A SKETCH OF LITHOTRIPSY, WITH CASES. 
By WILLIAM GIB&6n, M. D. 
Professor of Surgery in the University of Pennsylvania, Surgeon to Blockley 
Hospital, <$rc. 
(Extracted from the American Journal of the Medical Sciences, for August, 1836.] It is now generally admitted that the operation of lithotrity, in the 
hands of prudent and experienced surgeons, possesses decided advan- 
tages, in certain cases, over that of lithotomy. But it is also admitted 
that, to perform lithotrity with any prospect of success, requires 
great dexterity, extraordinary caution, gentleness, perfect familiarity 
with the use and knowledge of the mechanism of the instruments; 
and, above all, instruments so well constructed and tempered—so 
diversified in shape, size, number, and adapted to so many different 
purposes—as to place the operation within the reach of a very limited 
number of surgeons, however competent in other parts of their pro- 
fession to excel and even distinguish themselves. Perhaps it will not 
appear strange, then, when asserted, that no man, now in existence, 
can be called a perfect lithotritist, except Civiale, who, as conceded by 
all that have witnessed his exploits, is as dexterous and successful 
with his litholabe and other forms of apparatus peculiar to himself, 
as can be imagined. From all this, it may be reasonably inferred, that 
the cause of failure in so many instances, amongst European and 
American surgeons, is mainly owing to intrinsic difficulties in the 
operation itself, to want of experience, to deficiency in mechanical 
ingenuity and tact, to want of proper instruments and skill in 
manoeuvring them, as well as the idea so prevalent from the very mo- 
ment of the discovery of lithotrity down to the present time, among 
physicians and others little accustomed to operations of any descrip- 
tion, “that lithotrity is very easy and simple, and may be performed 
successfully by those who would not dare to venture on lithotomy.” 
Fortunately, in this state of things, an important discovery has been 
made within the last few years, that there is no longer absolute neces- 
sity for resorting to lithotrity, but that the same end may be accom- 
plished by other means, not less efficient, within the reach of a greater 
number of surgeons, less painful to the patient, attended with little 
or no risk, (if the surgeon is careful, the case adapted to the opera- 
tion, and the patient willing to conform to certain regulations,) and, 
under favourable circumstances, certain of success. I allude to the 
operation of lithotripsy, which may be said, perhaps, to have been in- 
vented by Baron Heurteloup. 
This operation is founded upon two principles—upon that of crush- 
ing and of percussion—the former chiefly adapted to soft and friable 
stones, the latter to hard and compact. To accomplish these pur- 
poses, several instruments have been invented, and various modifica- 
tions of the same instrument proposed and executed. It is not my 
intention, however, to describe or comment upon any except the in- 
strument of Heurteloup and that of Jacobson, both of which have 
been used sufficiently long in Europe and America, to enable us to 
arrive, with some degree of certainty, at conclusions respecting their 4 
Gibson on Lithotripsy. 
merits and defects. Heu r- 
teloup’s “ percuteur, ” 
“pince a deux branches,” 
or lithotripteur, as it 
should be called, is ex- 
tremely simple in con- 
struction, remarkable for 
strength, and consists 
chiefly of two portions— 
a male and female steel 
rod, about twelve inches long, the former enclosed 
in the latter, and calculated to move backwards 
and forwards at pleasure, about the size of an ordi- 
nary adult catheter, straight for eleven inches of 
its length, and, at its lower extremity, turned up 
and gently rounded in form of a beak, at an an- 
gle of about 55 degrees. Near the upper ex- 
tremity of the male rod, there is a graduated 
scale, intended to indicate the size of the stone, 
and the summit of the rod is terminated by a 
steel bowl, designed to receive pressure of the 
hand in crushing the calculus, or the blow of a 
hammer. In the latter case, the instrument is 
held within the grasp of a vice, which is applied 
to a square shoulder on the female rod, corre- 
sponding in situation with the graduated scale on 
the male rod. Above this shoulder, for two 
inches and a half in extent, is a male screw, 
upon which works a small tripod handle, calcu- 
lated to drive forward the male rod upon the fe- 
male, and, by graduated pressure, to break the 
stone. The extremities of the beak are serrated, 
(but, at the same time, so rounded off- and guard- 
ed, as to prevent the possibility of pinching the 
bladder or urethra) and extremely well calcu- 
lated to seize, retain, and fracture any stone of 
ordinary dimensions and hardness. The entire 
length of the instrument, from the summit head 
to the beak, for a full grown subject, is about 18 
inches. For younger subjects and for children, 
it will vary, proportionally, in length and diame- 
ter. (See Figs. 1 and 2.) 
Fig. 2, the termination of the 
same instrument, the beaks se- 
parated. 
Fig. 1, Heurteloup’s per- 
cuteur. Gibson on Lithotripsy. 
Jacobson’s instrument 
is not designed to act 
upon the principle of per- 
cussion, nor is it calcu- 
lated so to do, but is 
used, when shut, to de- 
tect the presence of a 
stone, and, when ex- 
panded, to close upon 
and crush it, and would 
seem, when superficially 
examined, admirably cal- 
culated for the purpose. 
It consists of a silver 
cannula, eight or nine inches long, a quarter of 
an inch in diameter, attached to the superior ex- 
tremity of which is a circular steel plate or rim, 
an inch wide. Through the cannula passes a 
steel rod, which projects beyond its lower ex- 
tremity, two or three inches, in form of an ordi- 
nary sound, flattened and serrated on its concave 
surface, and smooth and half round on its convex. 
Connected with this extremity by a hinge, resem- 
bling it in form and size, but only an inch in 
length, is apiece of chain, which, in like manner, 
is attached to a second and a third portion, the 
last of which is riveted to a straight rod, which, 
like the former, passes through the cannula, for 
the length of twelve inches, and is intended to 
retract or expand the links, so as to produce, at 
will, the form of a common curved catheter or 
that of a loop. The superior extremity of the 
straight rod, last mentioned, for three inches in 
extent, is a male screw, corresponding with a fe- 
male one, which passes through the centre of a 
double convex rim, intended to work the chain 
backwards or forwards, as may be required. (See 
Figs. 3 and 4.) 
With either of the instruments above described 
and figured, the operation of lithotripsy may be 
conveniently and successfully performed. In 
5 
Fig. 4, the termination of the 
same, with the loop open. 
Fig. 3, Jacobson’s instru- 
ment. 6 
Gibson on Lithotripsy. 
describing the mode of operating, however, I shall confine myself 
almost exclusively to the lithotripteur of Heurteloup, because I have 
been more accustomed to the use of it in practice, and because I think 
it possesses advantages over that of Jacobson, which I shall endeavour, 
afterwards, to point out, and which I think will be appreciated by all 
who are disposed to give trial to each, and are so situated as to be 
competent to decide between them. 
It is a matter of no little consequence, before undertaking litho- 
tripsy, to determine upon the cases best adapted to it. To want of 
care in this respect, and perhaps to want of judgment in some cases, 
I may add, may be attributed, there is reason to believe, the mishaps 
which have occurred in so many instances, and which have been so 
sedulously concealed from the public eye, in Europe especially, while 
the successful cases have been as carefully blazoned forth. I shall not 
be accused, I trust, of making such remarks invidiously, when I as- 
sert that the reference is not to individual cases, or to lithotripsy 
alone, but will apply particularly to lithotrity. At all events, I shall 
set the example, if not already done by others, of stating the success- 
ful as well as unsuccessful cases, the only mode by which the profes- 
sion will be able to form a correct judgment with respect to an opera- 
tion still in its infancy, and, in many points of view, so interesting to 
science and humanity. 
When applied to by a patient, supposed from the symptoms to have 
stone in the bladder, I would advise rest and quiet for three or four 
days, (especially if just from a journey,) the free use of diluents, and 
a gentle purgative. After this, and at a moment when the patient 
has less than his accustomed irritation about the region of the bladder 
and urethra, a simple steel sound, or a silver, or gum elastic catheter 
may be introduced very cautiously and deliberately, and moved in 
various directions for the purpose of detecting the stone, and judging 
in a measure of its size, situation, texture, shape, and for ascertaining 
whether it be rough or smooth; whether more than one, &c. 
It often happens that the sound is introduced with the utmost faci- 
lity, and without much inconvenience to the patient, the bladder 
carefully explored, and no stone felt. In such cases, the surgeon 
should not rest satisfied, but, discontinuing his examination after a 
few seconds, should renew it again in a day or two, and sound at 
one time when the bladder is full, at another when empty, and endeav- 
our to make his instrument, though in the most cautious and careful 
way, enter into every nook and corner of the bladder, where it would 
be possible for the stone to lurk. 
