apt to develop a cystitis, which readily becomes ammoniacal.
The cases of acute febrile disease associated with paresis of the bladder
should he regularly catheterized with exceeding care as regards asepsis As
convalescence is established the power of the Madder returns.
In old age paresis of the Madder may be treated by catheterization attended
by all due precautions; if allowed to catheterize themselves, old men can rarely
he made to take proper care in regard to asepsis. Retention with great dis-
tention in old men should be treated by gradual evacuation of the Madder at
several sittings, or by emptying the bladder at once and replacing the urine
by 100 to 1 50 c.c. of boric-acid solution.
If the greatly distended bladder is completely emptied at once, the subse-
quent history may be varied. The patient may at once develop a severe hem-
orrhagic cystitis, with chills, fever, prostration. If the kidneys are had. sud-
den or gradual suppression of urine, uremia, and death may follow. In other
cases the cystitis will come on gradually, hot will end by being severe, with am-
moniacal urine, ascending infection, and pyelonephritis. As elsewhere stated,
the ureters are often dilated in such cases, so that ascending infection i< easy.
In other eases, notably in those who already have a severe cystitis, retention
89
578 THE N EUE oSES OE THE BLADDER
of urine, great distention of the bladder, and sudden evacuation of its contents
is followed by acute and fatal septicemia.
In distinguishing between paresis of the detrusors alone and paresis of the
vesical sphincters, the following data may be used : In paresis of the detrusors,
if the individual is thin the bladder may be palpable as a rather flabby, but
distinctly elastic, fluctuating tumor above the pubes. So long as the sphincter
remains intact these patients do not dribble until the bladder is greatly dis-
tended. The catheter will evacuate from 200 to 1,000 c.c. or more, even when
the patient has urinated voluntarily. In paresis of the vesical sphincter, on
the other hand, no such amount of urine will be found in the bladder. These
patients will begin to dribble long before the bladder is much distended. Such
dribbling will be noticed during the daytime when the patient is up and about ;
at night, when he is recumbent, the action of gravity is not so favorable for
leakage. When catheterizing these patients, the following may be observed:
If the sphincter is intact some slight resistance will be met with at the bulbo-
membranous junction. If the sphincter is paretic the instrument slips into
the bladder without the slightest resistance. If the detrusor is paretic and the
patient be catheterized in the recumbent posture, the urine will begin to flow
in a full stream. Long before the bladder is empty the stream will grow weaker
and finally stop. Pressure above the pubes will cause the urine to flow again,
and, if now the patient assumes the upright posture, quite a quantity of urine
will still escape through the catheter by the action of gravity (Ultzmann).
Injuries of the spinal cord are commonly attended by disturbances of uri-
nation. Retention of urine occurs from loss of power in the detrusor muscle
of the bladder. Incontinence does not result from injuries of the cord, as a
primary condition. There is usually developed, after a time, incontinence
from overflow; either a constant dribbling or the discharge of small quantities
of urine at frequent intervals. Usually, though not always, the patient is
unconscious of his distended bladder. In some cases, soon after the injury,
incontinence will occur when the bladder becomes greatly distended ; in others,
the tone of the sphincter is such that the bladder would burst if the urine
were not drawn off. The center for the detrusor is in the lower sacral seg-
ments of the cord. The nervous mechanism for the sphincter is not definitely
understood.
Enuresis — Incontinence of Urine in Children. — Up to the second year of life
infants evacuate the bladder when it is full, irrespective of time and place.
The act is involuntary and beyond control. After that period they gradually
learn to urinate only on suitable occasions. "When they do not acquire this
habit and wet the bed at night, or their clothing in the daytime during violent
exercise, coughing, laughing, etc., they are said to suffer from nocturnal or
diurnal incontinence of urine, or, if the incontinence is constant, from continual
incontinence. This incontinence is usually observed between the ages of ten and
three years, and in the absence of some organic lesion is very rare after puberty.
The causes, in the absence of any local lesion, are rather obscure. Several
ENURESIS [NCONTINENCE OF [TRINE IN CHILDREN 579
theories have been advanced i" explain t 1 1 * - phenomena, Done of them quite
satisfactory. The incontinence usually occurs during Bleep. In ordeT i«. avoid
diagnostic errors, these children should be examined locally and generally with
cure. Among the nervous diseases which may I"- attended with incontinence is
chorea. In this disease the incontinence is spasmodic, and may occur at any
hour; other symptoms "I chorea will be present. Diabetes should I"- thought
of. I have observed the condition in children with defective mental develop
nii'iit due to original defects in the cerebrum, and in cases of retarded develop-
ment due to pharyngeal adenoids and enlarged tonsils. In the latter condition,
removal of the tonsils and adenoids has cured the incontinence. Among local
causes affecting both sexes are cystitis, vesical calculus, fissure of the anus,
gonorrhea of the urethra and rectum, and oxyuris vermicularis in the rectum.
