Elements of Surgery

by Robert Liston

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.

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.