He should also place his patient, while sounding, in a variety of Gibson on Lithotripsy. 
7 
positions—sometimes on his side, sometimes on his knees, and, upon 
other occasions, nearly on his head—never failing, in difficult or ob- 
scure cases, to introduce a finger into the rectum, for the purpose of 
elevating the stone, or of removing it from some cyst or hiding place, 
and of bringing it in contact with the sound. Very small stones, or 
fragments, may be touched repeatedly by a person unaccustomed to 
sounding, without his being sensible that there is a particle of foreign 
body in the bladder; and even an experienced surgeon will frequently 
find himself at fault in this respect. From having experienced more 
or less difficulty in detecting a stone, occasionally, I have, latterly, 
employed an instrument of peculiar construction for sounding, but 
not having fairly tested its advantages or brought it to the perfection 
I anticipated, I shall reserve further notice of it for a future occa- 
sion. 
If the stone is distinctly felt, is of small size, and has not existed 
very long; if the patient is an adult, middle aged, or even advanced 
in years, has, in other respects, a sound constitution, and the bladder 
and urethra are not remarkably irritable, lithotripsy may be always 
resorted to, and with every prospect of success. But, on the contrary, 
if the stone is large, hard and rough, has existed for many years, the 
bladder extremely irritable, contracted, its walls thickened, the kid- 
neys and ureters diseased, the prostate gland enlarged, the stone 
embedded in a cyst, or fastened upon a fungus; if there has been for 
months or years a discharge of purulent matter, or of large quantities 
of slime from the bladder, and the patient is advanced in years or en- 
feebled in constitution, there will be great risk in attempting litho- 
tripsy; and the chance of recovery will be greater, perhaps, from 
lithotomy,—though, from the latter operation, also, patients thus 
situated, will be extremely apt to die. Both of these are, of course, 
extreme cases; and between the favourable and unfavourable, there 
are many intermediate grades, where success must depend, in a 
great measure, upon the judgment and experience of the surgeon 
in the treatment of calculous complaints, whether by lithotomy or 
otherwise. Again, there are cases, as in children, or very young 
boys, where, from the very small size of the urethra, or the unman- 
ageable disposition of the patients, very little can be expected from 
lithotripsy, or any other operation than lithotomy, which last, in 
such subjects, fortunately, is almost invariably successful. Upon 
the whole, it may be stated, that there are many cases, particularly 
in middle aged and old people, which may admit of a cure by litho- 
tripsy, if performed before the stone becomes large and the bladder 
diseased; and, in this point of view, the operation holds out many ad- 
vantages; for there are hundreds of patients, who, if they could be 8 
Gibson on Lithotripsy. 
persuaded that their complaint, in its incipiency, admitted of relief 
bv a process comparatively easy and free from danger, would wil- 
lingly submit to it; but who would shrink from lithotomy, until 
compelled by years of suffering to undergo it, and then, unfortunately, 
with little chance of success. 
Having ascertained the existence of stone in the bladder by accu- 
rate sounding, and determined to submit the patient to lithotripsy, 
the next proceeding, on the part of the surgeon, is to prepare him for 
the operation, by a regular system of diet, by depletion, if necessarv, 
(and there is nothing in the case to contraindicate the measure,) and 
by the careful introduction of sounds, catheters, occasionally, in 
order to accustom the urethra and bladder to the use of instruments, 
to ascertain the exact position of the stone, its usual location, &c. 
In using such instruments, however, great care must be taken not to 
irritate the bladder, and to discontinue them the moment the patient 
complains; and, upon no occasion to rake the bladder, which cannot be 
done, even in the most insensible patient, without great risk of in- 
flammation of that viscus, and even death. Biel, too, is of so much 
importance, previous to attempting the operation, as to be, in my esti- 
mation, almost a sine qua non, and ought to be strictly enjoined, in 
some cases, for weeks together, previous to any attempt to seize or 
break the stone. With most patients, I find a dish of black tea and 
a bit of dry bread for breakfast, and the same for tea, with boiled rice 
for dinner, together with a quart of barley water, (to which may be 
added, if required, a small quantity of cream of tartar to keep the 
bowels soluble) in 24 hours amply sufficient to support any ordinary 
adult, and admirably adapted to lesson irritability, keep down inflam- 
mation and soothe the urinary passages. By steady perseverance in 
these measures, almost every patient can be brought into a proper 
state to undergo the operation with fair prospect of success; but extra- 
ordinary vigilance is sometimes necessary to guard against irregulari- 
ties and deviations, and to prevent a patient from deceiving himself 
as well as the surgeon. In this country, above all others, where food 
is so abundant that even beggars live luxuriously, and where the idea 
is so prevalent, among all classes, that strength is necessarily asso- 
ciated with plentiful supplies to the stomach, it is extremely difficult 
to persuade patients that they can go wrong in gormandizing. Un- 
fortunately, in too many instances, they find out their mistake too 
late, and the surgeon discovers, to his great mortification, that he has 
been deceived and trifled with.* 
* There is no establishment so much wanted in this and other large cities as a 
“maison de sante,” where patients, especially those from a distance, could be sub- Gibson on Lithotripsy. 
9 
As an important preliminary to the operation, a firm, thick mattrass 
and several substantial pillows will be required, the former for pre- 
serving the patient in the most easy and comfortable posture, and to 
prevent him from being overheated, which is so apt to be the case 
when smothered in feathers, the latter for elevating the pelvis to the 
requisite altitude, by which movement the stone will have a natural 
tendency to subside towards the fundus of the bladder, the only 
position in which it can be seized conveniently. Some surgeons, 
Heurtelonp, in particular, recommend an armed chair or kind of sofa, 
for the patient to lie on during the operation; but, independently of 
the trouble of carrying such a machine from house to house, more or 
less alarm is always created in the mind of the patient by such a for- 
midable array in the shape of an apparatus, and as, in reality, there 
is no necessity for any but the most simple means, such as are within 
the reach of the surgeon in most families, he should avail himself of 
them with as little parade as possible. A time having been appointed 
for the operation, the patient should be enjoined to suffer the urine to 
collect in his bladder from two to four hours previously, and, upon 
no account, to permit any of it to escape. But some patients cannot 
retain their urine beyond an hour, or even so long a time. In that 
case, a gum elastic or silver catheter may be introduced, and the 
bladder injected with tepid water, by means of a syringe or gum 
elastic bag—taking especial care not to employ force or to distend 
the viscus too suddenly, or to throw in so large a quantity as to give 
the patient pain, otherwise spasm of the bladder may follow, and a 
train of other alarming symptoms. If possible, it is best to dispense 
with the injection, inasmuch as the introduction of the catheter always 
renders it more difficult to pass any other instrument immediately 
afterwards. As a general rule, too, I would remark that the best 
period for the operation is in the morning, before the patient quits his 
bed; for I have almost invariably observed, particularly in winter, 
the moment the patient rises and walks about his room, that there is 
tendency to spasm about the neck of the bladder, and that an instru- 
jected to a regular system of dietetic discipline. The boarding-houses, even the 
best of them, are unfit for invalids, and the respectable ladies who often keep 
them too poor and too badly compensated to give the necessary attention to the 
sick. And as to nurses, they are often worse than useless, or only prove beneficial 
by consuming the delicacies, tid bits and potations intended by officious and fool- 
ish friends for their sick brethren. When will boarding-house ladies, moreover, 
divest themselves of the silly and pernicious idea, that by restricting the diet of 
invalids they will incur the reproach of starving them for mercenary purposes, 
and thereby hurt the credit of their establishments'? 10 
Gibson on Lithotripsy. 
ment cannot then be so readily introduced as it might have been a 
few moments before. 
These preliminaries having been settled, an assistant places one or 
more pillows beneath the patient’s pelvis, another under his head and 
shoulders, and while the thighs are relaxed and brought nearly toge- 
ther, the body lying parallel with the bed and along its edge, the 
surgeon standing on either side or in front, having well oiled the 
lithotripteur, introduces the beak of it (the blades closely approxi- 
mated) into the urethra, and by one slow but decided movement 
causes the instrument to glide along the passage, to which its own 
weight partly contributes, as far as the triangular ligament, which it 
is known to have reached by the slight resistance met with, and then 
by depressing the handle gently between the thighs, the point starts 
suddenly forwards through the prostate gland and enters the bladder. 