In boys a long and adherent or narrow prepuce, ;i very -mall meatus urinarius.
In girls an adherent preputium clitoridis, inflammation of the vestibule, poly-
poid growths ( urethra] caruncle ), ;i narrow and irritable urethra. I have cured
a number of eases in girls by repeated dilatation of the urethra with steel
sounds. In children otherwise healthy the trouble usually disappears before
puberty.
CHAPTER XXVIII
VESICAL CALCULUS
{Stone in the Bladder)
Vesical calculi may originate in the kidney or in the bladder. In the
former ease they pass as small stones through the ureter to the bladder and
become the nuclei of bladder stones. In these cases the history of attacks of
renal colic, of hematuria, or of the passage of urinary sand or gravel may aid
in the diagnosis. Chemically, bladder stones resemble for the most part those
found in the kidney. They consist of (1) uric acid and its salts, (2) oxalates,
(3) phosphates, (-i) rarely of cystin or indigo.
(1) Calculi of pure uric acid are rather rare. They are most frequent
during advanced age. In childhood calculi of uric-acid salts are common.
Many calculi consist of mixed urates combined with uric acid. (2) Calculi of
pure oxalates are rare, although oxalate of lime forms one of the ingredients
of many calculi. Usually oxalate stones have a nucleus of uric acid or urates.
(3) Phosphatic calculi consist either of earthy phosphates, or more commonly
they contain a nucleus of uric acid, or in rare cases of oxalate of lime. Phos-
phatic calculi originating in the kidney are usually very hard, and consist of
phosphate of lime and of crystalline magnesium phosphate. If, on the other
hand, they have formed in the bladder in the presence of ammoniacal fermen-
tation, they are very soft and consist of triple phosphate with a small amount
of ammonium urate (Ultzmann). (4) Cystin calculi consist of pure crystal-
line cystin, rarely mixed with a small amount of other ingredients. Among
the rare forms of calculi may be mentioned indigo, carbonate of lime, choles-
terin, and xanthin.
As is the case with renal calculi, bladder stones rarely consist of any one
material. Commonly the stone is composed of successive layers of several
ingredients, or of layers some of which consist of several ingredients, others
of but one. According to Ultzmann, the most common combinations are the
following: (1) The nucleus of uric acid or urates, the outer layers of oxalate
of lime; (2) the nucleus of uric acid or urates, the outer layers of earthy phos-
phates; (3) the nucleus of uric acid or urates, a second layer of oxalate of lime,
the outer layers of earthy phosphates.
Vesical Calculi, Single or Multiple. — The solitary calculi, when they develop
free in the bladder, were believed by Ultzmann to assume definite shapes, ac-
cording to the crystalline system to which the materials forming the calculi
580 *
VESICAL CALCULI, SINGLE OK MULTIPLE
58]
belonged. Tims, he believed thai caleuli of urates, cystin, and phosphates al-
ways had the shape of a Battened ovoid, and thai oxalate calculi were al
irregularly flattened spheres. The former group belonging t<> the rhombic
e.
Fio. 1S7. — a. Stone of crystalline uric acid. t>. Stone composed of urates, c. Stone composed of
earthy phosphates. </. Stone composed of cystin. p. Stone romposed of oxalate of lime, (After
Ultzmann.)
Bystem <>f crystallization had three diameters. The oxalates belonging to the
quadratic system had lmt two diameters.
The conclusions of Ultzmann in regard to the shape of bladder stones are
nut in accord with the views of more recent observers Rainey, Harting, Ord,
Ebstein, and others. Jlis researches led Rainey to believe that -tone formation
582
VESICAL CALCULUS
is not a simple deposition of salts present in excess in the urine. He believed
that the shape of bladder stones depends upon the law of molecular coalescence
— i. e., " in the presence of colloid or albuminoid substances, crystalline mate-
rials become spheroidal in shape and coalesce in rounded form." The albu-
minoid material may be furnished by
the irritation caused by crystals in the
urine, or any foreign body, or may be
ready at hand in the presence of cys-
titis, a blood clot, bacterial colonies, etc.
