principally of uric acid, soluble by solutions of the alkalies.
The brown and yellowish are also composed of uric acid, often in
combination with a base, and are likewise soluble in alkaline
solutions, or in alkaline carbonates. The white is most commonly the
ammoniaco-magnesian phosphate, soluble in acids; rarely, it consists
of phosphate of lime, not so white or friable as the preceding, but
likewise soluble in acids; or it may be a compound of phosphate of
magnesia, ammonia, and phosphate of lime, very white and soft, and
imparting a stain to the finger, soluble in acids, but principally
characterised by its fusible property. Specimens are here given of the
phosphate of lime, and of the triple phosphate formed as is usual on a
nucleus of uric acid, with some base, or upon the mulberry concretion.
The dark, hard deposit, chiefly occurring in children, consists of
the oxalate of lime, either pure, or in combination with one or other
of the preceding, very dense and soluble in acids. When these, by
accumulation within the bladder, are formed into concretions, they are
always mixed with more or less of a peculiar animal matter deposited
from the urine. Passed by the urethra, and settling at the bottom of
the vessel as the urine cools, they are termed either morphous, or
amorphous, according as they are crystallised or not.
To correct the calculous diathesis is an object of much importance;
solution of the concretion in the bladder is now allowed to be
impracticable. The principal attention is to be directed to the
digestive organs and skin; these must be brought into a sound state by
attention to diet, and the exhibition of laxatives, tonics, antacids,
&c., as the individual case may require, by exercise and baths. And
much benefit is also derived from the use of either alkalies or acids
in solution, according to the nature of the deposit. The uric acid
diathesis is the most frequent; in that, alkalies, as the carbonates of
soda or potash, are to be employed; the potash is preferable. Diuretics
and diluents are useful in carrying off the sand, and relieving the
painful symptoms; Venice turpentine with squill is on this principle
often a valuable remedy, and in some cases colchicum proves of benefit.
The symptoms attendant on the collection and passing of sand, or
gravel, as it is commonly termed, are,—pain in the loins; heat in
making water; heat in the urethra occurring afterwards, continuing
for some time, and usually at the orifice; frequent desire to empty
the bladder; and an occasional mixture of blood with the urine. When
aggregations of the deposit, forming concretions of some size, pass
along the ureters, violent pain is felt in the course of these tubes.
Often the patient complains of colicky pains all over the abdomen,
and of sickness without vomiting. There is pain in the thighs and
testicles, with retraction of the testicle on the affected side.
The calculous deposit may, instead of passing off along with the urine,
be accumulated in the body, forming concretions. It is produced by
the kidneys, and in them the concretions may be formed and lodged; or
it may not accumulate until it has reached the bladder. Usually the
stones are produced in the former situation, and after having attained
some size descend by the ureters, causing much pain. It is not often
that they remain in the pelvis or infundibula till they have become
too large to descend; in such cases they increase in their original
situation, producing, in general, much more uneasiness and greater
danger than if they had reached the bladder. Or they may enter the
ureters, and lodge in these canals, distending and obstructing them.
The concretions may be caused by the lodgement of extraneous substances
in the urinary passages. Foreign bodies introduced, even in the most
healthy persons, are soon incrusted by calculous matter; and the
rapidity of the incrustation is in proportion to the tendency to the
calculous diathesis. At first the deposit is generally of a brownish
colour. Catheters retained in the bladder are soon blocked up by it.
Needles, bodkins, leaden bullets, seeds of vegetables, kernels of
fruit, bits of catheters or bougies, have been found forming nuclei to
urinary calculi—more frequently in females than in males, for obvious
reasons.
