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Ureteral calculi
URETERAL CALCULI GEORGE R. LIVERMORE, M.D., P.A.C.S. MEMPHIS, TENN.
T is the generaIIy accepted beIief that uretera caIcuIi are formed in the kidney, then pass down the ureter. Hunner,l however, beIieves that caIcuIi are formed primariIy in the ureter, due to stasis and infection, the resuIt of stricture of the ureter. It is unquestionabIy true that stasis and infection play Ieading roIes in the formation of uretera caIcuIi, but that stricture of the ureter is the soIe cause is a statement that most of us are unwiIIing to accept. There are many theories as to the cause of urinary caIcuIi, none of which, however, is universaIIy accepted. The urine is a soiution of crystaIIine materia1, and the crystaIIine materia1 is said to be heId in soIution by certain constituents caIIed coIIoids. It is upon this that Spitzer and HiIIkowitz2 buiId their coIIoida1 theory as to the causation of urinary caIcuIi. The oId idea of a nucIeus or nidus being necessary for the formation of a caIcuIus, such as a foreign body, a bIood cIot, a cIump of pus, or bacteria stiI1 hoIds true, and the coIIoida1 theory fits in weII with it, as its advocates claim that when the coIIoids of the urine coaguIate, they no Ionger hold the crystaIIine matter in soIution, but themselves in the coaguIated state form a network, upon which the crystaIIine material is deposited. It is aIso cIaimed that the crystaIIine matter may act as the nucIeus and aIternate Iayers of crystaIs and coIIoids may be deposited to form a caIcuIus. CIumps of bacteria, too, may act as a nucleus, upon which crystaIs and coIIoids may deposit. The work of Keyser,3 and Rosenow and Meisser4 has concIusiveIy proved the prediIection of certain strains of bacteria to the formation of caIcuIi. Eisendrath and RoInick5 state that coIon and saImoneIIa baciIIi cause precipitation of
I
214
URETERAL
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215
the normaI coIIoids of the urine. One of the newer theories, a diet deficient in vitamins A and D, has recentIy been advanced and the feeding of such a diet to rats has been foIIowed by the formation of caIcuIi in both the kidneys and the bIadder. This has been confirmed by Dr. A. R. BIiss in the Iaboratory of the University of Tennessee. In addition to theforegoing, stasis and fauIty metaboIism must be considered as etioIogica1 factors in the formation of urinary caIcuIi. The triad: infection, stasis and fauIty metaboIism was given as the author’s theory as to the causation of urinary caIcuIi in a paper6 read before the section on UroIogy of the Southern Medical Association, November, I 924. If the coIon and saImoneIIa baciIIi cause precipitation of the norma coIIoids of the urine, as reported by Eisendrath and RoInick,5 perhaps other bacteria, under varying conditions, may produce the same resuIt. Therefore, the coIIoida1 theory further substantiates the author’s contention that infection, stasis and fauIty metaboIism are the chief factors in the etioIogy of urinary caIcuIi. SYMPTOMS
The symptoms of uretera caIcuIi vary according to the character of the obstruction, the degree of infection and the condition of the kidney. Eisendrath and RoInick5 give six different cIinica1 types, viz., (I) those with predominant symptoms of renaI infection with or without a history of pain or coIic; (2) those in which pain is the outstanding feature; (3) those in which anuria is predominant; (4) those presenting evidence of non-infected hydronephrosis; (5) those in which a hematuria or pyuria without IocaIizing signs is present; (6) those presenting no symptoms or Iatent cases. By far the most frequent symptom of uretera caIcuIus is pain, and this usuaIIy of a coIicky character with radiation to the groin, testicIes or gIans penis in the maIe, to the Iabia in the femaIe. Nausea and vomiting are present, especiaIIy
216
GEORGE
R. LIVERMORE
