the most easily eliminated so that the finding of it in excess in the blood indicates a grave deficiency in elimination on the part of the kidneys and a high operative risk. In cases of advanced secondary symptoms including anemia and loss of weight and strength, the determination of the alkaline reserve of the blood plasma, as indicated by the hydiogenion concentration of the blood and the carbon dioxide of the alveolar air, is valuable and should be made. Now the first remedy for the condition of pathological chemistry of the body from urinary obstruction, is improved urinary drainage and it is to this end that prostatectomy is undertaken. But to conserve the life of the patient, it has been found profitable to secure drainage by less formidable measures against the time of actual prostatectomy. No method of urinary drainage for the purpose of rehabilitating a kidney damaged by back-pressure has been found so effective as that obtained by a superpubic cystotomy, but this, in turn, cannot be safely employed at the outset in some cases. In cases where the residual urine is large, say, in the vacinity of 1000 cc, the sudden, full, complete and continuous drainage may cause such a high degree of congestion of the kidney to occur, as to stop its function entirely. It is consequently best to precede the cystotomy drainage by a period of intermittent, catheter drainage, say, over a term of two weeks, during which the bladder is completely emptied once daily. The cystotomy may, in desperate cases, be done under local anesthesia, but ordinarily it is best done under short gas anesthesia. In cases where there is in the vicinity of 150 cc of residual urine and no evidence of renal improvement, preliminary drainage for the purpose of rehabilitation is not useful. Preliminary cystotomy in prostatectomy constitutes the socalled two-stage operation. The two-stage operation is not only attractive from the standpoint of obtaining renal rehabilitation through drainage, but possesses other decided advantages. In cases having uninfected urine, the patient has not been prepared by a process of immunization for the inevitable infection of prostatectomy, and it frequently happens that the combined assault of the prostatectomist and the infection is more than can be withstood. In the interests of conservatism it is better to divide the operation and permit the infection to be overcome before enucleation is undertaken. The technic of enucleation is now well standardized and there is little new to be added. An attempt, however, should always be made to apply to the cases in hand that type of operation which will best serve. In all cases the operator should be particular to remove all of the obstructing tissue. In tumors made up of a number of small adenomata within the prostatic capsule, it is not infrequently occurs that one or more is left, which is likely to frustrate the otherwise successful issue. 907 Journal Bldg. PROSTATECTOMY A. E. MacKay, M.D., Portland, Ore. (Read before the Portland City and County Medical Society, Nov. 21, 1917) Abstract: The saving of time in the operation is of much importance, especially in elderly men. Before the anesthetic is started, the patient should be prepared, the legs encased in sterile dressings and the catheter introduced. If gas-ether anesthesia is used, the incision should be made while the patient is still under the gas. The incision should not be over one and one-half inches in length and should be from onehalf to one inch above the pubic bone, so that the space of Retzius will not become infected. After the bladder is exposed, the opening in it should be made as high as possible, as fistulae low down heal more slowly. The bladder should be picked up with two sutures and the opening made should be a small one. One who cannot see with his finger tip should not do prostatectomies. The capsule of the prostate should be entered through an incision made in the upper end of the urethra. The prostate is then enucleated with the finger, care being used to see that the entire hypertrophied portion is removed. If care is used, the seminal ducts will not be injured and sexual function will not be interferred with. In perineal prostatectomy as developed by Young, a large inverted V-shaped incision should be made extending through the skin and superficial fascia. From here all dissection should be by the finger or blunt instrument until the central tendon is reached. This tendon is cut, permitting the rectum to drop backward. The blunt dissection is now continued until the recto-urethalis muscle is reached. When this is cut, the prostate bulges out. By making a lateral incision over each lobe, it can be easily shelled out. One of the principal objections to this operation is that when there is an enlarged portion extending into the bladder, it is reached with difficulty. The suprapubic operation is the operation of choice in the majority of cases. In closing the wound made in the suprapubic operation as few sutures should be used as possible. If incision is small and the drainage tube large, no sutures are needed. The drainage tube is removed after twenty-four hours. The bladder should not be irrigated. Even when the bladder is infected, irrigation does but little good. Salt solution by the Murphy method should be given. DISCUSSION -J. E. E. Dr. W. B. Holden, in opening the discussion, stated that he believed that the proper