Remarks on Lithotrity. 
An Outline of a Series of Lectures Delivered before the Class of 1880 of the 
Evansville Medical College, February nth, 1880. 
BY REUBEN A. VANCE, M. D., 
113 West Ninth Street, Cincinnati, Ohio. 
[Re-print from THE INDIANA MEDICAL REPORTER, April 1880.] 
JllfjHAT is Lithotrity? Upon the answer returned this question will 
JUj depend the estimate you form of this procedure as a surgical meas- 
ure, and the value you accord certain proposed modifications of 
lithotrity as an operation for the cure of stone in the human bladder. 
Etymologically, lithotrity signifies a process of stone-crushing; as a 
technical term of surgery it denotes a procedure by which an instrument 
is passed along the urethra and into the bladder, and made to grasp and 
crush a calculus — the resulting debris being evacuated through the 
natural passages without recourse being had at any time to the knife. 
Such are the essential of lithotrity; in its details the surgeon has great 
diversity of choice. In one individual in whom the stone is neither very 
large, nor very hard; a single sitting may suffice for the reduction of the 
calculus to fragments so minute that they may be discharged spontan- 
eously; again, the development of symptoms indicative of local irrita- 
tion may cause the operator to re-introduce the lithotrite, and completely 
granulate all the remaining fragments in a case in which he originally 
intended to prolong the crushing through a number of sittings; in an other 
patient the lithotritist may see proper, not only to reduce the calculus to 
small particles at orie sitting, but he may pass an evacuating tube and 
remove all the fragments. Nevertheless, the general rule in this opera- 
tion is to perform the maximum of work with the minimum of disturb- 
ance ; to destroy as much of the stone as possible whenever the lithotrite 
is employed, but to avoid disturbing the bladder, or irritating the system. 
In the majority of the cases which should fall to the lithotritist it is pos- 
sible for the surgeon to so prepare his patient that the stone can be grad- 
ually reduced to fragments—treatment being prolonged over a number of 
'sittings, but great care being exercised to prevent vesical disturbance or 
systemic irritation—and these fragments discharged from the vesical 2 
cavity without the introduction of evacuating tubes or the employment 
of an aspirator. 
Too much attention cannot be paid to the instruments with which 
the stone is crushed by those who desire to familiarize themselves with 
lithotrity. Every point relating to the size, shape, construction, material, 
weight, form and mechanism of a modern lithotrite has only been deter- 
mined— as Thompson well expresses it — by careful attention to the 
necessities of hundreds of cases, and through long years of experience, 
and after the occurrence of numerous contingencies not anticipated at 
first, but now provided for. The parts common to all modern instru- 
ments are beak, staff and handle; the former consisting of two blades or 
jaws—the “male” and “female” blades, parts, also sometimes denomi- 
nated the “ shoe ” and “ foot”; the staff comprising shaft and sliding rod; 
and the handle containing the screw and mechanism for throwing it into, 
and out of gear, and surmounted by a wheel. The beak is the curved 
terminal (distal) extremity; the handle, the proximal enlarged end of the 
instrument; between the two is the staff, the longest section of the appli- 
ance. The staff is straight, about four inches longer than the urethra ; 
it consists of two portions, the shaft, continuous with the female blade, 
or shoe, and the sliding rod, continuous with the male blade, or foot. If 
we follow the female blade to the shaft, and thence pass along the exca- 
vation in the shaft designed to shelter the sliding rod to the proximal 
extremity of the lithotrite, we come upon the handle proper, which, in 
the most desirable form of the modern instrument is cylindrical in form. 
When the lithotrite is closed, the blades being in coaplation, the screw is 
within the handle and the wheel in immediate contact with the end of the 
latter. If, in like manner, we pass from the male blade to the wheel, we 
come first upon the sliding rod, then upon the screw, and last of all, reach 
the wheel. The male blade, the sliding rod, screw and wheel form one 
continuous whole, that can be readily removed from the remainder of 
the instrument. If the handle be grasped in the surgeon’s left hand, he 
can cause the blades of the beak to open and close by moving the wheel 
backwards and forwards with his right hand. If, furthermore, the blades 
be made to grasp any object the size and shape of a vesical calculus, the 
surgeon, by touching a button on the handle, can exchange the compres- 
sive force of his hands for the mechanical power of the screw. This 
button acts on a spring which throws into gear the threads of the screw, 
and now, by turning the wheel, the screw is made to revolve, and the 
object between the blades is subjected to an almost irresistible compres- 
sive force. A moment’s glance at an instrument of this kin,d and a little 
study of its mechanism, will speedily familiarize the student with its office 
and the proper method of handling it. 
