CONDITION OF RECURRENCE OF STONE AFTER Condition of Recurrence.—There are at least three forms or states under which recurrence takes place : (1) as connected with an imper fect removal, where portions of, or even whole stones are left behind; (2) the persistence of conditions favorable to the production of stone which are in no way influenced by the mere removal from the bladder of what has already been produced; and (3) the development of con ditions favorable to the production of stone, conditions which had no existence prior to the removal of the original calculus. It will be necessary to expand and illustrate these several headings.
(1) That imperfect removal is an antecedent of recurrence both in lithotomy and lithotrity, rare with the former and more frequent with the latter, is a fact which is generally admitted. Putting aside those instances which may be due to somewhat hasty and imperfect meth ods of examination at the time of operation, I will proceed to notice some of the conditions where exceptional obstacles to complete re moval are interposed, which may thus be regarded as contributing causes of recurrence. These will be found to have reference to the shape of the bladder or the prostate, rather than to anything con nected with the size or the form of the stone. Where a stone lies in a normally disposed bladder the probabilities of any recurrence taking place after removal are extremely remote; for if the operator were to succeed in removing everything but the smallest particles, the local conditions are such as almost to insure their spontaneous discharge. The success of lithotrity in early life, and the gradual increase in the number of recurrences as age advances, coincident with changes in the shape of the prostate and the posterior wall of the bladder, afford evidence of this. These contributing alterations in the shape of the viscus, as forming traps for stone or fragments, may briefly be no ticed.
Reference to specimens of pouched and distorted bladders will be sufficient to indicate more forcibly than words the obstacles that are sometimes placed in the way of the operator endeavoring to remove all traces of stone when it happens under such conditions. A stone in the mouth of a pouch or of a sacculus may sometimes act as a cork (Fig. 66), and permit, after its removal by the lithotrite, of the escape of a second stone into the general cavity of the bladder by either muscular action or accidental extrusion. This, I believe, hap pened in a case where I removed a calculus from an apparent healthy bladder in a young adult male. Shortly after this was done, symp toms of stone, without any evidence of renal colic, suddenly returned and another calculus was removed by a supra-pubic operation. At the time of the first operation I satisfied myself, as far as it was possible, that the bladder was clear, and I had uo reason to suspect otherwise. Again it has occurred that a flat shell of calculus after lithotrity has remained concealed under a projecting bar of prostatic tissue and subsequently getting on its edge has excited symptoms of most acute irritation. This has been the more pronounced when the mischief
has occurred in a bladder which is more or less dependent on the use of the catheter. Such abnormalities explain obstacles in the way of complete evacuation which, though we may be cognizant of them, are difficult to provide against.
(2) Proceeding to the second heading, I have observed that the mere removal of a stone from the bladder by a mechanical process in no way implies that the conditions which led to the primary forma tion have necessarily been altered or interfered with. Take, for in stance, those more obvious illustrations of stone formation which are sometimes seen in persons with paralyzed bladders, as from fracture of the spine where a series of these concretions form with remarkable rapidity, or in gouty subjects who excrete large quantities of lithic acid crystals. In the former case, so long as we have alkaline urine and shreds of cast-off mucus, we have all the conditions necessary for the production of phosphatic stones ad infinitum. So with the concre tions of uric acid which primarily form as renal calculi in the tubular portions of the kidneys. While there is a supply of these in conjunc tion with their necessary crystalline deposit, the process of stone for mation may readily be repeated, and as age proceeds and the prostate enlarges a condition is superadded favorable to the collection and con cretion of lithic acid which did not previously exist. Hence I be lieve the greater frequency of stone at advanced periods of life is accounted for, not only for the reason that the facilities for making lithic acid are frequently increased, but because the latter is often discharged from the urinary apparatus under circumstances of greater difficulty. If a person, for instance, has a stone in his bladder and also others in his kidney, or in course of formation there, while con currently he has developed an enlarged prostrate, or is doing so, I think he may consider himself fortunate if he escape without the ne cessity for having a second stone removed from the bladder. Some years ago I cut a man for stone; just as he was about to leave the hospital he had a most acute attack of renal colic, with hmmaturia, and passed a uric acid calculus almost as large as an ordinary marble. Had this stone remained in the bladder it would probably have grown by the aggregation of phosphates upon it. It will be seen how easily I might at a later date have been exposed to the charge of having left a stone in the bladder at the previous operation. Similar illustra tions of this kind of recurrence, quite independent of the selection of the operation or the manner of its performance, might easily be furnished.
(3) In the last place reference may be made to the development of conditions favorable to the production of . stone which had no exis tence prior to the removal of the original calculus. That such is probable is indicated from illustrations of which the following is an example.