In the majority of instances, I believe it is better practice to sound and remove the stone at the same time. In persons with fairly nor mal bladders the gentle movement of the stone with the sound is a matter of little consequence; but with stones more or less fixed in one position—as is so often the case where the prostate is large and the bladder pouched—the conditions and risks are very different; urine gets into the depression the stone has so well filled, some cystitis is set up, there is an unnecessary delay which is trying to the nerves and the sensations of the patient, the sleep is disturbed; and the sur geon finds himself almost obliged to operate (most probably by crush ing) with a bladder, as well, perhaps, as the dilated parts above, in fected with some of the worst varieties of bacteria. In a personal experience of lithotrity, now amounting to considerably over 400 cases, I have noted that not a few of the most rapid and complete recoveries followed when sounding and removal were concurrent. One anmsthetic covers the whole procedure, and the patient is spared needless suspense.
The risk connected with the sounding of an adult who has not been in the habit of using a urethral instrument is probably greater than that which attends the removal of a moderate-sized stone by lithotrity as now practised. In the latter case all antiseptic precau tions are taken, and the use of an anesthetic renders the parts involved less liable to any subsequent inflammation. The tissues are thus rendered lax and the process of crushing the stone is both painless and simple. Children and women, though the risk of sounding is not the same, should invariably be spared through anesthesia, being either alarmed or pained by having an instrument passed into the bladder.
In the selection of instruments for sounding we all have our pref erences as regards curves and construction. I use a solid steel sound, nickel-plated, not exceeding a No. 8 English bougie, of the shape here shown (Fig. 49). Some sounds are so thick in the shank that they actually fit the urethra, and consequently the bulb of the instru ment cannot be made to pass as easily as it should do over all parts of the mucous membrane of the bladder, including the dip behind the prostate. As a rule, sounds are too short. the prostate is large they should not be less than fourteen inches in length. I have no partiality for what are described as hollow sounds. Unless there is some necessity for combining a catheter with an explorer I would sooner not incur the risk of admitting air into an organ where it may do harm by aiding to cause decomposition. Though it is usually de sirable to have some fluid in the bladder when sounding, this can gen erally be secured by other means. A careful study of the alterations effected in the passage by which the bladder is entered in prostatic enlargement leads me to conclude that some variations in the shape of sounds is desirable, though these structural obstacles usually dis appear under an anaesthetic. A long copper probe, sufficiently flexi
ble for adaptation to any shape required, is an instrument I have used in instances such as these. Bigelow used to search for stone with a block-tin sound, bent up extemporaneously to suit the case.
I generally pass a "whip," or soft boogie, before introducing the metal sound. By this device the closed urethra is opened and greased and the more rigid instrument will then slip in easier; this is equally important, whether or not an anesthetic is used, as it is desirable that no damage should be inflicted on the parts traversed. Where the prostate is large this object is not so easily attained, and therefore these precautions are not superfluous.
Before sounding, an examination of the urine is desirable. Where there is any degree of kidney complication, rest in bed, warmth, di luent drinks, and doses of aconite or quinine have frequently pre vented or moderated uncomfortable symptoms following sounding. To sound persons, as a rule, in the consulting room, when seeing them for the first time, and perhaps fatigued by a journey, is incurring a risk which is often unnecessary, and which we may have cause to regret. In sounding, let it be remembered that the instrument is merely an imperfect substitute for the finger, and to obtain the infor mation required it will be necessary to conduct the operation with the same method as we should adopt in the digital examination of any cavity or space in the body which can be so reached. To pass a sound into the bladder, and aimlessly move it about on the chance that it may touch a stone or reveal a rugged or ulcerous surface, is not likely to be of much service.
Should there be a stone, its presence will probably be recognized both by the touch and the ear. A stethoscope applied over the pubes renders the sound more audible, and may be resorted to if there is doubt. The size of the stone can generally be ascertained by the lithotrite, while its probable nature is indicated partly by the char acter of the note that is obtained; the dull "thud" of the phosphates is as characteristic as the sharper "click" of the oxalates or urates ; and, further, the examination of the urine often adds evidence which is conclusive. Where there is a suspicion of a stone, which cannot be detected by sounding as described, an examination may be made on a subsequent occasion, with the patient in a different position. The sound may be passed with the patient standing and leaning for ward, with his hands on the back of a chair, and his legs apart, or even when lying on his belly.