Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson.

  • Thompson, Henry, Sir, 1820-1904.
Date:
1882
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Licence: Public Domain Mark

Credit: Clinical lectures on diseases of the urinary organs : delivered at University College Hospital / by Sir Henry Thompson. Source: Wellcome Collection.

    82/192 (page 70)
    its removal is a far less serious matter. You may promise the patient, in the case of a small stone, that it may be removed without risking his life; whereas, in the case of a large stone there is always some risk, often considerable danger. It is im- possible to overrate the importance o£ finding all stones when small,^ and this you can only ensure with an appropriate sound, rightly applied. In the next place, how are you to use this instrument ? First of all, it is not to be introduced in the same way as the ordinary catheter. With the ordinary catheter it is the cus- tom in this country to stand at the left side of the patient, and make a gentle sweep thus into the bladder. With the sound you stand at the right side, and use a different manipulation, which I shall .show you when introducing the lithotrite, the form of which is similar, upon the living patient, at another lecture, postpon- ing, therefore, my remarks on the subject until then {vide Lecture XIII.). But merely to discover the presence of stone in a patient's bladder is by no means all that is necessary. It is essential to possess other particulars respecting it, because the nature of the operation to be :performed will depend on them. First of all, you must know what is the size of the :stone, before you decide on what you will -do with it. From the note elicited by merely striking it, and by the sensation communicated to the hand, you can obtain some indication of its size; certainly whether it be laige or smal], a distinction not always sufficiently precise for our purpose. There is a more exact, and at the same lime a simple, method of determin- ing size, sufficient for most cases, which I have long employed myself and more recently have introduced to the profession. It is far less irritating to the bladder than is the action of any measuring sound with ^wo blades which I formerly used, or of the lithotrite, which is the same thing on :a larger scale. It consists in the mere addition to any ordinary sound of a little ring or collar which slides along the shaft, and which by proper manipulation, en- ables me to ascertain very nearly the size of a stone, as you have frequently seen in the wards. (Fig. 35.) The manner of using it is this. Introduce the sound, feeling the stone as the end passes over it ^ See also Lecture XIX. 03 --S by a succession of delicate taps, until you have placed the end of the instrument distinctly beyond the farther or distant extremity of the calculus as it lies in the bladder. This done, slide the 'collar' down the shaft to the end of the penis, so that it touches the external meatus. Now draw the end of the sound outwards over the stone, delicately tapping as before, until you have reached its near extremity, which is most likely close to the neck of the bladder. The distance of the ' collar' from the end of the penis is the diameter of the stone in the direction passed over. There is nothing painful or irritating in this pro- cedure if conducted, as it always ought to be, with a light and delicate hand. Then there is the other way, already mentioned. You may introduce a litho- trite and seize the stone in two or three directions, so as to ascertain its dia- meters. This proceeding, however, sometimes occa- sions considerable distur- bance to the patient, and should be accomplished with as little manipulation as is possible. At the same time it is desirable to ascertain the nature of the calculus. A phosphatic stone gives a very different note when struck with a sound from that given by the others. The specimen before me is dry, and, therefore, will not give the note to which I refer. When wet, it is spongy and soft, with a rough surface, and always gives a dull note when struck; whereas the uric-acid stone gives a note which is clear and sonorous. Then you will judge partly by the condition ef the urine. If the urine is acid, and if, also, uric acid is thrown down, you may con- clude that the patient has a uric-acid stone. If so, you may find on inquiry that he has passed small calculi before; and seeing what these are, you may pretty O r3