The instrument I now bring before you—which you will observe is 3 
simply a large rubber bulb with a glass tube or “cage” at its inferior 
extremity and a rubber pipe which connects its upper part with an ure- 
thral canula—is designed to aid in the evacuation of calculous fragments 
from the bladder. We are indebted to Professor Bigelow, of Boston, for 
the present improved form of this instrument. The original Clover 
apparatus was by no means so convenient as this one; the urethral can- 
ulae were too small, and the glass cage was not so advantageously situated. 
In what class of cases should we resort to lithotrity? A moment’s 
reflection will convince any one who has examined the instruments with 
which the stone is destroyed that it is not every patient with vesical cal- 
culus who can be cared by the crushing process. A patient to be relieved 
by lithotrity must possess an urethra sufficiently capacious to permit the 
introduction of an instrument designed to crush the stone. Not only 
must the urethra be sufficiently large to admit a lithotrite, but it must not 
be so sensitive as to prevent the retention of this instrument within the 
urinary passages for a few moments at a time. Again, the stone itself 
must neither be too hard nor too large to be crushed with safety. Mul- 
tiple calculi, if the aggregate bulk of calculous material be very great, 
contra-indicate lithotrity. Furthermore, the patient must be one in whom 
it would be reasonably safe to perform a capital operation; he must be 
free from circulatory and respiratory affections, and above all, have no 
organic affection of the kidneys. In such patients as can permit the 
surgeon to introduce a lithotrite readily and bear its presence for a few 
moments at a time; in whom the stone is neither too large nor too hard 
to yield to the screw power of a modern instrument; and in whom there 
is nothing to prevent the performance of a capital operation. Lithotrity 
is the proper measure for their relief, it matters not the age nor the sex of 
the patient. In certain individuals these essential conditions may be 
brought about as the result of treatment. Thus, occasionally the surgeon 
discovers such a degree of contraction of the external meatus of the 
urethra as prevents the introduction of the lithotrite. A small bistoury, 
a tenotome, or a Civeales’ urethrotome may at once be made to remove the 
trouble. In numerous other cases the urethra is so very sensitive that 
reflex contraction literally prevents the insertion of a lithotrite. Here 
preliminary treatment calculated to overcome hyperaesthesia of the 
urethra is urgently demanded. In brief, preliminary treatment may not 
only increase the size of the urethral canal in certain cases, but it very 
generally results in such a reduction of the tendency to reflex contraction 
characteristic of the urethral muscular structure that the surgeon finally 
succeeds in effecting an easy and satisfactory introduction of his instru- 
ments in cases that at first seemed utterly beyond control. 
The necessities of the occasion not only compel me to be concise, 
but make me omit' many points I should like to dwell upon. Thus I 4 
should like to say more about the advantages of preparatory treatment; 
and the necessity of making constant thermometric observations not only 
during, but before the crushing procedure is initiated. However, as my 
time is limited I prefer to devote attention to the details of the operation. 
A thorough acquaintance with the patient’s temperature and his reaction 
to morphia are essential to Lithotrity as I conceive the operation should 
be performed. A record should be made of the patient’s temperature as 
determined by the insertion of a thermometer into his rectum every six 
hours; his reaction to morphia should likewise be recorded. These facts 
noted, the stone is then to be measured and the operation commenced. 
