VESICAL CALCULI-REPORT OF 15 CASES.*

BY REGINALD H. JACKSON, M. D.,

MADISON, WIS.

In a brief paper on the subject of Vesical Calculus it is only possible to barely mention the various predisposing and exciting factors.

1. Age Children are especially liable to the formation of uric acid calculi. The uric acid being in feeble combination with the alkaline bases is liberated by an excess of acid of any sort in the urine, and unites with the vesical mucus forming the nucleus of a calculus.

In old men the presence of an enlarged prostate, cystitis, with alkaline residual urine, furnish the conditions favorable to the formation of phosphatic calculi around any nucleus which may be present, such as a uric acid concretion, foreign body, blood clot, string of mucus, etc. In a trabeculated bladder a heavy phosphatic deposit may easily form in one of the little cul de sacs.

Sex: The absence of obstructive disease, and the comparative infrequency of vesical disease naturally render women less liable to this condition than men.

ease.

Race: Negroes are comparatively infrequent subjects of this dis

Diathesis: The general conditions which favor the formation of an excess of urinary deposits are naturally predisposing factors in the formation of urinary calculi, viz., lithemia, gout, and allied conditions of disturbed metabolism.

Obstructions to the normal escape of urine predispose to calculus formation. Of these the most important is prostatic hypertrophy, with consequent accumulation of residual urine which undergoes decomposition, forming ammonia salts and carbonates. Also stricture of the urethra and vesical atony.

Mucus: Any catarrhal condition of the kidney, ureter, or bladder which increases the amount of mucus, increases the liability to the formation of a nucleus.

Foreign bodies: The presence in the bladder of foreign bodies, tumors, etc., provides a suitable nucleus for a calculus formation.

Vesical calculi may be composed of urates, phosphates, oxalates, carbonates; rarely cystin, xanthin, etc. According to their composition calculi may be soft and friable, or dense and hard, smooth or rough, single or multiple. They vary in size from a pin head to *Read before the Central Wisconsin Medical Society, Madison, July 28,

several inches in diameter, and may be single or multiple, round or faceted.

Position: The most frequent location is at the base of the bladder to which they naturally tend to gravitate and become adherent. They may, however, be found adherent to any part of the bladder. wall, or loose and movable.

SYMPTOMS. In brief the typical symptoms are:

Frequent, painful micturition. The desire to empty the bladder is sudden and irresistable and is aggravated by movements of the body which tend to agitate the calculus, such as jolting over rough pavements, riding, etc. It is more frequent during the day than at night, the patient then being in a recumbent position and the stone quiescent. In prostatic enlargement the frequency of urination is most marked at night. A small, freely movable stone would be more potent in this regard than a stone that is large, smooth and adherent.

Sudden stoppage of urination.. This is occasionally caused by the temporary lodgement of the calculus at the internal meatus (ball valve action).

Pain. The pain caused by vesical calculi is naturally dependent upon the amount of irritation of the sensitive vesical mucosa, and varies with the size, movability and roughness of the individual calculus. As a rule it is excruciatingly sharp, darting and paroxysmal in character, being greatly increased at the end of micturition, when the contraction of the bladder produces a greater approximation of the sensitive mucosa with the surface of the calculus. The pain is both local and referred to various parts, the so-called typical pain being a sharp darting pain in the head of the penis. Reflected pains may also be present in the rectum, perineum, thigh, scrotum, etc.

The urine. The condition of the urine varies. In the case of a smooth encysted calculus it may be normal. In cases where the irritation of the calculus or infection has incited a cystitis the urine indicates it. Occasionally a fragment of the calculus may be passed in the urine per urethram.

Hematuria. Very frequently the presence of the calculus causes a sufficient trauma to result in a hemorrhage from the abraded mucosa. Hence hematuria is one of the classical symptoms of vesical calculus. In many cases it is absent. In others it is only present during the early period of the trouble, the bladder later becoming more tolerant, or the calculus encysted, and this symptom disappearing. As a symptom taken alone it counts for little; but in conjunction with other corroborative symptoms it is strongly indicative of vesical calculus.

In a given case with the above symptoms one could be reasonably

sure of a correct diagnosis, but frequently pathognomonic symptoms. are only present to such a degree as to make us suspicious of the presence of a calculus.