when the pain is coIicky. BIood, pus, aIbumin and bacteria may be found in the urine. Often the pus and bIood ceIIs are so few as to be considered of no consequence and aIthough by no means can they be caIIed a pathognomonic sign of caIcuIus, in conjunction with the other symptoms and signs they shouId Iead to a correct diagnosis. In cases with marked obstruction there may be symptoms of pyeIonephritis : chiIIs, fever and sweats, a high Ieucocyte count and a high poIymorphonucIear percentage; and when the stone is impacted, in addition to the foregoing, there may be compIete anuria, obstructive on the affected side and reffex on the other or obstructive on both sides. In other cases, even though there is pus in the urine, there are IittIe or no symptoms of infection. The differentia1 diagnosis from disease of the gaI1 bIadder, appendix, coIon and femaIe peIvic organs is at times not easy and it is here that cystoscopy and x-ray prove so invaIuabIe. Often a shadow in the Iine of the ureter may be interpreted as a stone when stereoscopic fiIms wiI1 prove it to be behind or in front of the ureter. Kretschmer’ suggested the making of two exposures on the same fiIm, with a shift of the x-ray tube, with the catheters in position as a means of proving a shadow in the ureter, and Bransford Lewis* made it stiI1 more accurate by substituting a meta fIexibIe instrument for the uretera catheter. The sensation of obstruction to the passage of the uretera catheter is not pathognomonic for often the catheter passes the caIcuIus without the Ieast sense of obstruction. Scratches on the wax tipped catheter are heIpfu1, but great care must be exercised to be sure they are made by the stone. Intravenous urography is one of the newer aids in cIearing up the diagnosis, especiaIIy in caIcuIi that do not cast a shadow on the x-ray pIate, and the injection of pyeIographic media into the peIvis and ureter often makes visibIe a caIcuIus that wouId otherwise be overIooked. Oxygen urograms are especiaIIy vaIuabIe in such cases and aIthough air injections have proved
URETERAL
CALCULI
217
dangerous (Thompson’s9 series of cases without mishap seemq to disprove this) no harm has resuIted when oxygen was used. TREATMENT
The treatment of uretera caIcuIi depends upon (I) the size, (2) the number, (3) the Iocation, (4) the condition of the patient and (5) the functiona capacity of the kidneys. (I) With a caIcuIus of 0.5 to 0.75 cm. in diameter, every effort shouId be made to assist its passage down the ureter. (2) MuItipIe caIcuIi are much more diflicuh to pass than singIe ones, but it is remarkabIe what can be accomphshed by care, patience and persistence. (3) CaIcuIi near the bIadder are more easiIy freed than those higher up. They are more accessibIe to instrumentation and there is Iess danger of injury to the ureter in disIodging them. Stones in the Iower ureter wiII as a ruIe pass to the bIadder; aIthough when Iodged and constantIy added to, they may grow to a size that makes their further progress impossibIe. (4) The condition of the patient must be considered first, and if grave the method that offers the quickest and safest reIief from the constitutiona symptoms, with the minimum of shock, regardIess of whether the stone is removed or not, shouId be the method of choice. (5) The condition of the kidneys. Here, too, the same considerations as just stated shouId govern the method of treatment. I am a firm beIiever in the cystoscopic remova of uretera caIcuIi, and think every effort shouId be made to reIieve the patient in this way, when the size of the caIcuIus and the condition of the kidneys and the patient justify it. Some years ago I devised a uretera stone disIodger and Iater a uretera diIator, both of which have proved of great vaIue in assisting patients to pass uretera caIcuIi. (See Figs. I and 2.) The method as used by the author consists in first ascertaining the functiona capacity of each kidney. If at the first attempt we are unabIe to pass a catheter beyond the
GEORGE
218
R. LIVERMORE
stone in order to make a phenoIsuIphonphthaIein test and the patient’s condition justifies further instrumentation, we pass catheters, bougies and the Livermore diIator to the stone
FIG. I. Livermore
uretera
stone dislodger.
and by thus diIating the ureter beIow the stone, hope to cause its passage. FrequentIy the stone wiI1 pass after one such treatment. In those cases where the stone is adherent to the mucous membrane due to spicuIes or irreguIarities on the stone or is embedded in the mucosa, it may sometimes be freed with the Livermore stone disIodger. If, however, the patient’s condition is poor, then operation shouId be done a”t once. I have never seen any special benefit
FIG.
2.
Livermore’s
ureteraI
dilator.
A.
Entire
instrument.
