The difficulties which arise in making a diagnosis of stone in the bladder are for the most part traceable to the existence, as a compli cation, of one of the following conditions : First, the presence of a stricture or an enlarged prostate; secondly, a diverticulum, or recess within the bladder, in which a calculus may be lodged; and thirdly, the coating of the stone with an imperfectly organized, leather-like substance, which conceals it from detection with the sound.
Mr. Buckston Browne" has drawn attention to a source of difficulty in detecting stones when lodged in what he describes as a post-pros tatic or trigonal pouch. In such cases he suggests not merely search ing with the of the sound in the reversed position as it lies in the bladder, but with an instrument constructed, so far as the beak is concerned, like a flat-bladed lithotrite. The object of the latter is more readily to enter the slit-like opening of the pouch it is desired to explore. Tinder such circumstances I have found the distention of the rectum with a rubber bag of service in bringing pouched calculi within reach of the sound as well as of the lithotrite and evacuator catheter." Examination of the supra-pubic region with the hand ought also not to be omitted. I was reminded of the importance of this on look ing through the specimens in the Museum of the New York Hos pital. Appended to one (784), where there was a sac larger than a hen's egg opening into the bladder near the fandus, in which were several calculi, is the note : " These calculi could not be detected by the sound during life, but the pouch containing them could be felt through the abdominal parietes." There are probably no urinary cases presenting greater difficulties, both in diagnosing and treating, than those of rugous bladders; where phosphatic concretions are deposited on elevated and circumscribed portions of the mucous membrane. By the sound, something closely resembling a stone may be felt, but the absence of a distinct "ring," as the instrument comes in contact with the suspicious spot, as well as its fixity in position—unalterable by the use of the instrument, by changes in the posture of the patient, and by distention of the blad der with water—render the diagnosis tolerably easy. I have frequently remarked, in examining the bladders of persons who have died with greatly enlarged prostates, or with saccules or bars across them, how impossible it would have been, if the cases had been complicated with stone, to detect it with the ordinary sound, provided the stone pied a position which could be indicated. These are the instances where symptoms are almost sure to arise simulating stone, and ne cessitating an exploration to determine this point.
In the last place, the stone may be so constituted as in itself to oppose a difficulty to its detection by the means usually employed.
CASE.—In 1863, a boy was admitted into the Liverpool Royal In firmary, under the late Mr. Long, suffering from prolapsus ani, pur ulent urine, and painful and frequent micturition. He was sounded, but without any evidence of stone being afforded. Death occurred in a few days. On making a post-mortem examination, the kidneys were found disorganized. The bladder was small and contained a calculus, made up of a urate of ammonia nucleus the size of a damson stone, surrounded by a thick layer of soft material consisting of mucus, fibrin, and a little gritty, phosphatic matter. The outer cov ering could be cut or torn easily ; and after it had been in spirit it presented, on section, a laminated appearance, like the fibrinims lay ers of an aneurism. On striking the mass with a metal instrument, no ring was produced; hence the impossibility of determining its ex istence with the sound during life.
Mr. Bickersteth* records a similar instance.
Where the stone cannot be readily reached with the sound, means may be taken to bring the two in contact. This may be done by a plan which Dr. Freyer suggests : "A most careful search was made by means of sounds of various kinds, but no calculus could be detected till the aspirator was employed, when a distinct click was felt during the exhaustion of the water from the bladder, and clue to the calculus being carried with force against the eye of the canula by the outward stream. The sound of the fragments clicking against the eye of the mink during the evacuation of the fragments of a cal culus, in the operation of litholapaxy, suggested this mode of diag nosis, and I am now in the habit of having recourse to it when the symptoms of stone are well marked, and the sound fails to detect the presence of one in the bladder." It should be remembered, as with all surgical procedures, how ever slight, that the general condition of a patient may render even sounding inexpedient at the moment. I once attended in consultation for the purpose of sounding and clearing up a case of suspected stone, where we noticed at the time that the patient had a slight erythema tous-looking blush about a trifling abrasion caused by the razor on the chin. Sounding was consequently postponed; fatal erysipelas supervened. Had the sound or any instrument whatever been used, death would certainly have been attributed to it, as the patient hap pened to occupy a high social as well as political position.