Page:Encyclopædia Britannica, Ninth Edition, v. 24.djvu/209

Rh Diluent drinks are given, and tincture of hyoscyamus may be prescribed, as it has a very soothing influence. It may be necessary to give morphia, but generally the pain can be allayed without its use. In chronic cystitis the treatment depends very much on the cause, which must if possible be removed. Thus, if the cystitis is due to a calculus in the bladder, the treatment is to remove the calculus (see below). Very often, however, special remedies are employed to relieve the inflammatory condition, and one of the best is washing out the bladder. This is a simple operation, based on the principle of siphon action with a head of water, and is carried out as follows. A catheter is introduced through the urethra into the bladder, and to it the stem of a T-shaped tube is fixed; to each end of the horizontal part a piece of rubber tubing is attached, one piece terminating in a vessel which contains an aseptic warm lotion and is placed at a higher level than the bladder, while the other is led into a receptacle placed lower than the bladder. Six or eight ounces of the lotion are allowed to flow into the bladder; then the flow is checked, and the fluid passes out from the bladder through the other tube. Each tube should have a stop-cock, so that the surgeon can open or close it as he desires. Occasionally bladder drainage is resorted to, and is carried out on the principle of siphon action. Internal remedies have to be administered, one of the most valuable being benzoate of soda. The benzoate in its passage through the blood is changed into hippuric acid, and thus tends to render the urine less alkaline. Attention to the diet of the patient is of great importance in both acute and chronic cystitis; it should be very light, easily digested, and nutritious. Diluents are often of much value, lessening the irritability of the bladder. All wines and stimulants should be avoided.

Calculi.—Important information, as we have already said, is derived both by the surgeon and physician from a careful examination of the urine, whether this be done chemically or microscopically. Not infrequently on such examination crystals, varying in their chemical and physical characters, are found, and if these be in large amount distinct urinary deposits are got from the urine after it has been kept in a vessel for a time. The cause producing these crystals or their presence alone may give rise to disease, as, for instance, oxaluria, a condition in which, in addition to other symptoms, we find oxalate of lime crystals present in the urine. We have here to deal, however, with more than the mere presence of a few crystals disseminated in the urine, viz., with those conditions in which an amalgamation of crystals has occurred, giving rise to a concretion of such deposits into a mass, forming a calculus or stone. When such concretions are so small that they can be passed with the urine through the urethra they are known as gravel; but when they are prevented by their size from passing along the urethra they are termed calculi, and the patient is said to suffer from stone or calculus. Calculus of the bladder constitutes a most formidable and important disease, and its treatment, either medical or surgical, has probably attracted more attention than that of almost any other disease. Urinary calculi occur in all parts of the world and affect both sexes. They are much more common, however, in some regions than in others. Thus, in India they are very common, while in Great Britain, although many persons suffer from calculus in Norfolk and the north of Scotland, very few cases occur among people who live on the western side of the island. From the above facts many have attributed the formation of calculi to special climatic or geological influences, but it is probable that diet acts as a chief factor in their production. Calculi are much rarer in females than in males, and this may perhaps be explained by the shortness and more vertical position of the urethra, so that the contents of the bladder can be more easily evacuated, and by the fact that the habits of the female with regard to diet are more regular than those of the male. The cause of the formation of a calculus may be (a) a tendency in the kidneys to precipitate salts to an abnormal degree, the urine being concentrated and small in amount, or (b) some abnormal state of the urine in the bladder, or (c) the presence of a foreign body in the bladder. Probably the last is the most common cause; for very frequently, when a section of a calculus is made, it is found that some form of foreign body has acted as the nucleus round which urinary deposits have become agglutinated. Such foreign bodies may exist in the bladder or may be introduced from without. Occasionally clots of blood have been found as the nucleus; but one of the commonest is a small uric acid stone, which, having been formed in the kidney, has passed down the ureter into the bladder and there been surrounded by deposits of phosphate of lime, &c. Calculi vary much in their physical characters and chemical constitution. Most frequently only a single stone is present; but very large numbers have been removed from one bladder. The shape of the stone depends on whether it be movable or fixed, and whether there be only one or more in the bladder. A single stone is usually spherical or ovoid, but may be smooth or tuberculated or spinous, this last point being determined chiefly by the composition of the stone; when there are a number of stones present they are usually faceted or many-sided. Some stones are hard; others are soft. In size and weight they vary very much: we find them as small as a pea and as large as a child's head. The largest stone found in the bladder of a human being is in the Royal College of Surgeons museum of England; and in the Edinburgh university surgical museum there is a stone of very large size. The weight depends not only on the size but also on the composition, and varies from a few grains to the heaviest on record, which weighed 6 lb 3 oz.

