HKAi;ni AND DISEASE 



other, and now on the back, until every part of the bladder has Ijeen 

 thoroughly explored. Where the substance felt per rectum is a calculus, 

 its contact with the searcher will be clearly made known by the rough and 

 resisting character of the touch, and by the sound emitted when struck. 



Even with the exhaustion of all the methods and devices which .science 

 has designed for surgical diagno.sis, failure may still attend our efforts 



to detect a stone, and although 

 the existence of something in 

 the bladder be ever so obvious, 

 its precise nature cannot always 

 be clearly and definitely made 

 out. In those examples of stone, 

 partially or completely over - 

 grown by granulation tissue 

 (proud flesh) (fig. 147) spring- 

 ing from around an ulcerating 

 surface, or enclosed in false 

 meinbrane, the question of stone 

 or tumour is difficult to divine. Here the stone, hidden away in the 

 new growth or exudation matter, is sheltered from the sound, and the 

 instrument, striking the morbid mass, imparts to the hand precisely those 

 impressions which denote the existence of tumour. In this uncertain and 

 unsatisfactory condition no time .should be lost in opening the urethra at 

 the perineum, when the bladder may be again explored by means of the 

 short metal sound, to be referred to later on. 



It is not alone l)y active 

 changes in the bladder, such 

 as I have just referred to, that 

 stone is enabled to evade de- 

 tection. Passive alterations in 

 this organ are likewise to be 

 borne in mind as possible ob- 

 stacles in the same direction. 

 The most familiar example of 

 this anomalous condition is met 

 with in those cases where the weight of the stone, bearing on the an- 

 terior end or fundus of the bladder, creates for itself a diverticulum or 

 pouch, in which it becomes lodged (fig. 148). The mucous membrane 

 in those instances usually constitutes the sac, it having been pushed 

 between the widely separated and atrophied fibres of the muscular coat; 

 less frequently all the coats enter into the saccular offshoot. In some 



Fig. 148.— Stone Eniv" 



the Fundus of the Bladde 



