The operator should stay with the patient for half an hour, and within easy call for several hours, lest haemorrhage should occur: delay in arresting it in old anaemic people being very fatal. It is well to remember that bleeding may take place without itself externally by the wound. It may be suspected
showing
if there is
draining
a
from the urethra and the
general symptoms
of loss of blood.
The liability to haemorrhage, and the consequent necessity on the operator's part, is greatest in just those cases in -which, if it should take place, the effects would be for watchfulness
whom tho
in
serious ; namely?in old people, of veins is often enlarged.
most
prostatic
plexus
Treatment of hemorrhage.?Plugging the wound with
a
(which can be made by any blacksmith or carpenter), wrapped round with folds of lint and dipped in tincture of iron, has generally been successful. In only one case was the haemorrhage treated without the aid of this tube ; and in only four patients did this treatment straight
iron
or
wooden tube
fail. The case in which the tube
was
not
applied
was a
man, cetat
21, in whom haemorrhage, to the extent of 10 ounces, took place, six hours after the operation, during a fit of coughing. It as
stopped by swabbing the whole of the wound, the neck of the bladder, with tincture of iron. In a case in which, after the tube was applied, the was
as
high
bleeding pouring cold water from a height over the sacrum, pubis, &c. In another, washing the bladder out with cold water was successful ; and in two cases, compression of the bulb of the urethra, kept up for one and a half hours against the uuder surface of the symphysis, was followed by continued,
it ceased after
success.
Professor says: the
"
Humphrey, in his lecture previously quoted from By carefully sponging out and exploring the wound, arteries of those of the bulb
bleeding
branch of the
or
the transverse,
or
may usually be found and tied." This does not accord with my experience, as I have seldom
some
pubic,
been able to tie tho
arteries; though,
I have been successful
on
one
or
failed, by twisting
where this has
two occasions
them. " the trunk of tho artery of tho bulb says, that however be endangered, by opening tho urethra too up and lateralising the knife too early."
Erichsen would
high Again
he says
that serious
:
"
It may, 1 think, be stated, as a general rule, is usually best avoided by making
haemorrhage
tho incisions low ; and I beliovo the great secret of success i? lateral operation of lithotomy consists in making all the deep incisions as low as practical?tho knife the
the
of the stalf
from below
downwards."
entering
upwards,
rather than
groove
from above
I have found thore is less liability to haomorrhagc, if the fit'8'' are made midway between the anus and rectum than
incisions
LITHOTOMY.
IS;
W. P.
Harms, M.D., Section
neum
Civil
Surgeon, Shcihjehanpore.
VIII.?(Concluded.)
(Continued from page 234.^ Treatment ?Extraction of the stone being completed, tube need be applied unless hcemorrhago should come 011. This is not of uncommon occurrence for tiie first two or
After
no
three hours after the
operation, and may be distinguished the red-colored urine which is always passed, by the blood constantly dripping from the wound, and not coming away in gushes, and by its coagulating at the bottom of the
from
vessel
containing
it.
it made, as Erichsen and other writers recommend, a nearer the tuber ischii than anus, for tho arteries of tho
pudie
are
thus
cut
third
peri-
further from their origin in tho internal
than in tho latter
proceeding.
The introduction of tho tube into the bladder requires care ; for, on account of its open end and tho folds of lint around ifl) it catches in tho tissues, ami is therefore inserted with difficulty, being liable to pass to ono side of the neck of tho bladder. I he same precaution must be adopted as is done in introducing forceps?namely, tho finger must bo kept in the neck until as the tube arrives at that part, and must then bo slipped out the tube is passed in.
the
The difficulty is diminished if the tube is made with a closed f"r instead of an open extremity, tho opening being in the side ; it then passes forward with less obstruction from entanglement in the tissues. It should be kopt in for 24 hours. After the
CASE OF POISONING- BY FUNGI.?BY J. G. BAINDALL.
1873.]
