SAPID 
LITHOTEITY. 
BY Df[. HENRY H. MUDD, 
ST. LOUIS, MO. 
[Read before the Tri-State Medical Society at Indianapolis, 
Sept. 19, 1883,] 
[Reprinted from the “ Weekly Medical To mew ” of 
October 20, 
Published by J. II. Chambkrs & Co., 
Chicago, III. and St. Louis, Mo. RAPID 
LITHOTRITY. 
BY DIj. HENRY H.JJDH 
ST. LOUIS, MO. 
[Read before the Tri-State Medical Society at Indianapolis, 
Sept. 19,1883,] 
[Reprinted from the “ Weekly Medical Review ” of 
October 20, 1883.~\ 
Published by J. H. Chambers & Co., 
Chicago, III. and St. Louis, Mo. BAPID LITHOTBITY. 
DR. HENRY H. MUDD, ST. LOUIS, MO. 
It is not my object to review the history of the 
various operative procedures for the removal of 
stone, but to inquire concerning the best method 
of treating such cases as may be presented to us at 
the present time. 
Lithotomy and lithotrity have brought to sur- 
geons much repute and honor, but unfortunately the 
very causes that have surrounded the operators 
with renown have tended to develop in the laity a 
profound dread of the operation, hence we not in- 
frequently meet with patients who vainly hope to 
escape the surgeon’s attention. 
Such cases illustrate the tolerance of the bladder 
and the power of hygienic care and lithontriptics 
to mitigate suffering and prolong life. 
Rest, diet, habit of body, and prompt treatment 
of the recurring so-called “attacks of stone,” go 
far toward rendering endurable the suffering of 
these timid patients, who shrink from one of the 
safest and most gratifying operations in the pro- 
vince of surgery. 
Solvents are of course for internal administra- 
tion, and will aid at least in keeping the bladder in 
the best possible condition while subject to the ir- 
ritant action of a foreign body, and may in some 
cases diminish the size of the stone. 
Pure water in large quantity is the most potent 
solvent of urinary calculi. If the calculus is of 
uric acid, the lithia, or potash salts, are an aid to 4 
the solvent action of the water. Benzoic acid, or 
some of its congeners, are more suitable if the cal- 
culus is phosphatic. 
Injections into the bladder, given with a view of 
dissolving stone, have now nothing to commend 
them, for they demand as much and as severe me- 
chanical treatment as the more prompt and efficient 
“rapid lithotrity.” They have no redeeming feature 
to justify their use. In illustration of the influence 
of such care, and of the tolerance of the bladder to 
such irritation, I append brief histories of the two 
following cases: 
B. L., a German, aged thirty years, sustained a 
compound comminuted fracture of both legs in 
1870. He made a slow but good recovery. In 1872, 
in consequence of long confinement and suppura- 
tion, he suffered from lithiasis and passed a num- 
ber of small stones. His bladder has since contin- 
ued to give him trouble. In 1879, I sounded for 
stone and found one the size of a large walnut. He 
would not submit to an operation and tried various 
domestic remedies with the view of dissolving the 
stone! oak bark, rosemary, columbine, etc., etc. 
He was a grocer, but retired from business to care 
for himself. So successful was he that he wished 
to resume business at the end of two years, and, with 
bladder less irritable, and general health much im- 
proved, he is now at work and lives in comparative 
comfort, although he still carries his stone. 
In another case in which the stone, when finally 
removed *by Dr. HodgeD, weighed twenty-two 
ounces, the patient had carried it for many years, 
yet was able to attend to business until within a few 
weeks of death, having carried a daily mail a dis- 
tance of twelve miles and return. 
In a discussion provoked by a paper presented by 
Sir Henry Thompson to the Royal Medico 
Chirurgical Society, in March, 1878, the province 
of lithotrity was in a manner defined and its limits 
somewhat rigidly outlined by its opponents, while 5 
its advocates admitted its usefulness to be re- 
stricted, and applicable only to carefully selected 
and favorable cases. 
