resembling if not identical with those of the passage of a calculus may
occur when the substantial cause of them does not make its appearance;
and although many of these may perhaps be accounted for by the
ill-success of the search or by the calculus having ceased to pursue
its downward course and having become quiescent in the kidney, yet it
is well for the practitioner to be prepared for an occasional
disappointment in obtaining tangible proof of the nature of the attack.
Time may be required to decide whether an attack is due to calculus, or
is simply one of the spasmodic or neuralgic paroxysms mentioned above.
If after careful watching no stone makes its appearance, and on the
other hand the pain does not continue and no pus gives evidence of
pyelitis, it is highly probable that no stone is or has been present.
A true neuralgia of the kidney may undoubtedly exist. Lumbago and
lumbar neuralgia may simulate renal colic, but are almost always much
less severe, the pain less sharp and more dull and aching, aggravated
by movement, while the sympathetic phenomena, especially those
connected with the urinary apparatus, are wanting.
The diagnosis of the character of the calculus can sometimes be made
with a reasonable degree of probability. If crystals of uric acid or of
oxalate of lime have been or are present in considerable quantity, it
is highly probable that a possible stone may consist of those
substances. These crystals, however, are of little value in proving the
presence of a stone.
The important diagnosis of the occlusion of a ureter by a calculus, and
at the same time that of the soundness of the opposite kidney, may be
made with great certainty if the urine, which has previously been
purulent, bloody, or containing renal epithelium or casts, suddenly
becomes {45} clear coincidently with the occurrence of symptoms of the
impaction of a stone.
It is not of course necessary that in every case of impaction the flow
of urine from the affected side should be entirely stopped, since the
calculus may be of such a shape as to permit the passage of urine past
it.
The PROGNOSIS in this affection is extremely favorable, so far as the
recovery from the individual attack is concerned, since if the stone is
small enough to enter the ureter it will probably be successful in
forcing its way through sooner or later. It is of course possible that
this pain, like any other of excessive severity, might cause death, but
such an occurrence must be extremely rare.
Perforation of the ureter may occur, with consequent peritonitis. A
permanent plugging of the ureter from failure of the calculus to pass
will give rise to changes in the kidney to be subsequently described.
In cases where only a single kidney exists, and this becomes
obstructed, the symptoms of suppression of the urine may come on,
including death by coma if the obstruction is not relieved. Ten days is
the limit assigned by Ebstein beyond which recovery is not to be
expected, but he mentions a case in which it took place after thirteen
days of anuria. It must be remembered that a painful obstruction, or in
fact any severe shock to one kidney, may produce a very great
diminution in the amount of urine even when the other is sound. This is
undoubtedly the result of nervous sympathy.
One attack of renal colic renders another very probable, either
immediately or after months or years. Several hundred small calculi may
follow each other in rapid succession, or, on the other hand, a single
one may leave the patient in peace for a long time. Much depends on the
character of the calculus, the diathesis and habits of the patient, and
upon the treatment.
The subsequent history of the renal calculus belongs to surgery. After
it has reached the bladder and failed to be discharged, it increases in
size and is removed by lithotomy or lithotrity. The urethra, however,
will usually permit to pass any stone which has come through the
ureter. The patient who has just experienced relief from renal colic
should be instructed to pass his water into a vessel which can be
examined, and if the calculus do not soon make its appearance he should
void the urine when stooping forward or even lying on his face, so as
to bring the stone to the orifice of the urethra. It may catch in the
urethra and demand surgical interference.
The TREATMENT of the paroxysm consists chiefly in relieving the pain,
which may be partly done by the hot bath or hot applications. Opium, or
preferably morphine subcutaneously, is likely to be called for in large
doses. Attention has been called to the danger of morphine in
sufficient dose to relieve severe pain in cases where, as in renal
colic, the pain is likely to be suddenly terminated by the natural
progress of the affection, thus destroying the physiological antagonism
which exists between pain and morphine, and allowing the drug to
exercise its full power to an extent which may be over-narcotic. The
use of atropine with the morphine will mitigate to some extent its
danger, without interfering with its analgesic effects.
