PREVENTION OF RECURRENCE OF STONE AFTER OPERATION. Prevention of Recurrence.—From the foregoing observations some practical conclusions may be drawn under the several headings.
(1) In the conduct of all operations for the removal of stone from the bladder every care should be taken to render the process a com plete one. The impossibility of doing so by one method, either proved or rendered probable, would necessitate the selection of another. The recurrence of stone after lithotrity may indicate the propriety of an ocular or digital exploration of the bladder by some method, such, for instance, as perineal lithotrity, where the bladder and its recesses may not only be more effectually cleared of all stone and fragments, but where the viscus may be submitted, in addition, to a process of drainage. The shape of some bladders, as consequent on obstructive, mechanical, or developmental changes, is such as to render the removal of all particles almost impossible. On the other hand, where the bladder is healthy, or approximately so, the success of lithotrity cau now be almost absolutely guaranteed.
(2) As the mechanical removal of a stone from the bladder does not necessarily imply that the conditions which led to its production cease to exist with the completion of the operation, states favorable to reproduction—as, for instance, in the case of cliathetic stones, such as the urate, the oxalate, and even, it may be presumed, the cystine should be carefully watched. Persons in the habit of excreting large amounts of uric acid in a crystalline form, or in the shape of renal calculi, are placed at a considerable disadvantage when the prostate commences to impede micturition and to render certain parts of the bladder dependent. Under such conditions important alterations in the amount and form of crystalline excretions may be effected by means of diet, exercise, and suitable waters. On manifestations of the diathesis continuing after the removal of uric acid calculi from the bladder, I have seen excellent effects follow the use of the Con trexeville waters in combination with other means to which reference has already been made. In some cases this seems to have been at tributable to changes in the form of the excreted crystals thus arti ficially brought about.
(3) In the last place, much may often be done to prevent the devel opment of conditions favorable to the reproduction of stone in some form, after its removal. This has reference more particularly to those changes in the parts which are favorable to the formation of calculi or concretions consisting more or less of triple phosphates.
The urine of patients, after lithotrity especially, should be watched for some time, until, in fact, all traces, physical as well as chemical, which may be regarded as favoring such a tendency, have ceased to exist. Unless this can be brought about, the liability to recurrence must be said to continue. Urine that still contains shreds and particles of inflammatory exudation, or which is alkaline or ammo niacal, may be regarded as containing factors necessary for the for mation of triple-phosphatic stones. When such conditions are con stantly in existence, the completion of the process of stone formation is often only a matter of time which some mere accidental circum stance, in furnishing what is required, may determine. By local and general means, such as those mentioned in connection with the toilet of the bladder, these conditions may be prevented. In addition to these measures, benefit will often be derived, in bringing about a more natural condition of the mucous membrane of the bladder, as well as the urinary tract generally, by the sulphur springs of Harrogate or Strathpeffer in Great Britain, or the ferruginous waters of Wildun gen in Germany. Bethesda and Poland Spring waters are much used in the United States and I have reason to believe with advan tage, after stone operations, particularly where there is any doubt as to the character of the drinking-water. I have not, however, sufficient knowledge of the springs on the continent of America to enable me to speak of them in detail.
Reference has been incidentally made to a paper by Sir William Roberts where it is proposed to make the lactic fermentation predom inate over the ammoniacal, with the view of preventing the deposi tion of triple-phosphate concretions. In soine cases immediate and permanent benefit appears to have resulted, though further observa tion will be necessary for the purpose of establishing the value of the suggestion from a practical point of view. I have endeavored, in the few instances where the treatment has been tried, to bring this about by first washing out the bladder with tepid water containing from five to ten grains of citric acid to the pint, and then, after the bladder has been cleansed in this way, leaving within it a drachm of extract of malt (bynin) in an ounce or so of water. Of the value of this treatment I have already had some proof.