Once this crystalloid deposition is start-
ed the stone itself, by irritation of the
bladder wall, continues to cause an ex-
udation of albuminous material and the
deposition of successive layers of salts.
This appears to be the generally ac-
cepted theory of the formation of cal-
culi, although, so far as I am aware,
the theory of Ultzmann has never been
disproved.
When calculi are multiple, or though
single are fixed, they depart in shape
widely from these types. If numerous
small free calculi are in the bladder
they assume a more or less spherical
form. If several large stones are pres-
ent, so large that they can no longer move
freely, they often become faceted (see
Fig. 188). If a stone is partly or entirely contained in a diverticulum, it
assumes the shape of that cavity and may be quite irregular in form. A stone
fixed partly in the urethra and partly in the bladder may assume a shape
Fig. 188. — Faceted Vesical Calculi.
(After Ultzmann.)
Fig. 189. — Tobacco-pipe Calculus and Calculi from Diverticula of the Bladder.
(After Ultzmann.)
resembling the bowl of a Turkish tobacco pipe (see Fig. 189). If the nucleus
of the stone is a foreign body, the stone forming upon it will resemble the for-
eign body in shape. Stones which become so large that they fill the entire
CHEMICAL EXAMINATION OF CALCULI
bladder have ;i shape inure <>r less clpsely resembling a casl of the distended
bladder.
The Color of Vesical Calculi. — The color of vesica] calculi is varied, depend-
big upon a number of conditions. I ric-acid stones are 'lull yellow, reddish-
brown, or reddish-yellow. Oxalate stones are usually black or brownish or
grayish-black. Phosphatic stones are white or grayish- white. II' they have
long been exposed to blood pigmenl they may be black. The consistence of
pure uric-acid stones varies from brittle and crumbly to fairly bard. Stones
of uric-acid salts are quite hard. Stones of oxalate of lime are usually very
hard. (Jltzmann pointed out thai (lie hard stones consisted largely of needle-
shaped crystals which tended l<» interlock, and thai sofl stones consisted <>f
larger prismatic crystals which did nut tend to cling together. Phosphatic
stones arc usually very soft ; only rarely, when they consisl of crystalline phos-
phate of lime <>]• of crystalline triple phosphates, they may lie hard. The sur-
face of uric acid and urate .-tunc- is usually smooth, sometimes 1 gh. Oxalate
stones arc rough and have a warty, uneven surface (mulberry calculus).
Chemical Examination of Calculi (partly adapted from Ultzmahri). — Cal-
culi may lie examined chemically by sawing the stone into halves. If the stone
appears to consist of but one ingredient, the sawdust may lie \\>v(\ for chemical
examination. If the stone consists of several layers, a small bit may lie picked
• ml or scraped away with the point of a knife from each layer and examined
separately. Jn the former method the various ingredients may lie determined,
hut to determine how they arc arranged the second method is necessary. In
order to distinguish the several layers, Ultzmann recommended that the sawed
surface of the stone he polished on a whetstone, cleaned with water, then with
chloroform, in order to bring out the borders clearly.
Some of the powdered stone is placed on a platinum spatula and heated
over a Bunsen burner slowly to a red heat. Ultzmann called attention to the
fact that if the powder is incombustible, it nevertheless will undergo a peculiar
scries of color changes owing to the content of organic matter. The changes
are simply that the powder turns first black, then gray. These changes occur
even in pure white phosphates and enable us to distinguish a true concretion
from a stone produced for purposes of deception by an hysterica] individual
or malingerer, and alleged to have been passed per urethram. The following
schema (page 584) from Ultzmann gives in brief the method of analysis.
Those who desire further details are referred to Ultzmann on " The Uri-
nary Bladder"; Ferdinand Enke, Stuttgart ( L890, ibid.), on - Urinary Con-
cretions."
A more accurate diagnosis of the composition and structure of calculi can
be made with the microscope. The method of preparation is briefly as follows:
The stone is sawed as nearly as possible through its long axis into two equal
sections with a fine saw. If the stone is sofl and brittle it may be boiled in
Canada balsam before sawing. The sawed surface of one section LS polished
by hand, using first fine emery powder on a ground glass plate, then water on
584
VESICAL CALCULUS
THE PULVERIZED STONE OR ITS SAWDUST
The powder burns without
visible flame and with-
out odor.
The murexid test turns with
ammonia purple-red. With
KOH purple-violet.
