CASE. —A gentleman about 60, of a gouty habit, consulted me. I detected a moderate-sized uric acid calculus lying behind his large prostate, which I removed by crushing. When collected the frag ments were entirely composed of urates with no phosphates. After some months, his large prostate began to trouble him for the first time. He found he could not empty his bladder completely, and this gave rise to more or less catarrh. Three years after the removal of the uric acid calculus he came to me again, when I found he had two stones of moderate size. These I also removed by crushing. On examination, unlike the previous calculus, they were entirely made of triple phosphates, and did not contain one particle of urates in their composition.
The mode in which triple phosphatic stone, as the recurring type of calculus, is produced is a subject of considerable interest. In a paper "b relating to it Mr. Cadge evidently seems to connect the fre quency of stone recurrence with difficulty of ensuring that every portion of the primary formation is removed from the bladder. On the other hand, he believes that structural lesions, such as those observed in connection with lithotomy, are capable of providing a nucleus on which phosphates may be deposited, in the same way as upon a nu cleus of stone, provided the state of the urine admits of this. I ven ture to think that perhaps he somewhat underestimates the frequency with which lesions of this nature come into play in connection with lithotrity. the bladder is much pouched, as is the case with stones complicated with an enlarged prostate, though the bulk of the urine may be acid the contents of the sacs are often both alkaline and ammoniacal, as may be frequently noticed in cases where a residuum of urine always remains. Further, as I pointed out in my Hunterian Lectures, we do not attach sufficient importance to the influence that has been exercised on the bladder wall partly by the presence of the stone and partly by the protracted measures that are sometimes nec essary for the removal of the calculus by a crushing operation. A rough or uneven cicatrix or scar, as Mr. Cadge mentions in his paper, is not always the best substitute for a natural mucous membrane. I
have often been struck with the appearance presented by the urine at varying intervals after the stone has been taken away. Masses of flocculent matter are thrown off sometimes for weeks, which are as capable of furnishing a nucleus for phosphates as a feather, a vinous growth, or a rugose bladder. It may be objected that such argu ments would apply with equal if not greater force to lithotomy, where the proportion of stone recurrence is considerably less. On the other hand, I would reply that the involuntary urine drainage the latter operation entails is as salutary to the inflamed, or excoriated, or dis torted bladder as the drainage of pus often is to a chronic abscess ; and further, that the selection of lithotrity by no means implies that less damage to the interior of the bladder is necessarily done by this process. I have examined some cases after death where lithot omy had previously been practised, at various periods of time, with out being able to discover any internal trace of the procedure. Can we say the same of some cases of lithotrity where hemorrhage has been considerable both at the time and after the operation? Because urine may be comparatively stagnant or quiescent in a saccule or pouch connected with a bladder which in other respects is healthy, it does not follow that the conditions going on within the sac are the same as when a stone is removed from such an organ by a more or less protracted, and not necessarily innocuous, proceeding. In debating this point, Mr. Cadge shows that alkaline and offensive urine holding thick mucus in excess is not sufficient to lead to the formation of phosphatic stone, by reference to the common instances where this constantly exists in connection with some forms of pros tatic hypertrophy. What, however, may I ask, would be the effect of adding to these conditions favorable to the formation of a phos phatic stone, another one in the shape of constant contact with a more or less rough cicatrix, not to say anything of the presence in the urine of certain material products of inflammation capable of being demonstrated? It appears to me that there is sufficient evidence to indicate what is almost sure to follow.