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properly safeguarded, the operation is attended by very little risk. This favorable change is almost solely due to the recognition of the necessity of a careful preparation of the patient for operation. Indeed Cialis Pharmacy Rx One the preliminary preparation is undoubtedly the most important factor in the whole surgical management. It is of much greater importance than the selection of the particular type of opera- tion, perineal or suprapubic. Cialis Pharmacy Rx One In twenty consecutive prostatectomies performed by the two stage method the writer has not had a single fatality. Although this number is not large, it seems significant as in- dicating the safety of the procedure, especially in view of the fact that several of the cases were bad surgical risks. Only as recently as 191 Cialis Pharmacy Rx One 1, Rovsing ( I ) reported twenty-five prostatectomies performed by himself with a mortality of sixteen per cent. Page (2) in twenty-six cases operated Cialis Pharmacy Rx One on in four London hospitals froin 1906 to 1910 quotes a inor- tality of 21.5 per cent. Deaver (3) in 1905 col- lected from the literature the records of 186 cases ' of suprapubic prostatectomy with a mortality of 10.75 per cent. The more recent records, however, of Freyer, Young, Judd, and others show a much lower mortality, varying from three to 5.5 per cent. These improved records are undoubtedly to be as- cribed to a more intelligent preparation of the patients for operation. ^Jost of the fatalities after prostatectomy are due to impairment of renal function and to infection of the bladder and its surrounding tissues. ■ Often in addition to these complications prostatic subjects are victims of marked arteriosclerosis and myocardial degeneration. As Dekver (4) has said :' '*The vital organs show the scars of the battle of a life almost spent." Too much emphasis, therefore, cannot be given to the necessity of a careful examination and of the exercise of a wise judgtnent as to when rather than how the prostate shall be removed. Under no conditions is prostatectomy an emergency operation, and there is no longer any justification of the former rough and ready methods of Cialis Pharmacy Rx One proceed- ing to undertake the operation without any more preliminary study and preparation of the patient than would be given fo the usual healthy man with a hernia. Realizing that most of tlio fat.-ditics are clue to impaired renal function and to Cialis Pharmacy Rx One severe bladder in- fectioii, it is highly important that in the examina- tion, of every prostatic subject special emphasis should be given to these ])oints. In the author's hands the phenolsulphonephthalein test of Rown- 44« GRAHAM: TWO STAGE PROSTATECTOMY. (New Vukk Medical Journal. tn-c- and (jeragluy {^) lias provL-d of great value Cialis Pharmacy Rx One 111 (li-ieriuiniiig the oijerabilil} of tliis kind of cases, altliough other urinary lactors, such as sfjecific grav- it\, jircsence of casts, etc., must be considered. I'aiicnts who show a greatly delayed appearance of the suhstaiice, beyond twenty minutes after hypo- dermic administration of the drug, and who secrete Diily thirty-live t(; forty ]ier cent, or less of it in iwo hours have proved invariably to be bad risks. I'"(,r determining the degree of c_\stitis, one should not be content merely with noting the quantity of pus. Cialis Pharmacy Rx One The examination should also include the mak- ing of ijacteriologicai cultures. .l:lxamination with \hv cystoscope, while not always imperative, is nevertheless an important step in the loutine because !l reveals more accurately the nature of the prostatic hypertrophy, the presence of diverticula or calculi ; the suspicion of ni.nlignancy, etc. Cialis Pharmacy Rx One But the fact should not be lost sight of that even so compara- tively simple Cialis Pharmacy Rx One a procedure as a cystoscopic examina- tion occasionally leads to disastrous results in a prostatic subject. I'or ihc purpose of improving renal function the all important princi])les are to remove back pressure on the kidneys Cialis Pharmacy Rx One from an overdistended bladder and to cure if possible, or at least to diminish, the liladder infection. Crabtree and Cabot (6) consider the blood stream to be the most frequent source of infection. Regardless of whether the kidney im- |)airment is due to an ascending or a hematogenous infection from the bladder, the fact remains that one of the most important indications in the pre- operative handling of these patients is the removal of the original infection. To carry out these princi- ples it is obvious that drainage must be instituted, for improper drainage caused by the prostatic obstruc- tion has caused the complications. Adec|uate drain- age can be carried out only in one of two ways: i, Ijv frequent or permanent use of the catheter over a ))eriod of time, and 2, by establishing artificial drainage through a preliminary cystostomy. Of these two methods it is obvious that cystostomy, when properly done, certainly insures belter drain- age tiian occasional catheterizations and probably as good drainage as a jiemianent catheter in tlie ure- thra. Furthermore, a permanent catheter is so pain- ful to iTiany patients that it can not be tolerated. The only real disadvantages to a preliminary cys- tostomy are that it necessitates two operations and that the later ojieration for the removal of the prostate is perhaps a little more difficult technically. Neither of these objections is important. Sui)ra- pubic cystostomy is so simple, especially with local -inesthcsia, that it hardly deserves to be considered as an operation in itself, and the technical difficulties of the second operation are not sufficiently greater than those of a jirimary prostatectomy to constitute Cialis Pharmacy Rx One a serious objection to the method. In the writer's opinion the two stage operation has abundantly jus- itfied itself in the results obtained. Our procedure with prostatic subjects is invari- ably to perform a two stage operation, i, if there is an associated cystitis; 2, if the specific gravitv of the urine is persistently low — under TOio — -and if the phenolsulphonephthalein test shows marked de- lav in elimination of the dve as. e. g., onlv forty \)CT cent, or less within two hours after hypodermic