Some concretions are formed on the nucleus of condensed vitiated
secretion from the mucous coat of the bladder, and partly consist of
this deposit from the membrane. Such are generally of a dirty white
colour, soft, friable, small, and numerous; it is seldom that they
are collected into masses of any considerable size. They are usually
adherent to the mucous membrane, sometimes forming a broad and thin
sheet covering it extensively; other stones, though composed of
calculous deposit from the urine, are equally friable as the preceding,
and also both numerous and small. So brittle is their structure that
they frequently break up by rubbing upon one another, or by being
compressed one against the other by the action of the muscular coat of
the bladder. Their laminæ in fragments, and the nuclei entire, are,
in consequence, often evacuated along with the urine in considerable
numbers. Even large and apparently very solid concretions break up most
unaccountably in the bladder. This may be, perhaps, so far understood
when more than one stone is present. A sketch from a specimen in my
collection is here introduced. It was obtained from the body of a
medical man. He had, it seems, laboured under symptoms of stone for a
long period, and ten years previously to the attack which terminated
fatally, had himself ascertained by sounding the existence of calculus
in his bladder. One Sunday morning I met this gentleman in consultation
about a case of injury of the hip-joint. In three days afterwards I
was called to visit himself, nearly moribund, from inflammation of the
urinary apparatus, his urethra being blocked up by large fragments
of stone. It appeared that on parting with me he had been suddenly
summoned to an urgent case of midwifery. He ran quickly down a steep
street, and at the bottom of it was seized with an urgent desire to
make water, which he did in small quantity, mixed with much blood. He
passed some pieces of stone with very sharp angles. He went on from bad
to worse; he had retention, and the urethra was found much obstructed;
suppression followed, and death terminated his sufferings in a very
few days. Many portions of the calculus were voided; much stone, with
the nucleus, occupied the bladder and urinary passage; the kidneys
were dark-coloured, and one approached to a gangrenous appearance. The
practice in the first instance, and so soon as the nature of the case
was fully ascertained, should have been to cut into the bladder and
clear it of the nucleus and fragments.
[Illustration]
It has been elsewhere noticed, that cysts are apt to form in bladders
which have been long subjected to irritation from any cause; it need
therefore excite no surprise that such formations should be found in
patients afflicted with calculous disorders. In one of these unnatural
cavities a stone may lodge, both at first small. The concretion
receives gradual increase, fills the cyst completely, and then dilates
it in proportion to its own enlargement. So long as it is covered
by the cyst, the patient suffers but little from it; but when, from
the addition of calculous matter, it projects through the opening
of the cyst, coming in contact with the coats of the bladder during
contraction of the viscus, the usual symptoms of stone are manifested.
Sometimes there are several encysted calculi in the same bladder, but
in such cases they are seldom of large size.
The stone in the bladder—whether formed in the kidney, and
having descended, or originally concreted in the bladder, either
spontaneously or in consequence of the presence of foreign
matter—produces very marked and distressing symptoms. There is frequent
desire to empty the bladder, and the uneasiness is not relieved by
doing so. There is pain during and after the evacuation, referred to
the course of the urethra, particularly to the orifice. In children,
the patient is induced by the pain to grasp the penis, and pull
forwards the prepuce, often so habitually as after a time to cause
considerable elongation of the latter part. The flow of urine often
stops suddenly, and immediately afterwards the pain is unusually
severe; the stream reappears on change of position. The body is usually
inclined much forwards during the attempts to make water; sometimes
the patient rests on his knees and elbows, or on the top of his head,
having found that he obtains most ease in these postures. The urine
is mixed with ropy mucus, and in long-continued cases with a puriform
fluid. After exercise, or unusual exertion, the urine is bloody, a
bearing down pain is complained of during the making of water, and
often there is simultaneous and involuntary evacuation of the contents
of the rectum; the close sympathy between the bowel and the bladder
has been already adverted to. In young persons afflicted with stone,
prolapsus of the rectum is common, and sometimes it occurs also in
adults. Occasionally there is pain in the testicle, or in the back of
the thighs, and very frequently a burning heat in the hollow of one or
both feet; sometimes there is a fixed pain in the last situation.
