SURGERY

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j,eld fast, but allowed to move in the most favourable situation ; orhe finger is then to be introduced so as to place it properly for ex'fraction. If this cannot be done with the finger, it ought to beallowed to slip out of the forceps to get it more properly fixed;and as the most common form of the stone is flat and oval, or some-what like a flattened egg, the forceps should have hold of thesmallest diameter, while an end presents to the neck of the instru-ment. The stone should be grasped with no greater firmness than ismerely sufficient to fairly bring it out. It should be extracted in aslowand gradual manner. When a stone is broken in the bladder, allthe larger pieces are to be extracted by the forceps, which are tobe introduced by the finger serving as a director. The smallerparts are to be removed by a scoop, fig. 81, or the finger may bemore convenient; and as the least particle allowed to remain, orwhich is not washed off by the urine, may serve as the nucleus ofanother stone, a large quantity of water , properly warmed, is tobe injected by a bag and pipe, or by a syringe; and for this pur-pose the body of the patient should approach at least to an up-right posture ; and to give the particles of stone an opportunity ofcollecting near the incision of the bladder the wound maybe stop-ped for a little after the injection is thrown in. When a stone isextracted of a regular, firm, and rough surface, seldom any othersremain in the bladder. But when it is of an irregular shape, andsmooth and polished, particularly in certain places, with impres-sions formed upon it, there is the greatest probability of others re-maining. There are exceptions, however, to these rules; andtherefore the operator, instead of trusting to them, should introducebis finger, which will answer the purpose without any othersearcher. If, after the operation, any considerable artery bleedsmuch, it is to be taken up with a ligature, but if this be impractica-ble, the hetnorrhagy ought to be stopped by pressure; for thisa firm roller introduced at the wound answers sufficiently ; and toprevent any stoppage to the discharge of urine, a silver canula,covered with caddis, and dusted over with styptic powder, maybe introduced into the wound with advantage. Sometimes a con-siderable quantity of blood, instead of passing off by the wound,is collected in the cavity of the bladder, and may produce verydangerous symptoms. To prevent this, immediately upon theoperation being finished, the patient’s pelvis should be made con-siderably lower than the rest of his body; by which means theWound will be kept in a depending posture, and the blood willescapf more readily by the wound. But if it be found that bloodis still lodged in the cavity of the bladder, it must be immediatelyextracted. As soon as the blooding is stopped, the patient is tobe united, a piece of dry soft charpee put between the lips of the"murid, and often renewed, and the thighs brought together. Heis then to be laid in a bed, so that the pelvis may be considerablyiower than the rest of the body, to give a favourable direction toa *iy blood which may afterwards flow from the wound. A con-siderable dose of laudanum is now to be given. From 30 to 50drops for an adult will commonly be necessary. From thisPeriod, unless the stone has been large and difficult to extarct, thepatient commonly falls asleep, or at least lies quiet for a fewhours; but afterwards generally begins to complain of pain in the"Oder part of the abdomen. Anodynes are now to be given bothby the mouth and anus, and warm fomentations, by flannels orbladders filled with warm water, applied to the region of the blad-tIer - If by a continuance of these remedies the pain abates, noAnxiety need be entertained concerning it; but if it increase, and

■ hard and swelled, and the pulsesymptoms become gradually worse,

Especially if the abdomen becomeand quick, and these symptSjeat danger is to be apprehended, as they most commonly takeP ace in consequence of inflammation. In this situation, as much:. °°d ought to he taken as the patient can bear. A large injec-*! 011 of warm water and oil, or linseed-tea, should be given everysix or seven hours, and the fomentations continued at the abdomen,j th e symptoms continue to grow worse, the patient should be‘"mediately put into the semicupium or half-bath. By a properC0 “Unuan C * of these means, with a low diet and plenty of diluent

drink, the above symptoms may often be removed. The reverse,however, is sometimes the case. The wound becomes sloughyand ill-conditioned ; all the symptoms, in spite of every effort,continue to Increase, and soon terminate in death. But wherematters end favourably, the wound by degrees puts on a better ap-pearance ; the urine passes almost from the beginning by theurethra (but it is oftenest discharged by the wound for the firsttwo or three weeks;) the pain in the abdomen gradually abates,the feverish symptoms are soon removed, a complete cicatrix isformed, and the wound is sometimes cured in a month ; though atother times it will take three. But it depends greatly on theconstitution. The symptoms of stones in the kidneys are, pain inthe region of the kidneys, sickness, and vomiting, the urine some-times mixed with blood, at other times with mucus or pus ; but thesame symptoms are often induced by other causes, especially frominflammation and suppuration of the kidney. Nephritic com-plaints have often subsisted for a longtime, where stones have beenblamed as being the cause of them; and yet upon dissection puru-lent matter alone has been detected. From tins circumstance, aswell as from the great depth of the parts, aiid the large size of theblood-vessels of the kidney, the operation of nephrotomy cpuldnot be performed, but with the greatest uncertainty, and most immi-nent danger, and is therefore never attempted. A few cases indeedhave appeared where inflammation induced by a stone in the kid-ney terminated in abscess, and the stones were taken out; but itwas not till they had worked their way out of the kidneys into thecellular substance, so that it only remained to open the abscess andextract them : but otherwise the operation is never to be thoughtof. Those who are troubled with calculous complaints frequentlypass small stones along with their urine ; and when these are angu-lar, or of considerable size, they stick, and give much uneasiness.The symptoms are at first pain, then inflammation and swelling,attended with a partial, or total suppression of urine, which, iflong neglected, is apt to terminate in a rupture of the urethra, whenthe urine will be discharged into the neighbouring parts. Thegreatest attention is therefore necessary to get the stone extractedas soon as possible.

Of Incontinence and Suppression of Urine.

Incontinence of urine may arise from various causes, as, from aloss of power in the sphincter of the bladder, while the natural toneof that organ remains unimpaired; or from irritation about theneck of the bladder, produced by the friction of stones containedin it; or from a laceration of parts by the operation of lithotomy;or from the pressure of the uterus in a state of pregnancy. Whenthe disease is owing to a want of tone in the sphincter, the cure isvery difficult, because the constitution in general is frequentlyaffected. The most useful remedies are tonics, especially Peru-vian bark, chalybeate waters, and the cold bath, both generally andlocally applied. We shall here treat only of that species of suppres-sion of urine, where the urine is collected in the bladder, but fromsome obstructing cause is prevented from being discharged. Itarises from a great variety of causes. When it arises from a wantof tone in the body of the bladder, it is often connected with palsvof the lower extremities; it is frequently owing also to retainingurine too long. The catheter, in this case, is commonly an ef-fectual remedy, and ought to be employed as soon as the suppres-sion is evidently formed, and repealed from time to time, till thetone of the system is recovered by the use of proper remedies.The method of introducing the catheter is the same with that al-ready directed for sounding for the stone. Fig 82, is a catheterfor the male: fig. 83, one for the female. When the affectionarises from spasm about the neck of the bladder, opiates, warmwater thrown into the rectum, aud afterwards the warm bath, arethe best means of producing relief. When it proceeds from scirrhusof the prostate gland, or from other tumours, or from obstructionsof the urethra in consequence of gonorrhoea, a different treatmentis pursued according to the different circumstances in such com-plaints.

SURGICAL,