procedure because eclampsia is not primarily a renal condition; and recent experimental work by H. Ehrenfest1 has shown that after decapsulation there is a marked decrease in the urinary secretion for twenty-four hours. This fact alone contraindicates the operation in eclampsia.

If the patient has been delivered early, recovery usually takes place, manifested by returning consciousness, cessation of convulsions, increase in the secretion, and diminution of the pathologic elements of the urine. The patient is to be kept on milk diet until the albumin drops to 1 of 1 per cent., when she may be allowed cereals, bread, and toast, but nothing else until the urine has cleared. up entirely. The patient is usually able to get out of bed by the fourteenth day. In mild cases nursing is allowed, if there is any milk, after the third day. In the majority of these patients, however, the milk-supply is deficient or absent.

When, after delivery, the convulsions do not cease and the patient sinks more deeply into coma, death may be predicted with certainty.

Postpartum eclampsia is to be treated by the same medical measures as described for the antepartum. These cases commonly recover.

EARLY RISING AFTER LABOR

It may not be out of place here to say a few words on the subject of getting patients out of bed in the early days of the puerperium. Pfannenstiel and E. Martin3 were the first to carry out this custom in a considerable series of cases. Only absolutely normal cases were selected, and these were allowed to get up first at the end of fifteen to twenty-four hours after delivery, but were allowed only very light exercise. Their results were excellent. No case in either series developed thrombosis. Involution of the uterus proceeded normally, and strength returned quickly. Nevertheless, in spite of their good results, it must be remembered that the class of patients that make up the German clinics is very different from that which is met with in private practice in this country, and one must select with the greatest care the cases to get out of bed early.

1 Surg., Gyn., and Obst., 1911, xiii, 296.

2 Alvensleben, Centr. f. Gyn., 1908, xxxii, 1184.

3 Monatschr. f. Geb. u. Gyn., 1908, xxvii, 248.

CHAPTER XLVII

OPERATIONS ON THE PENIS, SCROTUM, URETHRA, AND PROSTATE

General Considerations. In all postoperative treatment it behooves the surgeon to conserve to the best of his ability the function of the eliminative organs, for faulty or disturbed elimination is likely to lead to disaster unless promptly alleviated. In genito-urinary work the attention paid to elimination must be doubled, because the chief eliminative system, the urinary apparatus, is involved by the operation and its function is already more or less impaired. The operation is performed with the intention of removing the cause of the functional impairment; the after-treatment must strive to restore natural function or, at least, preserve what is left. To this end the kidneys must be made to act freely and easily; their product, the urine, must be kept or made qualitatively normal, and given an unobstructed outlet; existing infection must be eradicated or subsequent infection prevented; and, last and always, the patient must be kept comfortable.

Renal Activity.'-Postoperative urinary suppression occurs more frequently after genito-urinary operations than after operations of any other sort. Its cause cannot always be determined, for infection does not explain every case. Suppression due to infection will be discussed later; the so-called idiopathic or reflex cases of suppression will here be considered. Many causes are assigned to explain this condition: poor general health, prolonged anesthesia and operation, shock, chronic nephritis, reflex irritation from the urethra, and so on. The thoughtful surgeon operates so far as possible only under the most favorable conditions, often delaying operation until he can improve the patient's general condition, and always operating as rapidly as safety permits; and nevertheless, in spite of every care, he often finds suppression threatening. It is a good plan, therefore, to anticipate trouble and to institute prophylactic treatment from the start. As soon as the patient's stomach

1 See also p. 386.

permits, he should be encouraged to drink as much water as he feels that he can take. A kidney will excrete a large amount of dilute solution when it will balk at concentrated fluids. An excellent device to increase the intake of water is to give palatable drinks; none excels the simple cream of tartar water:

Lemons....

Cream of tartar.

Hct water..
Sugar...

2

2 drams

I pint q. s.

Keep a pitcherful at the patient's elbow and see that he drinks long and often. He will take much more of this than of plain water. Moreover, it has a slightly diuretic action and is stimulating to the kidneys.

The diet should be liquid for at least the first few days, bland and non-irritating, with a low salt and proteid content, to spare the kidneys. Once renal function is well established, the diet may be gradually increased. Meat and meat soups and extracts contain too much protein compounds to be safe and had better be avoided until later.