{46} In the milder cases ether and chloroform may be of value given by
the mouth, while in excessively severe ones anæsthetics by inhalation
may be called for, and their use continued for hours. This course also
is not without its inconveniences. The writer has seen a case where a
somewhat prolonged maniacal attack, with delusions lasting several
days, came on after the long-continued use of chloroform to relieve the
pain incident to the passage of a multitude of small uric-acid calculi.
The use of diluents has been suggested as hastening the passage, but
there is no reason to doubt that the pressure upon the calculus is
always sufficient to move it forward as rapidly as its shape and size
will permit. The relaxation of the spasmodically contracted ureter is
of much more importance than an excessive vis-a-tergo applied to the
calculus.
The treatment of the incipient calculus in the kidney or of the
condition which gives rise to it must naturally vary according to its
chemical constitution, which can only be certainly determined after its
discharge, but as to which an approximate opinion can be formed from a
knowledge of the tendencies and diseases of the patient and from an
examination of the urine.
The use of a largely-diluted solution of citrate of lithia or of
acetate, citrate, or tartrate of potassium will probably prevent the
deposition of uric-acid sand, and might even dissolve a small calculus,
although the proofs of this having actually been done are not
conclusive. If the urine be largely diluted the risk of the formation
of a calculus of another kind--_i.e._ phosphatic--is not great. Simple
water would be of great value in many cases, both as dissolving uric
acid and as promoting the metamorphosis of tissue, upon some
abnormality of which the accumulation of uric acid is supposed to
depend. The benzoate of lithia, by the destructive action which Garrod
has shown benzoic acid or its derivative hippuric acid to have upon
uric acid and the solvent action of the lithia, may be of value. The
phosphatic deposit, on the other hand, although beneficially influenced
by a sufficient supply of water, is not so amenable to chemical
influence as the other form, because it is much easier to render the
urine alkaline than acid when any irritation of the urinary passages is
present.
The vegetable acids, however, pass into the urine, and may render it
acid if in sufficient quantity. Benzoic acid becomes hippuric acid, and
can be used to make the urine more acid, as it causes very little
gastric irritation even in considerable doses. Boric acid also passes
into the urine, and acidifies as well as disinfects it, and might
perhaps be used to promote the solution of a phosphatic stone, though
the writer is unaware of any instance in which this has actually been
done. It does much toward diminishing suppuration in the urinary
passages, upon which phosphatic urine largely depends.
The conditions which lead to the deposit of oxalate of lime are not
sufficiently well known to make the prophylaxis of this calculus easy
by any chemical means, except by dilution of the urine and by a general
tonic regimen with abundant exercise.
Although it is not usual for a calculus to be arrested in the ureter
after having once fairly entered, this sometimes occurs, and the result
is stoppage of the flow of urine upon that side, dilatation of the
ureter, followed in turn by dilatation of the pelvis, and finally
atrophy of the {47} renal substance. This does not happen suddenly,
however. The urinary passages do not rapidly dilate to any considerable
extent, and their increase in calibre under pressure from within has
been considered a growth rather than a distension. This condition will
be treated under the head of Hydro-nephrosis.
Calculous Pyelitis.
When a calculus remains in the pelvis of the kidney without completely
obstructing the flow of urine, it usually increases in size, while the
resulting irritation may be the cause of fresh deposits either upon the
surface of the original calculus or in the form of new concretions. In
this way immense deposits of urinary salts may be formed. Thus, in a
case given in detail in the second series of _Boston City Hospital
Reports_ there was found upon the one side a calculus which when
perfectly clean and dry weighed 204 grammes, filling the whole dilated
pelvis and sending prolongations into the calices, so that its shape
was compared to that of a hippopotamus. The resemblance was made more
complete by the wrinkling and roughness of the exterior. In the other
kidney were several hundred calculi, from the size (and shape) of a
large almond down to that of white mustard-seed. The latter were
composed of two apparently distinct substances--one a reddish-brown,
looking like uric acid, and the other of the color and polish of white
marble; both, however, were phosphates.
