CHAPTER VIII. STONE IN THE FEMALE BLADDER. URINARY CALCULI are probably formed as frequently in the female bladder as in the male; but the shortness of the female urethra and its remarkable degree of dilatability, so frequently provide means for a ready and spontaneous escape of the stone before it arrives at any great size, that the surgeon is less frequently consulted by women suffering from stone than by men. Diagnosis. The symptoms of calculus in the female are somewhat analogous to those in the other sex, but differ in this, that they are particularly liable to prove fallacious. Nothing is more common than for hysterical girls to complain of pain at the neck of the bladder, and at the extremity of the meatus, frequent calls to micturate, and a sudden arrest of the flow of urine before the bladder has been emptied. But upon examination by a sound or catheter, no stone can be detected. It is also by no means uncommon to find the female bladder occupied by a solid substance, very different in form and structure from ordinary calculi. Many cases are on record in which the female bladder has become the receptacle of extraordinary nuclei. A case is related in the Medico-Chirurgical Transactions (vol. i. p. 123), by Mr. Thomas, in which an ear-pick was extracted from the bladder of a young female. Dr. Toogood, late of Bridgewater, in his lately published and most interesting volume, "Reminiscences of a Medical Life," (page 155,) relates two cases, in which the surgeon accidentally allowed a catheter to slip into the female bladder. In one case it was in the bladder fifteen days, and produced but slight irri tation. It was removed by dilating the urethra by a sponge tent, and then introducing the finger, directing the catheter into the long axis of the bladder, and then seizing it with a pair of forceps, as recommended by Sir Astley Cooper. In the other case, it was in the bladder seventeen days, and removed in the same manner. In January, 1853, a young girl was admitted into St. George's Hospital under Mr. Hawkins,* who had suffered from symptoms of stone in the bladder for four years, in consequence of having passed a hair-pin through the meatus into the bladder. Attempts had been made repeatedly to extract it, but without success. On her admission the urine was found to be offensive, and it contained a large quantity of ropy mucus, but no blood. It came away involuntarily at first, but not afterwards, though the patient was obliged to pass it very frequently. When the sound was introduced, a foreign body, not easily moveable, was felt in the bladder. It was extracted with extreme difficulty by first incising and then dilating the urethra and introducing the forceps. The hair-pin was broken on extraction, and was surrounded by an incrustation of triple phosphate, with phosphate of lime. The urine was alkaline. After the operation, she could not retain her urine more than three hours at a time, except at night. In this case, as in many cases of calculus in the female, there was, before the extraction, rather an impediment to the retention of urine than a difficulty in passing it. Among the symptoms of stone in the female may be noted that the meatus is always dilated, there is always pain after passing the urine, generally pain in sexual intercourse, and the urine often deposits a mucous, and sometimes a sandy, sediment. Frequently there is vaginal cystocele in the first instance, followed by prolapsus uteri. Although the urgency of these symptoms varies a good deal in different cases, there is often much suffering produced. Sir Astley Cooper says:-"I think the symptoms of stone in the female are more urgent than those in the male. It is horrible to witness the sufferings which a woman experiences in consequence of this disease. She has a dreadful pain at the extremity of the meatus urinarius, and in addition to this, there is a forcing down of the lower parts of the pelvis, as if they were about to protrude; a frequent disposition to make water, and all the pains suffered during delivery. There is generally a prolapsus uteri, and a discharge of bloody urine. In addition to these symptoms, there is almost constantly an incontinence of urine, a great urgency to discharge it, and an incapacity to retain it."* These symptoms, or some of them, may arise from scirrhus, or from chronic inflammation of the mucous membrane of the bladder, polypous tumours within the bladder, or excrescences in the meatus. The detection of the stone by the sound is the only satisfactory evidence of its existence. Treatment.—Although stone in the female does not always produce much distress, and may even escape spontaneously, yet, when discovered, it ought not to be allowed to remain, as it may grow to a size indefinitely large; and, if the patient should become pregnant, it may prove a source of great difficulty and danger during parturition: it may even produce vesico-vaginal fistula. There are three ways of removing calculi from the female bladder,―incision, dilatation of the meatus, and lithotrity, with or without dilatation. 1. Incision.-Lithotomy in females is much more easy of execution, and less dangerous to life, than the same operation in the male subject. It may be done in various ways, but until recently the plan was to divide the urethra and neck of the bladder, and introduce a pair of forceps. The objection to this operation is, that incontinence of urine is apt permanently to follow the operation. The late Mr. Hey, of Leeds, cut two female patients for the stone, both of whom were afterwards unable to retain their urine. A modern method is to incise the anterior margin of the meatus, and then gradually dilate the remaining portion of the urethra until the finger can be passed into the bladder. But even this plan is often followed by a greater or less degree of incontinence of urine. . And to this point I shall have soon to call the reader's particular attention. 2. Dilatation of the Urethra.-The female urethra is well known to be capable of dilatation to a great extent, but few practitioners are aware either of the extent to which it may be dilated, or of the conditions on which that dilatation can be effected without laceration or subsequent incontinence of urine, or any other injury. In regard to the dilatability of this canal, there is ample evidence that it will admit a calculus to pass through it of almost any size which these concretions are likely to attain. Numerous examples are adduced by surgical writers in which calculi of immense size have been spontaneously voided through the meatus urinarius, either suddenly and without pain, or after more or less time and suffering. Heister mentions several well-authenticated instances of this kind. Middleton has also related a case where a stone weighing four ounces was expelled in a fit of coughing, after lodging in the passage a week. Collett speaks of another instance, where a stone about as large as a goose's egg, after lying in the meatus urinarius seven or eight days, and causing a retention of urine, was voided in a paroxysm of pain.* Dr. Molineux relates a case (" Philosophical Transactions”) in which a woman voided a stone of which the long circumference was between seven and eight inches, the shortest circumference (in the thickest part) five inches and three quarters. I have my self extracted a stone through the dilated meatus three inches and a half in circumference; and in the case already quoted, in which Mr. Thomas extracted an ear-pick from the bladder, he says, “The left forefinger was most easily introduced, and I believe, had the case required it, both thumb and finger would have passed into the bladder without the smallest difficulty." It is clear, therefore, that there is no absolute or mechanical necessity for incising the canal in order to allow ordinary calculi to pass. Still, objections have been brought against the practice of dilatation:-1. That it frequently takes a long time and gives great pain to dilate it effectually. * See Cooper's "Surgical Dictionary,” (Art, Lithotomy.) |