Vol. XXVII (Absorbed the Morgan County (Ill.) Medical Journal. January 1, 1903.) ST. LOUIS, MAY 25, 1905. Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R. EDWARDS, M. D., Chicago, Ill Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. The THE DIFFERENTIAL DIAGNOSIS of ureteral calculus belongs to the most complicated field in the pathology of the urinary tract. It is beset with many pitfalls. reason is that the symptoms of ureteral calculus are common to any other diseases of the abdominal viscera. A careful study of differential diagnosis should be pursued for apparently typical symptoms of ureteral calculus may exist, however, exploration of the ureter may fail to find the caclulus. Many diseased conditions of the abdominal viscera simulate calculus of the ureter. To illustrate, the difficulty of the differential diagnosis of ureteral calculus. I noted in the literature over eighty cases in exploration of the ureter for calculus in which it was found twenty-three times (27%) only. The diagnosis of calculus failed in 73%. Other remedial renal or ureteral conditions, however, were No. 10 I pro discovered in many of the subjects. pose to discuss the methods of differentiating the diagnosis of ureteral calculus from other diseases of the abdominal viscera from pain. Pain. The chief characteristic of ureteral calculus-pain, may be questionable. The differential diagnosis is finally that of exclusion. All symptoms of ureteral calculus are relative. Pain, practically an essential standard for the diagnosis of ureteral calculus, is a common feature of so many diseased conditions of the abdominal viscera that it is uncertain, unreliable as a single standard. Ureteral calculus may exist without pain. It may produce pain for a period and later become painless, quiescent for an indefinite period. In differential diagnosis as regards pain it is requisite to decide in which visThis is acceral tract the pain is located. complished by analysing and excluding the adjacent abdominal visceral tracts one by It is recognized that in sudden violent ureteral peristalsis or ureteral colic ureteral calculus is the most frequent cause. It is well to bear in mind what might arise in any visceral tract to occasion symptoms resembling that of ureteral calculus. It may be well to analyze the differential diagnosis of pain in each abdominal visceral tract. one. A. TRACTUS URINARIUS. What is the cause of ureteral pain (colic)? The function of the ureter is peristalsis (absorption and secretion). Its object is to transport urine from the kidney to badder. If no interference occurs in the anatomy (structure) or function (physiology) of the ureters or no obstruction occurs in the urinal steam the ureters perform their periodic peristalsis or regular rhythm continually without pain. However, if the ureter walls become inflamed, hypertrophied, atrophied it will perform its rhythm painfully and defectively, that is, with violent rhythm (pain, ureteral colic) or defective rhythm (paresis) failing normally to transport urine whence infection begins from bacterial growth. If obstruction to the ureteral stream arises (from stricture, calculus) intra-ureteral pressure increases and pain (ureteral colic) occurs. Stagnation of urine arises with consequent bacterial growth and infection. differentiate the colic of ureteral calculus from the ureteral colic caused by other dis To FIG 1.-Four ureters (over half life size) injected with starch mixed with red lead. X-rayed and drawn as a model. XXXVIII and XXXIX are from the same male individual. The ureteral dilatations are: Proximal, calyces and pelvis, 1 and 2; middle lumbar, 4; distal pelvic, 6. The ureteral constructions, isthmuses, are: Proximal isthmus or neck, 3; middle isthmus, 5, distal isthmus, 7. Observe the extensive varition in the ureteral dilatations (reservoirs) and constrictions (isthmuses). colic. (A sign is a distict clue to diseases chanker is a sign of syphilis, crepitant rale is a sign of pneumonia, crepitation is a sign of fracture. A symptom is simply an indication of disease). is The Character of Ureteral Pain (Colic). The character of the ureteral pain (colic) as intensity, duration, localization, beginning and ending, does not differentiate that of uretero-lithiasis from other ureteral diseases. Ureteral pain, like that of all the abdominal viscera governed by the sympathetic rhythmic periodic. Ureteral peristalsis, to become painful, must be violent, wild, disordered, irregular rhythm. (2) The character of the pain of ureteral calculus is so varied in degree, extent and location that it furnishes no clue to an exact diagnosis. The pain may be agonizing, so is that of gallstone or appendicitis. Its darting, aching, periodic rhythmical character is duplicated by gallstones, intestinal obstruction, pancreolithiasis. Suicide may be committed as well during gallstone attacks as during ureteral calculus attacks. The character of the pain in ureteral calculus may be of the most agonizing kind. The patient may roll on the floor in wild distress with unsightly contortion, vomiting, retching, pallid, fainting collapsed. The surface of the body may be cold and bedecked with drops of