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bid suspicion of everything and everybody. Oper- ated June, 1906. Right frontal, ethmoid and max- illary antrum contained pus and granulations ; modified Killian operation and maxillary antrum opened through canine fossae. Cured. Case IV. Female, white, age twenty-one. Disease of nose for several years ; for two weeks previous to operation, mind sluggish ; indifferent to her condi- tion or surroundings ; responds slowly and hesitat- ingly to questions, but accurately. Operation March, 1905. Both frontal, ethmoid, and both max- illary antra full of offensive pus and granulations. Cured. Case \'. Male, white, age forty-two. Disease of nose for fourteen years; for some months troubled with insomnia and mental depression ; feared he would take his life ; had syphilis in youth. Operation January, 1905. Left frontal and ethmoid full of pus ; no granulations. Cured. Case VI. Male, white, age thirty-three. Syphili- tic ; disease of nose for four years ; mentally de- pressed ; indifferent to his whereabouts or surround- ings ; slovenly and immodest in his dress ; whereas in his normal condition was a Chesterfield in his tastes. Operation June, 1904. Empyema of right frontal, ethmoid, and maxillary. Entirely relieved, but syphilitic deformity of nose Trimox 500 Mg rapidly followed operation. » Case \'ll. Female, white, age fifty-five. Great mental depression ; desired to be left alone ; this condition had existed for two months and growing worse ; had so increased that she remained in bed for five weeks prior to consulting me, two weeks of which were spent in hospital under treatment for melancholia. Operation May, 1905. Frontal -and ethmoid empyema. Cured. Case VIII. Female, white, age forty-one. Dis- ease of nose for seventeen years ; morbid fear she would take her life : Amoxicillin 500 Mg was in everybody's way ; feared to be left alone. Operation August, 1904. Empyema right frontal, ethmoid, and maxillary. Entirely re- lieved except occasional Trimox 500 migraine. Case IX. Male, white, age thirty. Disease of nose for six or seven years ; stupid from pain ; sleeps a great deal : mind enough to do his work but felt sure he was losing his mind ; would some- times wander miles from home without a motive. Operation December, 1905. Empyema Trimox Online right frontal, ethmoid, and maxillary. Entirely cured ten weeks after operation but relief was immediate. Case X. Male, white, age fifty-one. Disease of nose and throat for twenty years; had syphilis in youth ; increasing mental depression with suicidal inclination (threats). Operation August, 1905. Empyema left frontal, ethmoid, and maxillary. Com- plete relief. Case XI. Female, white, age thirty. Disease of the nose for eleven years ; syphilitic : melancholia with suicidal inclination : asked to be locked up so she would not disgrace her family by killing her- self. Operation May, 1905. Empyema left frontal, ethmoid, sphenoid, Generic Trimox and maxillary. Complete relief. The cause of the pronounced mental depression in the majority of my cases can better be explained by ihe neurologist and alienist, and we have as yet little data outside of the clinical history to base conclu- sions upon, owing to the fact Amoxil Trimox that medical men do not attach more importance to the condition of the nasal cavities, either Trimox Antibiotic at the bedside or on the post- mortem table. When this is done, the association of disease of the accessory sinuses and cranial cavi- ties will be more fullv substantiated. "Whether the symptoms and conditions described are due to intracranial pressure, direct or indirect meningeal irritation, reflex nervous conditions, disturbed cere- bral circulation, or toxemia, is not determined. But the fact remains that in these cases ventilation of the occluded sinuses or cure of the purulent process cured the psychosis : on the other hand, retention of pus aggravated the mental defect, or return of the purulent infection in the sinus w-as accompanied by return of psychosis'.' (W. Sohier Bryant). 822 MEDICAL RECORD. [Nov. 24, 1906 The Trimox Side Effects presence of pus or granulations in the sinuses is not necessary to produce marked toxic symptoms, with pain and mental depression. In some of my most aggravated cases, no pus was suspected and none found, but as soon as the obstructing middle turbinal was removed, the relief was immediate. "The etiology of this condition depends Buy Trimox on the anatomic relation of the middle turbinates to the hiatus semilunaris and infundibulum. The air, in the frontal and anterior ethmoidal cells is impris- oned there by pressure of the middle turbinal against the lateral nasal wall, the turgescent tis- sues filling in the hiatus semilunaris and effectually blocking it. Tlie lining membrane of the sinuses absorbs the oxygen in the imprisoned air and thus creates a vacuum. The absorption results in nega- tive pressure and consequent swelling of the lining- membrane with increased blood supply to this region. Stasis, to a greater or less degree, results; pressure of the congested tissues on the contained nerve end- ings, together with this stasis, produces the symp- toms and results in reflex vasomotor disturbances in the circulation of the neighboring structures. This theory is advanced by Brawley, Robertson. Ewing. and Sluder, and seems to me to be worthy of acceptance. Trimox Indications The mental symptoms in the class of cases under consideration may be due to a meningitis of a pass- ing type, namely a