CHAPTER XIV.

ON THE RELATION BETWEEN ENLARGED PROSTATE AND STONE IN THE BLADDER.

Vesical Calculus a frequent result of Enlarged Prostate.-How this may be accounted for.-Calculus often overlooked.-Best means of discovering it, by Sounding, &c.—Difficulties in removing it.-Lithotomy and Lithotrity. -Objections to each considered.-General applicability of Lithotrity.-Experience of various Surgeons.-Removal of Fragments by Scoop-lithotrite; by evacuating Catheter; Sir P. Crampton's Apparatus.-Position of the Patient.-Injection of Solvents.-Dr. Hoskin's proposal.-Decomponents.— Impaction of Fragments.-Treatment.-Course to be pursued when Bladder is extremely irritable.-Value of Treatment.-Preparatory Measures,— Palliatives.

So closely connected is enlargement of the prostate with the formation of earthy deposits in the bladder, that it is almost impossible to avoid a consideration in these pages of that great subject, at all events under one of its several aspects, and that certainly neither the least difficult, nor the least important one. It would be almost as easy or as consistent to decline treating of the best methods of affording relief to complete urinary retention arising from the same enlargement, as to overlook a result, no less important and no less frequent; although not so urgent in the course and nature of its symptoms. For it is impossible that any man can have the care of many cases of enlarged prostate, without meeting also several of calculous formation in the bladder, although, it is not less true that he may occasionally, perhaps more frequently than has been supposed, overlook its existence, so much are the symptoms of the one malady masked by those of the other. Of this

I have witnessed not a few instances. And it is not a matter to which the surgeon may be indifferent, although the distress which the calculus appears to produce in any given case of the prostatic affection may be comparatively slight in degree. Because, as we have seen in a previous chapter, any source of vesical irritation-and there are few more potent than the presence of such a foreign body—tends to augment the difficulties attendant upon the already-enlarged organ, it may be to increase its rate of development, and to hasten the catastrophe which all our treatment is, or should be, directed to avert. The importance of the calculous complication is therefore to be estimated, not altogether according to the marked character of the symptoms by which its presence is rendered obvious, nor by the actual degree of suffering which it causes to the patient himself.

That calculous disease and prostatic enlargement frequently coexist is a fact which our museums testify in unmistakable language, and which daily experience corroborates.

Not only does our experience of the living also point to the same fact, but the grounds of the relation are so obvious as to render it almost impossible that the result should be otherwise than it is. The calculus which is produced under these circumstances is generally, although not invariably, one of vesical origin, that is, one originating entirely in the bladder itself. From the altered condition of urine depending upon constant or long-continued retention within the viscus, of a certain quantity which cannot be expelled by the efforts of the patient, owing to the existence of obstruction at its neck, irritation of the mucous lining is set up, and much viscid secretion is often poured out. This action having long-continued, it will frequently be observed that some whitish soft or gritty matter, a phosphatic deposit, is evolved from the same source; at first, perhaps, only in inconsiderable quantity. This may pass off entirely with the

mucus, in which streaky portions are seen to be entangled. And no more than this may occur. The formation may

take place in small quantities, and may possess no very great cohesive power, in which case the bladder may be maintained tolerably clear by occasionally injecting it with warm water, either unmixed, or to which a minute quantity of mineral acid has been added. On the other hand, the calculous deposit may assume a more solid consistence, a nucleus may be formed, and aggregation taking place, a phosphatic stone may not slowly result. This condition is very much favoured by the state of the urine itself under circumstances of retention, as instead of being acid, and so affording a menstruum favourable to the solution of a phosphatic formation, it becomes alkaline; and not only aids in giving rise to irritation of the mucous membrane, but also in maintaining the exist ence of the earthy formation when produced. In the same manner, also, if a solid body be introduced into the bladder while the urine remains in this unhealthy condition, it is almost certain rapidly to acquire a coating of this same deposit. And so it happens that if a small renal calculus which consists of uric acid or urates, or of oxalic acid, descend at this time through the ureter, a large phosphatic stone will probably at no very long time be formed upon it as a nucleus. But this descent of the renal product is no mere contingency under the circumstances, no mere unlikely coincidence with the vesical state; there is very little reason to doubt that, in some cases, a formation results from abnormal action of the kidney set up by irritation propagated upwards from the bladder. Perhaps the vesical origin of renal calculus is not always sufficiently recognized; and it may be a question whether we are not rather too prone to attribute its existence to a calculous tendency in the system,to a uric acid, an oxalic, or a phosphatic diathesis. Far be it from me to ignore the constitutional tendencies which undoubtedly give rise to calculous formation in the human

constitution; I only believe that the phenomena presented by calculous patients must lead us in numerous cases, but especially among those who are the subjects of enlarged prostate to regard their complaints as of local rather than of constitutional origin.

The relation which prostatic enlargement bears to these formations may be explained more fully. Two circumstances commonly concur to play a chief part in the production of calculous matter. These act and react on each other, and intensify the state which favours such production. First,―There is the altered condition of the urine itself, resulting from its retention within the bladder by obstruction at the neck. This change consists in its alkalinity, and in its consequent tendency to deposit the earthy phosphates in the form of an insoluble precipitate. The alkalinity may be attributed primarily to the following source; viz. to the production of carbonate of ammonia from the decomposition of urea, favoured by the presence of some organic matter (probably mucus); a process which takes place in the urine of a healthy person, if permitted to stand in the air for a day or two after its removal from the body. It now deposits the phosphate of lime and magnesia, which in small proportion are normal constituents of healthy urine, but which require its normally-acid condition in order to remain in their natural state of solution. As soon as it becomes alkaline then, these tend to precipitate, and doing so in presence of the carbonate of ammonia just referred to, there results the formation of a triple phosphate of ammonia and magnesia, with some phosphate of lime, and a very small quantity of carbonate of lime. Such are the constituents of the deposits so frequently met with in these circumstances, and the same are found entering largely into the composition of a very considerable proportion of the calculi formed at all ages, but particularly of those which occur at advanced periods of life,

Secondly,―There is the unhealthy state of the mucous membrane lining the bladder, which results from the altered condition of the urine, and augments the tendency both to alkalinity and to deposit.

The highly-irritating salt carbonate of ammonia, being habitually produced in the manner described, unnatural vascular excitement in the mucous membrane is set up, and an unusual quantity of its secretion is poured out which is naturally alkaline; this added to the urine, even when the latter is in its normally-acid condition, is sufficient to render it alkaline. But when the urine is already decomposed from retention, the action of the irritated mucous membrane considerably intensifies the morbid quality. But again, this mucus, or muco-pus, which is so familiarly known by the tenacious and adhesive character which it presents when removed from the body and cooled, contains itself also earthy phosphates, chiefly the phosphate of lime, with a trace of the carbonate, and often to a large amount; these, being, of course, insoluble in the alkaline secretion, are also precipitated in addition to those derived from the urinary secretion proper. Thus the inorganic constituents of a phosphatic calculus are abundantly supplied, and in circumstances particularly favourable to its formation, viz. in a surrounding menstruum in which solution of the earthy precipitate cannot be effected; contained in a cavity from which, both on account of its form and impaired vital powers, the contents are with difficulty expelled, and in which, consequently, aggregation and concretion are promoted; while, lastly, all this takes place in presence of an adhesive organic material, well adapted to form a binding cement for the saline particles of calculous matter. As might be expected under such circumstances, the resulting formation most commonly met with is the fusible calculus, composed of the phosphate of ammonia and magnesia, intermixed with the phosphate of lime in greater or less abun