STONE IN THE BLADDER.
A stone in the bladder usually indicates its presence in a variety of ways, any one of which may be sufficiently significant to lead the surgeon to proceed to determine its position by demonstration with the hand and the ear. A calculus is, as a rule, a source of more or less constant irritation; it frequently provokes hemorrhage, especially after exercise, and it is generally associated with some reflex pain, of which that at the end of the penis is the most constant. Though in the majority of cases these symptoms are more or less combined in varying degrees, we occasionally meet with instances where there is perhaps only one prominent indication. In male children it sometimes happens that constant preputial irritation, or prolapse of the rectum, is the only symptom suggestive of the presence of a stone in the blad der. A patient when he first came under my observation complained only of slight hoematuria after taking a long walk, which _ he usually did once a week. The constancy of this symptom in connec tion with his exercise was suggestive; he was sounded, and a lithic acid calculus detected, which was removed by crushing, when the hemorrhage disappeared. It is curious to notice that very large stones not unfrequently give but slight symptoms of their presence. In some cases, where stones weighing many ounces have been removed by the supra-pubic operation, the patients appear to have suffered but little inconvenience from them, probably because, by reason of their size, they became almost stationary.
It being important to detect a stone in the bladder in its earliest stage, we should not sanction the treatment of a case of vesical irrita bility, otherwise unexplainable, without sounding the patient. It is impossible for any one to conclude from symptoms alone what a blad der may contain until a sound has been introduced, when positive evidence is afforded.
Sounding may be practised under the following circumstances, when the cause is not otherwise explicable, or symptoms pointing to the bladder continue in spite of treatment : (1) In children suffering from vesical irritability, incontinence of urine, sudden interruption to micturition, retention of urine, blood in the urine, penile irritation inducing the pulling of the foreskin, and prolapse of the bowel. (2) In the vesical irritability of adults after attacks of renal colic, where there are reasons for believing a calculus may be retained in the blad der; in cases of hmaaturia of a doubtful nature, or of chronic muco purulent or ammoniacal urine, or where the urine contains, on stand ing, an excess of cloudy mucus. (3) In pain after micturition, referred to the end of the penis. (4) In the enlarged prostate of elderly persons, with persisting symptoms of vesical irritability. (5)
Where calculi, or portions of them, have been spontaneously passed, and symptoms of irritation continue. (6) In cases of acute vesical spasm terminating the act of micturition, or where, though the blad der contains but little urine, there is frequently a sudden and uncon trollable desire to micturate. Though the indications of stone may be numerous, it will be seen that they all have reference to either a persisting source of irritation within the bladder, or a mechanical in terference with the act of micturition. In by-gone days the modes of ascertaining whether a patient had a stone in his bladder were very primitive. An old practitioner told me that an eminent surgeon of the last century often grounded his opinion upon this point by the manner in which the person conducted himself on being desired to jump on the ground, from, say, the height of a chair. Now, the pro cess is conducted on very different lines.
As a rule, I prefer that patients, when sounded, should have an anaesthetic, not because the process is necessarily a painful one, but for the purpose of making a complete examination. Formerly, on its detection, when there was only one method of operating for stone, its removal by lithotomy naturally followed. In the present day, where the choice of procedure has been extended, more precise information is required before we can determine whether the stone in a given case will be better removed by a crushing or a cutting operation. In ad vising an anaesthetic it is not merely on the grounds that the pro cess of searching may be a disagreeable one, but also and mainly, in cases of difficulty, that a complete relaxation of the parts may be se cured. Large, rigid prostates and contracted bladders are sources of error which can only be completely removed by an anaesthetic. But if on sounding the patient it should be proved that he has not a stone in his bladder, we are often none the less dependent on the informa tion the use of the sound affords for our future guidance. In some cases we have to eliminate the possibility of disease in the bladder or the parts below, before the physician can undertake the sole respon sibility of their care. In others, though there is no stone, there may be tumor, tubercle, or ulceration, which the skilful use of the sound can aid in determining. Hence, as a rule, sounding must be con ducted with that deliberation which can only be when an anaesthetic is employed.. When it is not administered much of the sensitiveness of the deep urethra may be removed by a preliminary injection of a ten-per-cent solution of cocaine before passing the sound.