In general, the introduction is effected immediately, but in some 
cases difficulties are experienced, arising, there is reason to believe, 
from the difference in the conformation of different patients, from 
some being more irritable than others, so that spasms are induced, or 
from rudeness or violence on the part of the operator, or from his 
being too sudden and rapid in his movements, from an over anxious 
desire of aiming at feats of dexterity. If any such difficulties should 
arise, it is better not to persevere by forcible endeavours to overcome 
them, but to postpone the operation to a future period. Should a 
stricture, either spasmodic or permanent, exist in the urethra, the 
surgeon must previously get rid of that before he ventures upon litho- 
tripsy. The lithotripteur having been introduced, is not to be carried 
about roughly from side to side, or fore and aft, for the purpose of 
raking after and suddenly hunting up the stone, brut should be carried 
very slowly and gently towards the fundus or most dependant part of 
the bladder, and by the slightest touches with the heel of the instru- 
ment, an attempt made in various situations, from right to left, or 
vice versa, to detect the foreign body. During these manoeuvres, there 
should not be the slightest whisper in the room, or complaint, if pos- 
sible to avoid it, on the part of the patient. An experienced hand and 
an accurate ear will soon detect the stone, and be able to say by the 
peculiar sensation communicated through the vibrations of the instru- 
ment, whether the stone be rough or smooth, large or small, hard or 
soft, whether there be more than one stone, &c. However, cases now 
and then present themselves in which it is not so easy to feel the 
stone at once and determine its character and position. This may 
be owing to a variety of circumstances. The patient may be uncom- 
monly irritable, spasm of the bladder may be induced, by which the Gibson on Lithotripsy. 
urine is forcibly driven from the bladder along the urethra and instru- 
ment, or there may be an hour-glass contraction of the bladder, the 
stone being in one part and the instrument in the other, or the stone 
may be encysted, or may lurk under the prostate, or there may be 
naturally uncommon width in the lateral diameter of the bladder, or 
the rectum may on one or both sides of the bladder, compress it and 
destroy its shape, or haemorrhoids or hardened foeces produce a cor- 
responding alteration in its figure. Under these and other trying 
circumstances, the surgeon should never forget that the longer he 
gropes about, and the more determined he is not to be foiled, the 
greater will be his chance of failure. “Nullum numen abest si sit 
prudential should be his motto, and the sooner he acts upon it, by 
withdrawing his instrument, the better. But suppose, on the contrary, 
that none of these difficulties have been encountered; that'the stone 
has been readily felt, without giving the patient much pain; that the 
instrument may be readily manoeuvred in the bladder, then the next 
object in view will be to loosen the blades of the lithotripteur, by 
turning the tripod or handle of the vice, cautiously opening the claws 
by pushing back the male rod, and then endeavouring by short, sud- 
den, but gentle lateral movements, with the heel of the instrument, 
on the floor of the bladder, to pass the gutter of the female rod be- 
neath the stone, the situation of which, with respect to this part of 
the instrument, may be readily ascertained by depressing occasionally 
the male rod. It is astonishing with what facility, in some cases, the 
stone, by a slight lateral movement, may be shuffled into the jaws of 
the lithotripteur, so much so that the first attempt, sometimes, in the 
hands of a dexterous surgeon, will suffice for this part of the opera- 
tion. Having secured the stone within the grasp of the forceps by 
quickly but gently pushing downwards the male rod, the surgeon 
next turns the tripod with one hand while he steadies the instrument 
with the other, and gradually strains upon the stone until he feels or 
hears it crack beneath the pressure of the serrated claws in which it 
is embraced. Soft and friable stones give way quickly under mode- 
rate pressure, and where no strain is perceived upon the tripod; hard 
and flinty stones, on the contrary, crack with a sudden jar or snap, 
and splitting asunder quickly, make a report like the distant smack 
of a whip, while the tripod is suddenly loosened, but generally resumes 
its hold upon the remaining portion of the calculus. There are some 
calculi, however, too hard and solid to be thus broken by graduated 
pressure; and if the surgeon, not aware of this, and possessing but 
little mechanical tact or skill, should apply inordinate force to his 
screw, the beak of the male rod 'might be broken off, or so sprung Gibson on Lithotripsy. 
as to prevent it from being disengaged readily from the stone. In 
such a case, then, instead of straining upon his instrument, in the 
vain hope of smashing the stone, the proper course to pursue is 
to loosen the tripod, and by gentle taps with a hammer upon the bowl 
on the summit of the male rod, to fracture the stone or quarry it. 
But let it not be supposed that such an exploit can be safely per- 
formed while the lithotripteur is merely held in the operator’s hand. 
The percussion, in that case, would necessarily extend to the walls 
of the bladder, and might be followed by disastrous effects. 'Fortu- 
nately, these are readily guarded against by a vice (lined with lead, 
adapted to the shoulder of the female rod, and held by the surgeon 
and assistants,) admirably calculated, in every respect, to fulfil the 
purpose for which it wras designed. Having broken the stone, either 
by graduated pressure or by percussion, the surgeon next closes his 
instrument and opens it repeatedly, while, at the same time, he moves 
it quickly from side to side to crush and wash out any small frag- 
ments that may project from the edges of the groove, and might wound 
or lacerate the neck of the bladder and urethra in the act of with- 
drawing the instrument from that viscus. If he has reason to believe 
that, by these manoeuvres, the fragments have not been gotten rid of, 
he may generally accomplish his purpose completely by slight strokes 
of the hammer in the manner already directed. After this, the sooner 
the lithotripteur is removed from the bladder the better, and the 
shorter the time the surgeon has taken to perform the operation, the 
greater will be the chance of success. In general, by the time the 
operation is completed, there is an urgent desire, on the part of the 
patient, to let off' his urine; but it seldom happens that large fragments 
come away with the first passage of the urine. In general, only a 
few small pieces are observed, together with a little sand, and now 
and then a few drops of blood, produced by the pressure of the shaft 
or fulcrum of the instrument on the neck of the bladder. It is not 
desirable, indeed, that the fragments should come away until the 
soreness of the urethra has passed off*, and, fortunately, most patients 
have the facility of retaining them by laying on their side, and not 
emptying the bladder completely at each time of evacuating, but al- 
ways retaining a small portion of urine. In a day or two, however, 
they begin to present themselves at the neck of the bladder, where 
they remain a short time, exciting more or less unpleasant feeling, and 
are then suddenly carried forward and bolted out before the patient 
is aware of it. In this way, one after another, fragments may pass 
in rapid succession, and in a few hours the patient has been able to 
make a large collection of them, the soreness gradually passes away, Gibson on Lithotripsy. 
13 
and after the lapse of five or six days, is prepared to undergo another 
operation. 
Such, however, is not the invariable result of an operation for litho- 
tripsy, for although the surgeon may have been abundantly success- 
ful in breaking up the stone, and may have been extremely rapid 
and dexterous in his operation, and communicated as little irritation 
as possible, still the bladder is very prone to resent any offence, even 
the slightest, that may have been offered to it, and will vent its dis- 
pleasure on the surrounding and even distant parts. Hence a few 
hours after the operation, or, in some cases, in a day or two, a chill 
is induced, followed by fever, profuse perspiration, spasms of the 
bladder, &c. or these symptoms may have been brought about by the 
lodgment of a fragment in the urethra. The best course to be pur- 
sued, I think, in this state of things, is to bleed the patient as soon as 
the fever has come on, to administer an opiate injection occasionally, 
to restrict the diet within the closest bounds, and not to permit the 
patient to get out of bed—a rule, indeed, which the lithotriptist would 
do well to observe after each operation, whether any bad symptoms 
show themselves or not. If a fragment has lodged about the neck of 
the bladder, and seems disposed neither to retire nor advance, the best 
plan is to push it back into the bladder by a large catheter or sound; 
if it has advanced within a few inches or a short distance of the exter- 
nal orifice of the urethra, then it may be got away generally by a bent 
probe, by a pair of urethra forceps, or, still better, by the curette of 
Leroy—a most ingenious little instrument, admirably adapted to this 
and many other purposes. 
