RENAL CALCULUS, DIAGNOSIS AND TREATMENT, WITH CASES SELECTED TO ILLUSTRATE SPECIAL POINTS OF DIFFICULTY IN DIAGNOSIS

David Newman
1909 The Lancet  
SURGEON TO THE ROYAL INFIRMARY, GLASGOW. (With Coloured Plate.) WHILE in the following paper the whole question of the diagnosis of renal calculus will be considered and the relative value of the various symptoms and physical signs discussed, its main object is to call attention to certain important difficulties which have been met with over an extended experience—diffiulties which are not sufficiently known and which in practice are very liable to lead to serious errors in diagnosis and
more » ... iagnosis and treatment. Before considering the question of methods of inquiry and the fallacies by which the clinical observer is beset, it may be well to narrate a typical case of renal calculus-a case the interest of which is enhanced in that the historical record is in the words of the patient himself, a general practitioner. CASE 1. Rheumatic family history; suspected stone in the kidney for 16 years, pain at fi.rst occasional and of no great severity but steadily increased in frequency, associated with hæmaturia and frequent mictezrition; two small stones passed pain relieved, but hæmaturia continued after four years ;renal colic very severe ;sudden attacks ;reflex pains; occasional severe hæmaturia; extreme sensitiveness on palpation, x ray shadow; irritation at orifice of right 2sreter ; large ragged stone removed; complete cure.-A. B., aged 38 years, was first examined on August 16th, 1907. There is nothing remarkable in his personal or family history, except that they exhibited a tendency to rheumatism; otherwise both he and his immediate relations enjoyed singularly good health, he until the onset of the present illness. The following is the patient's account of his illness :-" It is now some thirteen years since I first suspected the presence of a stone in the right kidney, but in all probability it had formed a considerable time previous to that date. In the summer of 1891, while I was stooping to pick up some small object from the ground, the muscles of the back being tense, a younger sister playfully gave me a blow immediately over the right kidney. For a few minutes the pain was intense, and when after some little time I passed urine, I observed slight traces of blood. Neither the pain nor the hæmaturia recurred, and nothing further was thought of the matter. In November, 1891, during the night I was seized with an acute pain in the right iliac fossa which altogether disabled me. As the pain increased in severity I sought the advice of the late Sir W. T. Gairdner, who diagnosed a perityphlitis and prescribed a sedative. After three or four day's rest in bed the pain subsided entirely. This pain recurred more or less frequently during the next two or three years, but never during that period with any great severity. In January, 1894, I undertook the charge of a practice in a country district. My duties there entailed much walking and I was conscious of being easily fatigued. On 12th February, 1894, when on my daily rounds I suffered much from frequent micturition, and at that I time I passed a considerable amount of blood of a bright colour and evenly mixed with the urine. During the next fortnight hæmaturia was very marked on each act of micturition, and at times the proportion of blood was so great that if the urine was allowed to stand in the vessel, distinct clot formed. As far as I can remember I had at this time absolutely no pain, and I still continued to attend to my duties. On the 25th of February, 1894, I passed per urethram with ease two stones ; both were voided in the one act. The first was the size of a large pea, the other half the size. Both were smooth and composed of uric acid. The haematuria continued for a few days in progressively diminishing degree, and ultimately disappeared entirely. During the date of the subsidence of these symptoms, I suffered no inconvenience of much moment till January, 1895, when I had my first attack of renal colic, but from that date until I obtained relief by operation, I never had a day entirely free from pain. The attack of renal colic referred to was induced by my running to catch a car. The seizure was sudden and for the time being altogether crippled me. The pain in the right lumbar region was so intense that it was only with the greatest difficulty that I was conveyed home, where after some rest I obtained relief by the use of hot fomentations. There was no hsematuria at this time; equally well-marked attacks of colic occurred for a time at unequal intervals for about a year, but since then there was a constant dull gnawing pain in the lumbar region, and frequently associated with other obscure pains in such various regions as the right iliac fossa, the rectum, the left testicle, ' , and the apex ot the left lung. Walking became more and more a toil ' , to me, but I was always comfortable when riding on horseback and suffered no inconvenience from hunting. A cycle ride of from fifty to ' , sixty miles caused me no distress, but to walk half a mile tired me. In driving a sudden jolt caused much pain, as also did the lifting of any considerable weight. Invariably I woke in the morning more tired I than when I went to bed. To lie on the left side was impossible, and I the only position in which I had any degree of comfort was when lying on my right side with a cushion well tucked into the lumbar region. "Life was truly a burden. In 1901 I consulted a well-known physician, who, after an examination, denied the presence of stone, and attributed the symptoms to acute lumbago. Much relief of a temporary nature was obtained from electro-massage, but if this treatment was suspended for two or three days I speedily and surely relapsed, and so matters continued till the afternoon of 29th June of this year (1907). For about an hour I had been comfortably seated in an easy-chair when, without warning, I experienced an acute pain in the left lumbar region of such a character that even the slightest pressure of clothing was intolerable. Hæmaturia once more appeared, and the desire to urinate was constant and intense. After a week's constant rest in bed these symptoms subsided entirely, and I once more relapsed intomy usual state which continued till the 16th of August, when I consulted you. Your diagnosis confirmed my suspicion. Since the operation which you performed on 14th September, all the obscure pains which you suggested were of a reflex nature, including the pleuritic pain on the right side, have entirely disappeared, and now I have no discomfort of any kind whatever (November, 1907)." Physical examination of the patient showed extreme sensitiveness on pressure over the right kidney; so that the slightest manipulation induced severe spasm of the lumbar muscles and pain in the renal region. This pain extended along the line of the ureter, down the thighs and to the left lumbar region, so much so that the patient feared the presence of a stone in the left kidney also. With the fluorescent screen a stone could be clearly seen in the right kidney only, and several x ray photographs gave a distinct shadow. fFig, 1.) FIG. 1. Examination of the bladder showed the mucous membrane to be slightly injected, especially along the line of the right ureter (Fig. II.) (see coloured supplement), but elsewhere it was normal in appearance and the organ was capable of containing a normal amount. The orifice of the right ureter was greatly dilated, oval in shape, and the lips of the orifice were of a dark red colour. On palpating the kidney while the cystoscope was in position several copious shoots of blood-stained urine were seen to escape, which imparted a distinct smoky appearance to the contents of the bladder. Immediately after the cystoscopic examination the right kidney was exposed (on Sept. 14th) by a lumbar incision and an irregularly shaped stone was removed entire (Fig. 3) . The Fm. 3. stone was composed of oxalate of lime, was roughly triangular in form, and had a very irregular surface. At two of the apices of the triangle sharp crystals. lancet-shaped, projected and were so hard and sharp that they appeared as knife edges when the stone was fresh, but after being dried the crystals lost their lustre and became more rounded. In the case just described the diagnosis of renal calculus was very easy ; all the typical symptoms were present and the physical signs were unequivocal. While in the great majority of cases met with in practice little difficulty is experiencd in determining the presence of a stone in the upper urinary tract by the means now at our
doi:10.1016/s0140-6736(01)28632-2 fatcat:2545s5epbrh3lmsu67fzked7d4