H
ft
O \
o
w
a
pq
Uric acid and
Uric-acid salts.
The murexid test with am-
monia yellow, with KOH
orange.
â–º Xanthin.
The powder burns with a feeble blue flame and gives off
an odor resembling burning sulphur, or fat, or like
asafetida.
Cystin.
The native powder effervesces with HC1.
Calcium carbonate.
The native powder does The heated powder effervesces
not effervesce with HC1. with HC1.
Calcium oxalate.
The heated powder does not
effervesce with HC1.
Earthy phosphates.
a fine hard whetstone, until a highly polished surface is produced. The surface
is cleaned first with water, then with chloroform. A portion of Canada balsam
is then placed upon a suitable microscope slide and heated. The polished sur-
face of the stone is then firmly pressed into the heated balsam. The balsam is
allowed to harden. The major portion of the stone is then sawed away, leav-
ing as thin a layer as possible of the stone upon the glass. This sawed surface
is then polished as before. "When by microscopic examination one sees that
the section of stone is thin enough (according to Ultzmann the section should
be thin enough to permit the use of an objective giving a magnification of
300 diameters) its surface is cleaned with a camel's hair brush, first with water
and then with chloroform. Canada balsam in chloroform is used as a per-
manent mounting material and is covered with a cover-glass. A number of
interesting data are to be derived from microscopic study of thin sections of
vesical calculi. (See Ultzmann, "Die Harnconcretionen des Menschen," etc.,
Wien, 1882; Toeplitz and Deuticke).
The crystalline forms as seen in these sections differ from those seen in
urinary sediments. The crystals are either prisms or needles. Stones composed
of the former type are soft, of the latter hard. Stones of pure calcium and
magnesium phosphates, of sodium urate, and of oxalate of lime are hard stones ;
when viewed under the microscope by polarized light they are seen to consist
of fine needles. Stones composed of uric acid, cystin, and of mixed earthy phos-
phates are composed of large prismatic crystals, or of such crystals mixed with
amorphous materials. These stones are soft and crumbly.
OCCURRENCE AND l.l [OLOG1
The Nuclei of Calculi. — Cystin calculi and the sofl phosphatic calculi, Buch
as are formed in ammoniacal urine, possess qo « \ i * i« n t nucleus. All other
calculi have one or several central masses upon which the outer layers of 1 1 1* *
Btone have been deposited. Such nuclei may lw minute or as large as a pigeon's
egg. Uric acid and its salts form the nuclei of atones much more often than
other ingredients. Thus Ultzmann examined the nuclei of 545 calculi, and
found as ;i nucleus uric acid or urates Ml times; oxalate of lime, ; !l times;
earthy phosphates, IT times; cystin, s times; foreign bodies, 18 times.
Spontaneous Fracture of Vesical Calculi. — It occasionally happens thai cal-
culi split up spontaneously in the bladder into two <>r more fragments. The
lines of fracture are usually radiating, thus producing more or less wedge-
shaped fragments; such fractures are confined almosl exclusively to uric-acid
stones. This has been explained upon the ground thai Budden diminution of
the specific gravity of the urine, as from drinking large quantities of water
and a change in its reaction, might cause the colloid material constituting the
matrix of the stone to imbibe urine and to swell. The nucleus becoming thus
enlarged mighl bursl the surrounding layers (Ord).
Ultzmann believed that spontaneous fracture of uric-acid stones only oc-
curred when a sofl porous intermediate layer existed of ammonium urate, and
thoughl that the contained urea was decomposed into ammonia and carbonic
acid, probably as the result of bacterial activity in alkaline urine. The am-
monia uniting with the surrounding layer of uric acid would produce soft
ammonium urate, the free carbonic acid would then break through this soft
layer. The process mighl be repeated until the stone was disintegrated into
several fragments. Disintegration of small uric-acid stones may take place by
slow solution in the presence of artificially induced alkaline urine. When
spontaneous fracture occurs, each fragment may form the nucleus of a new
calculus. Unfortunately, spontaneous disintegration of bladder -tone- is with-
out much practical bearing on prognosis. Stones are rarely broken up in such
a manner that the fragments can be passed j,< r urethram.
Occurrence and Etiology. — For the formation of calculi it i> assumed that
from diathetic or other causes the urine contains an abnormally large quantity
of some ingredient, and that further there must be presenl some foreign body
— a blood clot, a blood corpuscle, a fragment of dead tissue, a dead epithelial
cell, a hairpin, or what not — upon which crystallization takes place. This may
occur in the kidney or in the bladder. Among infants, uric-acid infarct- which
are not properly eliminated at birth may cause renal, or later bladder, calculi.
