The symptoms attending the existence of vesical calculus are far from uniform, either in their number, nature, or intensity. In some cases they are few, slight, and dubious, while in others they are many, pronounced, and easy of interpretation. The very slight physiological disturbance sometimes seen in stone disease has, in many instances, disarmed suspicion and frustrated detection, thus serving to sustain the prevailing idea that stone in the bladder is a disease of extreme rarity, a conclusion there is reason to think is too generally accepted by veterinary practitioners.
Vesical trouble arising out of the presence of stone is mostly exhibited, in the first instance, by frequent attempts at staling, some of which are abortive, and others more or less imperfectly and with difficulty accomplished. The urine is discharged in small quantities at brief intervals, and the completion of the act is signalized by a deep grunt indicative of pain. The desire to empty the bladder is more frequent and urgent during and after exertion, and particularly marked when the pace has been quick. Every now and again, while at work, the affected animal dwells in his movement and essays to stop. If permitted to do so, the body is at once extended, and a small quantity of urine discharged. Where the calculus is large, rough on its surface, and free to move in the cavity of the bladder, blood appears in the urine as the result of exertion. Whenever, therefore, exertion is immediately followed by the appearance of blood in the urine, the case should be regarded with suspicion, unless some other and more obvious cause is revealed. In some instances the penis is projected from the sheath, and again retracted, at short intervals, and we have seen it remain extruded in a pendulous condition during the whole period of the disease, and to return again only after the operation of lithotomy.
The discharge of urine is sometimes effected in a continuous stream, sometimes the flow is suddenly interrupted by the calculus blocking up the neck of the bladder, and occasionally it passes away involuntarily in small quantities. After the bladder has been freely emptied, the anus undergoes a repetition of spasmodic contractions. Now and again the stone becomes, impacted in the neck of the bladder, or, if a small one. may escape into and be arrested in the urethra, resulting in obstruction and over-distension of the organ, with the usual train of symptoms indicative of abdominal pain. In some examples of the disorder the gait during progression is wide and straddling, and when at rest the hinddimbs are occasionally raised from the ground as if in pain.
The diagnosis is, in the majority of cases, unattended with difficulty where proper methods of enquiry are pursued, but, as we shall presently show, the detection of stone sometimes taxes the resources of the ablest diagnostician. Tumours in the bladder, croupous cystitis, organic disease of the kidneys, and various other ailments pertaining to the urinary receptacle may, and do, occasion symptoms only distinguishable from those of calculous disorder by a careful and searching exploration of the bladder per rectum, and by catheter or sound through the urethral canal. In regard to this latter part of the enquiry it need hardly be urged that upon it the diagnosis mainly depends. Exploration of the bladder per rectum seldom fails to reveal to us any decided enlargement occurring within or without it, but the tact and discrimination of the surgeon is often sorely tried in distinguishing between a calculus and certain forms of tumour which now and again present themselves there. In searching for stone, the mind, and with it the hand, naturally turns to related organs, and, remembering the possible enlargement of the prostate gland, seeks first to determine the condition of this organ in particular whenever vesicular calculus is suspected. Tumefaction of the prostate is fortunately not difficult of recognition. The backwardness and fixed condition of the swelling, its intimate connection with the neck of the bladder, its peculiar outline of form and yielding nature, serve at once to distinguish it from stone. Tumours in the bladder usually disclose themselves by their diffuse, and maybe also by their lobulated and fixed condition.
The bladder should now be explored by means of a long sound passed through the urethra, assisted, in the case of a horse, by the hand of the examiner passed into the rectum. In searching the bladder for stone the organ is allowed to become moderately distended with urine, when, first in a standing, and then in a recumbent, posture, the sound (after being well oiled and disinfected) is introduced into the urethra, and gently forced on until it enters the bladder. It is now moved slowly backward and forward with a rotatory action, so as to bring the metal point of the instrument into contact with every part of the interior surface of the bladder, the operator noting at the same time any roughness or irregularity of surface or resistance it may meet with, or any sound or impression it may convey. If the result is not satisfactory, the position of the patient must be changed by turning the animal first on one side and then on the other, and now en the back, until every part of the bladder has been thoroughly explored. Where the substance felt per rectum is a calculus, its contact with the searcher will be clearly made known by the rough and resisting character of the touch, and by the sound emitted when struck.
