We not infrequently find urates in large quantity in the bladder of tbe newborn, and uric-acid infarctions in the kidneys of stillborn infants. Vesical calculus may also occur. In England, Russia, Persia and Egypt, stone in the bladder is especially frequent.' The shape, size, number, and composition of these c,alculi in women vary greatly. We find uric acid, phosphoric acid, oxalic acid, and cystin calculi, and combinations of them. The rarest of ull are those composed of cystin, they being 3 per cent. of all.
The seat of stone in women is usually in the deepest portion of the bladder, in the fundus.behind the trigonum. In one case, at the autopsy of a patient sixty-seven years old, at the Dresden hospital, I found a cal culus the size of a walnut lodged in a pocket of the bladder, above and behind the retroverted fundus uteri. The vesical neck was attached to the rectum by firm adhesions which forced the uterus backwards, fixing the upper part of the bladder as in retroflexio uteri gravidi, and in this curious place was lodged the stone. If the calculi are numerous and large, the bladder sinks with them, and a cystocele is produced (comp. page 83), as in the cases recorded by Rossel, Tolet, More,au, Ruysch, and others, in which there were from 11 to 55 stones. On the other hand, a neglected cystocele may cause vesical catarrh, and so lead to the formation of stone.
In my e,ase the calculus was lodged at one side behind the horizontal ramus of the pubis, so that it felt at first like an exostosis attached to that bone. Stones may also form in diverticula of the bladder, or may lodge in them after formation. Thus, in one of our Dresden city hospital post mortems (No. 10, v. 20, I., 1858) in a woman sixty-four years old, there was a sacculated diverticulum in the posterior wall which only communi cated by a very small opening with the general vesical cavity. In it was a hard, sharp-edged, cherry-stone-sized calculus. The case recorded by Cadge also belongs here.
The size of these calculi varies from that of a grain of corn to that of a child's head. Hugenberger extracted one weighing 3i ounces and meas uring 6 x 5.4 inches in 1871 by colpocystotomy; while Wendel records the passage of one per vaginam through a vesico-vaginal fistula in a woman sixty-two years old, the size of an apple.
The number of calculi may be very great. Rosset found 11, Ruysch 45. P. Adam saw 90 evacuated spontaneously. The cases of Josephi (page 154) and L6wenson (page 180) show that hundreds of stones may be present in the female bladder.
Symplom8 of Vedical depend upon the causes, shape, surface, size, and number of the stones, and upon the complications. Those calculi due to perforation of the bladder by ovarian cystomata„ fcetal sacs, etc., are preceded by symptoms of threatened cystitis with peritoni tis for a long time. On the other hand, calculi which have originated
inside the bladder, especially when round, small, and. smooth, may exist for yeara without the bearer suspecting their presence. In the Dresden city hospital in 1876, a patient was admitted after whose death 185 calculi were found in the bladder, without his having had any trouble during life.
But if the stone is of rapid formation, if it is heavy and rough, hyper zemia of the mucous membrane, hypersecretion, catarrh, or inflammation leading to perforating abscess will soon result Vesico -vaginal fistula is not infrequently caused in this way, Bouque finding it 6 times in 204 fistuhe. Before perforation occurs there will be dysuria, strangury, ria, incontinence, and sudden interruption of the urinary flow; impaction of calculi in the urethra and then spontaneous expulsion, are not only commoner in women than in men, but occur with much larger stones also. Such cases have been recorded in great numbers, most recently by Scan zoni, Hyrtl, Josephi, B. S. Schultze, Cohn, (see Hugenberger), Adam, Villebrun, etc. Thomas Bryant has collected in English alone the records of 13 cases of spontaneous expulsion, in some of which the stone was 6 inches in circumference and weighed 4 ounces. The seat of the pain, as long as the calculus still remains in the bladder, is various; sometimea it is above the symphysis, sometimes radiating to urethra and vagina, some times in the legs, the back, the loins, and even the upper extremities. In my case, when the finger was introduced into the vagina, there occurred a spasmodic contraction of the levator ani so severe, that I could hardly move the finger about at all; and touching the cherry-sized stone from the vagina was extremely painful. Hmaturia, sometimes of considerable amount, may also occur. Since calculi occur at all ages, they may be a serious complication in pregnancy, confinement and the puerperium. Hugenberger (see above) has investigated this subject very thoroughly, and has 23 cases of vesical calculus in women during the childbearing period, recorded from the 17th century to 1875. There are first 4 cases of De la Motto, Deschamps, Velpeau and Henry Thomas (Lance!, 1839, Vol. I., No. 21), who all relieved their patients by operations per formed while gravid. Thomas's case is of some interest. At the 4th month he removed, by Lisfranc's vestibular incision, a stone I inches long, 1 inch thick, and weighing 6 drachms. The wound healed entirely in 32 days, and at the 7th month the woman gave birth t,o a macerated child. The 5th case is one of Hugenberger and Heppner, where vesico-vaginal incision was done at the 8th month of pregnancy. PyTemia occurred after the sutures were removed, premature labor set in on the 23d day, and death followed on the 39th day.