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As his results had been so strikingly satisfactory, he related the histories of these eight cases. He believed that had he not operated in two stages, most, if not all, would have succumbed. A summary of the cases showed that the ages of the patients were 80, 53, 79, 67, 69, 65, 70. The two in the neighborhood of 80 were very feeble, and were bad risks. There was evidence of advanced renal implication in one case. Three others were emergencies, having suffered for several days with acute retention. One of these had infiltration of urine into the prevesical region and two Vasotec 10 Mg had intravesical hemorrhage. Three were more or less broken in health and neurotic. Complete radical removal of the prostate was done in all cases. Preliminary drainage was instituted in all but one case, where, on account of serious kidney complication, the galvanocautery technique was used. All up to the present time had done remarkably well. He laid particular stress upon the great value of formaldehyde gelatin as a local hemostatic. He had had Oct. 20, 1906] MEDICAL RECORD. 637 no serious hemorrhage since he had used it, and thought the postoperative conditions more comfortable. In em- ploying the secondary operation, Vasotec 20 Mg the parts, owing to circulatory decongestion and granulation, were much more accessible and the line of cleavage between the prostatic tissue and the capsular surroundings more easily separated. Hemorrhage was unimportant, shock trifling, the operative period minimized to a few minutes, and postoperative tox- emia was almost entirely eliminated, as the patient during Enalapril Vasotec the postoperative period had become inured to his own secretions and his normal resistance fortified. A Case of Stone in the Ureter, with Remarks Vasotec Iv Push on the Methods of Operating in Such Cases. — Dr. Paul Thorndike of Boston reported the case of a man who had had several mild attacks of renal colic within a period of two years, the pain on the right side extending from the kidney region to the penis. Physical examination revealed nothing. The 4-ray revealed a stone, which was supposed to be in the bladder, but the searcher could not Vasotec Iv find it. A suprapubic operation was done, and a long probe was passed into the ureteral orifice on the right side and a stone contact was made. The stone was dislodged and the pa- tient made an uneventful recovery. Seldom was stone found in this situation, the lower end of the ureter, with- out making known Vasotec 5mg its presence by symptoms referable to the bladder. Dr. Arthur T. Cabot of Boston said that he had always regarded the perineal route of performing prostatectomy as the safer, and was surprised at the statistics given. The death rate after perineal prostitectomy was 4 or 5 per cent, at the outside, while for suprapubic prostatectomy it was about 10 per cent. He considered the relief of small prostates through the perineal route a great triumph. He said that he understood that in the case of prostatism reported the patient was passing uric acid crys- tals, and that might account for the prostatic irritation. The preparation of the patient for prostatectomy was of the greatest importance. He mentioned several cases where preliminary drainage had brought about marked improve- ment and put the patient in condition for operation. Dr. Hugh H. Young agreed with the reader of the paper that we were in need of carefully worked up statistics. He had just finished an analysis of 150 cases of prostatectomy, which would be published in the next volume of the Johns Hopkins Hospital reports, and these analyses were very voluminous. Last year's work showed only one death in a large number of cases, and that man had a badly in- fected kidney before operation, so that he had had prac- tically no bad results from perineal prostatectomy Iv Vasotec so far as fatalities were concerned. Out of 164 patients that were using the catheter when they entered the hospital, only one was using it after operation. In 64 cases with com- plete retention of urine, there was not now one case of complete retention. He did not believe in paralysis of the bladder ; he had seen so many cases with residual urine of over 1. 000 c.c. that now had tonic bladders that he had dropped the term "paralysis of the bladder" from his vocab- ulary. Of 145 cases of hypertrophy of the prostate that could be called benign, only 5 could be said to have given imperfect results. Buy Vasotec Online Most of these had the small cirrhotic fibrous prostate. The bad results were because he did not appreciate enough the cicatricial contraction at the pro- static obstruction. The claim could be made that through the perineal route all of the obstruction could be removed absolutely. He did not consider it just to blame perineal fistula on the perineal prostatectomy. In the past two years he had 102 cases, and only four cases of perineal fistula followed, and two of those were quite recent, and would probably heal. Dr. Edward Martin of Philadelphia said that he had had some success in using dilators in the case of small prostates with contracted ring. He had obtained complete relief by dilating this contracture. Vasotec Mg There was but little bleeding, and the relief Buy Vasotec lasted for months. Dr. George K. Swinburne of New York said that in considering the statistics of the results of operation it should be borne in mind that there were a large number of cases which could not, or would not, be operated upon. He had a patient who had used a catheter for twenty years. The history of this case was given, showing how prosta- tectomy had been avoided and the man kept comfortable by draining the bladder and performing a suprapubic cys- totomy. Dr. Bransford Lewis of St. Louis thought the conserva- tism of both papers was highly commendable. He referred to the use of the retained catheter instead of the bouton- niere; in his experience this had been of great value. Blad- der drainage would not suffice in Purchase Vasotec cases of calculi. Here it was proper to give some preparatory treatment ; then, under local anesthesia, the bladder could be opened and the calculi taken out. He cited two cases in which he had followed this