When the irritation has entirely passed away, which generally hap- 
pens in four or five days, or, at farthest, a week, the surgeon renews 
his attempts to seize and destroy the stone, in the manner already 
described; but, as each operation generally becomes more difficult 
in proportion as the stone is diminished in size, owing to the greater 
difficulty of feeling a small foreign body than a large one, it will be 
proper to detail certain expedients which may be resorted to advan- 
tageously in most instances. The course to pursue, then, under such 
circumstances, is to introduce the lithotripteur, and having reached 
the fundus of the bladder, to withdraw the male rod for half an inch 
and upwards, and fish about from side to side, or in various direc- 
tions, with the groove of the female rod, and, by so doing, the opera- 
tor will be very likely to collect one or more fragments, the presence 
of which can be readily ascertained by closing occasionally the jaws 
of the instrument, crushing the fragments, and then again expanding 
and making further search, until all the pieces that happen to fall 14 
Gibson on Lithotripsy. 
within the gutter of the lithotripteur are completely broken up or pul- 
verized, and may afterwards be thrown off by the action of the blad- 
der. It is a leading principle indeed, now, with all lithotriptists, to 
reduce the fragments by successive attempts, to the smallest compass, 
so as to facilitate their passing off quickly, and with the least possible 
risk of irritating, or tearing the urethra; and fortunately the bladder, 
in most instances, seems to understand the surgeon’s views, and is 
abundantly disposed to second them. But, in other cases, old and 
debilitated patients, especially, there is sometimes so little power in 
the bladder, that it does not contract sufficiently to expel the foreign 
bodies which may have been broken up into numerous pieces, and, by 
accumulating, may still keep up irritation, or in time, by the con- 
glomeration and matting together of particles, lay the foundation of 
another stone. This was one of the strongest objections, some three 
or four years since, both to lithotrity and lithotripsy, so much so that 
it was customary at that period to recommend lithotomy in patients 
thus situated, rather than either of the other operations. By the in- 
genuity of Heurteloup, however, this difficulty has been in a mea- 
sure obviated, by means of the “evacuating sound” an instrument 
of peculiar construction, and exceedingly well calculated tb collect 
and bring away, without annoyance to the bladder and urethra, frag- 
ments of considerable size, as well as the sand, or debris which accu- 
mulates in such quantities in the hollows and certain rendezvous met 
with in most bladders. But, fortunately, there is another circum- 
stance independently of the advantage to be derived from the instru- 
ment referred to, which may serve to console patients in whom the 
power of the bladder to expel the urine with its accustomed force is 
diminished or destroyed—that there is reason to believe, in certain 
cases, that soft and friable stones are susceptible of solution in the 
urine, and are removed in the shape of sand or mud, mixed with 
slime and other matters. Heurteloup speaks of cases of the kind, and 
one of this description, I am very sure, has occurred in my own prac- 
tice. 
It will be remembered, I trust, that I do not profess, in this com- 
munication, to give more than a sketch or outline of lithotripsy, illus- 
trated by a few cases; and if what I have said shall answer the pur- 
pose of drawing the attention of the American surgeon to the opera- 
tion, of clearing up the doubts of some and confirming the sentiments 
of others, my labour will not be in vain. It has been said, and is even 
now often reiterated that I have decried the operation. This is a great 
mistake. I have never condemned lithotripsy; but have always 
doubted of the perfect success of “lithotrity.” In my text book and Gibson on Lithotripsy. 
15 
in lectures, I have spoken of the original idea of destroying, by instru- 
ments, stone in the bladder, as a most ingenious and beautiful one— 
have said that the time would come, when such instruments would be 
so modified and improved, as to deserve the highest commendation, 
and that the operation would become an established one, though it 
would, never supersede, in toto, lithotomy. Have not my predictions 
been verified? Have not the most disastrous consequences followed 
lithotrity, even in the hands of Civiale himself, the prince of lithotri- 
tists, whose magic powers are still unequalled and can never be sur- 
passed in his particular line, and in the management of his own tools? 
Is not lithotrity now spoken of in Europe, constantly and without re- 
serve, as the “old method,” the “ancient operation?” That more or 
less of the same difficulty, though never, I trust, to the same extent, 
will attend lithotripsy, 1 have no doubt; that patients will be subject- 
ed to the operation who are unfit for it; that mistakes will be com- 
mitted by the inexperienced and adventurous; that the most wary and 
prudent operators will be baffled, and foiled, and deceived in then- 
expectations, partly from perverse and obstinate patients, partly from 
neglect of those about them, and partly from the complicated nature 
of cases which no human wisdom could foresee, I am prepared to be- 
lieve and admit. But “Quia non omnes convalescunt idcirco nulla 
igitur est medicina,” is a maxim of sound sense and truth, which 
should never be lost sight of—which will apply, now and then, to 
every operation in surgery, and to every medical case, from the most 
complicated to the most simple. 
Before proceeding to detail the cases of lithotripsy in which I have 
been engaged, and from which most of the foregoing remarks have 
been derived, I propose to make a few comments upon the instrument 
of Jacobson, and to compare it with that of Heurteloup; in so doing, 
however, I beg leave to declare that it is not my intention to unfurl 
the banner of opposition on the one hand, or to be led captive on the 
other, but “to render unto Csesar the things which are Caesar’s.” 
One advantage, at least, an American possesses over Europeans, 
amidst their controversies concerning inventions, improvements, dis- 
coveries—that he can be impartial. Of Heurteloup, personally, I 
know nothing; of Jacobson, nothing; of French and English lithotrip- 
tists and anti-lithotriptists, their politics, parties and squabbles and 
academical debates, I know and care, if possible, still less. With 
their instruments I am well acquainted, and equally well disposed to 
give them all the credit, in my poor judgment, they deserve. 
Jacobson’s instrument is a most ingenious and beautiful one; ex- 
tremely simple; remarkably strong; not too bulky; of the very best 16 
Gibson on Lithotripsy. 
form for easy introduction; readily withdrawn if any part of it should 
give way; better adapted, as regards facility, than any other instru- 
ment to catch and inclose a small stone, when seized, of great power 
to break it; and, upon the whole, admirably calculated, apparently, 
for success. But, withal, it is a dangerous weapon; for the natural 
tendency of the closing of the loop, or zigzag chain, which binds upon 
the stone, in the act of demolishing it, is to drag the folds about the 
neck of the bladder and prostate into the embrace of the steel rods, 
where they emerge from the mouth of the cannula, and to pinch them 
to excess. Nor is this all—the irregular loop, full of small angulari- 
ties; the numerous joints, and rivets, and dovetails; the prominent 
knots, and depressions, about each hinge; the inaccuracy and uncer- 
tainty, and lateral irregularity of the closing of the different joints; 
the long line of loop, running from stem to stern along the perpendi- 
cular edges which frown from the serrated flat lining the interior of 
the chain; so well calculated to rake and harrow the plain surface of 
the bladder; so unadapted to descend into the nooks and hollows; to 
pass beneath the overhanging bank of the prostate; to enter into a 
cyst, or between the folds of a contracted bladder—together with the 
impossibility of enclosing a large stone; of the difficulty of picking up 
fragments after the stone has been quarried and of apply ing the principle 
of percussion to the instrument, and thereby its inaptitude to very 
hard stones; to say nothing of the difficulty of fixing the stone se- 
curely, and of preventing it from shifting from side to side of the 
instrument, in the act of closing the chain; which want of steadiness, 
in part, arises from the great length of chain which gives it a serpen- 
tine motion when dragged upon, and, in part, from the chain not 
hugging the stone closely over its entire surface, but standing off', 
(particularly if the stone is flat, as most stones are) at every part of 
the loop corresponding to a point in the chain; and, lastly, the com- 
plaint of most patients when the loop is expanded in the bladder, and 
an attempt made to scoop the stone within the bow of the instru- 
ment—a complaint so characteristic, that when I passed it upon one 
occasion the patient cried out, without knowing the conformation of 
the instrument, that “I had put a basket into his bladder.” These 
objections are the result of my own observation; I have not hunted 
up European publications to cull them from; I have seen, indeed, but 
one publication on this particular subject, and from that I will ven- 
ture to make an extract, as it seems to confirm the view I have 
taken:—“La decouverte de cette instrument, etait precieuse lorsque 
celui de M. Heurteloup n’existait pas, car on pouvait commencer 
avec l’instrument a trois branches et continuer avec le brise pierre Gibson on Lithotripsy. 
