[ Reprinted from The Philadelphia Polyclinic, Vol. IV, May 4, 1895, No. 18.] A CASE OF RENAL CALCULUS BY AUGUSTUS A. ESHNER, M.D. Adjunct Professor of Clinical Medicine iirffi'ei'hiladelphia Polyclinic. There was sent to me in March, 1894, a youth years old, the son of a gardener, on account of recurrent attacks of pain, lead- ing to profound impairment of nutrition, and giving rise to a good deal of anxiety. On inquiry it was learned that during infancy the patient had suffered from what the father designated " marasmus." At the age of 5 years he had an attack of hematuria, unattended with pain, and for four or five years subse- quently he had similar attacks at intervals of from a week to a month. He would thus have perhaps twenty in the course of a year. After this the attacks were attended with pain, but with an absence of hemorrhage. The pain would appear in either hypochondrium (most commonly in the left, but never in both at the same time) and extended to the loin. These attacks were repeated about once a month at first, but increased in frequency until they recurred once a week or oftener, and lasting from six to eight hours. They usually occurred at or toward night. The pain was relieved by morphin, but the incidence of the attacks bore no relation to season or weather or the state of the bowels. There had never been jaundice. Hematuria had been re- peated about a year before the patient came under my observation. There had never been an appreciable swelling, and I also was unable to detect any. There was, however, tenderness in both hypochondria and in the loins. To me the patient stated that there was an absence of pain referred to the penis or the testicles. The urine, examined a day after a parox- ysm, was perfectly clear, of amber color and acid reaction; it had a specific gravity of 1020.5, and failed to react to tests for albu- min and sugar. It contained a moderate number of colorless blood-corpuscles and a smaller number of red cells. Though the patient was pallid and spare and his expression somewhat anxious, his appearance was not cachectic. In the absence of distinctive physical phenomena, a tentative diagnosis of neuralgia was made and gelseminin (Merck), gr. t. d., was prescribed, together with quinin sulfate, gr. v., in the morning (the patient lived in a malarious neighborhood), and salts for the relief of constipation. The treatment exerted little or no influence upon the recurrence or intensity of the attacks, so that finally, by exclusion, it was concluded that there must exist either a renal neoplasm or a calculus in the kidney. The long con- tinuance of the symptoms was against malig- nant disease, while the variability in the situation of the pain in different paroxysms, as well as the absence of distinctive features from the urinary sediment, did not permit of an absolute diagnosis of calculus. The case was now seen by Dr. Thomas S. K. Morton, who confirmed the suspicion of renal calculus. Vesical stone or tumor was excluded by instrumental exploration. Dr. Morton having had success in dislodging renal calculi from the use of diethylene dia- min (piperazin), we determined to employ that drug in doses of five grains thrice daily, largely diluted. The lad was also put on a milk-diet and kept in bed. After six days of 2 this treatment the patient noticed a marked change in his symptoms, which pointed to the descent of a foreign body down the left ureter, and, at the termination of a few hours, signs of a vesical calculus were clearly present. There was frequent micturition, with stoppage of urine during that act, burn- ing in the bladder and much pain referred to the glans penis. A sound introduced into the bladder came in contact with a smooth, soft body, which conveyed the sensation of a firm, gritty blood-clot, and which measured about one-quarter inch in its smallest and three- eighths inch in its longest diameter. Dr. Morton, from this examination, concluded that we had to deal with a descended renal calculus, having its outer layers somewhat softened-perhaps as an effect of the action of the piperazin. The lad was anesthetized on the following day and litholapaxy performed by Dr. Mor- ton. The calculus was easily caught, crushed, and the fragments evacuated by the Bigelow washing-apparatus. Eighteen grains of debris were recovered. No blood was lost. The operation was unattended with shock or pain; subsequent catheterization was un- necessary, and at no time was there any blood in the urine. Two days later the lad was permitted to get up, and on the next day he was sent home, entirely without discomfort or any of his previous symptoms. There has been no recurrence of attacks, and the boy has gained notably in weight, and has changed in disposition for the better. He recently- almost a year after the operation-presented himself, and stated that he was in perfect health. The calculus removed proved to be com- posed of uric acid. The outer layers were soft and plastic, as if the dense portion had been dissolved away, leaving only the plastic matrix of blood and mucus. Whether or not this was an effect of the piperazin-propter hoc or post hoc-I do not presume to say, but am content to report the case for what it teaches. The Philadelphia Polyclinic AND COLLEGE FOR GRADUATES IN MEDICINE THE POLYCLINIC HOSPITAL, LOMBARD STREET WEST OF 18th STREET, PHILADELPHIA, PA. A Great Hospital devoted strictly to Post-Graduate Teaching. Actual clinical and laboratory work, and indi- vidual instruction in all branches of medicine and surgery. The general schedule offers a full day's instruction for six days of each week, with perfect economy of time. The special schedules enable the student to devote the whole day to work on one particular branch. For announcement, schedules, and full information, address: The Philadelphia Polyclinic. 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