perspiration, yet several other diseases of the abdominal viscera may duplicate the condition, as cholelithiasis, invagination, hernia, appendicitis. In ureteral calculus the characteristic of the pain is inconstancy, variation in radiation, and reflexion which lessens its trustworthiness as a diagnostic factor. In fact reliance upon pain alone is apt to lead to incorrect conclusions an uncertain diagnosis. Pain in ureteral calculus has a tendency to cause sympathetic aching, distress in other abdominal viscera from reflexes over visceral nerve plexuses diminishing its value in differential diagnosis. To prove this assertion pain may be absent in ureteral calculus as post mortems are rich in that testimony. Autopsies frequently demonstrate numerous ureteral calculi with no record of the patient's complaint. Certain conditions or manifestations of pain in ureteral calculus may aid in differential diagnosis. For example, I found in experimenting on the ureter of dog that its initiary peristalsis began at the ureteral pelvis and proximal ureteral isthmus. It appears that the sensitive portion of the ureter is: (a) In the proximal ureteral isthmus; (b) in the ureteral pelvis; (c) in the ureteral calyces in the order mentioned. Hence the proximal end of the ureter is the most sensitive segment. From this it may be concluded that the ureteral For pain, colic, depends (1) to a large degree to the position of the calculus, and (2) on the mobility of the calculus in this sensitive portion of the ureter. I have removed calculi that almost completely occupied the ureteral calyces and pelvis, but the patients complained only of aching in the region of the affected ureter. However, if the calculus is mobile in the sensitive ureteral pelvis and affects the sensitive proximal isthmus (as a small calculus) the pain, colic is frequently violent and agonizing-this pain can, however, be practically duplicated by the mobile, small hepatic calculus in the sensitive pelvis of the cholecyst. We know from experiments on animals and operations on the abdominal organs of man that healthy organs are not sensitive to manipulation, hence it is probable that when violent ureteral colic arises in the ureter ureteritis has occurred. Hence the character of the pain in ureteral calculus possesses such an extent of variation, degree and location that it offers limited value or differential diagnosis. example, the ball valve joint in the pelvis of the cholecyst and the pelvis of the ureter may produce practically identical manifestations as regards the character of the pain. The pain of ureteral calculus as regards its location at the glans penis is uncertain, however, it is liable to be more severe as the ureteral calculus is located more distalward in the ureter. The renal plexus of nerves is composed of many large bundles containing numerous strands which profoundly connect the kidney to the abdominal brain. ureteral irritation is rapidly transmitted to the abdominal brain (a nerve center composed of sympatheteic, cranial and spinal nerves) where it is recognized and emitted over all abdominal (sympathetic) visceral plexuses, over the lumbar (spinal) and sacral (spinal) plexus to the limbs. This accounts for the pain in the abdominal walls, foot, leg and thigh, during attacks of ureteral calculus. The pain in ureteral calculus is increased by physical trauma, yet that is not a differential sign as other ureteral diseases may simulate it. Exercise may increase the pain and hematuria in malignancy. The "stamping pain" in ureteral calculus of Clement Lucas is suggestive only. It is induced by directing the patient to place the hand on an object and flex the thigh strongly and sharply on the abdomen. This places the psoas muscle on tension which will disturb any calculus that may be in the ureter. The patient is then told to stamp vigorously, with the foot of the affected side. By the above means the calculus may he set in motion. It is claimed that unilateral pain in ureteral calculus is of differential diagnostic value. Unilateral Any ureteral pain may be especially, if it be on the right side, confused with appendicitis, hepatic colic, invagination of the ileo-cecal valve and enterolith. On the left side it may be confused with stricture of the left colon, sigmoid and rectum, with mesosigmoiditis and the results of pelvic exudates in the female, oviductitis. Also the calculus may be on the opposite side to the pain. It is uncertain. Some writers report that the pain of ureteral calculus is increased at night. If so it is probably due to diminished heart and arterial rhythm inducing congestion. However, this is of slight practical worth in differential diagnosis, as rheumatic or syphilitic pain may be worse at night. Pain during micturition is of slight value for differential diagnosis, as it may be of urethral, vesical, ureteral, renal origin. It may be from diseased adjacent viscera. The so-called reno-vesical reflex pain, that is, a pain radiating from the kidney to the bladder along the ureter is relatively limited in its value as a factor in differential diagnosis, because other factors than ureteral calculus could simulate it. This reflex pain may