ANTILITHICS[182] are remedies which have the power of preventing the
formation of those mechanical deposites from the urine, which give
origin to calculous concretions; and may belong either to the class of
Vital, or Chemical Agents.
LITHONTHRYPTICS[183] are those medicines which, by a chemical operation,
are capable of dissolving calculous concretions.
It has been already shewn, while treating the subject of Diuretics, that
certain substances, when internally administered, are capable of passing
the barriers of digestion, and of entering the circulation; and that,
moreover, these bodies may be again separated by the secretory vessels
of the kidneys, and be ejected from the body in the urine. It cannot
therefore be contended, that the urinary calculus is placed beyond the
sphere of direct medicinal influence, nor can any argument, founded upon
the alleged incompatibility of chemical and vital action, be fairly
maintained in this case; for the urinary calculus, as well as the urine
itself,[184] may very justly be considered as extraneous to the living
body. The existence of such a class of remedies as that of
Lithonthryptics being thus established, we have to consider the mode and
possible extent of their operation in the different varieties of the
disease, which they are thus calculated to palliate or cure. In entering
upon this inquiry, it is not my intention to prosecute the subject
farther than may be necessary to explain the _modus operandi_ of the
remedies in question, and in conformity with the object and plan of this
work, to establish some general principles that are to direct us in
their election, combination, and administration; for farther details the
practitioner must consult the systematic treatises of _Prout_[185] and
_Marcet_,[186] and the very able papers of Mr. _Brande_,[187] and Dr.
_Wilson Philip_.[188]
The urine may be considered as one of the most heterogeneous of the
animal fluids;[189] and since a knowledge of its composition, and that
of the morbid changes of which it is susceptible, must constitute the
basis of all our knowledge respecting the formation and cure of
calculous affections, the following results of an elaborate analysis by
_Berzelius_, are submitted with a view to elucidate our pathological
researches.
_Animal Principles._│Water 933·00
„ │Urea 30·10
„ │Lithic Acid 1·00
„ │Pure Lactic Acid, Lactate of Ammonia, and
│ Animal matters not separable from these 17·14
„ │Mucus of the Bladder ·32
_Alkaline and Earthy│Sulphate of Potass
Salts._ │ 3·71
„ │Sulphate of Soda 3·16
„ │Phosphate of Soda 2·94
„ │Phosphate of Ammonia 1·65
„ │Muriate of Soda 4·45
„ │Muriate of Ammonia 1·50
„ │Earthy Phosphates with a trace of Fluate
│ of Lime 1·00
„ │Silex ·03
———————
1000·00
———————
Besides the above ingredients, which appear to be essential to healthy
urine, Dr. Prout observes that in different diseases it may contain
Albumen, Fibrin, and the red particles of the blood; Nitric acid;
various acids, which are found to be modifications of the Lithic; Oxalic
acid; Benzoic acid; Carbonic acid;[190] Xanthic Oxide; Cystic Oxide;
Sugar; Bile; and Pus.
It will be necessary in this place to make a few observations upon the
nature and habitudes of those principles, which are more immediately
active in the production of calculi—
1. _Urea_ is a principle peculiar to urine, and must be regarded as a
result of the action of the kidneys upon some of the constituents
of the blood, perhaps, as Dr. Prout suggests, upon its albuminous
matter. For a long time it was regarded as the peculiar principle
upon which the colour and other sensible qualities of the urine
depended; Berzelius however has corrected this fallacy, and
considers that the Lactic acid, and its accompanying animal
matters, are the bodies which impart to this fluid the
characteristic smell and colour which distinguish it.[191]
2. _Lithic_, or _Uric[192] Acid_. As this principle is not found in
the blood, but is constantly present in healthy urine, it follows
that it must be generated by the action of the kidneys. M.