The position of the patient is very important in every instance in 
Avhich a lithotrite is introduced. If the bed be too low, the operator must 
assume a cramped and confined position; if too high, the surgeon will 
become fatigued before his work is done. What rule can be adopted 
applicable to all cases ? The following is a good one : let the pelvis of 
the patient be so elevated that when the operator advances to insert the 
crushing instrument — the latter held in his left hand, his left forearm 
being at a right angle with his body—his left hand will just pass over the 
lower part of the patient’s abdomen. Furthermore, when the surgeon 
stands facing the patient’s pelvis, the latter should rest upon an inclined 
plane, with his hips higher than his shoulders, his heels higher than his 
hips, his knees slightly separated, supported upon pillows, and elevated 
a little above the level of his feet. The surgeon can then stand erect and 
at ease by the right side of his patient, and work to advantage, while the 
latter is in the best possible position for the stone to be readily grasped by 
the lithotrite when introduced. Grasping the lithotrite near the handle at 
the point at which it “ balances” readily in his hand, and holding it in a 
line parallel with the patient’s body, the surgeon with his right hand takes 
hold of the patient’s penis, opens the lips of the urethra and cautiously 
and gently introduces the extremity of the beak into the mouth of the 
urethra. This done, with the fingers of his right hand he slowly slips the 
urethra forward and upwards until the beak and part of the staff of the 
lithotrite are ensheathed by the urethral tube. As this process approaches 
completion the beak is somewhat depressed and the handle a trifle ele- 
vated ; the instrument no longer remaining on a line with the patient’s 
body, but forming an angle with it which gradually increases the further 
it is introduced. This process is kept up until the surgeon is aware that 
the point of the lithotrite is near the triangular ligament—until the handle 
of the instrument approaches a right angle with the patient’s body. Even 
in a healthy person the lithotrite would have to be cautiously manipulated 
at this point, for not only does the firm contraction of the compressor 
urethrae interpose an obstacle to the further entrance of the instrument, 
but the lax tissues of the bulbous portion of the urethra readily allow the point of the beak to impinge upon the triangular ligament below the 
urethral opening. Should the surgeon think the beak in the membranous 
urethra and in consequence depress the handle too soon, he would run a 
great risk of rupturing the urethra. I am afraid the danger of overlook- 
ing this point, has not been sufficiently dwelt upon. Please remember that 
the surgeon can not be too careful in assuring himself that his instrument 
has passed through the opening in the triangular ligament before he per- 
mits the handle to depart from a right line with the patient’s body. One 
good method of obviating danger here, is, when the beak is near the ter- 
minal portion of the spongy urethra, for the surgeon to elongate the 
urethral tube by grasping the head of the penis and pulling it up on the 
staff at the same time, that he cautiously elevates the point of the beak so 
as to make it impinge upon the orifice of the contracted membranous 
urethra. If he resorts to this maneuver and holds the point of the beak 
in contact with the opening in the triangular ligament he will soon be 
rewarded for his care and caution by feeling the ccftnpressor urethrae relax 
and the beak of the lithotrite engage in the membranous urethra. So 
soon as the beak passes into the opening in the triangular ligament the 
handle of the lithotrite assumes a vertical position; at the same time the 
operator is conscious that the beak is firmly embraced by the surrounding 
structures. Yet, firmly as it seems to be held, if the surgeon but waits a 
moment, the grasp relaxes and the point can be made to advance a step 
farther on its journey to the bladder. There are three points at which 
the lithotritist must be prepared to overcome obstacles in introducing a 
lithotrite. One point is at the external meatus of the urethra, the second, 
at the membranous urethra and the third, at the posterior part of the 
prostate—at the internal meatus of the urethra. At the external meatus 
the most difficult problem can always be solved by a trifling incision — 
for the small size of the orifice is generally what has to be overcome at 
this point. At the anterior layer of the triangular ligament the canal is 
always large enough; the difficulty consists in making the point of the 
lithotrite touch, and for a few moments remain in contact with the con- 
tracted membranous urethra. The surgeon must remember that the beak 
is to be carried along the roof of the bulbous portion of the spongy 
urethra, if this end is to be attained; that the danger to be avoided con- 
sists in the point of the beak striking the triangular ligament below the 
urethral opening in that structure. A knowledge of anatomy and intelli- 
gent practice alone can make the operator master of this seemingly tri- 
fling, but in reality, very important practical maneuver. Even after the 
beak of the lithotrite has passed through the membranous urethra, the 
bladder has not been reached. If the surgeon were introducing the 
lithotrite into an individual free from stone, — much more so in case the 
patient had calculous disease—it would be desirable, after the beak has passed the opening in the triangular ligament, and been grasped by the 
compressor urethrae muscle, to wait a few moments for relaxation to ensue 
before endeavoring to pass the instrument into or through the prostatic 
urethra. As soon as the muscular tissue relaxes, the instrument will feel 
free—the surgeon should then permit it to advance by much less even 
than its own weight. If grasped after passing the opening in the trian- 
gular ligament, it will do no more than enter the prostatic urethra at the 
first relaxation — at this point even in an individual free from calculous 
disease it will now be held firmly and immovably for several minutes. 