meningitis serosa (Amberg). The anatomical conditions favor the easy appear- ance of such a coaffection of the surrounding parts of the sphenoid, ethmoid, and frontal sinuses. Un- doubtedly toxins developed by fermentation and putrefaction in the gastrointestinal tract — a faulty metabolism — and from the poison in the blood de- veloping from acute affections (Stevenson). These toxin-producing bacteria are probably the chief agents combined with the sepsis from' pus absorption, the influence of which acts upon the cortical cells and nerve fibers of the brain. The proximity of the acessory sinuses to the brain is of signal importance if we can assume that an irritation of the brain, directly or indirectly, in predisposed or pot predisposed cases, is caused bv an affection which has its seat in the sinuses, the indications for interference is plain. In conclusion it is worthy of note that in each case presented in this paper the ethmoid cells were extensively involved in the pathological process, and I do not now recall ever having seen a case of frontal or sphenoidal suppuration in which the ethmoid was not implicated. My observations almost force me to the conclusion that probably in the ethmoid or its "offshoot" the middle turbinate, is to be found the cause for the majority of cases of infection of the frontal, maxillary, and sphenoidal sinuses, and the statement made by me at this society in a paper on a similar subject Where Can I Buy Amoxicillin in 1904, is repeated with greater emphasis at this time, viz., "the middle turbinal most frequently causes obstruction of the natural openings of the accessory sinuses and thus inter- feres with free drainage and ventilation, and the early removal of its anterior third decreases the necessitv for more extensive and radical operations later." Only the mental symptoms that were most con- spicuous and gave rise Buy Amoxicillin to most anxiety are mentioned in this Amoxicillin 500 series of cases, but in these and in many other cases of chronic ethmoiditis I have noticed one or several of the group of symptoms associated with this disease mentioned by Beaman Douglas, Amoxicillin Amoxil the cause of which has not been explained. "It is evi- denced by a slow deterioration of the mental facul- ties, an inferior quality of work, loss of memory. disability for continued application, overanxiety, general incapability, and procrastination." In neurotic subjects and those with a lowered vitality from any cause, an ethmoidal, sphenoidal, or frontal sinus affection may start the vicious circle composed of the sinus affection proper and the neurasthenia or hysteric conditions which later we know, may reach a form and a degree which some- times allows us to classify the bearer as one "bor- dering on insanitv." THE Trimox 500mg DIAGNOSTIC VALUE OF THE CYST- OSCOPE AND URETERAL CATHETER.* By JOHN EGERTON CANN.\DAY. M.D.. PAINT CREEK, W. VA. SURGEON-IN-CHARGE SHELTERING ARMS HOSPITAL. Lesions of no part of the body are, perhaps, more difficult of diagnosis than those of bladder, ureter, or kidney. For many years surgeons felt the need of some means whereby they might obtain more definite information concerning the actual state of affairs present in a given pathological urinary tract. From comparatively simple and crude be- ginnings there have been gradually evolved through Order Trimox the united eft'orts of many colaborers diagnostic instruments of scientific precision and accuracy. The entire subject is of comparatively recent date. In 1874 Tuchman collected urine from one ureter by compressing the mouth of Buy Trimox Online the other with a forceps introduced into the bladder. About this time Hegar proposed tying the ureter per vaginam for the same purpose. In 1875 Simon catheterized the ureter by the aid of a finger used as a guide, passed through the dilated urethra. General anesthesia was required, the after-eff'ects were unpleasant, and the procedure was diflicult. Pawlik, a Privat Decent in the clinic of Billroth, discovered in 1880 a method of introducing the catheter by the guide of external anatomical land- marks ; this method is not easy and yet has some practical points to commend it. In this method the operator is guided largely by the sense of touch. Newman, Kelly, and Byford have worked along the same lines without Trimox Dosage adding anything to Pawlik's method. Later Brenner, Grunfield, and Kelly began to practise ureteral catheterization by aid of endoscopy, which rendered the orifices of the ureters visible. Kelly, in his dry method, dilates the urethra gradually then introduces a speculum with an obturator which, on with- drawal, allows the bladder to fill with air. Then, by the li.ght thrown from a head mirror, the ure- teral orifices Where To Buy Amoxicillin are located by direct vision. Morris exposed the mouths of the ureters by the use of straight tubes with obturators. In 1876 Nitze conceived the idea of a cysto- scope, after much patient effort, in which he was joined by Hill, Fenwick, Thompson, Boisseau, Du Rocher, Caspar, Albarran, and others, and by Lei- ter, an instrument maker of \'ienna, the cysto- scope has been so perfected that it leaves but little to be desired. Inasmuch as for obvious reasons a compara- tively limited number of physicians will ever make use of the cystoscope and ureteral catlieter, and as not all cases can be catheterized, there will always be a demand for some other means of obtaining the separate urines of the two kid-

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