Majendie[193] has lately endeavoured to prove that its secretion
depends upon the _Azote_ received in alimentary substances, and
for the following reasons, _viz._ 1. Azote is a component part of
_Lithic Acid_[194]—2. Those persons who use a large portion of
animal food, and fermented liquors, are liable to calculous
disorders—3. When animals are confined to food which contains no
Azote, no Lithic acid is formed—but of this anon.—Berzelius and
other animal chemists have supposed that this acid exists in urine
in a free state; but Dr. Prout, whose arguments appear very
satisfactory and decisive, is of opinion that it is always in
combination with ammonia (_Lithate of Ammonia_), from which
however it is very easily separated by the addition of any acid,
even the carbonic, in the form of a red powder. It moreover
appears to be susceptible of several important modifications, with
which it behoves the pathologist to be acquainted; the profession
is greatly indebted to the ingenuity and industry of Dr. Prout for
some very essential additions to our knowledge, respecting the
habitudes of _Lithic acid_ with different bodies.
_Erythric Acid._ When nitric acid diluted with about an equal bulk of
water, is poured upon pure lithic acid, and a moderate heat is
applied, an effervescence takes place, and the lithic acid is
dissolved; if we then concentrate this solution by a gentle
evaporation, we obtain transparent colourless crystals, which have
been found to constitute a peculiar acid, to which M. Brugnatelli
has given the name of _Erythric acid_.
_Purpuric Acid._ Dr. Prout has discovered that if into a strong
solution of the above crystals in water, whilst boiling hot, we
carefully drop some pure ammonia, the solution acquires a
beautiful purple[195] colour, and crystals of _purpurate of
ammonia_ speedily begin to form and subside. If these crystals are
treated by means of potass and sulphuric acid, pure _Purpuric
acid_ is obtained in the form of a yellowish, or cream-coloured
powder.
3. _The Phosphates._ As the Phosphoric acid and its compounds perform
an important part in the generation of calculi, their origin[196]
and history demand particular attention from the chemist. The
Phosphoric acid frequently exists in the urine in a free state,
when it would appear to act, like any other acid, as a precipitant
of the Lithic acid; this however is not the circumstance that
renders its presence formidable; it is to the abundance of its
compounds that we are to look for mischief. In healthy urine the
phosphoric acid appears to exist in union with soda and ammonia,
and partly with lime and magnesia; the latter salts being retained
in solution by an excess of acid; but the proportion of these
bodies is liable to considerable variation.[197]
Having thus briefly noticed those particular points in the chemistry of
the subject with which the therapeutic principles are more immediately
connected, we shall be better prepared to examine and appreciate the
several plans of treatment which have been proposed for the prevention,
cure, or palliation of calculous disorders; and here the subject
naturally divides itself into two parts; the one comprehending the
_modus operandi_ of Antilithics, or those remedies which prevent or
correct the calculous diathesis; the other, explaining the solvent
action of Lithonthryptics over concretions already formed.
The line of demarcation by which healthy and morbid urine are separated,
is so slight that it is difficult to define its limits; nor would the
circumstance appear to be materially important, for the boundary is
daily exceeded, not only with impunity, but even without our
consciousness of the event; and Dr. Prout has accordingly denominated
such occasional deviations, the “_Sediments of Health_.”
The same enlightened author considers that mechanical deposites from the
urine, although composed of the same general ingredients, may, in a
pathological point of view, be conveniently divided into three classes,
viz. _Pulverulent_ or _Amorphous Sediments_; 2. _Crystalline Sediments_,
usually denominated gravel; and 3. _Solid Concretions_, or calculi
formed by the aggregation of these latter sediments. The first of these
may be passed over, as unconnected with the present subject; the latter
however constitutes an essential object of research; for a complete
acquaintance with the chemical history of calculi can alone furnish the
true indications of cure.
Scheele,[198] with whom the inquiry originated, conceived that every
calculus consisted of a peculiar concrete acid, soluble in alkaline
lixivia, and which Morveau denominated the _Lithic Acid_; but the
subsequent researches of Fourcroy, Vauquelin, Wollaston, Pearson, Henry,
Brande, Marcet, and Prout, have demonstrated the existence of _several_
bodies in the composition of urinary calculi, viz. _Lithic Acid_;
_Phosphate of Lime_; _Ammoniaco-magnesian Phosphate_; _Oxalate of Lime_;
_Cystic Oxide_;[199] and _Xanthic Oxide_;[200] to which may be added an
_animal cementing ingredient_. The varieties of calculi produced by the
combination or intermixture of these ingredients, are represented in the
following Tabular Arrangement.