The surgeon should content himself with simply holding the instrument 
so that not more than one fourth of its weight is borne by the patient’s 
urinary passages, and patiently wait the next interval of relaxation. As 
just indicated, several moments may pass — when the beak is in the pro- 
static urethra — before the internal meatus of the urethra will open and 
the point of the instrument enter the bladder. In one in whom there is 
no vesical disease not only the point, but the whole of the beak, may 
pass into the vesical cavity. In such cases, the operator not only knows 
the fact by the extent to which the instrument enters the body of the 
patient, but he is rendered certain by the freedom with which he can 
revolve the beak to the right or left—a movement impossible when the 
beak is in the prostatic urethra. Another indication of the presence of 
the beak in the bladder is the small angle formed by the lithotrite with 
the body of the patient. You may have noticed that I have said nothing 
to you about changing hands, or making pressure upon the base of the 
penis. Neither measure is necessary in introducing a lithotrite into the 
healthy bladder. In a patient with stone in whom reflex contractility of 
the muscular tissues of the urinary passages is greatly augmented, both 
measures may be required. In such a case the surgeon as he stands by 
the right side of and facing the pelvis of his patient finds so much oppo- 
sition made to the entrance of the point of his lithotrite that mere fatigue 
may require him to change the hand with which he holds his instrument. 
However, even in such cases, relaxation alternates with contraction, and 
patience and gentleness enable him to introduce the beak of the lithotrite 
as far as the triangular ligament. As soon as the point passes along the 
membranous urethra and the handle of the lithotrite assumes a vertical 
position, the surgeon may change hands. Releasing his grasp from that 
portion of the staff near the handle of the lithorite at which the instru- 
ment readily “balances,” he now supports the cylindrical handle with the 
thumb and first two fingers of his right hand. When the beak enters the 
prostatic urethra and the handle begins to descend, the unpleasant feel- 
ing of tension about the perineum can be relieved by the surgeon, mak- 
ing pressure with his left hand at the root of the penis. Finally, when 
he parts holding the lithotrite once more relax, a little pressure may be required to carry the beak through the internal meatus. The manner in 
which the urinary passages have permitted the lithotrite to enter as far as 
the prostatic urethra must be the measure of the force exercised to carry 
the beak into the vesical cavity. If relaxation has speedily succeeded 
contraction and but little trouble has been experienced in introducing 
the lithotrite thus far, but little pressure will be required to carry its 
extremity into the bladder. On the other hand, if as in many cases 
of calculus, the relaxation has been but fleeting, and the contraction 
firm and long continuing, a considerable degree of pressure must be 
made finally in order to carry the beak into the vesical cavity. In 
these different and widely unlike cases there is but one unfailing instruc- 
tor—and that is personal experience. 
The cavity of the bladder gained, the manipulations executed will 
depend upon the object to be accomplished. Often you will be called 
upon to pass such an instrument for the purpose of exploring the ves- 
ical cavity for diagnostic purposes unconnected with calculous disease. 
Again, you may have to resort to the lithotrite in cases of foreign bodies 
in the bladder. But recently I was called upon to remove part of a 
hair-pin, inserted by a young lady of an investigating turn of mind, into 
the urethra and by the urethra grasped and carried into the vesical 
cavity. In other cases, calculi must be measured, their size determined 
and their number revealed. Finally you must pass this instrument for 
the purpose of grasping and crushing stone that has developed in the 
bladder. My remarks to-day must be limited to the latter. 