time to operate was immediately after the first acute retention. Cases without retention where the only inconvenience is that of urinating two to four times at night, should not be operated upon, for there is usually as much inconvenience after operation. He has had secondary hemorrhage a few times. Dr. A. C. Smith thinks that the two-step operation is of much value. Dr. H. S. Nichols called attention to the greatly reduced mortality due to the improved technic. Dr. J. Earl Else emphasized the necessity of careful diagnosis. Retention with an enlargement of the prostate does not necessarily mean that the prostate is the cause of the retention. He referred to such a case where the retention was due to a cord lesion, the postmortem examination showing that there was no interference with the urethra at all. Dr. G. Baar mentioned the condition where there is enlargement producing obstruction, but with no apparent enlargement of the prostate upon rectal examination. In these cases the diagnosis is made with the cystoscope. Dr. Howard, in closing, stated that the large vessels lie outside of the capsule about the new growth. If this capsule is not penetrated, severe hemorrhages are rare. PUBLISHED MONTHLY HENRY WALDO COE, M. D., Editor, Portland, Ore. Entered at the Postoffice at Portland, Oregon, as Second Class Mail Matter Address all communications regarding papers, subscriptions, advertising or business matters to the MEDICAL SENTINEL, 516 Selling Bldg., Portland, Oregon Contract practice has never met with general favor with the medical profession for several reasons, principal among which has been the denying to the patient the free choice of his physician. Further, there has been the tendency to pay the physicians less than their services were worth and to select physicians not because of their ability to do the work, but because of their willingness to work for a small compensation. Although, as stated, the medical profession, as a whole, has been opposed to contract practice, yet there have always been enough physicians to take up all of the contracts and positions open. With the advent of accident insurance, it has meant the withdrawing of the majority of the accident work from the profession as a whole and the giving of it to the contract surgeons. Unless something is done this condition will gradually become worse, for government industrial insurance in America, like that of Europe, will come to include sickness insurance for the workman first, and later for his family. The medical profession must prepare for it. It is a waste of words to talk against government industrial insurance, because, in the first place, society is not interested in medical ethics, and in the second place, such insurance has been demonstrated to be economically sound. The King County Medical Society has worked out a method of overcoming the contract feature. A service bureau has been organized which, under the law makes contracts with the employers for caring for the injured. The workman, when injured under this contract, is permitted to call any member of the King County Medical Society who has signified a desire to do accident work. The plan has proved popular with the workman, with the employers and with the physicians. Dr. Mowell stated that no complaints had been received by the Accident Commission from any source. During the five months since the bureau has been organized, contracts covering over 7500 men have been secured. One unexpected result has been that the receipts have not only paid the physicians according to the schedule fixed by the Commission and the expenses of running the bureau but that there has been a surplus of over six hundred dollars. Theoretically, probably no physician would favor the plan. It is in violation of the time honored precepts of our profession. But we are dealing with facts and not with theories. The laws are on the statute book. We cannot change them, but must abide by them. Therefore, let us use the law and use it in such a way that the people will see the error of contract practice and in the future make laws that will provide for the free choice of physicians. --J. E. E. LOWERING THE MORTALITY RATE The mortality rate in nephrectomy and prostatectomy, as shown by the compilation of the records of twenty-six of the Eastern hospitals by B. A. Thomas of Philadelphia, is 25.9 per cent in the former and 22.5 per cent in the latter. When this is compared with the records of eight of the world's leading urologists who, in about seven times as many operations, have a mortality of only 7.7 per cent in nephrectomy and 4.33 per cent in prostatectomy, it is startling, to say the least. If these records are correct, and we have no reason to doubt them, it means that 70 to 80 per cent of those who place their lives in the hands of surgeons operating at these hospitals, die unnecessarily. A study of the ability of the genito-urinary surgeons and the average operator, reveals that there are three important factors that enter into the increased mortality. They are in the order of importance first, diagnostic ability; second, knowledge of pathology, and third, finished technic. The average operator's idea of surgery is mechanical in the main. When he takes post-graduate trips he visits operative clinics chiefly. The articles he reads are those that deal with technic. He is constantly looking for new operative procedures. This is |