305 



LITHONTRIPTICS. 



LITHOTOMY. 



31X1 



stones, does the difficulty increase of making the work upon each 

 fall exactly upon its proper place in the general design ; for if any 

 one were misplaced only the fiftieth of an inch, the drawing and 

 colour of the whole would be disturbed. Hence it is found necessary 

 to arrange the register, or adjustment of the stones, with the utmost 

 care and precision ; and to exercise the most careful supervision in the 

 printing (which is entirely a hand process), since the sheet of paper 

 expands considerably in passing' through the press, and has to be dried 

 and re-damped before it can be passed through again. But practically 

 this is all accomplished with seeming ease, and a large and most 

 complex subject will be found, when the last stage has been reached, 

 to bear the most minute scrutiny ; and the result, even when the copy 

 is placed alongside the original, will surprise and delight equally those 

 who have followed the work through its several steps, and those who 

 may only examine the completed work. 



Transfer lithography has been applied in other ways than the one 

 already explained : indeed it would be difficult to fix limits to its 

 capabilities, improvable as they may be in the hands of able chemists. 

 Among the transfer modes, that of printing copper-plate engravings 

 from ttone is worthy of notice. An impression is taken on unsized 

 paper from the copper-plate, and without delay transferred, by passing 

 through a press, to a polished stone ; it is then acidulated, and the 

 printing proceeds in the visual way. In some kind of work the im- 

 pressions thus obtained are scarcely distinguishable from those printed 

 direct from the copper. The advantage which this application of 

 lithography holds out is most apparent where economy or great 

 despatch are important. These objects are both obtained by trans- 

 ferring impressions to several stones, or several impressions to one 

 stone if the design be small, when the numbers can be multiplied with 

 great rapidity, and without the original engraving being at all worn. 



Plates of zinc are for some purposes much used as substitutes for 

 the German stones, in chemical printing, and the practice is then 

 called Zincography ; but excepting the difference of the material on 

 which the work is performed, it is precisely the same art as lithography. 

 Zinc plates have the advantages of greater portability, and of being less 

 liable to break from the pressure in printing. 



LITHONTRIPTICS, termed also LITHOXTHRYPTICS, or ANTILITHICS 

 (Aiflos, a stone, and Tplfta, to rub or bruise), medicines or other means 

 which are thought to possess the power of dissolving stone or calculus 

 in the urinary organs. The calculous concretions which are apt to 

 form in the kidneys or bladder are of very different kinds, originating 

 in different constituting or in different habits of life or locality of 

 abode. They are also different, not only according to the time of life 

 when their formation began, but they often become varied in the pro- 

 gress of their increase, and are different in the strata of which they are 

 composed. 



It requires, therefore, not only very close investigation into the 

 characters of the urine of a person supposed to be affected with calcu- 

 lous concretion, but also no slight acquaintance with the chemistry 

 and physiology of that fluid, and the great influence of the nature of 

 the food and drink on its composition, to be able to direct the use of 

 medicines which are regarded as lithontriptic. With few exceptions, 

 their employment has been nearly empirical ; and aggravation of the 

 case has as frequently resulted as benefit from their employment. 

 The researches of recent chemists and pathologists have given some- 

 thing approaching to a scientific explanation of the circumstances 

 under which calculi form, as well as of their varied characters; so that 

 more good may reasonably be expected from the use of lithontriptics 

 than has hitherto been realised. [CALCULUS.] 



Of the twelve or thirteen varieties of calculus concretions which 

 have been discovered in the bladder or kidneys of the human subject, 

 some are of very rare occurrence, while the more common ones may 

 be classed under two distinct heads those which form under the 

 prevalence of the uric or lithic acid state of constitution, and those 

 which form under the prevalence of the phosphatic state of constitu- 

 tion. These sometimes alternate, and indeed the concretions which 

 belong to the last class have almost invariably a nucleus or centre of 

 the first kind, which shows how very important it is to avoid the 

 causes of the lithic acid formations. 



Independent of constitutional peculiarities, the leading causes of the 

 formation of calculous concretions are errors in diet or regimen. The 

 kidney is the great channel for the expulsion from the system of the 

 azotised or nitrogenous principles of the blood, as well as of many 

 saline particles, which were once an integral part of the body, but now 

 effete ; and to keep these in suspension, so as to ensure their elimina- 

 tion from the body, a due quantity of an aqueous menstruum is 

 required. Hence whatever reduces the quantity of urine below the 

 proper standard predisposes to the formation of calculi. Now an 

 Excess of animal food, particularly if exercise be neglected, and strong 

 wines in a word, rich living, with indolent habits are the frequent 

 origin of calculous complaints. Crude vegetables, with bad clothing 

 and exposure to cold and damp, which interfere with the healthy action 

 of the skin, equally predisposes to the formation of stone, and thus 

 the poor Buffer from it as well as the wealthy. The causes being so 

 widely different, the mode of treatment must also be different. A 

 pecific cannot therefore exist, and all unskilful tampering with a case 

 must lead to most hurtful results. Medicines taken by the mouth 

 (and such alone can be used where the stone is in the kidney) have 

 ABT8 AMD SCI. DIV. TOL. T. 



been hitherto more successful in relieving the distressing symptoms 

 than solvents thrown into the bladder. There is, however, ground for 

 believing that in certain cases, under competent direction, chemical 

 agents and perhaps galvanism may be made available to dissolve the 

 concretions in the bladder. These agents are quite distinct from any 

 mechanical means for crushing the stone. 



