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Related post: in an unbiased way which is the better? By com-
paring results obtained by the same operator and
corps of assistants. I have made up my mind to
go home and take the cases as they come and do
the suprapubic and perineal operations alternate-
ly with the pre- and post-operative care and the
operation done by the same men and compare our
results. If we can get better results by the sur-
prapubic route we will do suprapubic instead of
perineal prostatectomies. But few men do first
one and then the other. Each is convinced that
the plan he follows is ideal and follows it almost
regardless of conditions. I do not see why we
cannot take care of and prepare these cases for
operation by means of the urethral catheter. We
are never called upon to do a suprapubic puncture
in order to drain the bladder. We drain all of
them and do it through the retention catheter or
by intermittent catheterization. In this way the
pressure can be relieved by gradual reduction as
was suggested by the essayist. In the suprapubic
drainage you have the sudden relief of the pres-
sure to which the kidneys have been unaccuf
718
SOUTHERN MEDICAL JOURNAL
September 1921
tomed and sometimes anuria is produced by the
congestion following sudden and continuous re-
lief. If the patient dies before the prostate is
removed, the fatality is not charged up against
the prostatectomy because the prostate was not
removed. I wonder how many fatalities occur in
these cases before the gland is removed? I be-
lieve that Judd's plan of removing the gland is
probably the better. He does the complete oper-
ation, sutures the capsule and drains with the
catheter as well as suprapubically, or at least
drains some of his cases both ways.
Dr. Carl Wheeler, Lexington, Ky. — I am a
three-stage prostatectomist. The first stage I
shall call the preliminary catheter drainage. I
prefer to infect my patient with the catheter,
giving him his proverbial colon infection, thereby
vaccinating him and raising his resistance.
After about two weeks drainage you will notice
there has been a marked change in your patient.
The thrist has subsided; the dry tongue has van-
ished; the ache in the renal angles gone; the ap-
petite is improved; and the bladder is cleared of
its infection. The kidney function has been
raised. You have done much toward raising your
surgical risk.
Patients with greatly distended bladders over a
long period should be cautiously catheterized and
the back pressure upon the kidneys should be re-
leased very gradually, by intermittent catheteri-
zation for several days before the catheter is per-
manently anchored.
The second stage I shall call the suprapubic
cystostomy, and introducing the large dePezzer
drainage tube. The most important thing in this
operation, as I consider, is the two deep through
and through silk-worm gut sutures at the upper
and lower angles of the bladder wound. These
two sutures lift up the bladder, close off the up-
per and lower spaces and prevent infection. For-
merly I used to be very particular about small
wick drains especially in Buy Tadora the lower angle of the
abdominal wound.
The third stage I shall designate as the
enucleation of the prostate.
The interval between the cystostomy and the
enucleation is sixteen to twenty-one days, and
even longer if the risk of my patient is at stake.
We can usually forecast the kidney sufficiency
and shock, but the immediate bugbear following
the enucleation is hemorrhage, and for this I al-
ways use the Hagner bag anchored to a Wheeler-
Hamer cage to hold it in place.*
Some men contend that the bag gives our pa-
tients discomfort. Be that as it may, my mind is
far more tranquil for the first twelve hours.
There is no argument whatsoever against the two
or three stage prostatectomy, Tadora Online as it is the only way
that we can take many of the most unfavorable
risks through a successful operation.
It may take a little longer time, but we cannot
consider that when the life of the patient is at
stake.
I wish to ask three questions :
How many men have had ventral hernias fol-
lowing their suprapubic work?
How many have had incontinence following
suprapubic enucleations?
How persistent was it and how long did it last?
•Trans. Am. Urol. Assn., 1917.
Dr. John R. Caulk, St. Louis, Mo. — I believe
most of us prepare our patients for operation in
about the same way and have absolute faith that
the preliminary treatment is the most important
factor in the operation. I was glad to hear Dr.
Livermore lay stress on catheter drainage as pre-
liminary drainage. I think the first stage oper-
ation is done chiefly to wall off the prevesical
space and fascias to prevent infiltration, and if
we have prepared our patient with catheter drain-
age, we do not have to wait so long between stages
and can protect against sclerosis around the blad-
der and peritoneum. If we Tadora 20 Mg go in within ten days
we very rarely injure the peritoneum. In this
neighborhood the peritoneum will stand a good
deal.
As urologists we have an ideal method in seven
out of ten times of doing either a perineal or su-
prapubic prostatectomy on a bad risk, a man who
has uremia, or sepsis, or a severe cardio-vascular
lesion. That is sacral anesthesia. I have used it
on bad cases for several years, and recently on
good cases, and in seven out of ten times 30 to
60 cc. of novocain in the sacral or perisacral re-
gion, will give complete anesthesia to the neck of
the bladder. We have had complete anesthesia
at the time of removal and it is an excellent thing
for bad risks.
With reference to hemorrhage, after the sec-

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