┌─────────────────────────────────────────────────────────────────────┐
│ A TABULAR VIEW OF THE DIFFERENT SPECIES OF URINARY CALCULI. │
├───────────────┬─────────────────┬─────────────────┬─────────────────┤
│ SPECIES OF │ EXTERNAL │ CHEMICAL │ REMARKS. │
│ CALCULI. │ CHARACTERS. │ COMPOSITION. │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│1. LITHIC or │_Form_, a │It consists │It is the │
│ URIC. │ flattened oval;│ principally of │ prevailing │
│ │ _Specific │ _Lithic Acid_; │ species; but │
│ │ gravity_, │ when treated │ the surface │
│ │ generally │ with nitric │ sometimes │
│ │ exceeds 1·500; │ acid, a │ occurs finely │
│ │ _Colour_, │ beautiful pink │ tuberculated. │
│ │ brownish or │ substance │ It frequently │
│ │ fawn-like; │ results. This │ constitutes the│
│ │ _surface_ │ calculus is │ _Nuclei_ of the│
│ │ smooth, texture│ slightly │ other species. │
│ │ laminated. │ soluble in │ │
│ │ │ water, │ │
│ │ │ abundantly in │ │
│ │ │ the pure │ │
│ │ │ alkalies. │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│2. MULBERRY. │_Colour_, │It is _Oxalate of│This species │
│ │ dark-brown; │ Lime_, and is │ includes some │
│ │ _texture_, │ decomposed in │ varieties which│
│ │ harder than │ the flame of a │ are remarkably │
│ │ that of the │ spirit lamp, │ smooth and pale│
│ │ other species; │ swelling out │ coloured, │
│ │ _Sp. grav._ │ into a white │ resembling a │
│ │ from 1·428 to │ efflorescence, │ _hemp seed_. │
│ │ 1·976. │ which is │ │
│ │ _Surface_, │ _Quick-lime_. │ │
│ │ studded with │ │ │
│ │ tubercles. │ │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│3. BONE EARTH. │_Colour_, pale │Principally │ │
│ │ brown or gray; │ _Phosphate of │ │
│ │ _surface_ │ Lime_. It is │ │
│ │ smooth and │ soluble in │ │
│ │ polished; │ muriatic acid. │ │
│ │ _structure_, │ │ │
│ │ regularly │ │ │
│ │ laminated; the │ │ │
│ │ laminæ easily │ │ │
│ │ separating into│ │ │
│ │ concrete │ │ │
│ │ crusts. │ │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│4. TRIPLE. │_Colour_, │It is an │This species │
│ │ generally │ _Ammoniaco- │ attains a │
│ │ brilliant │ magnesian │ larger size │
│ │ white; │ phosphate_, │ than any of the│
│ │ _surface_ │ generally mixed│ others. │
│ │ uneven, studded│ with phosphate │ │
│ │ with shining │ of lime; pure │ │
│ │ crystals; less │ alkalies │ │
│ │ compact than │ decompose it, │ │
│ │ the preceding │ extricating its│ │
│ │ species; │ ammonia. │ │
│ │ between its │ │ │
│ │ laminæ, small │ │ │
│ │ cells occur, │ │ │
│ │ filled with │ │ │
│ │ sparkling │ │ │
│ │ particles. │ │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│5. FUSIBLE. │_Colour_, │A compound of the│It is very │
│ │ greyish-white. │ two foregoing │ fusible, │
│ │ │ species. │ melting into a │
│ │ │ │ vitreous │
│ │ │ │ globule. │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│6. CYSTIC. │Very like the │It consists of │It is a rare │
│ │ Triple │ _Cystic Oxide_;│ species. │
│ │ Calculus, but │ under the │ │
│ │ it is │ blow-pipe it │ │
│ │ unstratified │ yields a │ │
│ │ and more │ peculiarly │ │
│ │ compact, and │ fetid odour. It│ │
│ │ homogeneous. │ is soluble in │ │
│ │ │ acids, and in │ │
│ │ │ alkalies even │ │
│ │ │ if they are │ │
│ │ │ fully saturated│ │
│ │ │ with carbonic │ │
│ │ │ acid. │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│7. ALTERNATING.│Its section │Compound of │ │
│ │ exhibits │ several │ │
│ │ different │ species, │ │
│ │ concentric │ alternating │ │
│ │ laminæ. │ with each │ │
│ │ │ other. │ │
├───────────────┼─────────────────┼─────────────────┼─────────────────┤
│8. COMPOUND. │No characteristic│The ingredients │ │
│ │ form. │ are separable │ │
│ │ │ only by │ │
│ │ │ chemical │ │
│ │ │ analysis. │ │