In all cases it is necessary to pass a stone searcher and attempt to demonstrate by touch and sound the presence of the calculus before resorting to operative measures. This is generally easy, but occasionally a case occurs in which, although reasonably sure of the presence of a calculus, we are unable to demonstrate it by the ordinary procedures. In such cases the use of the evacuating searcher, which by its sucking action causes the stone to strike its end with an audible click, is of great aid. Of late the cystoscope has rendered great service in the diagnosis of obscure cases and incidentally has demonstrated the presence of many unsuspected calculi.

TREATMENT. The diagnosis once made it remains to adopt the best measure for the removal of the calculus. I will not mention even to condemn the various medicinal measures which have been in vogue since the days of the ancients.

In a certain number of cases, where the calculus is soft and friable in character, the urethra patent and the urine not indicative of a severe cystitis, its removal can be satisfactorily accomplished by means of the lithotrite and Bigelow evacuator. When there is a marked cystitis it is better to perform a perineal lithotomy for bladder drainage and rest. This also usually holds good when there is a deep stricture of the urethra or prostatic obstruction.

When a large, hard calculus is present many operators prefer the suprapubic route. Others prefer the lateral or the median perineal, if necessary crushing the calculus and removing it piecemeal. Either method is satisfactory in appropriate cases.

As a rule when the operation is made before the patient passes into that extremely bad general condition into which unfortunately so many of them are allowed to fall before an operation is thought of, the results are very gratifying. Occasionally, either the operator has been so elated over the removal of a calculus as to neglect carefully looking for others, or they have formed subsequently and had to be removed at a later operation.

When a calculus has been encysted in the bladder wall for some time there is apt to remain after its removal a chronic ulcer-like patch,· which is prone to give rise to trouble for a long time and occasionally terminates in an epithelioma.

A differential diagnosis must occasionally be made between vesical calculus and tuberculosis of the bladder, or a new growth. This can generally be satisfactorily accomplished by the use of the cystoscope and microscopical examination of the urine.

The following brief histories and specimens are from cases occurring in the practice of my father and myself.

Case 1. Male, age 82. History indefinite: has had bladder trouble for many years. For past two years has had frequent (every half hour), very painful micturition; frequent hematuria. The patient was in an extremely low general condition from old age, loss of rest from the frequent attacks of pain, which were so severe that when the presence of the calculus was satisfactorily demonstrated to the family by the audible click of the instrument they begged for an operation even though he should succumb during it. A grooved staff was passed, some 4 per cent cocaine solution injected into the perineum, and everything being in readiness, a few whiffs of chloroform were given and two calculi quickly and satisfactorily removed through a lateral lithotomy wound. The patient rallied nicely and in a week's time was in good condition. (Specimen No. 1.)

Case 2. Male, age 62. For several years has had symptoms of prostatic obstruction. During the past two years frequent attacks of excruciating pain in the bladder and penis with hematuria suggested the possibility of stone. For several months the patient has been unable to void his urine and it has been necessary to pass the catheter frequently. Urine shows marked cystitis. Patient has been taking large doses of morphine for some time. On rectal examination the prostate was not enlarged appreciably. The stone searcher detected. the presence of a stone. A median perineal lithotomy was made. Immediately there was found at the neck of the bladder an intra-vesicular prostatic growth which swung back and forth in the internal meatus with a ball-valve action and accounted for the symptoms of obstruction without enlargement of the prostate per rectum. was attached by a narrow base it was easily removed without any hemorrhage. Two calculi were then removed from a pouch at the dome of the bladder. The convalescence was somewhat protracted owing to the prolonged drainage of the bladder which was necessary and to breaking the opium habit which he had acquired. At the present time, three months since the operation, he is in fair condition. (Specimen No. 2.)

Case 3. Male, age 20. Typical symptoms of vesical calculus. Frequent painful micturition, hematuria. Stone easily found with searcher. Urethra free, urine clear. Under chloroform, litholapaxy performed with very satisfactory result, patient doing regular work in ten days. No return. (Specimen No. 3.)

Case 4. Male, age 18. For about a year patient had been under treatment for supposed tuberculosis of the bladder. History elicited frequent, painful micturition, hematuria. General condition extremely low. Marked emaciation. The diagnosis of stone could have been easily made by passing a sound, but the attending physician did not think of it. Lateral lithotomy under chloroform. Specimen No. 4 removed. Early and permanent recovery.

Case 5. Male, age 45. History of poor general health, indigestion, occasional attacks of severe renal colic. Frequent painful micturition, occasional hematuria. Patient found gravel in urine. Cal