The amount of local disturbance produced in the pelvis of the kidney by
the presence of a foreign body seems to depend somewhat upon the
character of its surface. Rough and uneven calculi, such as oxalate of
lime, are apt to produce inflammation much more rapidly than smooth and
polished ones, but it is seldom that any calculus remains without some
pyelitis. At first only a loss of polish of the mucous membrane, with a
little increase of mucus, may be observed, to which succeed roughening
and suppuration with occasional fibrinous deposit. The pelvis, more or
less dilated, may then contain a quantity of mucopurulent urine, with
perhaps some blood, in which are concealed the stones which have given
rise to this condition, and often phosphatic deposits not converted
into calculi.
Pyelitis is divided by some foreign writers into catarrhal and
diphtheritic--a distinction rather of degree than of kind. The mucous
membrane of the pelvis may, like other mucous membranes rarely, and
like serous membranes often, throw out a fibrinous exudation which
takes the form of false membrane. This indicates intensity of
inflammation, but has no necessary connection with diphtheria. A true
diphtheritic pyelitis, that is, connected with the general disease
known as diphtheria, is of course a conceivable lesion, but certainly
not a common one.
The renal symptoms--especially true albuminuria, so common and of such
grave import in this disease--are due to lesions of the secreting
substance, and not of the pelvis. It is important, but not always easy,
to decide whether there is more albumen present than is to be accounted
for by the pus. The pyelitis may be acute or chronic, being {48}
characterized by the intensity of the attack and the rapidity with
which the symptoms subside. The prospect of a given attack being acute
is decided largely by the supposed cause: a small calculus passing into
the ureter undoubtedly gives rise in most instances to a localized
pyelitis, which subsides after the cause of irritation has disappeared.
An inflammation from a larger one remaining is naturally of slower
development, but may be more acute while the calculus remains rough and
irritating, and partially subside when it becomes covered with a
smoother coating of phosphates. The mucous membrane, however, is not
likely to regain a completely healthy condition.
The mucous membrane in severe pyelitis may be deeply eroded, and even
perforated, so that the contents of the pelvis escape and give rise to
abscess in the perinephritic or prevertebral cellular tissue, which may
be discharged through the loins with resulting cure, or the
establishment of a fistula, from which issues pus and at times calculi.
Among the rarer results of perforation may be mentioned gastro-nephric
and duodeno-nephric fistulæ. These might be diagnosticated by the
presence of food and other intestinal contents in the urine, provided
that the ureter were still pervious. Vomiting of calculi and urine has
been reported by the older writers.
The writer is indebted to J. R. Chadwick for references to two modern
cases--one where such a fistula was diagnosticated during life;[16] and
another where a gastro-nephric fistula was found after death.[17] In
the latter case a diagnosis would have been impossible, as the kidney
was disorganized and the ureter occluded. The extent to which the renal
secreting substance suffers in calculous pyelitis varies considerably,
and is very probably connected with the amount of pressure exercised
either by the calculus itself when it attains a large size or by the
urine in cases of obstruction. It is rare for either pyelitis or
hydro-nephrosis to exist entirely independently.
[Footnote 16: _Giornale di Anat. e Fis. path._, iii. p. 370.]
[Footnote 17: Marquezy, _Thèse de Paris_, 1856.]
The changes which take place are those of atrophy. Interstitial
suppurative nephritis seems to follow this form of pyelitis much less
frequently than that which is due to extension upward of disease in the
lower urinary passages.
Corresponding to the pressure of solid or fluid, the papillæ are eroded
and the straight tubes shortened. In the cortical substance, which soon
becomes diminished in thickness, the interstitial tissue is
hypertrophied, dense, and hard, while the tubes become smaller or in
time disappear. The Malpighian bodies are changed to dense masses of
connective tissue, but are still plainly recognizable, irregularly
crowded together instead of being arranged as usual in more or less
symmetrical double rows. The cortex of the kidney may thus become but
little more than a mere skin stretched over a large stone, with perhaps
here and there a piece of renal structure recognizable and in a
comparatively normal condition.
