CHAPTER VII. PATHOLOGICAL EFFECTS OF URINARY CALCULI. THE propriety or inexpediency of operating in any given case of stone, in other words, the indications, mainly depend on the condition of the genito-urinary organs; it may, therefore, be of use to describe the various effects produced by vesical calculi on the urethra, prostate, bladder, and the urinary system in general. In the following remarks I shall confine myself to a notice of those changes which are more immediately connected with lithotomy and lithotrity. A few words on some physiological effects of vesical calculi may,. however, be useful. The urethra does not necessarily suffer from the presence of a stone in the bladder; the morbid changes observed in the urethral portion of the genito-urinary system generally depend on the development of small calculi in the canal, or on their stoppage in it during their passage from the bladder; but the effects of vesical calculi are sometimes exercised sympathetically on the urethra. These arise chiefly from irritation, which extends sometimes forwards along the urethra, as it unquestionably often does upwards along the ureters to the kidney. We can conceive how great and longcontinued irritation from a foreign body in the bladder may give rise to inflammation of the urethra, and possibly to inflammatory stricture of that canal; but this is a very rare occurrence. The disorder of the urethra, in the great majority of cases, is merely functional, and consists in a modification of its sensibility or contractile powers. Hence spasmodic stricture of the membranous portion of the urethra, is a frequent attendant on vesical calculus; the irritation excited by the pressure of the foreign body on the neck of the bladder is propagated forwards; the muscles and tissues of the membranous portion are frequently stimulated to contraction; and at last that form of stricture well known under the name of "spasmodic" is established. Such a condition exercises no influence on the operative proceeding in lithotomy; but it offers an obstacle to the introduction of lithotritic instruments, and impedes the subsequent manipulations. The sensibility of the urethra and neck of the bladder may be modified, and this morbid change is still more frequent than the one first alluded to. Even in the healthy state the sensibility of the urethra is very capricious, if I may use the expression. The introduction of a gumelastic bougie will produce a sensation of fainting or sickness in some healthy people, in others again an attack of fever. When stricture exists, the morbid sensibility is greatly increased, and the tendency to sympathetic disturbances aggravated in a proportionate degree. Severe constitutional disturbance, nervous affections of various kinds, and even death itself, have ensued on the mere passing a catheter into a stricture. It is not, therefore, surprising that the sensibility of parts which are so apt to resent disagreeable impressions when they are in a healthy state, should be frequently and greatly modified by irritation of the bladder. Experience proves this to be the case. In calculous patients the urethra and neck of the bladder are often affected with such a degree of morbid sensibility, that the introduction of any instrument whatever becomes impossible, and if injudicious attempts be persevered in, the consequences may be disastrous. Such patients are generally of a highly nervous temperament, and the sympathetic disturbance of the system may under such circumstances assume a dangerous character. In less unfavourable cases the morbid sensibility of the parts does not altogether exclude the use of instruments ; but their introduction produces very great pain, excites spasmodic contraction in the neck of the bladder, and gives rise to several secondary effects of a severe character. When this state depends on mere temperament, it may be greatly alleviated by proper treatment; but when it is connected with organic disease of the bladder, it presents, as I shall explain by and by, an almost insurmountable obstacle to the performance of lithotrity. The same modifications of sensibility and contractility may be observed in the bladder, as a consequence of stone. This we can readily understand, for here the foreign body acts directly on the organ. In nearly all old cases of vesical calculus the bladder has more or less tendency to contract with force on the fluid or solid matter contained within its cavity. This is a natural consequence of the presence of a foreign body, to expel which the bladder is incessantly stimulated. The morbid contractility of the organ is manifested by an urgent and constant desire to void the urine. This may be carried to a very great degree: the bladder will not hold more than a spoonful or two of urine at a time; and if a couple of ounces of fluid be injected into it, the injection is instantly thrown back with force. When the calculus is large, the bladder from its contractility, often envelopes the foreign body in a close grasp; and this state of parts is highly unfavourable for any operation. It renders lithotrity impossible, and is scarcely less unsuitable for extraction of the stone by lithotomy. An opposite condition of the bladder is occasionally met with as an effect of calculus. It occurred in one of the last patients on whom I operated in St. Mary's Hospital. Instead of contracting violently on its contents, the bladder seems to have lost more or less of its expulsive powers, it becomes sluggish, allows the urine to accumulate in considerable quantity, its sensibility is diminished; the organ, in fact, is struck with atony or partial paralysis. This is a very insidious state, for it masks many of the symptoms of stone; and though it may offer no obstacle to lithotrity, it exercises a great influence on the results of the operation, by favouring, on the one hand, retention of urine, and on the other, by impeding the free discharge of the detritus from the bladder. To avoid repetition, I shall defer further notice of atony, until I come to indications. The pathological effects of vesical calculus at an early stage have not been accurately determined by post-mortem examination, for the disease is never fatal at the commencement; but the symptoms indicate plainly enough the changes which are going on within. At first they are those of irritation, soon followed by unequivocal signs of chronic inflammation of the parts which have been irritated. The most common, indeed it might be said almost constant, effect of stone in the bladder, is to excite more or less inflammation of the mucous membrane with which it comes in contact. It is true that some calculous patients suffer little, and that a few have even remained unconscious of the disease under which they laboured, the symptoms being completely latent. But such cases are extremely rare. Stone in the bladder seldom exists for any length of time without producing more or less inflammation of the mucous surface of that organ, which may extend either to the other tissues of the bladder, to the neighbouring cellular substance, to the prostate, or upwards to the ureters and kidneys. The inflammation may be either acute or chronic. We might naturally infer that the severe irritation of a rough calculus, grasped, as it often is, by a contractile bladder, while the urine is at the same time highly offensive and irritating, should often produce acute inflammation of the mucous membrane: but this is not the case; the bladder is patient and long-suffering to an astonishing degree, and acute inflammation of this organ rarely sets in, except towards the last stage, when the disease draws to its close, and death is at hand. Chronic inflammation of the mucous membrane of the H |