(See Brodie, Lectures on Diseases of the Urinary Organs, 2nd ed. ; and 

 particularly the very excellent work of Dr. Willis, Urinary Diseases 

 and their Treatment, 1838.) 



LITHOTOMY (from \fflor, a stone, and Tfuva, to cut). Although 

 urinary calculi may be extracted from the kidneys, urethra, or bladder, 

 the term lithotomy is restricted to the operation of ciitting into this 

 latter viscus for the purpose of removing one or more stones. From 

 the complex nature of the fluid secreted by the kidneys, and the quan- 

 tity of saline matters which it holds in solution, deposits not unfre- 

 quently take place in one or other of the cavities to which the urine 

 has access. Hence solid concretions, or urinary calculi, may be met 

 with in the kidneys, ureters, bladder, or urethra ; but the majority of 

 these concretions are believed to be formed originally in the kidneys. 

 Now, if we suppose one of these calculi to have descended into the 

 bladder, it is easy to imagine that it would there form a nucleus, 

 around which the addition of fresh matter would be constantly adding 

 to its bulk : a priori reasoning would lead us to suppose such to be 

 the result, and that this actually takes place is proved by the fact that 

 many calculi have for their nucleus foreign bodies that have accidentally 

 entered the bladder, as bullets, splinters of bone, bits of bougie, &c. 

 The number and size of calculi met with in the bladder differ as much 

 as their form and composition vary, and their magnitude is generally 

 in an inverse ratio to their number. A case has been recorded in which 

 398 calculi, from the size of a pea to that of an olive, were found in 

 the bladder after death ; while, in a case described by the late Sir 

 James Earle, a stone was extracted after death which weighed 

 44 ounces, its long axis measuring 16 inches, and the shorter 14 ; but 

 the average size of vesical calculi is about that of a walnut. Their 

 form is mostly spheroidal, or egg-shaped, and sometimes flattened on 

 two sides like an almond. [CALCULUS.] 



According to their composition, they are either soft and friable, or 

 very dense and hard, and their surface may be quite smooth or beset 

 with numerous tubercles. These circumstances, together with their 

 loose or fixed position in the bladder, have considerable influence in 

 determining the comparative severity of the symptoms. Children and 

 aged persons are more subject to the disease than those in the vigour 

 of life, and males than females ; the inhabitants of temperate climates 

 than those of higher or lower latitudes. 



Symptoms of Stone in the Bladder. : These consist in a troublesome 

 itching, sometimes amounting to pain, at the extremity of the penis, 

 with a frequent desire to make water and evacuate the bowels ; thu 

 urine is voided with great pain, particularly the last drops, and while 

 flowing in a full stream is liable to be suddenly arrested, from the 

 stone falling against the vesical orifice of the urethra. When much 

 irritation is present, the urine on cooling becomes cloudy, and deposits 

 a large quantity of ropy mucus, not unfrequently mixed with blood, 

 especially after any rough exercise. All these symptoms vary in 

 degree, according to the size of the stone and the smoothness or rough- 

 ness of its surface, its fixed or loose position in the bladder, the quality 

 of the urine, and the condition of the bladder. Instances are recorded 

 of persons living with stone in the bladder for years, yet suffering little 

 or no inconvenience from it ; but these cases must be considered 

 exceptions. In general the health sooner or later gives way, and, 

 without recourse to one of the operations we are about to speak of, the 

 patient lingers out a miserable existence till death terminates his 

 sufferings. Nearly all the symptoms we have just described as belong- 

 ing to stone in the bladder may however be simulated by other diseases 

 of the bladder or neighbouring parts ; a positive diagnosis, therefore, 

 can never be made before sounding the patient. This consists in intro- 

 ducing into the bladder, through the urethra, a metallic instrument 

 called a sound, by means of which the stone can be plainly felt, and an 

 audible noise perceived on striking it : till this be rendered evident no 

 surgeon would be justified in undertaking the operation. It sometimes 

 happens that stones are forced, by the violent contractions of the 

 bladder during fits of the complaint, between the fasciculi of the mus- 

 cular coat of this viscus, so as to become what is termed encysted ; or 

 they may become adherent to some portion of the parietes of the 

 bladder : under these circumstances the surgeon would hesitate before 

 he undertook the operation. 



Modes of performing Lithotomy. To describe at length the various 

 modes of operating for the stone, and the modifications which each 

 method has undergone, would occupy too much space in a publication 

 not strictly surgical ; we shall therefore merely glance cursorily at 

 those formerly in use, while we direct our attention more particularly 

 to the method which is employed at the present day. 



Of the Apparatus Minor, Cutting on the Gripe, or Celsus's Method. 

 This is the most ancient kind of lithotomy, and has probably been 

 practised from time immemorial ; but Celsus having first described it, 

 it has been called Lithotomia Celsiana ; and from the stone, previously 

 fixed by the pressure of the fingers in the anus, being cut directly 

 upon, cutting on the gripe, a knife and a hook being the only instru- 

 ments used. The appellation of the lesser apparatus was given to it by 