The extremer grades of hydro-nephrosis do not seem to be met with in
this form of atrophy, but the pelvis is considerably dilated, while its
internal capacity is also added to by the atrophy of the renal
substance. The interior of the cyst thus formed usually retains
distinct traces of its original division into infundibula, and may be,
as already stated, almost filled by the calculus. Kidneys undergoing
this process of degeneration {49} often furnish up to a short time
before death a normal, or even more than normal, amount of urine, and
one is often astonished to find how little disturbance of elimination
has been caused in cases where the true kidney-structure seems to the
naked eye to have been almost entirely destroyed.
The DIAGNOSIS of a calculus remaining in the pelvis of the kidney
depends chiefly on the determination of hæmaturia and pyelitis for
which no other cause can be found, and upon the presence of pain in one
loin. It is naturally greatly assisted by the presence or history of
renal colic. An aching pain in the loins, more or less permanent, is a
frequent but not invariable symptom. It may be such as to prevent the
patient from standing upright, and cause him to assume an habitually
stooping posture in standing or walking. A careful examination of the
urine in conjunction with this symptom, especially if an unusually
abnormal condition has been preceded by an exacerbation of the pain,
may make the diagnosis almost certain. In the beginning of a case
occasional not severe hæmaturia, with some increase of mucus or a
little pus, may be all that can lead to the suspicion of calculus as
the cause of pain. At a later period an increase of these symptoms,
with a considerable quantity of the peculiar irregular epithelium
lining the pelvis, may be observed. The latter constituent, however,
can hardly be looked upon as entirely conclusive of pyelitis, since the
lower urinary passages may give rise to cells of about the same form
and size, and the irregularity is likely to be increased beyond
recognition by the presence of inflammation. They may also undergo
change of form in the urine. The presence of transparent or other casts
denotes the irritation of the renal parenchyma.
The point of chief difficulty in the diagnosis of pyelitis is the
determination of the origin of the pus, whether from the kidney or the
bladder. Cystitis may be only partly excluded by the absence of
dysuria. A point of considerable weight is the reaction of the urine,
that from the kidneys being usually acid, while that from the bladder,
when cystitis of much severity exists, is alkaline or rapidly becomes
so. The pus coming from the kidneys is more intimately mixed with the
often profuse urine than when formed in the bladder. The whole of it
does not in the former case completely subside, but remains in
sufficient quantity to form a turbid or opalescent mixture--the
polyuric trouble of Felix Guyon, according to whom this condition in an
acid urine is strongly indicative of renal as distinguished from
vesical lesion. In cystitis the pus subsides in more or less distinct
masses, but if the urine is alkaline, or when it becomes so, is altered
to a ropy consistency usually spoken of as muco-purulent.
The procedure recommended by Thompson may be resorted to in order to
determine whether the urine comes from the kidneys loaded with cellular
detritus, or whether the addition is made in the bladder. This consists
in washing out thoroughly the bladder with several successive
quantities of water through a single catheter, until the water comes
away clear and the bladder has contracted itself around the instrument,
when the urine from the kidneys will for a time come through direct and
comparatively uncontaminated.
In cases where the urine is alkaline in the kidney, which may happen,
distinctions founded on the reaction cannot be of value, and the same
{50} may be said of cases where cystitis is known to exist, but where
there is in addition a possibility of a renal calculus. In these some
such mechanical procedure as that just described must be resorted to.
The presence of a calculus as a cause of pyelitis cannot always be
demonstrated, but may be more or less strongly suspected according to
the conclusiveness with which any other cause can be excluded, by the
definiteness and character of the local pain, the history of renal
colic, the presence of uric-acid crystals in the urine, and perhaps in
some cases the results of palpation. The exploring-needle may be used,
and may of course, if reaching the calculus and giving a characteristic
grating feeling and sound, give absolutely positive results; but a
failure to strike a stone could hardly be regarded as proof positive of
its absence.
