Gruenfeld examined the bladder more satisfactorily than any of his predecessors, through a simple straight metal tube blackened on its inner surface, and with a pane of glass fixed obliquely at its vesi cal extremity. For the illumination, lie employed a head-mirror with an electric light attached. He was enabled in this way to bring the ureter into view. He was also able to catheterize the ureter by passing a small catheter through the urethra into the bladder beside his endoscope. By inclining the endoscope to the proper angle, which he determined to be from 30 to 35 degrees, the ureteral orifice came into view, and the point of the catheter which was kept in front of the endoscope was engaged, the endoscope withdrawn, and the catheter pushed farther up into the ureter.
Another means of examination is that of Nitze, very generally used .at present for examination and catheterization of the ureters in men. The source of illumination is here a little electric light at the extremity of the endoscope. The view of the inner surface of the bladder distended with water is transmitted by a telescopic arrange ment to the eye of the observer at the outer end of the instrument. This complicated, delicate, but useful instrument has been used with equally great advantage in examining the female bladder.
Dr. Skene, the first American authority on this subject, says (" Treatise on Diseases of Women," New York, 1889, page 697) : " The cystoscope of Nitze and Leiter is the only instrument for thor oughly investigating the bladder." Rutenberg made a radical departure from both of the methods described by devising a speculum with a glass partition and a little tube, running down beside the speculum, attached to a rubber ball by which he puffed the bladder full of air. By means of a reflected light and a mirror attached to a handle, which could be pushed in and out and rotated, the various parts of the bladder wall were in spected. To use this instrument, it is necessary to dilate the ure thra almost to a diameter of 2 cm. (t in.), which can only be done by anesthetizing the patient. Professor Wiuckel of Munich speaks of this speculum with especial satisfaction.
My own method was first published in the Johns Hopkins Hos pital Bulletin, for November, 1893, and in a longer and more fully illustrated article in the American. Journal of Obstetrics for January, 1894. Its essential features are : 1, an atmospheric dilatation of the bladder induced by posture; 2, the introduction of a simple straight speculum without fenestra; 3, the examination of the mucous sur faces of the bladder and urethra by means of a light conveyed into the bladder.
This last and newest method is so important, promising as it does to clear up all the difficulties under which we have been laboring hitherto in the diagnosis of these affections, and to afford a simple and effective means of treatment, that I shall devote some space to a consideration of the exact method of making the examination and its various advantages.
The following instruments are required: A good light and a head-mirror; a urethral dilator; a speculum with an obturator (see Fig. 75); a suction apparatus to empty the bladder completely (see Fig. 79) ; a pair of long mouse-tooth forceps (see Fig. 80) ; a searcher for discovering the ureteral orifice (see Fig. 81).
A general anmsthetic is not necessary, unless the patient is so nervous that she will not submit to any kind of an examination. For this reason, it is sometimes of advantage to use ether or chloroform during the first examination, which is apt to be more prolonged than the subsequent ones. If the urethra requires any dilatation, a drop of a ten-per-cent. solution of cocaine painted on its external orifice, or a piece of cotton wrapped on an applicator saturated with a four-per cent. solution and laid just inside the orifice, will be sufficient to blunt the sensitiveness.
Immediately before examination the patient must pass water, pre ferably in the standing position. In spite of this effort to empty the bladder completely, a little residual urine almost always remains be hind. If the examination is delayed ten or fifteen minutes, five or ten cubic centimetres will be added.
The urethral orifice is now dilated by using a conical dilator (Fig. 82, 2), blunt at the point, 72 mm. long, and 16 mm. in diameter at the base and 4 mm. at the point. This is covered with vaseline and, with a screw-like movement, gently bored into the urethral orifice. Two or three gentle movements, holding the dilator poised between thumb and forefinger, will be sufficient to carry it in as far as the number 10 mark on the scale on its side. This indicates a dilatation of 1 cm. in diameter, sufficient for all ordinary purposes of investigation of the bladder, treatment of its surfaces, and catheterization of the ureters. In many cases, particularly in women who have borne children, the orifice needs no dilatation to permit the introduction of a speculum of this size. The utmost damage done by the dilatation is a slight superficial injury to the mucous surface of the posterior margin of the urethra, which never requires attention.