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Under persistent after-treatment the chronic cys- titis improved and the residual fell to one and a half ounces. It is now stationary at two ounces. The incontinence obliged him to wear a urinal for about two weeks and continued in varying but gradually decreasing degree, favorably affected by rest and massage of the prostate, unfavorably by exercise and any dilatation of the urethra beyond 20 F., until at the end of six months it ceased. A few drops escap- ing Tricor Fenofibrate when his bladder is very full and he is fatigued is all that remains of it to-day. His urinary intervals have been normal since he left the hospital ; very rarely has he had to urinate at night ; his general condition and health are good ; he has gained about 18 pounds. For a time his potency was as before the operation ; but latterly it has shown a decline. In view of the otherwise good result, it is to be regretted that the very last portions of the prostate were not removed. Had this been done he might have been permanently relieved of all residual urine and that, in all probability, without having increased or prolonged his temporary incontinence. C.\SE IV. brings out one of the indications for suprapubic prostatectomy and presents other inter- esting features. I. E., 68, married, came under observation last June in a forlorn condition due to prolonged suffer- ing and neglect. The salient points of his long history were, that, about three years ago (having been on catheter life), he had had galvancH cautery prostatotomy performed through a perineal incision ; that he had left the hospital unimproved, had visited many dispensaries without benefit, and that from time to time sudden attacks of retention had occurred which he had relieved by passing the soft rubber catheter he used regularly before the prostatotomy. His constant subjective symptoms were great frequency, some urgency, marked tenes- mus, and exhaustion. Very little study showed that the attacks of re- tention were mainly, if not wholly, due to spasm. Under test, the bladder capacity was about two ounces. The searcher promptly detected a calculus and suggested a second. When cystoscopy became possible it revealed a deep, median groove below the internal meatus ; prominent lateral lobes bounding this groove ; a phosphatic calculus lodged beyond the border of the right lobe and partly overhung by it, and a second calculus, apparently caught in a sec- ondary groove above the level of the internal meatus. Knowing that the true state of the prostate could not be determined until some time after the calculi had been removed, litholapaxy was undertaken. Much to mv chagrin the calculi could not be dis- lodged ; only their free portions could be seized and crushed. A suprapubic cystotomy was therefore subsequently performed. The actual enlargement of the prostate was much greater than suspected; it resembled a thick ring obliquely surrounding the internal meatus. The groove dividing the median lobe was not deep enough to completely drain the bladder. The remains of the calculi were removed, complete prostatectomy was performed, and drain- age above and below established. The Buy Tricor Online patient's powers of resistance were so low that the suprapubic wound became badly infected as soon as the tubes had been removed, which was on the fourth day. The perineal tube therefore had to be reintroduced. It was not until eighteen days later that it became permissible to remove it perma- nently. Thus, unavoidably a perineal sinus resulted which persisted despite every attention on my part consistent with his daily work, leaking more or less continuously Tricor 145 Mg for four and a half months. He left the hospital on the thirty-fifth day with the supra- pubic wound firmly healed. Incontinence, apparent as soon as the perineal tube had been removed, per- sists, obliging him to wear a urinal. As was the case Tricor Cost with the leakage, the incontinence ceases when he lies down, sometimes when he sits down. There is Tricor Prices no nocturnal urination. On rising in the morn- ing he voids from six to eight ounces in a free, forcible stream. The urine is feebly acid : but con- tains an Tricor Online excess of mucus and a few flakes and small shreds. Possibly the patient could have been classed among those who do better when a preliminary suprapubic cystotomy is performed to rest the blad- der by drainage and allow the patient to recuperate Nov. 24, 1906] MEDICAL RECURD. 819 his vitality before undergoing the prostatectomy. He Purchase Tricor has, however, done well, all things considered. He has gained ilesli and strength ; he is now able to do a full day's work in the factory with Tricor 48 Mg fair comfort. Sexually, he is as negative as he was for some time before the operation. Case V. illustrates the condition called "prosta- tism without enlargement," the treatment of which calls lor considerable study. F. K. M., 67, married, complained that for "sev- eral years" past he had had to urinate once during the night and for a year past had had diurnal fre- quency — from once every hour to Order Tricor once every three hours, depending upon the quantity of fluid ingested and upon the character of his immediate mental occupation. To these facts Coupons For Tricor he voluntarily added that some form of urethral instrumentation, given him three times weekly for six months about a year before, when the diurnal frequency Tricor 145 first developed, had been of no benefit; but that after three days of treatment in bed for a gastrointestinal disorder, the urination had Cheap Tricor returned almost to normal and had so remained for "several days." He had escaped the venereal diseases, though his sexual life began when he was seventeen years old. From the day of his marriage until he was 50 he had cohabited several times weekly, thereafter once weekly, and had practised withdrawal regularly until he was about 45. He was still vigorous