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MEDICAL RECORD. [August S, 1896 what is an endothelial cell. Anatomists were inclined now to make no distinction between epithelial and en- dothelial cells. Personally, he had seen only what appeared to be undoubted endotheliomata in connec- tion with the pleura and dura mater of the brain. In these cases there appeared to be a definite endothelial structure, and the cells, when teased out, were flat or irregularly Micardis Mycard shaped, with large nuclei with a loose open reticulum — a distinct endothelial Micardis Plus 80 Mg arrangement. He did not think too much stress should be laid upon die shape and size of cells: one should depend rather upon the relation of the cells to the stroma than upon the cells themselves, for pressure alters greatly the shape of cells. It was well known th4t the cell body might differ very materially in different conditions of degeneration. The society then went into e.xecutive session. (I'Uniail gcpavtmcut. REPORT OF .\ CASE OF APE.X LWTARRH SIMULATIXG XASAL TROUBLE.^ By H0\V.\RD .S. .STR.\If.HT, M.D., CLEVELAND, O. June 1 1, 1894, a young woman, aged twenty-two years, consulted me as to a nasal difficulty. Until within a short time she had never had any trouble with her nose or throat. For a few weeks she had been troubled with stuffiness in the nose and an inability to breathe through her nose continuously. From a careful in- quiry as to her history, little of importance could be obtained. Her pulse and temperature were normal. She insisted that she felt as well as usual, that she had not noticed any diminution of strength or loss Micardis Hct 40mg 12.5mg of appetite, and scouted the idea that there was anything in her case except the nasal difficulty. She admitted finally that maybe she was a little tired out, but said that she had been working unusually hard in s:hool for the last eight months. While Is There A Generic For Micardis I was suspicious that possibly some constitutional condition might be present, I could not find any symptom that justified my suspicions. Her complexion seemed to me to be a little sallow, and whether she was slightly ana;mic was a question I could not decide. The patient's own belief that it was useless to consider anything except the nasal con- dition also assisted in quieting my suspicions that there was a possible catarrhal condition of the apex of one or both lungs. I felt certain that an examination of the chest would be looked upon as unnecessary, that it might needlessly alarm the patient, nor could I detect anything in the case to justify a suspicion I al- ways entertain in throat, nose, and ear cases, in pa- tients over ten and under forty years of age. If I had not waited until a later date for an examination of the chest, my error in treating tlie case might have been avoided. An examination of the upper air passages revealed in the nose a longitudinal deviation of the septum on the right ^de and a hypertrophy of the left lower turbinated. Having concluded I had a local condition only to deal with, the hypertrophy was cau- terized, the patient was given an alkaline wash, and directed to return in three days. Upon her return she seemed to have been more affected than ordinarily as a result of the cauterization. Her pulse was about 90. and her temperature 100" F. While it is not at all unusual to observe such symptoms after any intranasal operation, in my experience a patient with an apex ' Read before the .\merican l.arjngological. Rhinological, and Otological .Society at its second annual meeting in New York City, April iS, 1896. catarrh is much more apt to present such symptoms than a patient in whom no such condition exists. Micardis Telmisartan 80 Mg Still being somew hat suspicious as to the constitutional con- dition, I gave the patient a prescription of benzosol. Four days later she returned. Her temperature and pulse were normal, and she seemed as well as at her first visit. These observations deceived me more completely than before. The constitutional treatment was discontinued and the case thereafter treated from the local standpoint only. The return of the temperature to the normal within four days can be explained only by rem'embering that the patient had a normal temperature before any local interference. She had a catarrhal process at the left apex at the time of coming under observation, as later developments proved, but, contrary to rule, she had no fever. As a rule, in spite of any treatment, the slight elevation of the evening temperature will persist for weeks in such cases. The deviation was removed from the right side of the septum, and after keeping her under observation for about five weeks — until July 13, 1894 — she was discharged as cured. September 18, 1894, two months after being dis- charged and three months from the time she first came under observation, she returned. She had been in the country on a vacation. She had not felt well for a number of %veeks. She had had a poor appetite, had been nervous, had slept badly, Micardis Plus 80 25 Mg had lost ten pounds of flesh, was sallow and an.tmic, had a coated tongue, a temperature of 101'^ F., and a pulse of 108 in the morning. An examination of her chest revealed at the left apex slight Micardis Plus 40 Mg flattening in the left Generic Micardis Hct subcla\ icular re- gion. There was tenderness on percussion in the sec- ond interspace next to the sternum, no change in pitch on percussion. Transference of heart sounds, cog- wheeled breathing, and slightly shortened inspiration were apparent on auscultation. The following diag- nosis was made : A well-marked simple catarrhal process at the left apex, or a condition of