In January, 1878, in the American Journal of 
Medical Science, there appeared an article by Henry 
J. Bigelow, of Boston, announcing his discovery of 
the tolerance of the bladder to prolonged instru- 
mentation, demonstrating the feasibility of using 
large evacuating tubes, and defining the principles 
of litholapaxy, or, “rapid lithotrity.” I had been 
accustomed to see such good results from lithot- 
omy in the practice of my associate, Dr. Hodgen, 
that I thought there was little to be desired in the 
way of improvement on the lateral operation. I 
had learned to regard it as one of the safest and 
most uniformly successful of the so-called capital 
operations. It was only when Bigelow’s paper ap- 
peared that my attention, in common with that of 
the majority of surgeons, was turned with renewed 
interest to lithotrity, an operation which was sup- 
posed to have found its limit in the restricted pro- 
vince defined by carefully selected cases in the 
hands of few surgeons. , 
Lithotrity (where no single sitting was for more 
than five minutes) was limited to the removal of 
small stones of the size of a chestnut, possibly one 
ounce in weight, occurring in adult males, where 
cystitis was slight, where the patient was able to 
bide his time and wait for the slow subsidence of 
the inflammatory action produced by the sharp frag- 
ments resulting from a short sitting and the timidity 
of the surgeon’s action. This operation, where the 
patient was forced to take the chance of being able 
to pass the fragments through the unprotected 
urethra, was suddenly developed into the vastly 
improved and widely useful operation of “rapid 
lithotrity ” or litholapaxy. So well satisfied was I 
of its utility that I have since that date found that 
the great majority of patients were amenable to 
this much less severe operation. 6 
Rapid litliotrity has revolutionized the treatment 
of stone in the bladder, for the author grasped in 
its widest significance the fact that prolonged 
instrumentation (an hour or two hours, not five 
ten minutes) was less harmful than the con- 
tinued presence of ragged, sharp foreign bodies 
in the bladder—the fragments of a partially crushed 
stone. He pushed his thought to its legitimate con. 
elusion, and demonstrated that it was safe to crush 
large stones if the fragments were immediately 
removed. 
He supplemented this discovery by using large 
evacuating tubes, so large that it was no longer 
necessary to pulverize the stone. Complete evacu- 
ation, even if obtained at the expense of two or 
more hours continuous work, is preferable to an in- 
complete operation, no matter how carefully it may 
have been done. Rapid lithotrity has left but few 
patients over sixteen years of age for lithotomy, 
and it may be that much younger patients may with 
propriety be subjected to this operation. The age 
of the patient should impose a limit only where the 
bladder or urethra is deficient in size, and this de- 
ficiency will, I think, be harder to overcome 
in the urethra than in the bladder, for the bladder 
of a child three and a half years old, when mod- 
erately distended, will hold about three and a half 
or four ounces, sufficient to give room for the use of 
a small lithotrite. The youngest patient on whom I 
have made lithotrity was in his fifteenth year, but I 
believe that we shall find that much younger pa- 
tients are amenable to this operation. The pro- 
portion of cases fitted for lithotrity will vary iu the 
hands of different operators. Out of nine succes- 
sive cases coming under my observation during the 
past fifteen months, only two in my judgment de- 
manded lithotomy. The oldest patient subjected 
to lithotrity was sixty-two years of age. The 
largest stone weighed 720 grains. 
There are but few essential conditions necessary 7 
to make success probable, presuming ordinary 
manual dexterity in the operator, and care and 
moderate practice in the use of instruments. 
We need first, a free urethra; second, a bladder 
capable of moderate distension—sufficient to make 
room for the free movements of the lithotrite. The 
first condition may be made evident very generally 
by the operation of sounding; the second, I think, 
is not quite so readily determined. 