[Illustration]
Some of the symptoms are more prominent than others, nor is the
severity of these uniform. At times the patient is tolerably free from
uneasiness; but then a fit of increased suffering supervenes, often
attributable to intemperance, or to over-exertion. The intensity of
the symptoms also depends on the nature and size of the concretion,
and on the idiosyncratic irritability of the patient; in some people
the bladder is naturally so acutely irritable as to be thrown into the
utmost disorder by the most trifling cause, whilst in others sources
of greater irritation produce but very little uneasiness. The mulberry
or oxalate of lime calculus, a specimen of which is here sketched, is
of very rough surface, and gives rise to the most violent symptoms.
But the projecting portions of this, or of other rugged concretions,
may become covered by additional and smoother deposit—or the surface
may become smooth, polished, and water-worn, receiving no addition for
a long time—and in such circumstances the sufferings are mitigated.
However, in consequence of fresh incrustation, they may soon become
again much aggravated, and almost intolerable.
The increase of the stone is in some cases exceedingly slow; after many
years, the size may not exceed that of half a walnut. In others, large
dimensions are attained within a short period. The mulberry is always
of gradual formation; and the rapidly increasing are generally of the
alkaline and earthy or alternating character.
The symptoms above detailed—many, and sometimes all of them—may be
produced by other causes than stone in the bladder. Irritation of the
bowels, more particularly of the lower, by worms, foreign bodies, or
feculent matter of a bad kind—irritation of the kidney—alteration of
structure of this viscus, and the lodgement of concretions in its
pelvis—are all attended by many of the symptoms of vesical calculus.
Irritability of the bladder, the nature of which has been elsewhere
detailed, also possesses somewhat similar indications; but the pain
is usually referred to the hypogastric region and the perineum, as
well as to the point of the penis, perhaps more frequently, and is
generally relieved after evacuation of the urine: such is not the case
in calculus.
The symptoms and sizes of stone, when severe, will lead the patient
to take such means as are necessary to ascertain the cause of them—to
ascertain whether or not stone exists in the bladder. The term
_sounding_ is applied to such examination. In this proceeding the
bladder should contain some urine, so that the object may be effected
more readily, and with less pain to the patient; he should be desired
to retain his urine for one, two, or three hours, as he may be able;
or from four to six ounces of tepid water may be injected. In the
contracted state of the viscus, the stone may escape detection, if
of no great size, from being embraced by the bladder, and concealed
in its folds; or, on the contrary, it may be discovered either after
or during evacuation of the urine, having eluded the surgeon’s
search during an over-distended state of the viscus. Also, it may
be discovered in one position of the patient, whilst it is lost in
another. When the symptoms are decided, examination is to be made, both
during the recumbent posture, and during the erect, with the body bent
forwards, and likewise with the bladder in various states of fulness;
and if unsuccessful, the search is to be repeated. But in general no
difficulty is experienced in discovering the stone. The instrument
used should be pretty large, with a smooth metallic handle, and either
with a large curve and long point, or straight till near the farther
end, and then having a short curve. The latter form is preferable,
as admitting of the curved part being introduced completely within
the bladder, and turned in all directions and into every part of the
viscus—the urethra being brought into a straight line by the remaining
part of the instrument. The posterior fundus, behind the prostate, is
the situation most commonly occupied by the stone during the recumbent
posture; and there it is in a measure concealed, when small and the
gland enlarged. The surgeon, aware of this, examines that part of the
organ very carefully, and, as already stated, explores every corner
with the utmost gentleness, and at the same time minutely, never
employing the slightest force or rudeness of search. Upon bringing
the instrument in contact with the foreign body, or moving it quickly
upon it by turning the handle, the sharp clear sound of the stroke can
be distinctly heard; and this is one reason why the instrument should
be throughout metallic. The prudent surgeon is not satisfied of the
existence of calculus in the bladder without this sign.