B. Tip closed. c. Tip open.
from the injection of steriIe oIive oi1. If the stone does not pass in a week, and the patient has no untoward symptoms, we again attempt to pass a bougie or a catheter, preferabIy one with a filiform tip (a BIassucci), beyond the stone and in the majority of cases are successfu1: A functiona test is now made, and if the kidney function is good, the catheter is Ieft in and with drainage estabIished and the back pressure on the kidney
URETERAL
CALCULI
219
reIieved, we now feel safe in proIonging our cystoscopic manipuIations as Iong as the condition of the patient wiI1 permit. You doubtIess know that there are some patients who are intoIerant to cystoscopic manipuIations and whose reactions to them are rather severe. The intravenous injection of hexamethyIenamine tetramine gr. xxxi, given when the treatment is finished, often prevents reactions and given twice a day diminishes their severity after they have occurred. In patients of this type, operation must be done at once. After succeeding in passing one catheter beyond the caIcuIus and Ieaving it in for severa days, we are frequentIy abIe to pass one or more catheters beyond the stone by the side of the one passed at the first treatment. The progress of the stone may be noted by repeated x-ray fXms. DiIating the ureter beIow the stone with the Livermore, WaIther or Dourmaskin diIator aids materiaIIy in assisting its passage to the bIadder. When the stone reaches the intramura1 portion of the ureter, it is often heId there and no amount of diIatation wiI1 cause it to enter the bIadder. FuIguration of the edema about the orifice, or better stiI1, meatotomy with the NeiI Moore eIectrode, or with the Bumpus scissors after fuIguration aIong the Iine of incision aIIows it to pass into the bIadder. We have used the cutting current (of the McCarthy unit for prostatic resection) with exceIIent resuIts and no hemorrhage in performing meatotomy for the remova of stones near the uretera meatus. The twisting of three or more catheters about the stone foIIowed by gentle puIIing on the catheters as suggested by Bumpus wiI1 often disiodge the caIcuIus and deIiver it into the bIadder. How Iong can cystoscopic manipulations be continued? Our guide is the functiona output of the kidneys and the reaction of the patient. If the function of the kidney remains good, we can continue our attempts at removal, provided the condition of the patient is satisfactory. When the kidney function begins to fai1 and the catheter drainage does not restore it, then the stone shouId be removed by operation. It is a fact in some cases that the obstructing caIcuIus has
220
GEORGE
R. LIVERMORE
produced so much back pressure on the kidney that there may be no excretion of phenoIsuIphonephthaIein, when the catheter is first passed beyond the stone. We must not jump to a hasty concIusion that such a kidney is hopeIess for often with continued drainage the function is restored to norma or nearIy so. In that type of case where we have stones in both ureters with symptoms of acute pyeIonephritis-rigors, fever, sweats and perhaps anuria, usuaIIy a very III patient, it is safest to attempt to pass a catheter beyond the stones to each peIvis and estabIish drainage which in the majority of cases wiI1 enabIe the patient to get in condition to stand an operation or eIse the diIation of the ureters wiI1 permit the stones to pass, thus bringing about the same resuIt without operative interference. A note of warning must be sounded, however, as to the danger of too proIonged attempts at cystoscopic remova of uretera caIcuIi, for if persisted in when the kidney function is faiIing or when catheter drainage does not cause the prompt subsidence of rigors and fever or in that type where we are unabIe to pass a catheter or bougie beyond the stone, there is grave danger of causing destruction of the kidney and perhaps the death of the patient. It has Iong been recognized that patients with chronic kidney infections, provided their kidney function is fairly good, withstand acute attacks much better than those who have their first acute attacks. This is due to the fact that a certain amount of antibodies (opsonins) has been deveIoped in fighting the chronic infection. These act as the first Iine of defense whiIe a second or reserve force is being prepared. In addition the kidney has become somewhat fortified against back pressure and is more capabIe of protecting itseIf against it than the kidney which has never been subjected to it before. Such chronic cases often mask the seriousness of the true condition of the patient by their Iack of grave symptoms.
