Parish Nurse

From the Parish Nurse – January 2018 ….

Kidney Stones – One of the oldest surgical operations is “cutting for stone.”  Samuel Pepys describes his own operation (on March 26, 1658) quite vividly, and notes in his diary that he spent 24 shillings for “a case for to keep my stone, that I was cut of.”  Benjamin Franklin has written eloquently of the symptoms of stone in the bladder which he and many of his contemporaries had.  The specialty of cutting for stone was known in the time of Hippocrates, and was quite a restricted specialty.  Hippocrates admonishes fellow physicians not to cut for stone, but to leave this condition to the specialists.  Many operative procedures for removal of stones were developed in the seventeenth and eighteenth centuries.

Stones in the kidney and urinary tract are quite common, and still a major problem of urology.  How kidney stones form is reasonably well understood.  Urine is a complex supersaturated solution of many substances, including mineral salts.  Under the right conditions, certain of these substances may precipitate out, condense upon some microscopic nucleus—perhaps a bacterium or a speck of mucus—and grow larger and larger.

Stones, then, are formed of dissolved substances brought to the kidney.  Why they form in some people but not in others is not at all well understood.  Prevalence of stone varies geographically; in some areas it is endemic.  For example, the southeastern part of the U.S. is an area with high incidence of kidney stones.  The location of stones in different parts of the urinary tract has varied historically.  At present, in certain areas of the Near East most stones are present in the bladder and are found in children.

Despite these subtle mysteries, a great deal of practical medical and surgical knowledge is available to the troubled patient.  Stones come in many shapes, sizes, and differences in structural material.  If a stone can be obtained from a patient, analysis of its chemical makeup gives valuable information.  Calcium phosphate stones are very common; among other kinds are urate and cysteine stones.  The latter are primarily due to an error of metabolism in the body’s handling of an amino acid of protein foods.  Sometimes a tumor in certain areas, such as the parathyroid glands, increases the excretion of calcium and phosphorus in the urine and predisposes to calcium phosphate stones.

Other factors that may encourage stone formation are obstructions anywhere in the urinary tract which may cause urine to “back up” and not drain freely from the kidney; prolonged recumbency; infection; and abnormally concentrated urine which may result from insufficient intake of water.  It is obviously important to correct any abnormalities in the urinary tract which may predispose to the formation of new stones, and to correct changes in the urinary tract which may have been brought about by the presence of stones.

Some stones thrive in acid urine, others in alkaline.  Medicines and special diets, such as an acid-ash diet, may help to maintain desired balances and deter future stone formation.  There are other medical measures which a doctor can institute from his special knowledge of the patient’s body chemistry and physical condition.  It is of immediate importance to remove stones that are causing serious trouble, and this generally requires surgery.  Sometimes it is desirable to remove the entire kidney, if its function has been markedly impaired by a large stone or stones, and if the remaining kidney is healthy and quite capable of continuing the labors that it has shouldered anyhow.  Naturally, it is far more desirable for a person who is susceptible to stone formation to co-operate with his doctor in regular checkups, with x-rays and other measures, which may keep trouble from progressing and do everything possible to avert eventual surgical removal of a kidney.

Some stones cause no symptoms, at least for a long time.  Fine crystals, no larger than grains of sand, may pass down the ureter and to the outside world without the patient’s being aware of it.  Some “silent” stone are too large to enter or obstruct the ureter, but they may move about in the kidney and do quiet injury to delicate tissues.  Some stones may practically fill the kidney pelvis and take on the irregular shape of the cavity, like a cast.  These are called “staghorn” calculi from their antler-like appearance.

Many stones, however, do cause acute attacks of excruciating pain.  A bout of “kidney colic” is never forgotten by the person who experiences it.  The agony is caused by a stone which enters the ureter and works its way down, gouging as it goes.  The pain is not necessarily felt in the mid-back, in the area memorialized by old-time advertisements for kidney nostrums, but may be referred to the pelvic region.  Indeed, pain is not invariably excruciating, and the immediate symptoms may be nausea, vomiting, chills and fever.

If the stone gets stuck in the ureter, and medical measures can do little more than relieve pain, surgery will probably be necessary to remove an obstruction which can cause urine to back up, distend, and injure the tract above it more gravely.  Stone-harried kidneys generally are more prone to infections; modern antibacterial drugs afford potent measures of control.

Often a stone passes into the bladder and acute pain subsides.  Bladder stones are relatively easy to remove with instruments which leave no operative scar.  The surgical instrument is inserted through the urethra, the stone grasped and crushed, and the particles withdrawn.  Occasionally, a stone will lodge in the urethra and prevent urination.  Its removal is comparatively easy and always an immense relief to the patient.

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