be so severe as to cause almost urinal incontinence. The reno-ovarian reflex pain is a pain coursing from the kidney to the ovary, traveling over the ureteral and ovarian nerve plexuses the pain is intensely localized in the region of the ovary. The reno-testicular reflex pain is a single pain of intense localization radiating along the spermatic nerve plexus to the testicle. The reno-uterine reflex pain is as its name indicates a radiating pain from kidney to uterus. The special pains aid in differential diagnosis and are all of relative worth as each one may be caused by various factors. In general the pain (colic) of ureteral calculus. occurs suddenly, continues for several hours or days and subsides suddenly forever (spontaneous evacuation) or may recur (unsuccessful attack). In this it resembles hepatic and pancreatic calculus as well as numerous other diseases. In general the pain of ureteral calculus is referred to the lumbar region, front of the abdomen and chiefly to the side of the affected ureter, yet the most skilled expert may confuse it with appendicitis or hepatic colic. Owing to the vast nerve connection of the ureter the pain of the ureteral calculus is radiated over extensive regions of peripheral sympathetic and spinal nerve, confusing the differential diagnosis. Pain from ureteral calculus may depend to some extent on the condition of the surface of the calculus. The rough uneven, spicular projections of the surface of the calculus causes violent painful peristalsis, colic. The calcium oxalate possesses a rough surface while the uric acid calculus is smoother. Anatomic and physiologic rest generally lessens ureteral colic, however the same occur in almost all colic and violent visceral peristalsis. Calculus may induce a peculiar gait; it adjust the body to the least pain, but so does other diseases. Pain accompanies so many different urinary diseases that its worth as a factor in differential diagnosis of ureteral calculus is limited. Pain may be present in the following: (a) acute nephritis; (b) ureteritis; (c) calculus; (d) cystitis; (e) vesical growths and calculus; (i) polycystic kidney; (j) ureteral blood clot, pus collections, debris and tissue remnants induce ureteral colic in attempting passage; (k) malignancy (renal carcinoma, sarcoma nephroma; (1) suppurating pyocystic kidney; (m) extravasation of blood beneath the renal capsule; (n) ureteral obstruction (stricture, flexion, torsion, angulation, stenosing, valves which checks the ureteral stream (inducing hydro-ureter, pyoureter with pain from increased intra-ureteral pressure; (o) renal (and ureteral) constriction; (p) prostatic diseases; (q) hematuric nephrolgia (naevus of renal parenchyma, congestion); (r) hysteria nephralgia (plexus nervosus renalis); (s) periodic hydro-ureter from obstruction; ureteral flexion at its proximal isthmus or valvular obstruction: (t) para-nephritic abscess (u) tuberculosis of the ureters (producing paresis of the ureteral wall and stenosing its lumen). B. TRACTUS INTESTINALIS. Pain accompanies many intestinal diseases which simulate and resemble those of ureteral calculus as the following: (a) enteroliths; (b) intestinal stricture, partial and complete; (c) gastro-duodenal ulceration; (d) malignancy and tuberculosis; (e) appendicitis; (f) cholelithiasis; (g) pancreo-lithiasis; (h) invagination; (i) volvulus; (j) hernia; (k) splanchnoptosia; (1) acute indigestion; (m) violent peristalsis (lead colic); (n) enteritis; (0) colitis; (p) gastritis; (q) dysentery; (r) mucous colitis (secretory neurosis); (s) typhoid fever; (t) gastric dilatation; (u) gastric pain. C. TRACTUS NERVOSUS. Numerous states in the nerve plexuses of the abdomen give rise to pain resembling that of ureteral calculus as: (a) neuralgia of (sympathetic) the plexus renalís, pelxus ovaricus (ovarian pain) or spermatic (testiclar pain), plexus mesentericus (superior et inferior), especially of the rectum, plexus hepaticus, plexus gastricus; (b) neuralgia of cerebrospinal nerves the intercostals, lumbar (ileo-hpyogastric and ileo-inguinal attributed to ovary by patient); of the lumbar plexus of nerves especially the genito-crural branch: Plate II.-Halftone half life size. It illustrates the form of 16 ureters filled with paraffin, 11 and 12, 14 and 15, 16 and 17, 19 and 20, 21 and 22. 23 and 24, 25 and 26 are pairs from the same subjects. 19 and 20 from a recently born female. 21 and 22 present marked ureteral dilatations and constrictions. The ureteral dilatations are: calyces and pelvis, 1 and 2; lumbar, 4: pelvic, 6 The ureteral constrictions are: Proximal ureteral isthmus, 3; middle ureteral isthmus, 5; distal ureteral isthmus, 7. psoas muscle on the ureter might induce ureteral peristalsis (in ureteritis); (b) in vigorous walking, bending and exercises the trauma of the abdominal muscles, diaphragm, quadratus lumborum might change the position of the kidney (nephroptosia) inducing to a minimum. Jordan Lloyd's "stabbing pain" from violent percussion (blow of the fist on the erector spinae) is simply muscular trauma. The pain from rough riding, shaking is muscular trauma as well as the patient insisting on sleeping on the side of the calcu |