Even with the exhaustion of all the methods and devices which science has designed for surgical diagnosis, failure may still attend our efforts to detect a stone, and although the existence of something in the bladder be ever so obvious, its precise nature cannot always be clearly and definitely made out. In those examples of stone, partially or completely over -grown by granulation tissue (proud flesh) (fig. 147) springing from around an ulcerating surface, or enclosed in false membrane, the question of stone or tumour is difficult to divine. Here the stone, hidden away in the new growth or exudation matter, is sheltered from the sound, and the instrument, striking the morbid mass, imparts to the hand precisely those impressions which denote the existence of tumour. In this uncertain and unsatisfactory condition no time should be lost in opening the urethra at the perineum, when the bladder may be again explored by means of the short metal sound, to be referred to later on.
It is not alone by active changes in the bladder, such as I have just referred to, that stone is enabled to evade detection. Passive alterations in this organ are likewise to be borne in mind as possible obstacles in the same direction. The most familiar example of this anomalous condition is met with in those cases where the weight of the stone, bearing on the anterior end or fundus of the bladder, creates for itself a diverticulum or pouch, in which it becomes lodged (fig. 148). The mucous membrane in those instances usually constitutes the sac, it having been pushed between the widely separated and atrophied fibres of the muscular coat; less frefjuently all the coats enter into the saccular offshoot. In some rare instances, as one recently related to me by Mr. F. Wragg of London, not only does the stone occupy the pouch, but, enlarging by accretion in the direction of the interior of the viscus, comes also to project into the proper cavity of the bladder (fig. 149). This is an important condition to consider in relation to the success of the operation of lithotomy, as will hereafter be explained. Where the stone becomes thus encysted it may or may not be accessible per rectum in a standing posture, or to the sound through the urethra, according to the extent to which it has extended from the pelvis in the direction of the abdominal cavity. If, however, the horse be placed on his back, the stone will be caused to fall towards the spine, and thus be brought within reach of the hand.
Fig. 147. - Stone Overgrown with Granulation Tissue.
Fig. 148. - Stone Empouched in the Fundus of the Bladder.
Referring again to the general symptoms of stone, it may be remarked that they undergo various modifications of character and intensity, according to the size, nature of the surface, and the relations of the calculus with the general cavity of the bladder.
Stones of large dimensions occasion much pain and suffering, especially where the surface is rough and the stone free to move from place to place with the movements of the body. Here the mucous membrane suffers much irritation, and, with the muscular coat, becomes considerably thickened. As a result, the walls of the bladder lose their expanding power, and, by failing to open out for the accommodation of the incoming urine, provoke and render necessary frequent acts of micturition. Inflammation and purulent urine are among the worst consequences of a heavy rough calculus.
Smooth calculi (which are rare), and such as are confined in pouches of the mucous layer, occasion much less disturbance, and may even fail to excite suspicion of their presence.
Various methods, physiological, chemical, and surgical, have in turn been practised and extolled for the prevention and eradication of stone, and each succeeding decade, with its larger experience and resource, has called forth either the condemnation or modification of the one, or the improvement and consolidation of the others. For a considerable period belief and reliance in the efficacy of internal remedies was largely entertained; but as time advanced, and the teachings of anatomy, physiology, and physics led to the improvement of surgical methods, surgical means, and surgical handicraft, the treatment of stone passed well-nigh altogether from the domain of the physician to the more practical and radical dispensation of the surgeon.
Fig. 149. - Stone Empouched in the Fundus, and extending into the Cavity of the Bladder.