In spite of every care, suppression of urine may supervene. As a rule, the warning is ample. The only sure way to detect its onset is to measure the twenty-four-hour amount of urine in every case. This procedure is as simple as it is important, and should be faithfully carried out until satisfied that all danger is past. A steady decrease in the twenty-four-hour amount is a danger-signal worth observing. If this occurs, the patient should be kept in bed on a milk diet and given alkaline diuretics, such as the acetates, citrates, and tartrates, and cathartics until the bowels are freely open. These simple measures suffice to arrest a certain proportion of cases. A continued decrease in the twenty-four-hour amount calls for free watery movements and active diaphoresis. A poultice, which may be made of digitalis leaves, over the kidneys acts surprisingly well in promoting excretion of urine. All the usual treatment for acute renal disease must be promptly giventhe case is desperate and calls for desperate measures.

Urine. Most genito-urinary cases coming to operation are passing urine which possesses pathologic constituents. In the majority of cases the urine as it leaves the kidneys is nearly normal; it is the pathologic process lower down in the urinary tract that changes its character. Infection anywhere along the urinary tract adds to the urine pus, bacteria, blood, and local tissue-cells. Mechanical obstruction causes stasis and retention of urine, which gives rise to anatomic changes in

the urinary tract, with concomitant alterations of function. The retained urine decomposes and ferments; a catarrhal condition of the mucosa results, with its profuse discharge of mucus. Such a condition readily favors infection, which sooner or later is bound to supervene. The operation supposedly removes the cause for the pathologic state of the urine, but the process may have gone on for a sufficient length of time to cause tissue changes which, in turn, serve to perpetuate the abnormal constituents of the urine.

As an infected or decomposed urine flowing over an operative wound is a real danger, the sooner the abnormal urine can be corrected, the better. To this end the free diuresis already advocated serves, by thoroughly washing out the urinary tract and by causing increased frequency of urination, to prevent retention. In addition, as a urinary disinfectant, hexamethylamin (urotropin), 7 gr. three times a day after meals, should be given as soon as the stomach will tolerate it. Owing to the slight renal irritation which this drug causes, it is well to omit it every fourth day. Continue the drug until the urine becomes normal. If the urine remains foul in spite of the antiseptic drugs and cystitis is present, wash out the bladder with some mild antiseptic, such as boric acid. Strong antiseptics may give rise to pain and make the cystitis worse. If, however, there is no improvement, a dilute solution of silver nitrate may be used (1: 4000), increasing gradually up to 1 : 800. In washing out the bladder only 2 or 3 ounces of fluid must be injected at a time and allowed to run out again, this being repeated until the solution comes back clear. The fluid should have a temperature of about 100° F. The best apparatus is a soft-rubber catheter attached to a funnel, or a glass irrigating nozzle connected with a fountain syringe. (See also Chap. XIV, p. 154.) If the urine is strongly alkaline, benzoate of ammonium can be given in 10-gr. doses; if strongly acid, bicarbonate of soda in 10- to 20-gr. doses should be used.

Locally, much can be done to improve the urine. The field of operation is, as has already been stated, commonly the seat of a lowgrade, but nevertheless persistent, infection, which it is the object of the operation to relieve, and that, too, in the presence of infected urine. As Francis S. Watson has epigrammatically expressed it, "Asepsis in genito-urinary work is drainage." All operative wounds, except in the rare clean cases where there is a fair chance for first intention, must heal from the bottom by granulation. There must be no chance for pocketing of infective material; no blind recesses to harbor small collections of urine; and, so far as possible, no uphill drainage.

Thorough frequent irrigations of all wounds with mild antiseptics serve to keep them clean and free of débris; gauze packs and wicks rarely stay placed in wounds discharging urine, and when they do, become plugs rather than drains. In many cases for the first few days the urine escapes by preference through the operative wound, which must, therefore, be kept unobstructed.

Unobstructed Natural Outlet for Urine.-Many genito-urinary cases come to operation for the relief of urinary obstruction. The operation relieves the difficulty, often, of necessity, by making a temporary artificial outlet for the urine as well as removing the obstruction in the natural outlet. During the process of healing, therefore, the natural passages must be kept wide open. Failure in this regard may mean that the

operation is a failure; and in those cases where an artificial outlet has been made, this outlet will persist indefinitely as a urinary sinus so long as obstruction to the natural outlet exists. The means of keeping the urinary passages open will be taken up in detail later.

Infection.--Existing infection is best combated by the free diuresis, competent drainage, frequent irrigation, and administration of urinary antiseptics already described. The same measures serve also to prevent the occurrence of infection. In addition, the operative wound should be kept covered with a sterile dressing, frequently changed. Infection once started calls for more frequent irrigations and the relentless use of the knife. All the tissues must be laid wide open. Hot soaks in a sitz-bath are invaluable and comforting. Uncontrolled infections have a direful tendency to spread upward along the urinary tract, where the difficulty of combating them is doubled.