17 
tie M. Jacobson: mais a present il est devenu absolument inutile: 
1’ instrument de M. Iieurteloup le remplace toujours: et j’ai prouve, 
dans le chapitre precedent, que le perceuteur peut s’appliquer, avec 
le moins de dangers, et le plus de facilite possible, dans tous le cas 
oil la lithotritie est practicable; c’est pourquoi il est evident que 
1’ instrument de M. Heurteloup est preferable a tous les autres, et 
que M. Velpeau aeu tortde choisir P instrument de Jacobson comme 
le meilleur. La preuve la plus manifeste de la verite de mes paro- 
les est que cet instrument n’est employe par aucun lithotriptiste 
connu.”*—Not to be unjust, however, to Jacobson’s instrument, 
(whatever my own impressions of it, or those of others, may be) it is 
but fair to state, that it has been employed successfully in this 
country in several cases by Dr. Jacob Randolph and others; and the 
inference, therefore, is plain that it must be an instrument of some 
merit,—and this I am not disposed to deny, whilst, at the same time, 
I am inclined sti’enuously to contend that the lithotripteur of Heurte- 
loup is a better one—and, for the following reasons: 1st. That in ad- 
dition to its working upon the principle of graduated pressure, it 
combines the important power of concussion; 2nd. That it does not 
give the patient so much pain, either during the introduction or whilst 
manoeuvred in the bladder; 3d. That it can grasp a larger stone; 
4th. That its beak can descend behind the prostate and enter every 
corner or pocket of the bladder; 5th. That it is extremely well adapt- 
ed to seek out and pick up fragments; 6th. That it is so constructed 
as to render it almost impossible to pinch the bladder, were the sur- 
geon even disposed so to do; 7th. That although not so strong, 
perhaps, as Jacobson’s chain, that it would be next to impossible, 
when well tempered, to break it; 8th. That the only inconvenience I 
have ever experienced from it, is the liability of the groove, in the 
female rod, to become clogged with sand and small fragments, so as 
to give the patient pain in withdrawing the instrument—that this, 
however, is easily obviated, after a little practice, by opening the 
forceps, and by slight lateral movements, washing out the fragments, 
and afterwards crushing the remainder by a few taps of the hammer. 
One remark, however, may be made in conclusion, and should not be 
lost sight of, as regards the employment of instruments in general— 
that almost every surgeon, when once accustomed to a particular in- 
strument, even although that instrument may be an awkward and 
ungainly one, will perform better with it than another surgeon equal- 
ly skilled but unaccustomed to it. From numerous sources entitled 
* Sur La Lithotripsie et la Taille par M. P. Doubovitzki; Paris, 1835. 
2* 18 
Gibson on Lithotripsy. 
to credit, and particularly from my young friend, Dr. E. Peace, (who 
has just returned from Paris, and has been attending particularly to 
lithotripsy) I learn that the modifications of Heurteloup’s and other 
instruments are almost endless, and that there is scarcely a lithotri- 
tist but has some instrument peculiar to himself. Hence, probably, 
the great variety of opinions on the subject, and the endless and bit- 
ter controversies which have been for some time past, and still are, 
waging among them. Time, the greater instructor in all things, 
will be able “tantas componere lites.” Many of the foregoing remarks 
will be illustrated by the following cases. 
Case I.—Dr. F , of North Carolina, consulted me on his 
case in June, 1835, which, in several respects, was a distressing one. 
He had submitted to lithotomy some months before I saw him; and 
although the operation had been performed skilfully, the wound never 
healed, but remained fistulous, and in a little time the stone made its 
appearance again, and seemed to be enlarging with rapidity. He had 
been making attempts, I found, to crush it, by means of Jacobson’s 
instrument, but had never succeeded (owing to the severe pain and 
spasms which followed each trial) in seizing it, or in detatching frag- 
ments. I proposed the employment of Heurteloup's lithotripteur, 
and explained to him its mechanism, with which he was so much 
pleased as to consent to its introduction a day or two after. So ex- 
tremely sensitive, however, was the bladder, and so great his appre- 
hension, that he would not suffer the instrument to be introduced 
except in the slowest and most deliberate manner, consuming five or 
six minutes, frequently stopping its progress with his own hands, 
and, in fact, almost performing the operation himself. Having at last 
reached the bladder and felt the stone, I expanded the forceps to an 
inch and upwards in width, seized the stone and broke oft' a large 
piece of it. All this was effected so quickly, according to his ideas 
of time, as greatly to delight him, and determined him to submit to 
further efforts to obtain relief. Accordingly, a fewr days afterwards, 
another trial took place; and although the operation was performed 
partly by me and partly by himself, it proved equally successful as 
the first attempt, and encouraged him to proceed with other trials, at 
one of which Dr. Hays and other gentlemen were present. After 
each operation, however, there was always more or less chill and 
fever; and as the patient’s constitution had been greatly impaired by 
long suffering previous to my having seen him, I was almost afraid, 
after each trial, to touch him again. In proportion, however, as the 
fragments were gotten away (though sometimes by sticking in the 
urethra they gave him great uneasiness,) his constitution continued Gibson on Lithotripsy. 
19 
to improve so rapidly as to enable us to renew attempts with greater 
frequency, but always with more or less success. Towards the end 
of July, however, I was obliged to leave town, and to take my instru- 
ments with me, which put a stop to further proceedings for several 
weeks. During my absence, the patient had procured an imitation of 
Heurteloup’s lithotripteur, and assisted by some of his friends, parti- 
cularly by Dr. Rose, had succeeded in removing other fragments. 
From that period, during the whole of the last winter, he was engaged 
in operating on himself, with occasional assistance from myself and 
Dr. Rose, and was enabled, by great industry and perseverance, to 
make in the spring a collection of fragments and sand amounting to 
3 5 12 grs. in weight. By this time his health was so much im- 
proved as to enable him to return to Carolina. Such is the tendency, 
however, in his particular case, to generate calculous matter, that it 
is very questionable whether he will not be liable, always, to its for- 
mation, unless by change of diet, water, and climate, he can effect 
such a change in his constitution as to get rid of the diathesis—a 
result earnestly wished for by his numerous friends, who sincerely 
sympathize with him in his great distress and sufferings. 
Case II.—At the request of Dr. Tyndale, a most intelligent and 
respectable practitioner, whom I had the pleasure of meeting during 
a visit of a few days at the White Sulphur Springs, in Virginia, in 
the summer of 1835, 1 saw, in consultation with him, W. T., Esq., 
of Pittsylvania. Believing, from the symptoms, that the patient had 
stone in the bladder, I was induced to sound him, and discovered 
a calculus of considerable size, under which he had laboured, in all 
probability, for several years. From this and other causes, his health 
had been long impaired and his constitution irritable. In some re- 
spects, however, his case appeared to be adapted to lithotripsy, but 
totally unfit for lithotomy. Having my instruments with me, and 
wishing to ascertain whether the stone was hard or soft, I prevailed 
on Mr. T. to submit to the introduction of the lithotripteur of 
Heurteloup; and although the bladder had not been fully distended 
with water, or the patient prepared by diet for the operation, I suc- 
ceeded in detaching small portions of the stone, which were brought 
away in the gutter of the instrument, and which proved to be soft and 
mortar-like, but full of sharp, needle-like points. A slight chill and 
fever followed this attempt; from which, however, after a few days, 
no inconvenience resulted. I then took leave of the patient, and 
advised him to repair to Philadelphia the ensuing autumn and undergo 
the operation of lithotripsy, enjoining upon him at the same time the 
necessity of regular preparation, by appropriate diet, for several weeks Gibson on Lithotripsy. 
previous to leaving home. Shortly after my departure from the Springs, 
Mr. T., from eating boiled corn and other unwholesome articles of 
food, had a violent attack of cholera morbus, and with great difficulty 
recovered from it. From that period his constitution became enfeebled, 
and he suffered more than ever from the disease in his bladder, pass- 
ing occasionally lumps of sabulous matter, like mortar in consist- 
ence, but full of so many sharp crystallized points as to create great 
pain and soreness in passing them. During the whole winter he re- 
mained at home, unable to set out for Philadelphia; but towards the 
spring, finding his health somewhat improved, made the attempt, and 
arrived, after encountering bad roads and very unfavourable weather, 
on the 27th of April, 1836, exhibiting great marks of fatigue and long 
suffering, and very much changed in appearance since the period I 
had first seen him. Finding that Mr. T. had been making no prepa- 
ration in the way of regimen to facilitate the operation of lithotripsy, 
and to guard against irritation and inflammation, I placed him at once 
in lodgings, as near to my own residence as possible, in order that I 
might watch him closely and be with him at a moment’s warning in 
case of difficulty, impressing at the same time upon his landlord the 
necessity of the strictest attention to diet, &c. Having consumed 
nearly a month in subjecting him to dietetic discipline, and dilating 
the urethra by gum elastic catheters, I commenced regularly, May 
24th, assisted by Dr. Mutter, with the operation of lithotripsy, intro- 
duced Heurteloup’s instrument, touched the stone, but could not seize 
it, owing to the small quantity of urine contained in the bladder, but 
which, notwithstanding, the patient informed me, had been collecting 
for several hours. From this operation no inconvenience followed, 
and the patient was ready on the 26th for another trial. At this 
operation also Dr. M. assisted. The lithotripteur being introduced, 
the stone could not be felt, owing to the small quantity of urine con- 
tained in the bladder. To obviate this difficulty I withdrew the in- 
strument, injected the bladder with tepid water, again introduced the 
lithotripteur, seized a portion of the stone, which readily crumbled 
beneath the pressure exerted upon it, and brought away small mortar- 
like fragments. Other pieces of similar appearance were discharged 
along with the urine in the course of the day. To facilitate the seizure 
of the stone upon this occasion, I found it necessary to introduce a 
finger into the rectum, and raise the stone from the fundus of the 
bladder, or the bed, or cyst, into which it had been accustomed, as I 
had reason to believe, to lurk. Four hours after the operation the 
patient complained of having a slight chill; this continued for an hour, 
and was followed by a little fever. These symptoms I thought might Gibson on Lithotripsy. 