In the fall of ’79 I made some experiments con- 
cerning the amount of pressure necessary to dis- 
tend the bladder in the cadaver, and reported them 
to the State Medical Association in 1880, at Car- 
thage, Mo. A bladder may be generally thickened, 
or it may be thin and weak at certain points of di- 
latation. How are we to know the very essential 
fact that the bladder is regular in outline, normal 
in its distensibility, and with walls not so seriously 
diseased as to make unsafe the requisite distention 
and manipulation for litholapaxy. Any change in 
the structure of the bladder-wall by inflammatory 
thickening, by ulceration or by sacculation would 
almost certainly interfere with its distensibility, 
except in the abnormal dilatation of the bladder, 
which is associated with retention, a condition not 
often accompanying stone. Dr. Harry Hodgen, now 
assistant physician at the City Hospital, made some 
experiments on the cadaver during August, 1883, to 
determine the force necessary to inject six and 
eight ounces in the normal bladder. I think these 
experiments fairly show the slight force required to 
inject the living healthy bladder, when the patient 
is under the influence of anaesthetics. 
In a series of fifteen consecutive experiments on 
the cadaver, it was found that the average pressure 
required to inject through a catheter and rubber 
tube six ounces, was represented by a column of 
water 12.8 inches in height from the level of the 
table on which the body lay. The extremes of 
pressure required were represented by columns of 8 
water respectively six inches and twenty-seven 
inches in height from the level of the table. 
In a series of fourteen consecutive experiments, 
it was found that to inject eight ounces required an 
average pressure represented by a column of water 
15.2 inches in height from the level of the table on 
which the body lay. 
More pressure than this is unnecessary, and if 
required should be regarded at least as a 
ing, which if heeded may save the patient's life. 
Lithotritists have recognized the possible danger of 
rupture of the distended bladder, by the violent 
muscular contractions of vomiting; so it may, when 
diseased be ruptured by forcible injection. 
Surely in an operation of so much importance, 
too much care and attention cannot be exercised in 
the search for possible danger from pathological 
changes in the wall of the bladder. 
Little else beside free working room is required. 
Capability of the bladder to hold six ounces of 
fluid without undue distention, is the one prime 
factor always necessary to a safe lithotrity. In 
many cases this can be determined only after full 
anaesthesia is established, by injecting with this 
very slight pressure the quantity desired. The 
column of water 12.80 or 15.2 inches high would 
represent a pressure greater by at least six inches 
in height of column than is necessary, for the 
pubes which is a guide to the position of the 
bladder is about six inches above the level of the 
table. 
There may be serious changes in the bladder that 
will be difficult or impossible to definitely determine 
before operation, but a constant remembrance of 
the very slight pressure necessary to distend a nor- 
mal bladder, when muscular resistance is absent, 
will prevent disaster by the use of any undue 
pressure in injecting the bladder, and compel the 
surgeon to abandon lithotrity for the then safer 
lithotomy. 9 
The details of the operation are well described in 
the many articles that have appeared in our jour- 
nals . All call attention to many minor details of 
great practical importance. Some profit may be 
gained by considering the causes of death in lithot- 
omy, as shown in the case book of Dr. Hodgen and 
myself. Some of these sources of danger will not 
pertain to lithotrity. 
Our case book gives a record of (85) eighty-five 
lithotomies, of which (80) eighty were made by the 
late Dr. John T. Hodgen, and (5) five by myself. 
Three of these were secondary operations made on 
children under the age of puberty for the recur- 
rence of stone. In one of these vesico-rectal fis- 
tula remained. It first followed an operation by 
Dr. Chas. A. Pope, and remained after secondary 
operation by Dr. Hodgen. 
Deaths occurred in (12) twelve cases, of which (4) 
four are properly chargeable, not to the operation, 
but to conditions which would have resulted fatally 
under any operative procedure or without any in- 
terference. Of these (4) four cases one died of 
chloroform in 1869; two others, aged respectively 64 
and 62 years, one with thirty-five stones, the other 
with twenty-one stones, died of uraemia, while the 
fourth, aged 21, died of haematemesis. Of the re- 
maining (8) eight, three died of peritonitis, one of 
cellulitis, one of pyaemia, and three of uraemia, con- 
ditions which may supervene after either operation, 
but pyaemia, cellulitis and peritonitis are not so 
likely to result from lithotrity as they are to follow 
lithotomy. 