└───────────────┴─────────────────┴─────────────────┴─────────────────┘
Let us now inquire into the circumstances under which the several
substances enumerated in the foregoing table, are found to be deposited;
and first of the _Lithic acid Diathesis_. It has been already stated,
that the lithic acid exists in the urine in combination with ammonia, so
as to be held in solution under ordinary circumstances; if however any
free acid be generated, the lithic acid is immediately precipitated,
giving rise to the appearance so well known under the name of _red
gravel_; from this view of the subject the lithic acid deposite must be
considered as arising, not from the excess of that substance in the
urine, but from a decomposition of the compounds into which it enters by
the agency of a free acid. M. Majendie is therefore incorrect in
attributing its appearance to the quantity of azote in the ingesta; an
opinion which has been very ably controverted by Dr. Philip, in a paper
published in the sixth volume of the Medical Transactions. It appears,
moreover, that whatever tends to disturb the process of digestion, by
favouring the production of acid, may be considered as the exciting
cause of the lithic deposites; especially where the cutaneous functions
are imperfectly performed; for Dr. Philip is of opinion, that the
precipitating acid, in a healthy state of the system, is thrown off by
the skin; and he supposes that even when generated in excess, it may be
diverted to the surface of the body by merely increasing the insensible
perspiration. The medical treatment of the lithic diathesis is thus
rendered simple and satisfactory; and if the opinion of Dr. Prout be
true, that at least two-thirds of the whole number of calculi originate
from lithic acid, the extreme importance of the subject is too apparent
to require comment. Remedies, medicinal and dietetic, that are capable
of correcting dyspeptic symptoms, such as slight bitters,[201] will
doubtless prove valuable resources; while all those agents which have a
tendency to correct and regulate the insensible perspiration, will
necessarily fall under the head of anti-lithic remedies. Mr. Copland
Hutchison, in a paper which has been published in the Transactions of
the Medico-Chirurgical Society, has shewn a comparative rarity of
calculous disorders in British seamen. Can the quantity of muriate of
soda taken with their food, from its stimulating influence upon the
cutaneous functions, be considered as affording a plausible explanation
of this fact? The _Phosphatic Diathesis_ seems to be accompanied with
considerable derangement of the chylo-poietic viscera, and Dr. Prout
very justly remarks, what I have frequently observed, that the stools
are extremely unnatural; as the phosphates are retained in solution by
an excess of acid, it would appear as if an alkaline principle was
occasionally developed, and it is not unreasonable to suppose that this
may be sometimes derived from bilious regurgitations;[202] in some
cases, the alkali is derived from the spontaneous decomposition of urine
itself, especially where the bladder has lost its _governing
power_,[203] as from some injury[204] of the spine; or from some local
affection of the bladder or prostate gland; wherever the urine undergoes
an incipient process of decomposition, ammonia will be generated, and an
_ammoniaco-magnesian phosphate_[205] be immediately precipitated: hence
in cases where the bladder is unable to discharge its contents, this
deposite is very apt to take place, as in diseases in the prostate; and
this explains the reason why the triple phosphates are so frequently
formed in elderly people, who cannot wholly evacuate their bladder.
