year or two intense and increasing mental depression, with fixed idea that his end is near and he will die suddenly. Operated June, 1904. Complete Killian operation on the frontal and ethmoid (both sides) ; offensive pus, granulations and necrotic bone removed. No syph- ilis or tuberculosis. Cured. Case HI. Male, white, age thirty-two. Disease of nose for five or six years. Last few months increased mental activity or Purchase Trileptal Online excitability ; insomnia and mor-

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