Those of you who have given attention to the literature of the sub- 
ject are aware that there are two widely different methods of destroying 
stone by means of the lithotrite. In one method the stone is made to 
come to and fall into the jaws of the crushing instrument. In the other, 
the instrument is made to seek for, find and grasp the stone without 
the latter executing any movement whatever. Each method has its par- 
tisans, but the latter seems the popular measure at the present time; 
in fact every lithotritist has a method more or less peculiar to himself, 
the growth and development of his own experience. In order that the 
operator may assure himself that nothing has been overlooked—no part 
of the bladder unexplored—something like the following course should 
be pursued : 
So soon as the beak passes through the internal meatus of the urethra 
and is fairly within the vesical cavity, pass it gently and slowly back- 
wards until it touches the posterior wall of the bladder. Should the 
stone have been touched in its journey, incline the beak a little to the 
opposite side from the stone and withdraw the male blade (by operat- 
ing upon the wheel with the right hand while the left hand grasps the 
cylindrical handle) until its anterior surface is in gentle contact with the lining membrane of the anterior wall of the bladder; then so revolve 
the side at which the stone is situated to an angle of forty-five degrees; 
and then slowly force the male blade home until its posterior surface 
is brought in contact with the stone—as soon as the male blade touches 
the stone, stop moving it, but draw the female blade forwards until 
the stone is grasped between them. Press the blades together with suf- 
ficient firmness to hold the stone between them; - then so revolve the 
handle of the lithotrite that the stone passes along the semi-circumfer- 
ence of a circle—in this manner the presence or absence of a second 
calculus can be determined. The stone returned to its original posi- 
tion, without relaxing the grasp of the blades with which it is held, 
touch the button on the handle by which the screw movement is thrown 
into gear, and bring the blades under the control of the screw. You 
now have a firm hold upon the stone: a hold that can be augmented or 
diminished at will. Grasping the cylindrical handle of the lithotrite with 
your left hand, you hold the wheel in your right, and are ready at any 
moment, to subject the calculus to the crushing power of the screw. 
Revolve the handle so that the blades occupy the center of the vesical 
cavity; then, as you gradually turn the wheel you feel a constantly 
increasing resistance. By turning the wheel rapidly, for a few seconds, 
then stopping and for a moment slightly relaxing the grasp of the blades 
upon the calculus; then repeating the whole series of maneuvers again 
and again ; you subject the stone to a peculiar sort of percussive force 
that is exceedingly effective in breaking even a large and hard stone. 
You will notice that I now exhibit two lithotrites alike in every essential 
respect save that in the one the floor of the female blade is excavated and 
the beak and staff slightly larger than in the other. The one is a “fen- 
estrated,” the other a “ non-fenestrated ” instrument. The fenestrated 
lithotrite is the largest and most powerful instrument made, and I think I 
am safe in saying that the surgeon can crush any stone which will rest 
between its blades when the screw movement is in gear; that once the 
stone is fairly caught, and by turning the instrument to and fro, he has 
assured himself of the safety of the bladder-walls, the operator can go 
ahead and crush — exercising any power he pleases upon the wheel until 
the calculus yields—feeling assured that the stone and not the instrument 
will be the one to give way. I need scarcely say that this is not the case 
with the non-fenestrated lithotrite. The latter is designed for fragments, 
and not for unbroken calculi; while the former is made to crush the stone 
originally and prepare fragments for the latter. Consequently, the man- 
euvers of an operator, after grasping a stone, will depend somewhat upon 
the size of the calculus, and the instrument used. If the stone is large, 
and his instrument a fenestrated lithotrite, he first assures himself of the 
safety of the bladder walls, and then seeks to determine so far as possible, 9 
the nature and composition of the calculus he has caught. Having satis- 
fied himself that there is but one stone, he slowly turns the screw and 
carefully attends the sensations he appreciates as the teeth of the instru- 
ment enter the outer layers. If the stone is of oxalate of lime, a very 
different sensation is communicated than is developed when the soft phos- 
phates yield to the lithotrite; while a layer of the oxalates succeeding the 
urates can be readily distinguished from layers of the urates, deposited 
about an oxalate nucleus, or a coating of phosphates upon a central body 
of uric acid or the urates. A soft external coating about a hard central 
body should always be watched for. Whatever the phenomena developed, 
so soon as the stone yields, the male blade is to be worked home, the 
screw ungeared, the blades separated and an endeavor made to grasp a 
fragment just beneath where the stone was crushed. Open the blades as 
before, turn them to the same side to the same extent (an angle of forty- 