URETERAL
CALCULI
221
I have recentIy had such a case in a man fifty-eight years of age, who has had chronic pyeIonephritis for twenty-five years. He has been cystoscoped on an average of once a month during this entire time and as he is a traveIing saIesman, and covers nearIy a11 the States in the Union, I fee1 sure he has been cystoscoped by practicaIIy every prominent uroIogist in a11 the Iarge cities of the country. In the past five years he has deveIoped caIcuIi in both kidneys; three in the Ieft, and two in the right. The function of both kidneys has remained remarkabIy good unti1 the caIcuIi deveIoped, when with repeated uIceration, sIoughing and profuse hematuria the function has been much impaired. About six months ago one of the caIcuIi in his Ieft kidney peIvis entered the ureter and when I saw him about six weeks Iater was about midway from the kidney to the bIadder. A catheter was easiIy passed by the side of the caIcuIus to the peIvis of the Ieft kidney and a Iarge amount of pus and urine withdrawn. The function of the kidney, however, was about the same as when seen before the caIcuIus began its descent. FoIIowing this treatment, he made an extensive trip and was as we11as usua1, aIthough he had some pain in his Ieft Ioin and repeated attacks of marked hematuria. About two months ago he had an attack of Ieft uretera coIic with rigors, high fever and sweats, a high Ieucocyte count and a high polymorphonuclear percentage. Under catheter drainage in another city he had a stormy convaIescence, being both septic and uremic, but in two weeks his temperature was norma and his output good, and remained so for four days when the retention catheter was removed. He again had rigors, fever and sweats, which promptIy subsided when the uretera catheter was repIaced. An x-ray showed the stone Iodged in the Ieft ureter near the peIvic brim and too Iarge to pass. His condition was too serious to admit of operation, so the catheter was Ieft in for one week, when after five days of freedom from fever, it was removed. He had no fever for four days, then it rose to IOO’F., was normaI for four days, then IOI’F., was normaI one day, then for two days did not go above 100°F. The next day it reached 101 OF. He had had no rigors or drenching sweats and no severe pain or tenderness since the catheter had been repIaced the Iast time and none since its remova1, and he had been sitting up in a chair on the days when his temperature was normaI. The Iower poIe of the Ieft kidney, which had been paIpabIe for years, was now feIt 2 inches beIow the free border of the ribs. An attempt was made to repIace the catheter, but it couId not be passed beyond the stone. As his condition was so poor, I feIt that a nephrostomy offered the best chance, and under gas and synergistic anaIgesia an incision was made over the Ieft costovertebra1 angIe and a Iarge perirenaI abscess encountered, from which IOOO C.C. of fou1 (coIon) pus were drained. A nephrostomy was then done and 6 oz. of fouI (coIon) pus were evacuated
222
GEORGE
R. LIVERMORE
from the Ieft kidney peIvis. A 36 inch rubber tube was sutured in the nephrostomy wound, the kidney peIvis washed with saIine and then 2 ounces of 2 per cent mercurochrome injected and aIIowed to run out. He has made a satisfactory recovery and when his condition permits, I wiI1 operate and remove the caIcuIus from the Ieft ureter and aIIow the nephrostomy to hea1. This case is cited to show how a chronic case can mask symptoms of most profound gravity. REFERENCES I. HUNNER, G. L. CaIcuIus of the urinary tract, treated by new methods. End results. Trans. South. Surg. Assn., 40: 1-17, 1927. 2. SPITZER, W. M., and HILLKOWITZ, P. The cause of stone in urinary tract. J. urol., g: No. 4, 1924. 3. KEYSER, L. D. The mechanism of the formation of urinary caIcuIi. Ann. Surg., 77: 210, 1923. 4. ROSENOW and MmSSEn..Nephritis and urinary cafcuh, fohowing the experimental production of chronic foci of infection. J. A. M. A., 78: 266, 1922. 5. EISENDRATHand ROLNICK. UroIogy. PhiIa., Lippincott, x928. 6. LIVERMORE, G. R. Nephrohthiasis. South. M. A. J., 18: No. 8, 1925. 7. KRETSCHMER,H. L. The diagnosis and treatment of stone in the ureter. J. A. M. A., 80: No. 20, ‘923. 8 LEWIS, B. A new sign in the diagnosis of ureteral stones. J. Ural., 7: 487, 1922. g. THOMPSON, R. Observations on air urography. South. M. J., 22: 422-28, 1929. IO. BUMPUS, H. C., JR. UreteraI meatotomy for removal of stones from the ureter. J. Vrol., 16: 359, 1926. [For Discussion see p. 25I .]