They consist always of sodium urate. Their occurrence is ran'. During adult
life, when the muscular power of the bladder is strong, calculi coming down
from the kidney are usually passed through the urethra at once, unless they
are ton large to go through the canal. Thus many persons who have an abnor-
mal quantity of uric acid, oxalate of lime, or, more rarely, phosphates in the
urine, suffer from what is known as urinary sand or gravel. If the bladder is
sufficient the line material i- passed per urethram, and vesica] calculus does
586 VESICAL CALCULUS
not result; but during advanced age, when the bladder is insufficient from
prostatic obstruction, or earlier in the presence of stricture, or at any age when
the bladder is }Daretic, such is not the case. Then the calculus is retained in
the bladder and becomes the nucleus of further stone formation. Thus, in
males, calculus is observed in early childhood and in advanced age more often
than during middle life, except in cases of stricture and in paretic conditions
of the bladder. In women, on the other hand, the urethra is short and wide,
obstructive lesions are extremely rare, so that they seldom suffer from stone
in the bladder unless a foreign body is present to form a nucleus.
Diathesis. — The gouty diathesis and the cystin diathesis are predisposing
causes of calculi. Both may be hereditary; the latter, though rare, to a more
marked degree than the former. This hereditary tendency in certain families
to the formation of cystin and uric-acid calculi is quite marked, though of other
calculi it does not obtain. Thus Poland found that among 22 cystin calculi,
11 occurred in 4 families. Teale found cystinuria in 3 members of the same
family. The habits of life have some bearing upon the occurrence of calculi.
Among the neglected and ill-nourished children of the poor, it was observed by
Thompson, in England, that calculi were more common than among the chil-
dren of the well-to-do. In elderly men, on the other hand, who eat and drink
much and exercise but little, calculi of uric acid and oxalate of lime are rather
frequent. Among the elderly, however, insufficiency of the bladder from vari-
ous causes, with its attendant residual urine and ammoniacal cystitis, accounts
for a large number of bladder stones.
Climatic and Telluric C onditions.— Calculi occur in every land. They are,
however, much more frequent in certain localities than in others. The reasons
for this are for the most part obscure. In the countries where Bilharzii ha?ma-
tobia and Filaria sanguinis hominis are endemic (Egypt, India, etc.), calculi
are exceedingly frequent, from evident causes (see sections on these diseases).
On the western coast of the United States, notably in California, oxalate of
lime calculi are very common. Chismore attributed this to the large quantities
of fruit habitually consumed by the people.
Size of Bladder Stones. — In the East (Egypt, India) and in some other coun-
tries where, among the poor, calculi are very numerous and surgeons relatively
few, bladder stones have been removed weighing from 20 to 30 ounces. In
America, stones of great size are extremely rare. A stone weighing 5 to 6
ounces is unusual, and many surgeons of large experience have never removed
one of such a size.
Symptoms and Diagnosis of Stone in the Bladder. — The symptoms of vesical
calculus, after the stone has reached a certain size, are usually quite character-
istic. They consist of painful and frequent urination, most marked when the
patient is up and about, less marked or absent when he is in bed, and of
hematuria. While the stone is small the symptoms will depend to a great
extent upon its shape, its surface, and its weight. Smooth, light calculi of uric
acid or cystin may give few symptoms so long as they are small. Rough calculi,
SYMPTOMS AND DIAGNOSIS OF STONE IN THE BLADDER 587
Buch as heavy oxalate Btones and phoaphatic calculi, the Burface of which re-
sembles sandpaper, produce marked disturbance while yel small. Calculi in
diverticula, which are fixed and do aol move ;ili<>nt in the bladder, may produce
few or no characteristic Bymptoma (Ultzmann). The mosl prominent symp-
toms produced by calculi are pain and frequenl urination. The pain may be
continuous while the patienl is in motion. It is always fell during urination,
am! Is in"-' severe al the end of this act, as the wall of the bladder closes down
upon tin- stone. At this time the pain i- spasmodic and often excruciating.
The straining which accompanies this spasm is attended by rectal tenesmus,
sometimes with the passage of flatus or feces. Hemorrhoids and rectal prolapse
are prone to develop. Rest and the recumbent posture cause subsidence or dis-