Not a few practitioners have been deceived, and have subjected their
patients to incision of the bladder when no stone was there. A false
and deceptive grating is sometimes felt during the passage of the
instrument through the prostate; or the point may be made to rub
against dense and rough fasciculi of the bladder; or a more distinct
feeling, as of stone, may be communicated from the instrument being
brought in contact with particles of sabulous matter entangled in
mucus, and adherent to the inner coat. The last deception is to be
expected only in those advanced in life. But the greater number of
those cut necessarily have been young persons. In them the symptoms of
stone are closely simulated by irritations of the alimentary canal, and
the crying of the patient prevents the stroke on the stone from being
distinctly heard.
Perhaps the practitioner may be very anxious to discover a stone and
have the glory of removing it, and is satisfied with feeling a rubbing
or grating of the instrument; he cuts into the bladder, and to his
dismay and discomfiture nothing is found. No foreign body may have
existed; or perhaps some small particles of sand which gave rise to the
feeling may have escaped detection, being carried off along with the
urine and blood. On the contrary, cases have occurred in which a stone
actually existed, but was overlooked; and the patient, after recovering
from the first incisions, has been relieved by a second and better
conducted operation. In diseases of the urinary organs, the surgeon
cannot be too cautious and considerate in all his proceedings and
interferences. For example: I on one occasion went to see an operation
for stone in the bladder, and was asked to feel the stone, but could
not. There was merely a sense of grating during the introduction of
the instrument; and the operator was dissuaded from his intention. The
patient did not live many weeks; a small ulcerated cavity was found in
the situation of the verumontanum, but no stone.
By a dexterous use of the sound the size of the foreign body can be
tolerably well judged of, as well as the state of its surface, and it
may also be known whether there are more stones than one. The bent
part of the instrument is passed over and beyond the calculus, and
then under it, if possible, so as to ascertain its thickness; and by
moving it on each side, the other dimensions are also arrived at. No
information can be obtained as to the size of the stone—at least in
adults, and when it is not encysted—from any examination by the rectum.
Concretions resembling horse-beans in size, and even larger, can
be brought through the adult urethra without incision, by means
of properly constructed forceps. The facility with which this is
accomplished will depend much on the state of the passage, whether
naturally capacious and free from morbid contraction or not, and also
upon the condition of the prostate gland. Notwithstanding the greater
irritability of the parts in young persons, this operation may be
readily performed on them; on several occasions I have removed from
children concretions of considerable size through the natural passage.
Various contrivances have been used for the purpose. Modifications of
what are called Hunter’s forceps have been recommended,—two elastic
blades shut by being withdrawn into a canula, and made either straight
or curved; but they are not so applicable as the forceps of Sir A.
Cooper, as modified by Weiss. These are of different curves and sizes,
and the handles should be made of metal, smooth on the flat surfaces;
for thus the concretion will be more readily felt. The instrument is
passed along the urethra, and used in the bladder as a sound; when
it has touched the stone the blades are opened, and by raising the
handle, pressing the convex part downwards, and then allowing the
blades to close slowly, the concretion is embraced. If the stone lie
on the forepart of the instrument, on its concavity, it will fall
between the blades as soon as they are sufficiently separated. By
observing whether or not the wire goes home into the canula, it is
ascertained whether or not the foreign body is between the blades; if
it is not, the manœuvring must be repeated; if it is, the instrument
is to be withdrawn carefully—of course bringing the concretion along
with it. Some slight resistance is felt in passing the prostate, as
also anterior to the sinus; and on reaching the orifice, some little
force is requisite to complete the removal, or the orifice may be
dilated by a slight incision so as to facilitate the disentanglement
of the forceps with the concretion. By one or more operations of this,
nature many stones may be removed, and the patient thus freed entirely
from the disease. There is no great risk of seizing and pinching the
coats of the bladder with this instrument, whilst there is a tolerable
certainty of doing so with most of the others.