T is the generaIIy accepted beIief that uretera caIcuIi are formed in the kidney, then pass down the ureter. Hunner,l however, beIieves that caIcuIi are formed primariIy in the ureter, due to stasis and infection, the resuIt of stricture of the ureter. It is unquestionabIy true that stasis and infection play Ieading roIes in the formation of uretera caIcuIi, but that stricture of the ureter is the soIe cause is a statement that most of us are unwiIIing to accept. There are many theories as to the cause of urinary caIcuIi, none of which, however, is universaIIy accepted. The urine is a soiution of crystaIIine materia1, and the crystaIIine materia1 is said to be heId in soIution by certain constituents caIIed coIIoids. It is upon this that Spitzer and HiIIkowitz2 buiId their coIIoida1 theory as to the causation of urinary caIcuIi. The oId idea of a nucIeus or nidus being necessary for the formation of a caIcuIus, such as a foreign body, a bIood cIot, a cIump of pus, or bacteria stiI1 hoIds true, and the coIIoida1 theory fits in weII with it, as its advocates claim that when the coIIoids of the urine coaguIate, they no Ionger hold the crystaIIine matter in soIution, but themselves in the coaguIated state form a network, upon which the crystaIIine material is deposited. It is aIso cIaimed that the crystaIIine matter may act as the nucIeus and aIternate Iayers of crystaIs and coIIoids may be deposited to form a caIcuIus. CIumps of bacteria, too, may act as a nucleus, upon which crystaIs and coIIoids may deposit. The work of Keyser,3 and Rosenow and Meisser4 has concIusiveIy proved the prediIection of certain strains of bacteria to the formation of caIcuIi. Eisendrath and RoInick5 state that coIon and saImoneIIa baciIIi cause precipitation of
I
214
URETERAL
CALCULI
215
the normaI coIIoids of the urine. One of the newer theories, a diet deficient in vitamins A and D, has recentIy been advanced and the feeding of such a diet to rats has been foIIowed by the formation of caIcuIi in both the kidneys and the bIadder. This has been confirmed by Dr. A. R. BIiss in the Iaboratory of the University of Tennessee. In addition to theforegoing, stasis and fauIty metaboIism must be considered as etioIogica1 factors in the formation of urinary caIcuIi. The triad: infection, stasis and fauIty metaboIism was given as the author’s theory as to the causation of urinary caIcuIi in a paper6 read before the section on UroIogy of the Southern Medical Association, November, I 924. If the coIon and saImoneIIa baciIIi cause precipitation of the norma coIIoids of the urine, as reported by Eisendrath and RoInick,5 perhaps other bacteria, under varying conditions, may produce the same resuIt. Therefore, the coIIoida1 theory further substantiates the author’s contention that infection, stasis and fauIty metaboIism are the chief factors in the etioIogy of urinary caIcuIi. SYMPTOMS
The symptoms of uretera caIcuIi vary according to the character of the obstruction, the degree of infection and the condition of the kidney. Eisendrath and RoInick5 give six different cIinica1 types, viz., (I) those with predominant symptoms of renaI infection with or without a history of pain or coIic; (2) those in which pain is the outstanding feature; (3) those in which anuria is predominant; (4) those presenting evidence of non-infected hydronephrosis; (5) those in which a hematuria or pyuria without IocaIizing signs is present; (6) those presenting no symptoms or Iatent cases. By far the most frequent symptom of uretera caIcuIus is pain, and this usuaIIy of a coIicky character with radiation to the groin, testicIes or gIans penis in the maIe, to the Iabia in the femaIe. Nausea and vomiting are present, especiaIIy
216
GEORGE
R. LIVERMORE
