lus, as hot brandy-and-water, ammonia, &c., are to be given; in a word, the usual treatment of excessive exhaustion must be pursued, until some reaction sets in. In other cases, where the extraction of the stone has been rapidly performed, with violent and sudden distention of the neck of the bladder and prostate, the nervous system experiences a shock in the true sense of the word, and the patient sinks rapidly, with symptoms nearly the same as those just described. Finally, the effect of the shock to the nervous system may be rather irritative than depressing. Though much less dangerous than severe prostration, or sinking, this is a very troublesome state. It bears much resemblance to the one met with after lithotrity. Sometimes the irritation manifests itself by a severe attack of delirium, unaccompanied by prostration. This is a dangerous form. In other cases, the patient is seized with shivering soon after the operation, becomes extremely restless, wanders at night, and if the state continues, falls into a condition very analogous to that denominated irritative fever; perfect rest, with the use of anodynes and gentle stimulants, are the best remedies in such cases. As I propose reserving hæmorrhage, cystitis, infiltration of urine, purulent infection, and the chief causes of death after lithotomy, for a separate chapter, I shall pass them over here, and conclude with a notice of some minor accidents. Retention and incontinence of urine occasionally follow the lateral operation. An impediment to the free discharge of urine through the wound may occur under two very different circumstances. Sometimes it arises from sub-inflammatory engorgement of the wound along its whole course. At other times the impediment depends either on spasmodic action about the neck of the bladder, or more frequently on coagula produced by some slight vesical hæmorrhage. The retention of urine from these latter causes is never complete; but it gives rise to many disagreeable symptoms, and may become dangerous if neglected, from its influence in exciting renal disease. Spasmodic retention is easily relieved with the catheter; to that form depending on coagula in the bladder, the instrument is not so well suited, because it soon gets plugged up. M. Civiale recommends us to inject tepid water into the bladder, and pass up a small flexible sound through the wound into the perinæum ; other surgeons advocate the use of cold over the region of the bladder. The retention may go on to complete suppression of urine. Here the kidneys have become implicated, and the accident is, I believe, beyond the resources of our art. Incontinence of urine also occurs occasionally. It is a rare accident. I have never met with it myself, though in Deschamps' time, it seems to have been more frequent, for that celebrated lithotomist met with ten examples in his own practice and in that of others. Surgeons are not agreed on the precise cause of this disagreeable accident. It was much more frequent when the lithotome caché was in vogue, and hence may sometimes be connected with too free incisions of the neck of the bladder. In other cases the incontinence may reasonably be attributed to loss of power, arising from over distention of the neck of the bladder during extraction of the stone. In children, incontinence has occurred after very simple operations, and the symptoms may continue for many years in spite of treatment. Impotence, from division or inflammation of the seminal ducts, is so rare an accident after the lateral operation, that I shall not notice it here. does occur, we have no remedy for it. Besides, if it In speaking of the after treatment, I mentioned that, in the ordinary course of things, the wound through which the stone has been extracted gradually contracts, and is finally healed in about thirty or forty days. But it may happen that the healing of the wound does not proceed in so favourable a manner. Sometimes it makes no progress whatever, remaining pale and flabby; yet no evident cause can be discovered. In other cases the wound goes on well for several days, after which it rapidly assumes an unhealthy aspect; constitutional symptoms set in, and the patient dies. Here the condition of the wound depends on some internal disease which has been developed. Finally, whenever the soft parts have been much injured during the extraction of a rough, large stone, they may inflame as a necessary consequence of the violence used. of the violence used. In such cases the inflammatory action usually commences within twenty four hours after the operation, and may assume an erysipelatous character, or run into gangrene. This accident is often followed by fistula in the perinæum. When the wound has not healed kindly, or when any portion of it has been destroyed by gangrene, a fistulous communication with the bladder is, of course, most likely to ensue. The discharge of phosphatic gravel through the wound may also be the cause of fistula; and in some cases the Q urine is so highly charged with the phosphates, that it deposits them in its passage over the surface of the wound. Some diversity of opinion exists as to the frequency of perinæal fistula after the lateral operation. From my own experience I should be disposed to say that it is a very rare accident; but some foreign writers take a different view of the matter. These fistulæ are extremely difficult to heal. A catheter must be kept constantly in the bladder, and an attempt made to heal the fistulous track with the aid of caustics. It has been observed that a second operation has cured the fistula left by the first one. Relapse of the complaint is the last accident that remains. It has, however, been noticed in a former chapter. Phosphatic deposits are sometimes reproduced in great quantity after the operation; when this occurs, we must leave the wound open, wash out the bladder frequently with tepid injections, and combat the inflammatory state of the bladder, on which the tendency to phosphatic secretion depends. CHAPTER XIII. CAUSES OF DEATH FROM LITHOTOMY. I HAVE thought it might be useful to reserve the principal accidents of lithotomy, and describe them together under the head of "Causes of Death." These latter shall form the subject of the present chapter. 1 The most formidable accidents of the operation of lithotomy are hæmorrhage, infiltration of urine into the cellular tissue of the pelvis, suppuration and abscess of this tissue, inflammation of the bladder, peritonitis, purulent infection, and finally, secondary disease of the kidneys, or other parts excited by the irritation which the operation has produced. The "shock" is also an occasional cause of death; but since the discovery of chloroform this accident has lost so much of its gravity that it seldom gives rise to a fatal result, and I have therefore described it with the other less formidable accidents. The hæmorrhage connected with lithotomy may be of two kinds, and occur at different periods. It may be arterial or venous; and it may occur either during the performance of the operation, or at an uncertain interval after it; being, in surgical language, primary |