21 
be attributed in part to the weather being uncommonly cold, raw and 
damp, from the continued prevalence for some time of easterly winds. 
Towards night the constitutional symptoms passed away, and the 
only complaint the patient made was of unusual soreness along the 
urethra, which I accounted for by the passage of the mortar-like sub- 
stance* armed with its crystallized points. 
Upon visiting the patient next day, (27th,) I found him complaining 
of desire to evacuate urine every twenty minutes, and of a discharge 
of ropy mucus of yellowish tint. These symptoms continued through- 
out the day, more or less, and were unabated on the next day (28th,) 
which induced me to order the hip bath and 30 drops of black drop, 
and a weak opiate injection per anum. Under the influence of these, 
Mr. T. slept soundly until 3 o’clock, P. M. During the afternoon, 
however, more or less of drowsiness continued, and the desire to make 
water had nearly ceased, and so remained throughout the night, but, 
in the morning (29th,) returned with its former urgency. To combat 
this as soon as possible, the opium was again resorted to, both in form 
of injection and black drop, internally. In the afternoon, also, an 
aloetic pill was administered, and a blister applied to the sacrum. 
Under the influence of these the patient passed a good night, almost 
undisturbed by spasms. On the next morning, (30th,) the desire to 
pass urine, accompanied by spasms, returned and continued all day, 
at intervals of fifteen or twenty minutes. At five o’clock, P. M., a 
suppository, consisting of three grains of cicuta, and two of opium, 
was administered. At eight o’clock, P.M., the pulse, for the first 
time, became full and bounding, owing to two much nourishment 
(consisting chiefly of raw oysters) having been taken, and to the room 
being filled with the gas of anthracite coal, which is as deleterious in 
its operation as that of charcoal. To remove these symptoms, the 
patient was bled to ten ounces. Notwithstanding the bleeding, the 
patient passed a restless night, and on the next morning (31st) the 
spasms returned with more violence than ever. In the course of the 
forenoon, a laxative enema was administered two or three times, and 
produced copious evacuations. At 3 o’clock, P. M., it became ne- 
cessary, on account of frequency of alvine discharges, to administer 
an opiate enema. This checked the diarrhoea and spasms for the 
night, but in the morning (June 1st) the spasms returned again, and 
continued with more or less violence throughout the day. Various 
remedies, besides the opiates and other means detailed, were tried 
ineffectually, and, although the symptoms varied from time to time, 
the spasms and pain in passing urine were the prominent ones, and 
came on at last with such violence, and at such short intervals, as to 22 
Gibson on Lithotripsy. 
prostrate the patient beyond the possibility of recovery. Two days 
afterwards (June 3d) he died. Permission could not be obtained to 
examine the bladder and its relations, a circumstance much to be re- 
gretted, especially as lithotripsy is still in its infancy and requires all 
the light that can be shed upon it. But, although denied the oppor- 
tunity of examining the condition of the bladder, and of ascertaining 
•positively the cause of death, there are several circumstances con- 
nected with the case exceedingly well calculated to unravel a part of 
the mystery. From the history of it I have detailed, it will be seen 
that extraordinary pains were taken to prepare the patient for the 
operation, by restricting his diet in every possible way—by confining 
him to his room, and by the use of instruments calculated to enlarge 
the urethra and accustom it afterwards to those to be employed for 
the destruction of the stone. Unfortunately, however, the interesting 
sufferer was not aware of his own danger, and with the best possible 
intentions, in deceiving me in what he supposed to be little matters 
of no moment, he deceived himself, and led to results which I am very 
confident would not otherwise have followed. Instead, then, of at- 
tending strictly to the regimen I had prescribed, (as I have since 
ascertained from the best authority,) instead of living entirely on 
barley water, black tea, dry bread, and rice, and avoiding altogether 
animal food during the entire month of preparation preceding the 
operation, his meals were taken with the family with which he lived, 
and every article on the table he happened to fancy freely indulged 
in. This course, together with undue exercise, either in his room or 
abroad in the streets, was calculated, as I am sure every experienced 
surgeon will admit, to produce the worst effects, especially in a pa- 
tient advanced in years, of irritable constitution—one who had long 
suffered from violent attacks of other diseases—whose bladder had 
been thickened and contracted by the lodgment, for years, of a large 
stone—whose kidneys, in all probability, were also diseased, besides 
other organs, more or less important in the animal economy. I trust 
it will not be supposed that I mention these facts by way of exculpa- 
tion or for the purpose of casting a veil over any errors I may have 
committed. Those who know me, I think, will acquit me of such in- 
tentions. Nor would I have it supposed that I am casting unjust and 
unnecessary censure upon the respectable patient for whom I felt the 
highest personal regard and respect, and in whose case I took the most 
sincere and lively interest. My only motive in detailing such cir- 
cumstances, is the public good, and for the benefit of those who may 
be now engaged in treating similar cases, or w ho may do so hereafter; 
for there is nothing more likely, than that patients similarly situated Gibson on Lithotripsy. 
23 
with Mr. T., (who, from having always been accustomed to plentiful 
and luxurious living—to all the comforts and delicacies of life,) will 
not voluntarily refrain from such enjoyments, especially if they can 
persuade themselves that the indulgence in them cannot interfere, 
materially, with their complaints and the mode of treating them. 
Cas* III. At the request of my friend, Dr. Joseph G. Nancrede, 
I saw, in consultation with him, in April, last, Mr. Charles O’H., 63 
years of age, who, for the last few years, had led a sedentary life, and 
complained, latterly, of symptoms of stone in the bladder. Upon 
sounding the patient, a stone of large size was distinctly felt, both by 
Dr. Nancrede and myself, and the case pronounced, in every respect, 
suitable for lithotripsy. The patient having consented to the opera- 
tion, was accordingly prepared for it, by being placed on a diet of rice, 
barley wrater, and black tea; very little time, however, was required 
for this purpose, inasmuch as he had abstained for some time pre- 
viously, from animal food, by advice of Dr. Nancrede. 
On the 1st of May, 1836, I commenced the operation in presence 
of Dr. Nancrede and Dr. J. Y. Hollingsworth of Maryland, by intro- 
ducing a large silver catheter, and injecting the bladder with tepid 
water, until the patient complained of uneasiness from a sense of 
distension. The catheter was then withdrawn, and the lithotripteur of 
Heurteloup introduced, but the stone not felt until the patient turned 
a little on his side; I then perceived it to roll over the instrument 
heavily, which convinced me, at once, that it was large. Upon placing 
the patient on his back, and elevating his hips with pillowrs, the heel 
of the lithotripteur came in contact with the stone, Avhich was readily 
seized, (though not until I had expanded the blades of the instrument 
beyond an inch and a quarter,) and, by a few turns of the tripod, 
broken it into several large fragments, the cracking of which, as they 
were rent asunder, could be distinctly heard. During these manoeuvres 
the patient remained perfectly still, experienced not the slightest un- 
easiness, (except that arising from over distension of the bladder,) 
and was conversing, cheerfully, during the whole operation, which 
did not exceed in duration five minutes. Upon withdrawing the 
lithotripteur, and directing the patient to stand up and evacuate his 
urine, numerous small fragments were discharged, besides those con- 
tained in the blades of the instrument. The catheter being again in- 
troduced, and the bladder injected, other fragments were brought 
away. Neither pain, chill, nor fever followed the operation; the 
fragments, in small quantity, continued to pass away, but not with as 
much rapidity as if the muscular power of the bladder had been 
greater. 24 
Gibson on Lithotripsy. 