when the pain is coIicky. BIood, pus, aIbumin and bacteria may be found in the urine. Often the pus and bIood ceIIs are so few as to be considered of no consequence and aIthough by no means can they be caIIed a pathognomonic sign of caIcuIus, in conjunction with the other symptoms and signs they shouId Iead to a correct diagnosis. In cases with marked obstruction there may be symptoms of pyeIonephritis : chiIIs, fever and sweats, a high Ieucocyte count and a high poIymorphonucIear percentage; and when the stone is impacted, in addition to the foregoing, there may be compIete anuria, obstructive on the affected side and reffex on the other or obstructive on both sides. In other cases, even though there is pus in the urine, there are IittIe or no symptoms of infection. The differentia1 diagnosis from disease of the gaI1 bIadder, appendix, coIon and femaIe peIvic organs is at times not easy and it is here that cystoscopy and x-ray prove so invaIuabIe. Often a shadow in the Iine of the ureter may be interpreted as a stone when stereoscopic fiIms wiI1 prove it to be behind or in front of the ureter. Kretschmer’ suggested the making of two exposures on the same fiIm, with a shift of the x-ray tube, with the catheters in position as a means of proving a shadow in the ureter, and Bransford Lewis* made it stiI1 more accurate by substituting a meta fIexibIe instrument for the uretera catheter. The sensation of obstruction to the passage of the uretera catheter is not pathognomonic for often the catheter passes the caIcuIus without the Ieast sense of obstruction. Scratches on the wax tipped catheter are heIpfu1, but great care must be exercised to be sure they are made by the stone. Intravenous urography is one of the newer aids in cIearing up the diagnosis, especiaIIy in caIcuIi that do not cast a shadow on the x-ray pIate, and the injection of pyeIographic media into the peIvis and ureter often makes visibIe a caIcuIus that wouId otherwise be overIooked. Oxygen urograms are especiaIIy vaIuabIe in such cases and aIthough air injections have proved
URETERAL
CALCULI
217
dangerous (Thompson’s9 series of cases without mishap seemq to disprove this) no harm has resuIted when oxygen was used. TREATMENT
The treatment of uretera caIcuIi depends upon (I) the size, (2) the number, (3) the Iocation, (4) the condition of the patient and (5) the functiona capacity of the kidneys. (I) With a caIcuIus of 0.5 to 0.75 cm. in diameter, every effort shouId be made to assist its passage down the ureter. (2) MuItipIe caIcuIi are much more diflicuh to pass than singIe ones, but it is remarkabIe what can be accomphshed by care, patience and persistence. (3) CaIcuIi near the bIadder are more easiIy freed than those higher up. They are more accessibIe to instrumentation and there is Iess danger of injury to the ureter in disIodging them. Stones in the Iower ureter wiII as a ruIe pass to the bIadder; aIthough when Iodged and constantIy added to, they may grow to a size that makes their further progress impossibIe. (4) The condition of the patient must be considered first, and if grave the method that offers the quickest and safest reIief from the constitutiona symptoms, with the minimum of shock, regardIess of whether the stone is removed or not, shouId be the method of choice. (5) The condition of the kidneys. Here, too, the same considerations as just stated shouId govern the method of treatment. I am a firm beIiever in the cystoscopic remova of uretera caIcuIi, and think every effort shouId be made to reIieve the patient in this way, when the size of the caIcuIus and the condition of the kidneys and the patient justify it. Some years ago I devised a uretera stone disIodger and Iater a uretera diIator, both of which have proved of great vaIue in assisting patients to pass uretera caIcuIi. (See Figs. I and 2.) The method as used by the author consists in first ascertaining the functiona capacity of each kidney. If at the first attempt we are unabIe to pass a catheter beyond the
GEORGE
218
R. LIVERMORE
stone in order to make a phenoIsuIphonphthaIein test and the patient’s condition justifies further instrumentation, we pass catheters, bougies and the Livermore diIator to the stone
FIG. I. Livermore
uretera
stone dislodger.
and by thus diIating the ureter beIow the stone, hope to cause its passage. FrequentIy the stone wiI1 pass after one such treatment. In those cases where the stone is adherent to the mucous membrane due to spicuIes or irreguIarities on the stone or is embedded in the mucosa, it may sometimes be freed with the Livermore stone disIodger. If, however, the patient’s condition is poor, then operation shouId be done a”t once. I have never seen any special benefit
FIG.
2.
Livermore’s
ureteraI
dilator.
A.
Entire
instrument.