five degrees) and slowly close the male blade. Should the latter come in 
contact with a fragment, stop moving it, but draw forward the female 
blade so as to grasp whatever is between them; so soon as the fragment 
is caught, revolve the blades as already detailed to assure yourself of the 
safety of the vesical walls, bring the screw into gear and crush. When- 
ever a stone is caught, just after the screw movement is in gear, note on 
the scale at the handle the size of stone or fragment and have its dimen- 
sions at once recorded by an assistant. In the same manner have the 
result of every movement of a lithotrite within the bladder recorded by 
an assistant at the moment it is executed. This fragment crushed, repeat 
the maneuver and crush again. Finally, when no more fragments can be 
caught by inclining the lithotrite to an angle of forty-five degrees on the 
side the stone was caught originally, turn the lithotrite to the opposite side 
to the same point. Generally, several fragments of good size can be 
seized there. So soon as no more can be grasped, turn the lithotrite to 
the opposite side and depress it to an angle of ninety degrees, and grasp 
and crush as before. The operator may alternate from one side to the 
other, until all the large fragments are seized. With a non-fenestrated 
instrument, in certain cases, it may be advantageous for the operator to 
reverse his lithotrite, directing the blades directly downwards. This man- 
euver is accomplished by depressing the handle as the blades are revolved 
until the handle is on a line with, or even a little below the horizon, the 
well-opened blades are then directed vertically downwards, and if the 
handle be sufficiently depressed, their extremities will impinge but slightly 
upon the floor of the bladder. At this point I am in the habit of moving 
first one and then the other blade until one of them touches a piece of 
stone ; then the other is moved up to it until the fragment is grasped; they 
are held in opposition and slowly revolved until it is clear none of the 
bladder wall is caught when they are restored to their proper situation 10 
and the fragment crushed. Often, when the fragments seized are small, 
manual pressure suffices for their destruction. 
Having succeeded in crushing your stone very thoroughly, how can 
you evacuate the fragments should you desire to do so? This aspirator 
and these urethral canulse—the device of Professor Bigelow—will enable 
you to do so. The canula is introduced just as you would pass a straight 
catheter; so soon as it is in, connect its free extremity with the rubber 
tube of the aspirator, and, as the latter is filled with warm water, by 
pressing its yielding sides you can throw into the bladder from one to four 
ounces of water. As I now compress this aspirator, but two ounces 
would be forced through the canula and into the bladder; yet this quan- 
tity is amply sufficient to stir up and scatter about the entire mass of cal- 
culous matter. The evacuation of fragments, like everything else, is 
something to be learned by practice — still it is an art readily acquired. 
Direct the opening of the canula towards the fragments and force the 
water into the bladder; this separates and whirls away the pieces—then 
depress the canula into the floor, holding its mouth upwards and slowly 
permit the water to return by gradually letting the elastic walls of the 
aspirator expand : at once the fragments will collect in the glass tube at 
the bottom. Should the aspirator expand slowly, you can rest assured a 
fragment has been caught; the canula must be withdrawn and the frag- 
ment removed. You must remember this fact: although you may crush 
with safety when there is but very little urine in the bladder, yet, when 
you endeavor to evacuate the fragments, you must remove what urine 
there is when you pass the canula and at once introduce from three to six 
ounces of warm water before connecting the aspirator with the canula. 
This prevents the injury of the vesical walls by suction, and guards 
against the complete emptying of the bladder while the evacuating pro- 
cedure is in operation. 
How much work should be done at once, how long should a sitting 
be prolonged, and how many sittings are necessary for the removal of a 
calculus? These questions are hard to answer, for individual cases differ 
so widely. Certain principles are plain, however. You should endeavor 
to avoid local irritation, or systemic disturbance. Although we now know 
the bladder is a more forbearing organ than we were taught, I am still 
far from believing that we should, as a rule, resort to ether, and in the 
majority of cases strive to cure the patient at a single sitting by prolonged 
and complete crushing, followed by evacuation of the fragments. On 
the contrary, I think that as a general rule the vast majority of individ- 
uals for whom crushing is the proper operation can be relieved with less 
danger by prolonging the operation over a number of sittings and doing 
but a small amount of work each time. Anyone who has studied litho- 
trity as an operation and practiced it as an art, is well aware that one 11 
skilled in passing a lithotrite, can introduce an instrument and do a cer- 
tain amount of crushing without subjecting the patient to any more dis- 
turbance than usually succeeds an ordinary paroxysm of straining such 
as in calculous patients follow almost every attempt to void the urine. 