It will appear evident from these cursory observations, that some
varieties of Calculi will be influenced by acids, and others by
alkalies, and that the exhibition of such remedies will be liable to
palliate, or to aggravate the symptoms, according to the character and
composition of the offending calculus, and according to the prevailing
diathesis of the patient; as a general rule to direct us in the
chemico-medical treatment of these cases, Dr. Marcet states, that
“_Whenever the lithic acid predominates, the alkalies[206] are the
appropriate remedies, but that when the calcareous or magnesian salts
prevail, the acids are to be resorted to_.” But if it be asked how we
are to discover the nature of the calculous affection, so as to direct
the suitable remedy? the reply is obvious—by an examination of the
sediment deposited by the recent urine, or by an analysis of the small
fragments which are frequently voided with it; the Phosphates subside
from the urine as a _white_, lithic acid, generally, as a _red_ deposit;
and since the phosphates are held in solution in the urine by an excess
of acid, it is evident that whenever such acidity is diminished by the
hand of Nature or art, a white sabulous deposit will ensue; hence, says
Mr. Brande, it occurs in the urine of persons who drink soda water, or
take magnesia; the remedy of such a deposit, when it takes place
habitually, is a course of acidulous medicines; on the contrary, since
_lithic acid_ is precipitated by the acids, alkalies are naturally
suggested for the prevention of that deposit. In the _compound_ calculi,
acids and alkalies may be equally injurious or beneficial, for since
these bodies are composed of a variety of ingredients, the action of any
one solvent must be partial, and may convert the smooth calculus into a
rough and highly irritating body, or vice versa. In the _alternating_
calculi it may be judicious to exhibit these remedies alternately, as
the symptoms of the case and the deposit of the urine may indicate.
After all, however, the solvent powers of Lithonthryptic remedies must
be very limited, and in advanced cases we can never expect to procure
more than palliation. With respect to the agency of these different
remedies, as _Antilithics_, I would observe, that while experience bears
us out in confiding in the production of certain chemical effects from
their use, we must not forget that much is to be effected by their
judicious administration as _vital_ agents: and it will be hereafter my
duty to point out the many advantages that may be obtained, by combining
in one formula, medicines which individually belong to each class.
Independent of any chemical effect, alkaline substances are found by
daily experience to allay the morbid irritability of the urinary organs
in a manner not yet explained; alkalies may also prove _generally_
serviceable in these disorders, by acting immediately upon the digestive
organs, for the disposition of forming calculi is always, more or less,
accompanied with the indications of deranged digestion; and it is
probable that the first link of the series of actions, which cause this
disposition, has its origin in the stomach.
The alkaline carbonates are found to answer as effectually as the pure
alkalies, and they have the advantage of being less liable to disagree
with the stomach. Mr. Hatchett has proposed the carbonate of magnesia,
in doses of ℈j to ʒj, as a valuable substitute for alkaline remedies in
cases of lithic calculi; but as its insolubility must render its
absorption equivocal, the beneficial operation of the substance must
principally depend upon its neutralizing any excess of acid in the primæ
viæ, and in this way there can be no doubt of its lithonthryptic agency;
“but,” says Dr. Marcet, “such is the tendency which the public has to
over-rate the utility of a new practice, or to take a mistaken view of
its proper application, that there is every reason to believe that the
use of magnesia has of late years become a frequent source of evil in
calculous complaints.” Lime-water has been also recommended for the
purpose of fulfilling the same indications, and as not being liable to
produce that irritability of stomach which frequently attends the long
continued use of the fixed alkalies; besides which, some chemists have
maintained that it exerts a peculiar solvent power over the cementing
animal matter of the concretion, and thereby destroys its cohesion.[207]
Where an acid is indicated, the _Muriatic_ will in my judgment be found
as convenient and effectual as any that can be administered. Mr. Brande
proposes _Cream of Tartar_ for this purpose; upon this point I differ
with him, for this salt, to say the least of it, is questionable in its
mode of operation; for although its first impression upon the stomach is
that of an acid, the subsequent processes of digestion decompose it, and
eliminate its base, which being absorbed acts upon the urinary organs as
an alkali. I have seen a white sabulous deposit, consisting of the
Phosphates, in the urine of persons after the constant use of _Imperial_
as a beverage, which I am at a loss to explain upon any other principle.