B. Tip closed. c. Tip open.
from the injection of steriIe oIive oi1. If the stone does not pass in a week, and the patient has no untoward symptoms, we again attempt to pass a bougie or a catheter, preferabIy one with a filiform tip (a BIassucci), beyond the stone and in the majority of cases are successfu1: A functiona test is now made, and if the kidney function is good, the catheter is Ieft in and with drainage estabIished and the back pressure on the kidney
URETERAL
CALCULI
219
reIieved, we now feel safe in proIonging our cystoscopic manipuIations as Iong as the condition of the patient wiI1 permit. You doubtIess know that there are some patients who are intoIerant to cystoscopic manipuIations and whose reactions to them are rather severe. The intravenous injection of hexamethyIenamine tetramine gr. xxxi, given when the treatment is finished, often prevents reactions and given twice a day diminishes their severity after they have occurred. In patients of this type, operation must be done at once. After succeeding in passing one catheter beyond the caIcuIus and Ieaving it in for severa days, we are frequentIy abIe to pass one or more catheters beyond the stone by the side of the one passed at the first treatment. The progress of the stone may be noted by repeated x-ray fXms. DiIating the ureter beIow the stone with the Livermore, WaIther or Dourmaskin diIator aids materiaIIy in assisting its passage to the bIadder. When the stone reaches the intramura1 portion of the ureter, it is often heId there and no amount of diIatation wiI1 cause it to enter the bIadder. FuIguration of the edema about the orifice, or better stiI1, meatotomy with the NeiI Moore eIectrode, or with the Bumpus scissors after fuIguration aIong the Iine of incision aIIows it to pass into the bIadder. We have used the cutting current (of the McCarthy unit for prostatic resection) with exceIIent resuIts and no hemorrhage in performing meatotomy for the remova of stones near the uretera meatus. The twisting of three or more catheters about the stone foIIowed by gentle puIIing on the catheters as suggested by Bumpus wiI1 often disiodge the caIcuIus and deIiver it into the bIadder. How Iong can cystoscopic manipulations be continued? Our guide is the functiona output of the kidneys and the reaction of the patient. If the function of the kidney remains good, we can continue our attempts at removal, provided the condition of the patient is satisfactory. When the kidney function begins to fai1 and the catheter drainage does not restore it, then the stone shouId be removed by operation. It is a fact in some cases that the obstructing caIcuIus has
220
GEORGE
R. LIVERMORE
produced so much back pressure on the kidney that there may be no excretion of phenoIsuIphonephthaIein, when the catheter is first passed beyond the stone. We must not jump to a hasty concIusion that such a kidney is hopeIess for often with continued drainage the function is restored to norma or nearIy so. In that type of case where we have stones in both ureters with symptoms of acute pyeIonephritis-rigors, fever, sweats and perhaps anuria, usuaIIy a very III patient, it is safest to attempt to pass a catheter beyond the stones to each peIvis and estabIish drainage which in the majority of cases wiI1 enabIe the patient to get in condition to stand an operation or eIse the diIation of the ureters wiI1 permit the stones to pass, thus bringing about the same resuIt without operative interference. A note of warning must be sounded, however, as to the danger of too proIonged attempts at cystoscopic remova of uretera caIcuIi, for if persisted in when the kidney function is faiIing or when catheter drainage does not cause the prompt subsidence of rigors and fever or in that type where we are unabIe to pass a catheter or bougie beyond the stone, there is grave danger of causing destruction of the kidney and perhaps the death of the patient. It has Iong been recognized that patients with chronic kidney infections, provided their kidney function is fairly good, withstand acute attacks much better than those who have their first acute attacks. This is due to the fact that a certain amount of antibodies (opsonins) has been deveIoped in fighting the chronic infection. These act as the first Iine of defense whiIe a second or reserve force is being prepared. In addition the kidney has become somewhat fortified against back pressure and is more capabIe of protecting itseIf against it than the kidney which has never been subjected to it before. Such chronic cases often mask the seriousness of the true condition of the patient by their Iack of grave symptoms.