October 1,
has been extracted, if the operation has been a prolonged and the patient be much collapsed, do not leave him until reaction has taken place. Children are especially liable to col-
stone one
To
lapse.
a
boy
of 8 years of age, if
collapsed,
as
much
as
261
allowed with benefit. All the astringents and some of the tonics may be tried ; of these, acid sulphuric dil. is the most useful: but small doses of opiates, catechu, lead and opium enemas, pulv. cretse co. cum opio, Dover's powders, wine of iron, dec. of cinchona, may all be tried in turn. In one case, port wine was found the most useful medicine ;
minims of liq. ammonias may be given every quarter of an hour with benefit. and in another patient, cetat 5 years, the following,?acid nit. dil. As a rule, no opinion should be given after the operation, and in ixss, tincture of opium in. xss, rum jij, water gij ; and 5vi : no of 3 or 4 ten
days; though occaaperient until after the lapse sionally, iu strong and plethoric men, the oil may be taken as early as the second day. under ordinary cirI agree with Professor Humphery that, cumstances, a restless night is less damaging than a night of sleep induced by a sedative." The oil is generally required on account of the bowels obstinately refusing to act until stimulated by an aperient?perhaps from exhaustion of the influence of the spinal cord. At times the wound will remain quite inactive, like a piece of raw flesh, until the aperient has been given. The diet ought to be supporting, though given with judgment, on account of most of the patients having weakened digestions and damaged kidneys, and consequently being unfit to eliminate the large amount of unassimilated food, which is the result of au excessive and ill-regulated diet. The most common and troublesome complication during convalescence is secondary haemorrhage, coming on generally from the sixth to tenth day; sometimes after the action of a purgative, but often without any apparent cause. It has occasionally followed a purgative when taken stronger than usual, perhaps on account of the blood being thus impoverished ; or if the motion passed be hard, it may occur from clots in the prostatic and other veins having been loosened. Plugging with tincture of iron, combined with dilute sulphuric acid, gallic acid, or tincture of iron internally, has always been "
of this?one table spoonful?was During the convalescence of
and morning. enlarged prostate, especially if combined with signs of weak heart, we must guard against the sudden supervention of collapse. A case in point occurred, where six days after being operated upon a man with enlarged prostate, he passed a little clotted blood and two thin motions with slight vomiting, and immediately afterwards became so collapsed that it was necessary to give him rum every hour with sulphuric ether in the intervals to induce reaction. Old weakly men should be kept under observation, and in good hygienic circumstances, for a period of not less than fo.ur weeks after the operation; otherwise, exposure to cold and injudicious diet may set up kidney irritation after their discharge from hospital. In conclusion. I will give a memo, on the frequency of the recurrence of stone, and on the proportion of cases who suffer from incontinence of urine after the operation. The cases on which this table is founded were seen by me during the cold season of 1864 and 1865, having been operated upon by myself between the year 1861 and the latter year.
Total ber of
numcases
reinspected.
Number out of 1st have who column suffered from a recurrence
of stone.
successful. in which secondary haemorrhage occurred, tendency to it from the first?the urine having had a reddish tinge from the completion of the operation until the attack of haemorrhage set in. Some of the
showed
The lesson to be learnt
is,
to be
urine does not become clear
on
prepared
the third
day
after the opera-
In an elderly and weakly person, the scrotum ought to be suspended, to prevent its becoming moistened with urine, and a soft pad placed under the buttocks. He should also be made to change his position occasionally, from his back to one or the other side. It is also a good plan to cut away the mattress underneath his buttocks, filling up the space with soft pads only. Another complication during convalescence is intermittent fever, which is apt to show itself in patients with a malarious taint in their blood. As long as the irritation of the bladder continues, this poison may remain latent; but as soon as that weakened by loss of blood and the ceases, the system being shock of the operation, the malarial poison, lurking in the blood, shews itself by rigors and daily fever. Tenderness on pressure over the liypogastrium often occurs, and when very acute and attended with fever, may require the application of leeches with the internal administration of Dover's and grey powders. Leeches, however, are not often called for. Diarrhoea is another troublesome complication. In many cases, this is no doubt an effort of nature to supplement the defective action of the kidneys, and therefore it should not always bo stopped by
often of a dark green color, food. A diet of ground rice and milk boiled smooth (kheer) is then useful. Also curds (cluhee) with rice may occasionally be In this
containing
state
the motions
slime and much
are
undigested
with
Number out of 1st column who suffer from so much incontinence of urine as to interfere with the duties of life.
59
2
3 Distressing incontinence Much inconvenience from 2 incontinence ...
Total
...