On the lGth of May, I repeated the operation, in presence of Drs. 
Nancrede, Horner, and Mutter, seized, without difficult}", fragment 
after fragment, and fractured them, without giving the patient any pain 
whatever, except upon withdrawing the instrument, which, from being 
a little clogged with pieces of the stone, produced slight irritation at 
the external orifice of the urethra. No constitutional disturbance fol- 
lowed, and the patient, as heretofore, passed again small fragments. 
May 19th, in presence of Drs. Nancrede, Hays, Mutter, Caldwell, 
and Bush, of Kentucky—Cabell, of Virginia, and several medical 
students, I renewed my attempts upon the fragments of Mr. O’H.’s 
stone, with the success I had hitherto met, and without the operation 
having been followed by a single unpleasant symptom. Fewer frag- 
ments, however, than usual, passed away, immediately after the opera- 
tion, and for several succeeding days, owing to continued inactivity 
of the bladder, or want of muscular power. 
24th, in presence of Dr. William Crump, a distinguished physician 
of Powhattan County, Virginia, Drs. Mutter, M'Crea, Stewardson, 
Pennebaker, Smith, Mr. W. Tunstall, of Virginia, and many medical 
students, I performed upon Mr. O’H. the operation he had, upon 
former occasions, undergone. Previous to commencing it, however, 
it was necessary to remove a fragment from the urethra, which lodged 
about an inch behind the glans and was easily removed by a bent 
probe. Several of the fragments in the bladder, notwithstanding the 
former operations, measured, by the graduated scale, half an inch, and 
even three quarters. These were distinctly heard to crack by seve- 
ral of the gentlemen present, under the pressure of the tripod. This, 
like the former operations, was followed by no unpleasant occurrence. 
29th. (Drs. Nancrede, W. P. Johnson, and J. Wallace being pre- 
sent,) I performed lithotripsy for the fifth time on Mr. O’H., and 
without injecting the bladder, seized upon fragment after fragment, 
and instantly reduced them to pieces so small, that scarcely a parti- 
cle could be caught larger than a quarter of an inch, though in the 
commencement of the operation, two or three fragments, exceeding 
half an inch in size, were met with. As usual, the patient bore the 
operation without a murmur. Several fragments and a good deal of 
debris came off in the blades of the forceps. But several days elapsed, 
after this operation, before any pieces of consequence were discharged 
with the urine. Early in the morning, however, on the 1st of June, 
I was sent for to remove a fragment that blocked up the urethra near 
the neck of the bladder, which I thought best to push back with a 
catheter. 
June 12th. Accompanied by Drs. E. Peace and W. P. Johnston, Gibson on Lithotripsy. 
25 
I again visited Mr. O’H., introduced a large silver catheter and drew 
oft" a small portion of urine, which the patient could not expel by his 
own efforts, injected the bladder with tepid water, and introduced 
the lithotripteur of Heurteloup, with a view of crushing any fragments 
that might remain, but, much to my surprise, found that none could 
be detected; not satisfied, however, with this examination, I deter- 
mined to explore the bladder with the common sound; but still with 
the same result. This was accounted for by examination of the bot- 
tle containing the discharged pieces, which had accumulated since the 
last operation, (May 29th,) so considerably, as to add, largely, to the 
portions previously expelled, and which taken, collectively, from first 
to last would have been sufficient to form a stone of the size of a wal- 
nut, and one much larger might have been formed, if the patient had 
taken pains to collect all the pieces—but owing to inaccuracy in this 
respect, a great deal of sand and numerous fragments, there is reason 
to believe, must have been lost. As usual, no inconvenience resulted 
from this examination; but, four days afterwards, (June 16th,) I was 
sent for, early in the morning, to visit the patient, who felt alarmed at 
the idea of a fragment being lodged in the urethra; such, however, upon 
passing the instrument, I could not discover, and, therefore, concluded 
that irritation had been created by the patient having changed his 
diet too suddenly, after having been told that he was nearly rid of his 
calculus. Upon this occasion, indeed, I found him over a large bowl 
of coffee, and surrounded by piles of bread and butter. By directing 
him to resume his tea and barley water, all uneasiness about the blad- 
der and urethra disappeared in a few hours. On the 20th of June, I 
paid him another visit, and found him complaining of slight tenderness 
in one testicle and a prickling sensation in the urethra. Suspecting the 
lodgment of a fragment, I introduced a pair of small forceps, and ex- 
tracted a piece about a quarter of an inch in length. 
In the presence of my friend, Dr. Norcom, an eminent physician of 
North Carolina, Dr. Chase, Dr. Nancrede, and Mr.Schively, I repeated 
the operation to-day, (June 29,) on C .O’H.,by injecting the bladder, in- 
troducing the lithotripteur, and searching for the stone; but, after mov- 
ing the instrument in every direction, within the bladder, I could not 
touch a fragment. The lithotripteur was withdrawn, and the patient 
rose and passed his urine. It then occurred to me, that by sounding the 
patient with the bladder empty, I might be able to feel the stone and 
crush it. Upon so doing, accordingly, a fragment about half an inch 
thick, was distinctly felt, and almost immediately seized and demo- 
lished. Another was also caught, and as i*eadily destroyed. In the 
groove of the instrument, as usual, portions of mortar-like matter 26 
Gibson on Lithotripsy. 
were found. Fully convinced from the accurate examinations made 
at different periods that the fragment destroyed to-day was the only 
one the bladder contained, I feel very confident that the patient will 
be entirely rid of his complaint, as soon as the pieces come away, 
which will probably take place in a few days. 
Case IV. H. M., of Virginia, 34 years of age, arrived in Philadel- 
phia on the 29th of April, 1836, and consulted me on his case, which, 
in some points of view, was a singular one. According to the patient’s 
statement, a persimmon seed had been introduced into his urethra, 
and found its way into the bladder, where, in all probability, it had 
served as a nucleus for a stone; for, in a short time after, symptoms 
resembling those of stone, were manifested. Upon sounding the 
patient, I discovered a calculus of small size, and (judging from the 
feel communicated to the sound) of soft consistence. Anxious to un- 
dergo lithotripsy, or lithotomy if I preferred it, he was placed, at 
once, upon appropriate diet, directed to drink plentifully of diluents, 
and while pursuing this course, had the urethra dilated with bougies, 
catheters, &c. After persevering in this system for three weeks, the 
patient became exceedingly desirous of submitting to the operation it- 
self, and, as he possessed considerable mechanical skill and ingenuity, 
and had examined with great curiosity the instruments for litho- 
tripsy, expressed a decided preference for that of Jacobson. To 
gratify him, therefore, it was employed, and, with the utmost caution 
and gentleness, attempts made to seize the stone; but, so great was 
the irritation, and so severe the spasmodic action of the bladder, 
induced by its presence, that it appeared to me it would have been 
forcibly expelled from that viscus. I was obliged, therefore, to with- 
draw the instrument, after the lapse of a few seconds. This attempt 
was followed by severe chill and fever, which confined the patient 
for several days. 
On the 26th of May, assisted by Dr. Mutter, I commenced, regu- 
larly, with Mr. M., and, at his request, again employed the instru- 
ment of Jacobson, notwithstanding the suffering it had previously 
occasioned him. Accordingly, it was introduced, but created so 
much pain and inconvenience that he peremptorily demanded its re- 
moval. Upon withdrawing the instrument, the urine which had been 
retained three or four hours, escaped, and rendered it necessary, 
before proceeding further, to inject the bladder with tepid water. 
After this, the lithotripteur of Heurtelonp was introduced, and the 
stone almost immediately seized and crushed under the pressure of 
the tripod or screw—creating a sound similar to that of chalk, 
when broken between the fingers. In the groove of the instrument, Gibson on Lithotripsy. 
27 
numerous small fragments were found, and, in course of the day, 
several large pieces discharged along with the urine, some of which 
were encrusted with a dark brown or black skin, similar to the husk 
of a persimmon. The stone, as I had predicted, was of rather soft 
consistence, and apparently composed of the ammoniaco-magnesian 
phosphate. Before the completion of the operation, the patient suf- 
fered a good deal from pain and spasm of the bladder, but these soon 
ceased, and were not followed, as in the former attempts, by chill and 
fever. Two days (May 28th) after the operation, however, the patient 
complained of great pain in the urethra, but was suddenly relieved 
by the discharge of a large fragment, in the centre of which was a 
hollow or depression, corresponding in shape and size with a per- 
simmon seed. 