Considering only adult patients, we may fairly 
eliminate from the list of dangers attending rapid 
lithotrity phlebitis, erysipelas, and pelvic cellulitis, 
while acute peritonitis will occur only in case great 
injury is done to the bladder by more or less com- 
plete rupture. 
Anaesthesia is an essential part of rapid lithot- 
rity, where the operation is prolonged, and the 10 
danger from this agent is greater than in lithotomy, 
because the time for its influence is prolonged and 
the impression demanded no less profound. 
Cystitis is more likely to follow lithotrity, since 
drainage is not so perfect or continuous as in lithot- 
omy, and the bladder is not left in a condition to 
be at as perfect rest as after lithotomy. Cystitis is 
much less likely to follow the modern lithotrity 
than it was to remain after the operation as per- 
formed before Bigelow’s advance. Cystitis is how- 
ever sometimes well treated by the incision as made 
for a lateral lithotomy. 
In the absence of ulceration the absorption of 
decomposing urine is less apt to occur than in lithot- 
omy, where the prostatic urethra is cut and bruised 
and the cellular tissue exposed. 
Haemorrhage is less liklely to be troublesome, 
and it is hardly possible that it should be danger- 
ous in its results. The greatest danger would be 
in the distress occasioned by its coagulation in, and 
distention of the bladder, but we have at hand the 
evacuating tube and bulb of Bigelow, which are 
most efficient and safe in their action. I have re- 
peatedly cleansed the bladder of clotted blood by 
their use, in cases of haemorrhage from an hyper- 
trophied prostate. 
Pyelitis and suppression of urine are not likely to 
follow in either case, unless there is serious disease 
of the kidney, aud in this case the less severe oper- 
ation without cut or abrasion, as in rapid lithotrity, 
is not so likely to provoke disturbance as the more 
severe operation of lithotomy. 
Urinary infiltration and abscess occasionally oc- 
cur in lithotomy, but not in rapid lithotrity, for 
there is no laceration of the urethra by passing 
fragments, nor is there a cut in membreaio-prostat* 
urethra. 
Again, the shock from lithotrity, except it results 
from prolonged anaesthesia, is not likely to be 
more severe than from the passage of a large 11 
and is much less severe than from lithotomy, and 
when suppression of urine results, it comes, I sus- 
pect, from this anaesthesia rather than from the 
manipulation of the operation. 
The period of confinement and restraint in the 
sick-room is lessened by at least three-fourths. I 
have had patients at their work in three days after 
lithotrity. 
The recurrence of stone after the modern rapid 
lithotrity will, I venture to assert, be imjch less fre- 
quent than after the old lithotrity, and not more 
frequent than after lithotomy, for I suspect it is 
very rare that any considerable fragment will re- 
main in the bladder; since one of the most efficient 
means of sounding for small stones, stones that are 
apt to escape the ordinary sound, by reason of their 
small size, or by concealment in pockets, or folds of 
the bladder, is found in the use of the evacuating 
tube and bulb, after moderately filling the bladder 
with water. The fragment, unless so small as to be 
represented by the merest grain, adherent to the 
soft and vascular surface of the bladder, will be 
dislodged from its pocket by the distention of the 
bladder, and the current of water when drawn 
into the tube and bulb will carry the stone against 
the tube with an audible click, or into the bulb— 
thus making the exploratory operation one of rad- 
ical relief. 
American surgeons may well be proud to boast 
that one of their number possessed the boldness 
and discrimination to demonstrate the feasibility of 
rapid lithotrity, and to popularize the operation; 
for it is one of the greatest advances of modern 
surgery.