Sir Gilbert Blane has also very satisfactorily shewn, that a fixed
alkali produces the same effect upon the urinary organs whether it be
exhibited alone, or in combination with citric acid; in this latter case
the salt undoubtedly undergoes a decomposition _in transitu_, as I have
more fully explained under the consideration of Diuretics, (_page 94_.)
During an alterative course of Lithonthryptic remedies it may be
beneficial to interpose occasionally a purgative medicine, but we must
not combine it with the lithonthryptic, at least, if we wish this latter
medicine to reach the urinary passages; for it is a law which I have
already attempted to establish (_see page 94_), that _Catharsis suspends
the process of alimentary absorption_.
There remains to be considered another mode of applying a solvent, and
which would seem on the first view of the subject to be full of
promise,—that of injecting the proposed menstruum into the bladder.
Unfortunately, however, the irritable state of this organ will generally
preclude the possibility of preserving the menstruum, for a sufficient
length of time, in contact with the calculus to accomplish any material
solution; nor am I aware that any case, in favour of such a practice,
stands recorded. An ingenious and novel application of the powers of
Electro-chemistry has been lately[208] proposed by M M. Prevost and
Dumas, as capable of affording means for the solution of the calculus
within the bladder; the suggestion is highly plausible, and ought not to
be hastily rejected without trial. Could the functions of the part be
protected against the influence of so powerful an agent, it is evident
that, by a galvanic battery of sufficient intensity, a calculus composed
of alkaline or earthy salts might be transferred from the bladder by the
simple introduction of a double sound, communicating on one hand with
the calculus, and, on the other, with two vessels filled with water, in
which are plunged the opposite poles of a galvanic apparatus.[209] This
arrangement would transfer the acid constituents into the vessel
connected with the _positive_ end, and the bases into that of the
_negative_ end. So far, however, as the experiments have hitherto been
carried, this degree of galvanic operation would seem to excite too much
irritation in the bladder to be admissible; but it still offers a
resource of an apparently more practicable nature. This consists in
giving to the calculus a tendency to crumble from the slightest force;
such a friability, in short, as shall render it easily broken into
pieces sufficiently small to be evacuated through the urethra,
especially by the aid of dilating that passage, an operation upon which
much has lately been said and written. A fusible calculus from the human
subject was submitted to the action of a pile, consisting of 120 pairs
of plates, for twelve hours in succession. The platinum wires,
constituting the poles, were placed in contact with the calculus, about
six or eight lines distant from each other, and the whole plunged in a
vessel filled with pure water. During the galvanic action, the bases and
phosphoric acid first arrived at their respective poles, then re-entered
into combination, when the salt thus reformed was precipitated in the
state of powder. The calculus weighed 92 grains before the experiment,
and was reduced at its termination to 80. The process being continued,
at the end of sixteen hours it presented a mass of such friable texture
as to be reduced into small crystalline particles by the slightest
pressure; the largest of which did not exceed the size of a lentil, so
that it might have easily passed through the urethra.
In order to ascertain how far this decomposition could be effected in
the living body, the ingenious experimentalists selected a dog of rather
large size, into whose bladder they introduced a fusible calculus
attached to a sound, and between two conductors of platinum; the bladder
was next distended by injecting tepid water, and the apparatus subjected
to galvanic influence. After a little struggling, the animal became
calm, and was subjected to the operation during an hour. On removing the
sound, the calculus shewed unequivocal marks of decomposition. The same
process was repeated, night and morning, during six days, when the
friability of the calculus rendered it impossible to continue the
experiment. It had lost weight in the same proportion as in the
preceding trial. The bladder, which was afterwards examined, exhibited
no appearance of injury or disease.[210] The authors assert that this
organ does not suffer any inconvenience from this more moderate degree
of galvanic action, and suggest, as a proof of the mildness of its
influence, that we should immerse the tongue in a vessel filled with
water, in which a calculus is undergoing decomposition, and it will be
found that the tongue, which is far more sensible than the bladder, will
scarcely perceive the galvanic action, even when decomposition is going
on briskly. The authors add, that this process cannot offer any
advantage for the removal of those calculi which consist wholly of _Uric
acid_, or which contain a large proportion of it.[211]