On the 29th, another fragment wras discharged, but, as no other 
made its appearance from that period until the 6th of June, I intro- 
duced, on that day, in the presence of Mr. Saltmarsh, the instrument 
of Heurteloup, and used it as a sound, but could not detect any por- 
tion of stone. However, the next day, (June 7th,) a fragment, half 
an inch long, and hollowed out in the centre, passed off with the urine. 
At the same time, a portion of black skin resembling the rind of a 
persimmon was thrown off. On the 9th of June, the lithotripteur 
was introduced, but without detecting a fragment. The same operation 
was repeated four days after (June 13th) in presence of Drs. Johnson 
and Peace, but with no better success. Having experienced no in- 
convenience from the two last examinations, another was made 
(June 17th) in presence of Mr. Saltmarsh, and a fragment about the 
size of a bean felt at the fundus of the bladder, which was readily 
caught and crushed. In the course of the day, three oblong frag- 
ments, a quarter of an inch thick, passed away with the urine. With 
the view of ascertaining whether other fragments still remained in 
the bladder, the lithotripteur was again introduced, (June 20th, Mr. 
Saltmarsh being present,) but nothing could be felt. Soon after this 
examination, the patient changed a pair of cloth pantaloons for thin 
ones, and walked about the streets for some time, and, when he re- 
turned to his lodgings, was seized with chill, followed by high fever, 
which rendered it necessary to bleed him and restrict his diet more 
than ever. Since that period he has been confined to his room with 
sore throat, cold, and more or less fever, which, for the present, pre- 
vent the operations from being continued. That any fragment of 
stone remains in the bladder, seems to me extremely doubtful; it is 
more than probable, however, that the persimmon seed is still there, 
inasmuch as no portion of the substance of the seed has been yet dis- 28 
Gibson on Lithotripsy. 
covered, and, as he complains, after passing urine, of something pre- 
senting itself at the neck of the bladder. Whether the lithotriptcur 
will be able to destroy the texture of such a substance, (which closely 
resembles softened horn,) I am at a loss to say. In truth, until I 
saw the pieces of black skin discharged along with the fragments, I 
did not believe that such a foreign body had found its way to the 
bladder, and had placed the patient’s account of the mode of its get- 
ting there to the effect of imagination. 
On the 28th of June, the patient having recovered, in a great mea- 
sure, from the effect of his cold, another examination was made with 
the lithotripteur, but smaller in the shaft and shorter in the beak than 
the one commonly employed. This did not enter with facility, but 
met with considerable obstruction at the neck of the bladder; it tinaily 
started forward, very suddenly, and was completely introduced. 
Some hours after, the patient discharged, along with the urine, more 
or less venous blood, the result, no doubt, of the pressure of the short 
beaked instrument upon the prostate and neck of the bladder. To-day 
(June 29th) the urine is colourless and the patient free from soreness 
in the urethra, and, as the weather is becoming warm and oppressive, 
and he complains of being weakened and reduced, I have advised him 
to postpone further operations for the present, and retire for a few 
weeks to the country. 
Case V.—P. P., Esq., about 48 years of age, of literary and se- 
dentary habits, troubled more or less with dyspepsia, came to Phila- 
delphia last fall, by advice of my friend, Dr. Thomas, a distinguished 
physician of Westchester, to consult me about symptoms resembling 
those of stone in the bladder. His engagements, however, at that 
period, were such as to prevent him from being sounded, and from 
remaining in town. About the middle of May, 1836, he returned to 
Philadelphia, and upon sounding him I discovered a small stone, and 
concluded, from its ringing distinctly when struck by the sound, that 
it was a hard one. Believing the case adapted to lithotripsy, I ad- 
vised the operation, placed him in suitable lodgings, and commenced 
a system of diet, which, indeed, he himself had been observing, in a 
measure, for some time before, having anticipated the necessity of 
such a course. After using, also, gum elastic and other instruments 
to familiarize the urethra with such guests, I commenced the regular 
operation (May 21,) by introducing Jacobson's instrument, which, 
however, gave excessive pain, brought away blood, created severe 
chill and fever, and rendered the patient so ill as to induce me to 
advise him to return to the country after the symptoms had abated, 
and remain until he recovered sufficiently to undergo a trial with Gibson on Lithotripsy. 
29 
another instrument. Accordingly, he left town on the 26th of May, 
and returned on the 4th of June, improved in appearance and health. 
On the 8th of June, assisted by Dr. Mutter, I introduced thelitho- 
tripteur of Heurteloup; and after searching for the stone a few 
seconds, discovered, seized, and fractured it, as it lay iit the fundus 
of the? bladder on its right side. During the turning of the screw, the 
fragments could be heard cracking distinctly, the report being very 
sharp and sudden, like that of a whip. Upon removing the instru- 
ment, numerous small fragments were found in its claw and gutter, 
of a yellowish or gamboge tint, intermixed with harder portions of 
dark brown fragments; which, from appearance, I should suppose 
were made up of oxalate of lime and lithic acid. During the opera- 
tion the patient scarcely complained of pain, and remarked that the 
uneasiness arose more from sense of distension, from having retained 
his urine two or three hours previous to the operation, than from the 
instrument. Neither chill nor fever followed this operation; and 
the next day sand and several small fragments were discharged with 
the urine. 
On the 14th of June, the patient felt well enough for another 
trial, which was accordingly made, and with the same happy re- 
sult—the stone having been seized instantly and crushed with an 
audible noise. Numerous fragments came away in the groove of the 
lithotripteur, and the next day three larger than a pea were dis- 
charged along with the urine—the whole collection, from the two 
operations, being sufficient, if put together, to form a stone the size of 
an almond. During the operation, the patient did not complain of pain 
or spasm of the bladder; moi’e or less of which last he had usually 
experienced while the instruments remained in that organ. 
On the 17th, I visited Mr.P.again, (accompanied by Drs.Peace, Chase 
and Johnston) with the view of searching for fragments; but the patient 
not having allowed the urine to collect in sufficient quantities to seize 
them with safety, 1 declined the operation, but merely used the litho- 
tripteur as a sound, to determine the size and situation of the pieces. 
On the 22nd of June, in presence of Mr. Saltmarsh, I made another 
examination, but without being able to detect a fragment, and repeat- 
ed the effort on the 25th and 29th, but with no better success. That 
there is still a fragment in the bladder, however, is rendered probable 
by the circumstance of the patient feeling an obstruction, occasion- 
ally, about the neck of the bladder after walking or remaining for some 
time in the erect position, an obstruction sufficient to impede the flow 
of urine for a moment, or until removed by a change of position. But 
the patient’s engagements are such as to prevent him from staying 30 
Gibson on Lithotripsy. 
longer in town at present; anil as he is desirous of recovering, also, 
from the effects of his restricted system of living, he returns to his 
farm, and, after harvest, intends to have the bladder still further ex- 
plored. 
In examining the details of the above cases, it will be seen that I 
do not report them as perfect cures, although they are, I think, in a 
fair way to become so. They are of too recent occurrence, moreover, 
(so far as the operation is concerned) to expect that I should have 
been able to pronounce decisively as to the result. But I prefer, at 
any rate, giving an account of them at this time, because it will be 
expected that I should notice them hereafter, and state, for the benefit 
of the profession, whether they have been cured or not, or whether 
there has been a return of the complaint. It has been objected, in- 
deed, to the operation of lithotripsy in Europe, that many of the 
patients, reported as cured, have not in reality been so; that in several 
instances death has followed a few months afterwards, from long con- 
tinued irritation of the bladder and urethra, or from other disease; 
and that when such has been the result, the operators have not 
deemed it incumbent upon them to disabuse the public on the subject. 
For my own part, I can with confidence, declare that truth, and no- 
thing but truth, is the object of my inquiries, and of the practice 
in which I am now engaged; that if I find, after full trial and 
ample experience, lithotripsy unworthy of the commendation which 
has been bestowed upon it, I shall renounce it; that, on the con- 
trary, if it turns out, as I ardently hope it will, to possess, in many 
instances, advantages over lithotomy, I shall advocate and sup- 
port it. In conclusion I may state, that I have not introduced 
into this paper an account of several cases in which I have been con- 
sulted, because they were either unfit for the operation, and, there- 
fore, abandoned, rather than risk the patient’s life in the attempt, or 
because the patients themselves were unwilling that the trials should 
be continued, rendering it thereby impossible for any just inference 
to be drawn from them, either in favour of, or against lithotripsy.