plan. Dr. L. Bolton Bangs of New York thought the impor- tant question was not what operation to choose, but whether to operate or not. We should not decide to operate because a man had retention of urine, with possi- bly a slight enlargement of the prostate. Of late a great many people had been preserved from radical operation, and he thought the desire of the laity to be operated upon was less than formerly. He was a believer in the prepara- tory care of patients before operation. He had resorted to perineal drainage only in exceptional cases. In opening the bladder, where obstructive symptoms were present, he had made it a rule to place his finger in to Vasotec Uses determine whether there was any fibrous exudate that produced Vasotec 5 Mg obstruction. He sometimes dilated these with the forceps, and sometimes with the fingers, and this occa- sionally gave relief. Dr. Pedersen said that in regard to Dr. Cabot's criticism of the death rate, as he had reported it, he would say that his paper had aimed to take an analysis of the average results as found in reports coming in to him. Therefore, the death rate of certain operators was better than the average. It was important that we should know definitely the end results of these operations ; we should know about the sexual function, the bladder function, etc. It was undoubtedly true that crystals in the urine would account for symptoms of prostatism. In regard to the question of rectal fistula, he said that the reports were those of Albar- ran ; that in this country we saw few fistulas due to pros- tatectomy in the hands of competent men. Dr. Chetwood said that he did not want to be under- stood as favoring long drainage or as recommending pro- ceeding with enucleation and other procedures without using the catheter. He did not think the catheter was able to do what perineal drainage would. Does Syphilis in Some Cases Spontaneously Abort in the Primary Stage? — Dr. R. \V. Taylor of New York said that he had for a number of years been making a study of this question. It was one of the canons of medical belief that a chancre was always followed by gen- eral syphilis. A review of statistics showed that out of 1.291 cases of general syphilis a chancre had preceded in all but 22. He had become convinced that Generic Vasotec spontaneous abortion of syphilis in the primary state did sometimes occur. He reported four cases in detail which had occurred in his e.xperience, in which the patients had undoubtedly Hunterian chancres, and yet who never devel- oped general syphilis. In these cases he was very sure that there was no previous history of acquired or heredi- tary syphilis. He had noted altogether ten cases reported by seven observers. Burnett thought it altogether possible that these sores were typical chancres, and through some influence modifying the virus the disease was checked in the primary stage. He was of the opinion that some of the cases reported as successful excision Vasotec Enalapril of chancres were instances where the disease had aborted in the first stage. • In the study of such cases w« should acquaint ourselves 638 MEDICAL RECORD. [Oct. 20, 1906 as far as possible with the patient's history and with that of his immediate progenitors. An antecedent-acquired syphilis might be followed by chancriform-relapsing lesions which might mislead the observer. While hereditary syphilis might confer, and usually did confer, immunity Order Vasotec on its bearer, it was possible for the hereditary disease to wane, and immunity to be lost. A Case of Hereditary Syphilis.— Dr. Taylor also re- ported this case. He said that a man of thirty years had presented himself with syphilis, and when told what ailed him, said that no doubt his wife was also infected, as she had a sore on the vulva and a generalized rash. She was in the eighth month of her first pregnancy, and had prob- ably been infected when about five and one-half months pregnant. Neither parties took any true antisyphilitic treatment. An apparently healthy male child was born at term, and was scrupulously watched for months, but nothing abnormal was found. The child had but little antisyphilitic treatment, as the parents were not particu- larly careful on this point. The child grew apparently normally, but the second teeth were of the Hutchinson type. At the age of four years periostitis of the right humerus and synovitis of the right knee developed. Under mixed treatment and the local use of mercurial ointment the pains ceased, the articular lesions subsided, and the child entered into very satisfactory health. This case, though unusual, was explicable in the light of the fact that it was now conceded that there was a virulent form of hereditary sj-philis, in which the old-time classic features were Vasotec 2.5 Mg marked, and there was a dystrophic form, in which there was slight ill health at times, scarcely appreciable, and yet dystrophic changes in the bones, teeth, ears, eyes, brain, etc., might occur. Dr. Wood Ruggles of Rochester, N. Y., related the instance of a man forty-five years old, who had had as characteristic a chancre as he had ever seen. He had pro- nounced adenopathy in both groins. No roseola had appeared up to four and one-half months after the infection occurred. Dr. Edwin C. Burnett of St. Louis, whose patient Dr. Taylor referred to in his paper, said he had been able to hear from him for the past seventeen years, and he was hale and hearty and the father of perfectly healthy children. Dr. N. B. Carson of St. Louis thought that before arriving at definite conclusions we should investigate the source of infection, and see if the case really was one of syphilis, as sores upon and about the genitals often closely resembled chancres. Dr. George K. Swinburne of New York said that when he had been interne at St. Luke's Hospital he had seen many cases that passed as true chancres which were fol- lowed Vasotec Hctz by no secondary sequels except the adenopathy. He knew of a case where chancre was apparently Vasotec 2.5 not followed by secondary symptoms. Seven years later one side of this man's body became paralyzed, and he was placed under mercurial treatment. He partially recovered, and six

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