5
for it whenever the
tion.
powerful astringents.
men
...
cases
a
given night
.
/
showing
if there is
draining
a
from the urethra and the
general symptoms
of loss of blood.
The liability to haemorrhage, and the consequent necessity on the operator's part, is greatest in just those cases in -which, if it should take place, the effects would be for watchfulness
whom tho
in
serious ; namely?in old people, of veins is often enlarged.
most
prostatic
plexus
Treatment of hemorrhage.?Plugging the wound with
a
(which can be made by any blacksmith or carpenter), wrapped round with folds of lint and dipped in tincture of iron, has generally been successful. In only one case was the haemorrhage treated without the aid of this tube ; and in only four patients did this treatment straight
iron
or
wooden tube
fail. The case in which the tube
was
not
applied
was a
man, cetat
21, in whom haemorrhage, to the extent of 10 ounces, took place, six hours after the operation, during a fit of coughing. It as
stopped by swabbing the whole of the wound, the neck of the bladder, with tincture of iron. In a case in which, after the tube was applied, the was
as
high
bleeding pouring cold water from a height over the sacrum, pubis, &c. In another, washing the bladder out with cold water was successful ; and in two cases, compression of the bulb of the urethra, kept up for one and a half hours against the uuder surface of the symphysis, was followed by continued,
it ceased after
success.
Professor says: the
"
Humphrey, in his lecture previously quoted from By carefully sponging out and exploring the wound, arteries of those of the bulb
bleeding
branch of the
or
the transverse,
or
may usually be found and tied." This does not accord with my experience, as I have seldom
some
pubic,
been able to tie tho
arteries; though,
I have been successful
on
one
or
failed, by twisting
where this has
two occasions
them. " the trunk of tho artery of tho bulb says, that however be endangered, by opening tho urethra too up and lateralising the knife too early."
Erichsen would
high Again
he says
that serious
:
"
It may, 1 think, be stated, as a general rule, is usually best avoided by making
haemorrhage
tho incisions low ; and I beliovo the great secret of success i? lateral operation of lithotomy consists in making all the deep incisions as low as practical?tho knife the
the
of the stalf
from below
downwards."
entering
upwards,
rather than
groove
from above
I have found thore is less liability to haomorrhagc, if the fit'8'' are made midway between the anus and rectum than
incisions
LITHOTOMY.
IS;
W. P.
Harms, M.D., Section
neum
Civil
Surgeon, Shcihjehanpore.
VIII.?(Concluded.)
(Continued from page 234.^ Treatment ?Extraction of the stone being completed, tube need be applied unless hcemorrhago should come 011. This is not of uncommon occurrence for tiie first two or
After
no
three hours after the
operation, and may be distinguished the red-colored urine which is always passed, by the blood constantly dripping from the wound, and not coming away in gushes, and by its coagulating at the bottom of the
from
vessel
containing
it.
it made, as Erichsen and other writers recommend, a nearer the tuber ischii than anus, for tho arteries of tho
pudie
are
thus
cut
third
peri-
further from their origin in tho internal
than in tho latter
proceeding.
The introduction of tho tube into the bladder requires care ; for, on account of its open end and tho folds of lint around ifl) it catches in tho tissues, ami is therefore inserted with difficulty, being liable to pass to ono side of the neck of tho bladder. I he same precaution must be adopted as is done in introducing forceps?namely, tho finger must bo kept in the neck until as the tube arrives at that part, and must then bo slipped out the tube is passed in.
the
The difficulty is diminished if the tube is made with a closed f"r instead of an open extremity, tho opening being in the side ; it then passes forward with less obstruction from entanglement in the tissues. It should be kopt in for 24 hours. After the
CASE OF POISONING- BY FUNGI.?BY J. G. BAINDALL.
1873.]
