Elements of Surgery

by Robert Liston

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.