URETERAL
CALCULI
221
I have recentIy had such a case in a man fifty-eight years of age, who has had chronic pyeIonephritis for twenty-five years. He has been cystoscoped on an average of once a month during this entire time and as he is a traveIing saIesman, and covers nearIy a11 the States in the Union, I fee1 sure he has been cystoscoped by practicaIIy every prominent uroIogist in a11 the Iarge cities of the country. In the past five years he has deveIoped caIcuIi in both kidneys; three in the Ieft, and two in the right. The function of both kidneys has remained remarkabIy good unti1 the caIcuIi deveIoped, when with repeated uIceration, sIoughing and profuse hematuria the function has been much impaired. About six months ago one of the caIcuIi in his Ieft kidney peIvis entered the ureter and when I saw him about six weeks Iater was about midway from the kidney to the bIadder. A catheter was easiIy passed by the side of the caIcuIus to the peIvis of the Ieft kidney and a Iarge amount of pus and urine withdrawn. The function of the kidney, however, was about the same as when seen before the caIcuIus began its descent. FoIIowing this treatment, he made an extensive trip and was as we11as usua1, aIthough he had some pain in his Ieft Ioin and repeated attacks of marked hematuria. About two months ago he had an attack of Ieft uretera coIic with rigors, high fever and sweats, a high Ieucocyte count and a high polymorphonuclear percentage. Under catheter drainage in another city he had a stormy convaIescence, being both septic and uremic, but in two weeks his temperature was norma and his output good, and remained so for four days when the retention catheter was removed. He again had rigors, fever and sweats, which promptIy subsided when the uretera catheter was repIaced. An x-ray showed the stone Iodged in the Ieft ureter near the peIvic brim and too Iarge to pass. His condition was too serious to admit of operation, so the catheter was Ieft in for one week, when after five days of freedom from fever, it was removed. He had no fever for four days, then it rose to IOO’F., was normaI for four days, then IOI’F., was normaI one day, then for two days did not go above 100°F. The next day it reached 101 OF. He had had no rigors or drenching sweats and no severe pain or tenderness since the catheter had been repIaced the Iast time and none since its remova1, and he had been sitting up in a chair on the days when his temperature was normaI. The Iower poIe of the Ieft kidney, which had been paIpabIe for years, was now feIt 2 inches beIow the free border of the ribs. An attempt was made to repIace the catheter, but it couId not be passed beyond the stone. As his condition was so poor, I feIt that a nephrostomy offered the best chance, and under gas and synergistic anaIgesia an incision was made over the Ieft costovertebra1 angIe and a Iarge perirenaI abscess encountered, from which IOOO C.C. of fou1 (coIon) pus were drained. A nephrostomy was then done and 6 oz. of fouI (coIon) pus were evacuated
222
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from the Ieft kidney peIvis. A 36 inch rubber tube was sutured in the nephrostomy wound, the kidney peIvis washed with saIine and then 2 ounces of 2 per cent mercurochrome injected and aIIowed to run out. He has made a satisfactory recovery and when his condition permits, I wiI1 operate and remove the caIcuIus from the Ieft ureter and aIIow the nephrostomy to hea1. This case is cited to show how a chronic case can mask symptoms of most profound gravity. REFERENCES I. HUNNER, G. L. CaIcuIus of the urinary tract, treated by new methods. End results. Trans. South. Surg. Assn., 40: 1-17, 1927. 2. SPITZER, W. M., and HILLKOWITZ, P. The cause of stone in urinary tract. J. urol., g: No. 4, 1924. 3. KEYSER, L. D. The mechanism of the formation of urinary caIcuIi. Ann. Surg., 77: 210, 1923. 4. ROSENOW and MmSSEn..Nephritis and urinary cafcuh, fohowing the experimental production of chronic foci of infection. J. A. M. A., 78: 266, 1922. 5. EISENDRATHand ROLNICK. UroIogy. PhiIa., Lippincott, x928. 6. LIVERMORE, G. R. Nephrohthiasis. South. M. A. J., 18: No. 8, 1925. 7. KRETSCHMER,H. L. The diagnosis and treatment of stone in the ureter. J. A. M. A., 80: No. 20, ‘923. 8 LEWIS, B. A new sign in the diagnosis of ureteral stones. J. Ural., 7: 487, 1922. g. THOMPSON, R. Observations on air urography. South. M. J., 22: 422-28, 1929. IO. BUMPUS, H. C., JR. UreteraI meatotomy for removal of stones from the ureter. J. Vrol., 16: 359, 1926. [For Discussion see p. 25I .]