October 1,
has been extracted, if the operation has been a prolonged and the patient be much collapsed, do not leave him until reaction has taken place. Children are especially liable to col-
stone one
To
lapse.
a
boy
of 8 years of age, if
collapsed,
as
much
as
261
allowed with benefit. All the astringents and some of the tonics may be tried ; of these, acid sulphuric dil. is the most useful: but small doses of opiates, catechu, lead and opium enemas, pulv. cretse co. cum opio, Dover's powders, wine of iron, dec. of cinchona, may all be tried in turn. In one case, port wine was found the most useful medicine ;
minims of liq. ammonias may be given every quarter of an hour with benefit. and in another patient, cetat 5 years, the following,?acid nit. dil. As a rule, no opinion should be given after the operation, and in ixss, tincture of opium in. xss, rum jij, water gij ; and 5vi : no of 3 or 4 ten
days; though occaaperient until after the lapse sionally, iu strong and plethoric men, the oil may be taken as early as the second day. under ordinary cirI agree with Professor Humphery that, cumstances, a restless night is less damaging than a night of sleep induced by a sedative." The oil is generally required on account of the bowels obstinately refusing to act until stimulated by an aperient?perhaps from exhaustion of the influence of the spinal cord. At times the wound will remain quite inactive, like a piece of raw flesh, until the aperient has been given. The diet ought to be supporting, though given with judgment, on account of most of the patients having weakened digestions and damaged kidneys, and consequently being unfit to eliminate the large amount of unassimilated food, which is the result of au excessive and ill-regulated diet. The most common and troublesome complication during convalescence is secondary haemorrhage, coming on generally from the sixth to tenth day; sometimes after the action of a purgative, but often without any apparent cause. It has occasionally followed a purgative when taken stronger than usual, perhaps on account of the blood being thus impoverished ; or if the motion passed be hard, it may occur from clots in the prostatic and other veins having been loosened. Plugging with tincture of iron, combined with dilute sulphuric acid, gallic acid, or tincture of iron internally, has always been "
of this?one table spoonful?was During the convalescence of
and morning. enlarged prostate, especially if combined with signs of weak heart, we must guard against the sudden supervention of collapse. A case in point occurred, where six days after being operated upon a man with enlarged prostate, he passed a little clotted blood and two thin motions with slight vomiting, and immediately afterwards became so collapsed that it was necessary to give him rum every hour with sulphuric ether in the intervals to induce reaction. Old weakly men should be kept under observation, and in good hygienic circumstances, for a period of not less than fo.ur weeks after the operation; otherwise, exposure to cold and injudicious diet may set up kidney irritation after their discharge from hospital. In conclusion. I will give a memo, on the frequency of the recurrence of stone, and on the proportion of cases who suffer from incontinence of urine after the operation. The cases on which this table is founded were seen by me during the cold season of 1864 and 1865, having been operated upon by myself between the year 1861 and the latter year.
Total ber of
numcases
reinspected.
Number out of 1st have who column suffered from a recurrence
of stone.
successful. in which secondary haemorrhage occurred, tendency to it from the first?the urine having had a reddish tinge from the completion of the operation until the attack of haemorrhage set in. Some of the
showed
The lesson to be learnt
is,
to be
urine does not become clear
on
prepared
the third
day
after the opera-
In an elderly and weakly person, the scrotum ought to be suspended, to prevent its becoming moistened with urine, and a soft pad placed under the buttocks. He should also be made to change his position occasionally, from his back to one or the other side. It is also a good plan to cut away the mattress underneath his buttocks, filling up the space with soft pads only. Another complication during convalescence is intermittent fever, which is apt to show itself in patients with a malarious taint in their blood. As long as the irritation of the bladder continues, this poison may remain latent; but as soon as that weakened by loss of blood and the ceases, the system being shock of the operation, the malarial poison, lurking in the blood, shews itself by rigors and daily fever. Tenderness on pressure over the liypogastrium often occurs, and when very acute and attended with fever, may require the application of leeches with the internal administration of Dover's and grey powders. Leeches, however, are not often called for. Diarrhoea is another troublesome complication. In many cases, this is no doubt an effort of nature to supplement the defective action of the kidneys, and therefore it should not always bo stopped by
often of a dark green color, food. A diet of ground rice and milk boiled smooth (kheer) is then useful. Also curds (cluhee) with rice may occasionally be In this
containing
state
the motions
slime and much
are
undigested
with
Number out of 1st column who suffer from so much incontinence of urine as to interfere with the duties of life.
59
2
3 Distressing incontinence Much inconvenience from 2 incontinence ...
Total
...
5
for it whenever the
tion.
powerful astringents.
men
...
cases
a
given night
.
/