sexually, and now cohabited normally with perfect satisfaction. He had been a total Tricor Coupons abstainer from alcohol and coffee for the past year and from tobacco for the past thirty years. Considering his partially sedentary life, he was overeating and was not drinking enough water between meals. Examination showed a healthy, active man, vig- orous alike in mind and body. His urine, voided in a good stream without the slightest abnormal sen- sation, showed uric acid and calcium oxalate crystals in abundance, thus confirming the suspicion that the quality of the urine might be a Tricor Price partial cause of his frequency. The residual urine amounted to one and a half ounces. The prostate, by rectum, was of the small, firm variety, indicating interstitial changes. It was slightly tender. The urethral length was 8 inches. I'nder regulation of his diet and fluids, supple- mented by local treatment, the residual soon fell to half an ounce and the urinary intervals lengthened to an average of two hours when at his desk, to somewhat longer when exercising, and to four houcs when recreating. Coitus once weekly not only was allowed, but also advised, observation proving in his case that it added to his comfort by helping to relieve the prostatic congestion. This patient has been under my observation nearly two \ears. During this period he has had three slight and two sharper exacerbations, the former marked by increased diurnal frequency, the latter by a nocturnal frequency as well. plus, on two oc- Cost Of Tricor casions, the characteristic pains of prostatic hyper- emia. Coincidently there was an increase in the residual urine : but it Tricor Mg never reached the original ounce and a half. The average residual to-day is six drams. Retention has never even threatened. All five of the exacerbations followed definite errors in diet : two were accompanied by subacute rheu- matism in certain joints : one was aggravated by an unsatisfactory coitus. Through all, the urine has kept its normal appearance. None of the exacerba- tions kept him from business. In the intervals the days have been few v.hen he could not hold his urine five hours if necessity demanded, though more fre- quent urination was more comfortable. Though this degree of frequency is an interruption, it Tricor Coupon is not an interference in his case ; therefore even so com- paratively trifling an operation as dividing the prostatic bar with bistoury or the Bottini instrument in the hope of further improving his bladder func- tion has not been advised. In my opinion he is as near normal as a man of 69 can expect to be, and by reasonable attention to his diet, habits, and mode of life, I believe he can always keep his "prostatism" under control. Whereas Bottini's operation has failed ot uni- versal application, it nevertheless has a well-defined, though limited place in the surgery of the prostate. This should be more generally conceded than it is, as the end-results reported by competent observers are undeniable. Granting that surgical intervention is demanded in the given case, the indications for the Bottini operacion are : Prostatic bars : .\lbar- ran's chronic hypertrophic prostatitis without me- dian lobe enlargement of any extent (chronic con- traction of the vesical neck) ; advanced carcinoma of the prostate (Willy Meyer) ; prostatic enlarge- ment when positive contraindications to prostatec- tomy e.xist. The contraindications to prostatectomy are those of any major operation ; but advanced kid- nev disease probably will become less of a contra- indication than in other fields of surgery, in propor- tion as operators attend to the preparatory treatment for prostatectomy, and as the two-stage operation comes more into vogue in critical cases. Among the writers making special mention of these points is .Mbarran, who counts chronic overdistention of the bladder and systemic infection from the bladder contraindications to prostatectomy until those con- ditions shall have been first relieved by catheterism, irrigation, and. if necessary, by drainage. It is doubtful whether we can yet assure a patient that he will be both potent and virile after prostatectomy. More evidence is needed. The procreative power, therefore, when made an imperative requirement, will still be a contraindication to anv radical treat- ment. Old age, taken alone, is no contraindication. Taking the patients with the symptoms of pros- tatic enlargement as they have presented themselves Tricor 145mg to my observation, the foregoing cases being type- illustrations, it is my opinion that the teaching which advises surgical intervention as soon as Buy Tricor catheter life fails, comes nearest to being correct. Even this cannot be accepted, however, without further defini- tion and a clear understanding of its qualifications. Thus, catheter life may fail at once upon attempting to establish it, or not until it has progressed for years: the patient may be unwilling to enter upon it, and insist upon immediate radical ineasures : the patient's susceptibilities, his intelligence, and his dex- terity are factors for or against trying catheter life. Who shall say that the intelligent, dexterous man, able to care for himself, or that the man of extreme sensibilities, able to have a trained attendant, will not live at least as long and as comfortably as to his bladder function as his less fortunate neighbor who had to submit to an early operation, which, though it has enabled him to urinate perhaps with comfort, has not necessarily freed him from all complications nor sequence ? .Attention may be called at this point to what is implied in Albarran's statement that peri- neal prostatectomy is preferred because of the lower mortality; but that suprapubic prostatectomy will become the operati'^n of choice as soon as the tech- niaue shall have been perfected, its results being remarkable, because it is followed by "no permanent

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