On one occasion, when practising the operation on the dead body, I
found that the instrument had got several stones in its grasp, and
was kept so dilated as to be withdrawn with much difficulty—there
being no means of disentangling the stones but by farther expansion of
the blades, which was impossible. A great many foreign bodies—pieces
of pebble—had been introduced; but had the same number of urinary
concretions been laid hold of—which is scarcely possible—those farthest
from the point and most compressed would have crumbled down, and thus
the expansion of the blades would have been diminished. I have not
experienced the least difficulty in operating with this instrument, in
numerous cases, and at all periods of life. The preferable instrument
for the purpose is, however, the small screw scoop. The concretion can
by its use be crushed and reduced in volume, so that the urethra does
not suffer in the extraction, and the patient is saved much pain. The
safety of the proceeding is its greatest recommendation. It is very
seldom that any unpleasant symptoms follow; there may, perhaps, be a
trifling effusion of blood, and some slight pain in making water may
continue for a day or two. Should either irritability of the bladder,
or symptoms indicating inflammation of the mucous coat supervene, these
must forthwith be combated.
Concretions of such a size as cannot be made to pass through the neck
of the bladder, and along the urethra, and yet are not much larger than
a filbert, may, if soft and friable, be laid hold of in the bladder by
properly contrived instruments, and acted upon so as to be reduced to
powder and fragments, which may either pass off along with the urine,
or be extracted by means of forceps. This proceeding is not advisable
in children, owing to the small size of the parts and their greater
irritability, and in consideration also of the concretions in them
being in general exceedingly dense; as formerly noticed, they are most
frequently composed of the oxalate of lime. In the adult, it cannot be
adopted with safety and propriety, when the bladder is irritable and
will not bear a certain degree of distention, and when the prostate
gland is large. The cases in which the concretion is small, soft, or
brittle, and the parts sound and free from irritation, form but a small
proportion of those labouring under stone who present themselves to
an operating surgeon. However, the bruising, grinding, and rubbing
down of stones has been tried in all kinds of cases, but with neither
a satisfactory nor an encouraging result; a case will now and then be
met with favourable to these proceedings, but they can never become
generally applicable, and attempts to make them so will, as experience
has shown, be followed by disappointment and disaster.
A stone of a larger size than I have indicated, and of dense
structure, may be laid hold of in the bladder, and may by repeated
and tedious operations be broken into fragments; but each sitting,
as it is called, of the patient, and each attack upon the stone, is
attended with more pain, greater risk, and far more exhaustion, than
its removal by incision would inflict. The repeated introduction of
the instruments, their expansion, and the turning of them about in
the bladder, and, if their object is accomplished, the action of the
angular and rough surfaces of the fragments on the mucous coat, are
certainly followed by an attack of inflammation of the viscus, always
tedious and annoying—often excruciating, dangerous, perhaps fatal.
Attacks of inflammation of the testicle are also not uncommon, probably
from irritation of the prostate, and from the pinching and bruising
of the verumontanum, which it is almost impossible to avoid, whatever
care and precaution be adopted, when the three-branched instrument is
used. In turning to the records of _Lithotrity_—and under this term we
shall include all attempts to break down stones within the bladder,
whether by drilling, or filing, or hammering—it will be found that many
patients have died from the mere exploration; and altogether, nearly a
half of those who have fallen into the hands of the experimenters and
adventurers have perished in consequence. Every successful case is well
advertised; the dead men rest in peace.
But still the operation of breaking up a stone in the bladder is very
advisable in certain cases, and may be resorted to with every prospect
of a safe, speedy, and successful conclusion. But it can be recommended
and employed only within certain limits; the case must be well chosen,
and every circumstance must be perfectly favourable as regards the
condition of the urinary passage and of the bladder, and the size and
nature of the stone. Every operating surgeon should make himself well
acquainted with the instruments and their mode of application, so that
he may resort to them as occasion requires.
A great deal of ingenuity has been expended of late years in inventing
and improving upon the apparatus. Many useless, inapplicable, and
highly dangerous machines have been produced, a few efficient and
perfectly safe.
The knowledge of the fact that the curvature of the urethra can be
effaced, and a perfectly straight instrument, or one with a short
curve can be passed into the bladder with equal ease and freedom from
uneasiness as a largely curved one, has facilitated very much the
application of means for seizing and acting upon a stone in the bladder.