Again, in many cases, the central nucleus is the only part of the stone 
that is hard; the layers which envelope it are phosphatic in character and 
do not break up into sharp angular fragments. In numerous instances 
this hard central nucleus can gradually be divested of its coatings, and 
these external layers granulated by the lithotrite and voided with the 
urine; numerous sittings may be required, and the operation prolonged 
over weeks or months; but the stone is steadily reduced in size, and finally 
the hard central part is broken up, its fragments pulverized and the 
debris evacuated wfthout a single thing occurring to render the employ- 
ment of an anaesthetic necessary. Inasmuch as preliminary treatment 
can do so much to render lithotrity safe and painless, I cannot but think 
that in the majority of cases lithotritists will still cling to the traditions of 
Civeale and hold to the doctrine that the true principle for their guidance 
is to effect the maximum of work with the minimum of disturbance, 
always striving to destroy as much of the stone as possible without either 
leaving sharp, angular fragments to irritate the bladder, or producing 
vesical disturbance by the length of time they permit their instruments to 
remain in the urinary passages. 
In certain of these cases the lithotritist may grasp the stone with the 
fenestrated instrument, and, as he subjects it to the teeth of that litho- 
trite, find that the external layers have given way, permitting the calculus 
to slide out of his grasp. He may at once remove the instrument, place 
his patient in the recumbent posture with counter-irritation—such as 
camphorated stupes—over the bladder. Two days afterwards he may 
pass a non-fenestrated instrument and granulate a quantity of rough, 
irregular, but soft phosphatic material. If he grasp the stone he finds it 
but half its former size; he may even dislodge more phosphatic matter by 
this very maneuver. Finally, after thus removing the soft coating of the 
hard center, the time comes for the destruction of the latter. Imagine 
this round, hard central portion to be either of uric acid or oxalate of 
lime; that it requires considerable force to break it; and that after frac- 
turing it, the pieces are each broken into several fragments, the lithotrite 
removed and the patient placed flat on his back with strict injunctions 
not to deviate from that position, especially when urinating. All goes well 
for ten or twelve hours; then the patient has a chill, fever, furred tongue 
and great pain in the bladder — what is to be done ? Now it is true that 
similar symptoms may succeed the passage of a catheter; yet when they 
develope after a sitting that has left a quantity of sharp fragments in the 
bladder they are very alarming. This is one of the situations in which 12 
Bigelow’s aspirator and urethral canulae are invaluable : pass a straight 
canula, inject a few ounces — not more than two — of warm water after 
permitting the bladder to discharge what urine it may contain (which 
sometimes presents significant traces of blood) and connect the canula 
with the aspirator. With great gentleness and care evacuate what frag- 
ments you can. Should some still remain, pass a non-fenestrated litho- 
trite granulate the fragments you come in contact with, then evacuate the 
debris, making sure you remove the whole. There is no objection to the 
use of ether, although it is better to get along without it when you can. 
Again: Suppose the stone you have to remove is one composed of 
oxalate of time. Here you will have very hard and very sharp fragments. 
In such a case, lithotrity at a single sitting might be a desirable measure. 
In cases complicated by stricture of the urethra or organic disease of the 
bladder, the operator may, at any moment be compelled to resort to evac- 
uation in order to set the bladder instantly at rest. In fact, the power 
this apparatus gives the surgeon over the contents of the bladder—enabling 
him at any moment to empty that viscus — constitutes one important 
advantage. Not only in cases where these complications exist does this 
method prove valuable, but also in cases where accidents have occured. 
Thus, retention, haemorrhage, inflammation of distant organs, cystitis, 
orchitis, epididymitis, etc., may compel the surgeon to resort to it. 
The limited time at my disposal has compelled me to omit many 
things I would have been pleased to dwell upon. It would have been 
interesting to trace the manner in which this method of evacuating frag- 
ments—of emptying the bladder of debris — first came into existence. 
An Irish surgeon — Sir Phillip Crampton — first devised an evacuating 
apparatus. An English surgeon, Mr. Clover, modified it, and improved 
it—nevertheless, the idea is essentially the same as the one that animated 
Crampton. Prof. Dettell subsequently devised a Syphon-Suction Evacu- 
ating Apparatus that had its day. Professor Bigelow finally constructed 
the appliance I now exhibit—one admirably adapted to accomplish the 
end the surgeon has in view, and one that will doubtless remain in use 
for some time to come.