disturbance of function of the mucous membranes of the body, the gastro-intestinal being in the majority of such cases the one of which greatest complaint is made — a Generic For Micardis Hct condition, however, in which some Micardis Plus 80 12.5 Mg one or all of the physical signs found in tiie case reported may be detected at the apices of the lungs, and one which is of much greater importance than a simple unassociated disturbance of the gastro- intestinal mucous membrane, for which the disease called apex catarrh is often mistaken. My belief is that at her first visit to me in June the patient had a slight developing catarrh at the left apex. This belief is not founded upon .this one case. Over and over again have I had a similar experience, although in no case has my experience been as humil- iating as in this one. I have recently discharged a patient after four months' constitutional treatment w hom I treated altogether locally for tlie first four weeks she was under my care, and I realized the need of constitutional treatment in the case only after finding, marked transference of the heart sounds at the left apex. These experiences have not occurred to me be- cause of carelessness. The possibility of such a con- dition Micardis Hct Generic is considered in the case of every- patient under forty years of age and over ten. I ain'Tiot qualified to speak as to the occurrence of the condition mentioned in other localities, but in Cleveland apex catarrh — a disturbance of the functions of all the mucous membranes of the body, the disor- Buy Micardis Hct dered functions of the gastro-intestinal mucous mem- brane often being the one of which the patient makes- most complaint, but a condition in which certain defi- nite physical signs at one or both apices of the lungs can be detected — is of very frequent occurrence; and after years of observation and large opportunity in the study of the diseases of the ear and upper air pas- August 8, 1896] MEDICAL RECORD. 20: sages, I believe that this condition — call it what you Micardis Mycard Program will — is in Cleveland more important to the throat specialist than all other constitutional conditions com- bined. The question arises as to whether the subse- quent ill health and loss of flesh were not due to the local treatment. It is most natural for the patient to hold this opinion. It is not at all uncommon for pa- tients in perfect constitutional condition to feel de- pressed for a short time after intranasal treatment and even to lose flesh, but they quickly recuperate and take no such course as the one reported. If this patient had presented herself to a general practitioner instead of a throat specialist, and he, knowing nothing of the nasal condition, had detected the condition of her left ape.x and treated her consti- tutionally with as much success as attended my elTorts, when she returned to the city in September what would have been the result as to the local lesion ? She prob- ably would have been relieved so much that the local lesion -would have caused no more trouble than had been e.xperienced when she was perfectly well. You remember she had had no trouble with her nose until within a few months. The local treatment certainlv did no harm, for constitutional treatment would not have remedied or relieved the hypertrophy of the mu- cous membrane of the left lower turbinated or a devi- ation of the septum ; but the overlooking of Micardis 40 Mg Price the con- stitutional condition was an error indeed Micardis Alternatives — such an er- ror as brings specialism into merited disrepute. The oversight was made by one fully alive to the impor- tance of looking beyond the local lesion, and one who was a general practitioner for years. This e.xperience has simply added weight to an opinion long since formed, that the specialist should alwavs seek an explanation of local symptoms in a pa- tient's constitutional condition. It may not always be easy or possible to decide which factor is the more important in a given case. The necessity of studying the patients as a whole is understood by every one. The general practitioner errs ordinarily in paying too little attention to local conditions. The specialist, on the other hand, errs too often in paying too Micardis Telmisartan 40 Mg great at- tention to local conditions. The golden mean is the position all are striving to attain. When the general practitioner more carefully studies the importance and possible influence of local conditions, the specialist will no longer complain of lack of support in his work; and when the specialist more carefully consid- ers the possibilities and bearings of constitutional conditions, he will command more respect and support from Micardis Substitute the conservative, sensible general practitioner. Little may have been proven in this report. It is necessarily fragmentary because of the length of time already occupied in the discussion of the case. I know no way of absolutely proving one's opinion in a medical case. The experience added weight to a lesson learned often Micardis Generic Equivalent before and often since. While the opinion e.xpressed in the report may be such as is not generally held by the profession, it is certainly worthy of consideration, for I am positive that my success in the treatment of the ear and upper air passages has been much greater and much more satisfactory since I properly appreciated that which was the key to the situation in the case reported, and which I have called apex catarrh. Al'BIL 13, 1896. THE STRENGTHENING AND STERILIZATION Micardis 80 Mg Price OF CATGUT. Bv DONALD li. PRITCIIAKD, M.D., WINONA, MFN.V.

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