1889 Journal of the American Medical Association (JAMA)  
In the examination of the several modes of treating urinary concretions, the question of their indications and contraindications is worthy of special attention, since adherence to a single procedure belongs to the medicine of a remote past. Modern medicine demands that preventive measures be taken in threatened calculous affection at the first sign of coming of hyperlith\l=ae\mia ; that when hyperlithuria exists, medicinal treatment be resorted to; that when calculi are formed, mechanical means
more » ... d, mechanical means be promptly applied for their removal ; that when the calculi have been removed, the cure be accomplished by suitable after-treatment ; and that when mechanical treatment is contraindicated, a judicious course of palliative treatment be adopted. Therefore the treatment of urinary concretions is now arranged into the preventive, medicinal, palliative, mechanical and post \ x=req-\ mechanical treatment. The preventive treatment embraces hygienic, medicinal and mechanical means. The needed hygienic observances comprise diet, exercise, ablutions and raiment. The medicinal means of prevention are directed against dyspepsia and intestinal and hepatic inaction. The mechanical means of prevention are applicable to cases of bladder injuries, of foreign bodies in the bladder, and of stagnation of urine. 'The medicinal treatment is applicable to cases of persistent hyperlithuria,nephralgia, and very small uric acid concretions, but is of no avail as a dis¬ solvent of medium sized or even of small calculi, It has long been supposed that alkalies taken by mouth and excreted by the kidneys act chemically upon uric acid stones, forming soluble salts, and so disintegrating these stones. Such, however, according to Denamiel, is not the case. He be¬ lieves that much good is accomplished by the use of alkalies, that they act little, if at all, directly upon the saline constituents of stones, but rather upon their mucous cement, thus disgregating without disintegrating the calculous particles and rendering the stones inordinately friable. In persistent hyperlithuria, continuance of the me¬ dicinal part of the preventive treatment, and the use of solutions of salts of potash, soda, and lithia-natural preferable to artificial solutionsin moderate doses for two or three weeks ordin¬ arily fulfil the indication of dissolving uric acid sand and of preventing the formation of stone, besides relieving the irritation caused by the sharp-pointed crystals. Soap pills, and potash and soda solutions, long continued, greatly dis¬ turb digestion and even tend to increase uric acid formation. The palliative treatment is indicated in patients who are enfeebled by intercurrent disease or by grave lesions of the urinary organs caused by the presence of a stone which cannot be safely re¬ moved, and comprises medicinal and mechanical means designed to mitigate pain and prolong life. In such a case the failing strength of the patient is supported by suitable food and mild stimulants. The teasing spasms of the bladder are relieved by the judicious use of belladonna, and the pain assuaged by opium. Much comfort can be obtained from cleansing the bladder with acidulated warm water, which tends to counteract the bad effects of ammoniacal urine ; from occa¬ sional vesical injections of mucilaginous decoc¬ tions ; and, in the case of phosphatic calculus, from irrigations with acetate of lead solution, which may cause such a decrease in the volume of the stone as materially to mitigate the suffer¬ ing. Hot fomentations to the hypogastrium, hot hip baths, posture, etc., and all useful adjuvants. The mechanical treatment consists in the appli¬ cation of means adapted to the removal of calcu¬ lous concretions by the natural route to the blad¬ der or by an accidental or an artificial route to the urethra, bladder, ureter or kidney, according to the particular exigency. Preparatory treatment is needed in the great majority of cases. The required instruments are rendered aseptic, and all operations are performed with antiseptic precautions, even simple cathe¬ terism.
doi:10.1001/jama.1889.04440050001001 fatcat:k3c6awnhwvdsfps3aw5mvtqssu