The diagnosis of renal calculus from lumbago or neuralgia should rest,
in case the pain is severe enough or long-continued enough to really
cause the question to arise, upon an examination of the urine.
A very important point in diagnosis, especially when the question of
operative procedure arises, is that of the soundness of the other
kidney. Accidental circumstances will sometimes permit this to be
determined; as, for instance, when one ureter is suddenly blocked by a
calculus, and at the same time the urine, which has previously been
found purulent, bloody, and containing renal cells and casts, becomes
clear and normal until the obstruction is removed and the abnormal
ingredients reappear. Cases of exstrophied bladder, where of course it
is possible easily to separate the urine of the two kidneys, may be,
from their rarity, practically left out of the account. Various
proposals for obtaining the separate urine of the two kidneys have been
made. A small catheter has been passed into the female ureter through
the dilated urethra. In the female also a finger in the vagina may
succeed in temporarily blocking one ureter, while the secretion of the
other alone is filling the bladder, a catheter with a bent portion at
the end being used for making counter-pressure from the inside. It
would probably remain doubtful in most cases how successful this
manoeuvre had been in completely stopping the flow of urine, although
experiments upon the dead body have been made by Polk,[18] who proposes
the method, with entire success. The male bladder offers greater
difficulties, which are at present insurmountable. A point opposite the
lower end of the ureter can, it is true, be reached with some
difficulty in the rectum, and it is possible that a catheter might be
so adjusted as to make counter-pressure to the finger in this position,
but there could be no certainty that the occlusion was complete.
[Footnote 18: _New York Med. Journ._, Feb. 17, 1883.]
The whole hand in the rectum, after Simon's method, would enable the
object to be accomplished with more certainty, but this procedure has
risks of its own. A staff with flattened extremity, as suggested by
Weir,[19] may more conveniently, though with somewhat less certainty,
be used for pressing from within the rectum on the ureter where it
passes over the brim of the pelvis. A compressorium consisting of an
empty and folded bag, to be introduced into the bladder and there
expanded by the introduction of metallic mercury, has been described
and used, with the result of partly checking the flow of urine.[20] The
proposition to pinch up the extremity of one ureter in the bladder by
means of the lithotrite is still {51} more open to the objection of
great uncertainty, and would, to say the least, demand very special
skill to obtain even a chance of success.
[Footnote 19: _Ibid._, Dec. 27, 1884.]
[Footnote 20: See Weir's article, just quoted.]
None of these procedures have as yet been put to practical use, and it
is doubtful whether any of them, unless we except perhaps the use of a
staff in the rectum, would be justified for purely diagnostic purposes,
considering the great risks involved. For the present, at least, the
possibility of separating the secretion of one kidney from that of the
other must be looked upon as depending chiefly upon accident, and in
case of contemplated operation it is not possible to assure one's self
of the integrity of the other kidney before the abdomen is opened. In
many cases after opening the abdomen both kidneys may be examined
before deciding upon further steps. Lawson Tait considers an
exploratory incision distinctly indicated whenever abdominal disease
not malignant threatens the life of the patient. The soundness of the
other kidney, however, may be considered highly probable if in spite of
demonstrated extensive disease of one kidney a sufficient quantity of
urine with a normal amount of urea and salts continues to be formed.
The SYMPTOMS arising from a large calculus producing destruction of the
renal substance, when both kidneys are affected or one is insufficient
to supplement the partial or total loss of the other, may closely
resemble those of diffuse nephritis, either interstitial or
parenchymatous, or perhaps it would be more correct to say that these
forms of nephritis are the symptoms of such a change. Thus we may have
polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. The
enormous calculus described above as resembling a hippopotamus had
given rise to no marked symptoms until palpitation, dyspnoea, and
oedema were complained of; the heart was hypertrophied.