Seven different kinds of calculi are described, but only three are very common. Vesical calculi are classified according to their composition, and five different forms are very generally recognized; but layers of different salts may be found in the same calculus. (1) The first class embraces uric acid and uratic calculi. Pure uric acid stones are small and hard, and usually vary in colour from a reddish orange to a brown tint. They are frequently rough, but may be smooth. Uratic stones are seldom pure. They frequently form the nucleus of calculi the outer layers of which are phosphatic. (2) Phosphatic and calcareous calculi consist chiefly of calcium phosphate; stones formed purely of the carbonate of calcium are rare. The stones of this group are white, soft, and friable, especially those composed of phosphate of lime. They frequently attain to a large size, and most commonly occur in persons whose general health has run down to a low ebb. (3) Oxalate of lime calculi are excessively hard and dense, of a dark brown colour and tuberculated or spinous on their surface; hence they are often called mulberry calculi. This is a form which gives rise to great pain and irritation, so that they are generally removed before they become very large. (4) Cystine and (5) xanthin calculi are rare.

When a stone is present in the bladder, whatever its nature, it acts similarly to any other foreign body, and usually gives rise to a series of definite symptoms. The patient complains of pain in the end of the penis at the completion of micturition. Rough or jolting movements give rise to pain in the region of the bladder. Occasionally there is a sudden stoppage of the flow of urine, which is overcome by a change in position. He suffers from frequency of micturition, just as in any other irritable condition of the bladder. If, in addition to these symptoms, the patient states that at varying intervals he has passed "gravel," the surgeon is almost certain that a calculus is present; but even with all these symptoms there is only one certain diagnostic sign of the presence of a stone, and that is to feel it. This is done by "sounding" the bladder with a sound,—an instrument resembling a bougie, but made of steel and with a shorter curve. It can be easily turned from side to side within the bladder, the whole of which must be systematically examined, and not only enables the surgeon to ascertain the presence of a stone but, when judiciously used, assists him in determining the size, mobility, situation, number, and hardness of the calculi. This additional information is of the utmost importance in guiding the surgeon to the best method of treatment. In the child the stone can be occasionally felt by passing one finger into the rectum, laying the other hand above the pubes, and pressing; the stone lies between the two hands. In other cases the size can be gauged with the lithotrite, by observing the distance to which the blades are separated when the stone is grasped.

The treatment of calculi by other means than operative surgery has been found to be of very little value. Attempts have been made to dissolve calculi by internal remedies or by the injection of chemical agents into the bladder; but, although many such methods have been used, and have for a time in many cases been apparently successful, they have without exception been found in the long run to be practically worthless for removing calculi once actually formed. Further, the improvements in operative means for the removal of calculi have advanced to such a degree that it is probably better for a patient, in our present state of knowledge, to be treated by some one of them rather than undergo any attempt at their removal by other means. Nevertheless much can be done towards preventing the formation of calculi in those who have a tendency to their formation, by attention to diet and by the internal administration of drugs.

Urinary calculi are removed by one of three methods, (i. ) lithotomy or cutting for stone, (ii.) lithotrity or crushing the stone, and (iii. ) litholapaxy, a modification of lithotrity, and the method now most commonly adopted. In about nine cases out of every ten the stone may be crushed; but occasionally there are some circumstances which render the operation of lithotomy preferable to lithotrity. Thus, where the urethra is constricted, as in organic stricture or enlarged prostate, or where the stone is very large or extremely hard, it is right to cut for the stone instead of making any attempt to crush it. Again, in children lithotomy is safer than lithotrity.

Lithotomy.—Cutting for stone has been very long known and practised by surgeons; but up to the commencement of the 19th century it was performed only by a few men, who, bolder than their contemporaries, had specially worked at it and had attained celebrity as skilful lithotomists. Patients went very long distances to be operated on by them, and certain of the older surgeons, as Cheselden, performed a large number of operations with very