I wish to call especial attention to the fact that dilatation of the external orifice of the urethra by a conical dilator alone is sufficient for the investigation. A series of dilators intended to dilate the whole canal may be discarded. The speculum is a simple metal cylinder 8 cm. (3 in.) long, of equal diameter from end to end, funnel shaped at its outer end, and with a long handle that can be conveni ently grasped in the full hand, and which is provided with an obturator. The diameters of the specula vary from 5 mm. up to 20 mm. to in.), shown by Simon to be the safe outside limit. I have all sizes made between these extremes, the successive numbers in the series differing 1 mm. in diameter. They are not conical like Simon's dila tors. The sizes most useful are Nos. 8, 10, and 11. No. 8 (8 mm. in diameter) can be introduced into almost any urethra without pre liminary dilatation, as it is scarcely larger than an ordinary catheter. This is the size which will be more frequently used by the practised examiner.
The patient may be examined either in the dorsal or knee-breast position. If in the dorsal position, she is placed on the table with legs and thighs well flexed, and hips elevated from 15 to 30 cm. (6 to 12 in.) above the level of the table. If she be a thin woman, when the speculum is introduced in this position, the air immediately rushes into the bladder, distending it. But this simple process will not suc ceed with a fat woman. The most convenient and universally applic able position is the knee-breast posture, with the chest as close to the table as possible, and the back well bent in. Frequently a more satisfactory posture is the knee-breast, with the patient squatting a little backward, so that the buttocks are in a position directly over the calves of the legs or the ankles, instead of being vertically over the thighs. The speculum is now taken in hand, as shown in the illustration (Fig. 74), and held with the thumb firmly pressing upon the handle of the obtura tor. The urethral orifice is first well cleansed with a boric-acid solution. The point of the spec ulum is placed upon the orifice and pushed up through 11 urethra into the bladder in a direction describing a gentle curve around the under surface of the symphysis. As the speculum is being introduced, the vulva is held open with the other hand; in the case of a stout patient the buttocks are held widely apart by an assis tant. On withdrawing the ob turator, air rushes at once into the bladder, distending it with an audible suction sound. If it is undesirable or difficult to keep the patient in the knee-breast position, she may be gently turned to the dorsal position, taking care to keep the hips constantly ele vated above the level of the rest of the abdomen (Fig. 76). The in testines which have gravitated out of the pelvis will not return at all, or will return but slowly, so long as the hips are kept thus elevated.
It is well to place a pledget of cotton or a vessel beneath the mouth of the speculum to catch any urine driven out by forcible breathing, coughing, etc.
The examiner wears one of the ordinary head-mirrors used by the laryngoscopists, and by its means reflects a light from an electric lamp resting on a towel on the sacrum of the patient (if in the knee-breast position), through the speculum, into the bladder. The illumina
tion may also be derived from a small electric light attached in front of the mirror, or from a mignon lamp conveniently attached to the mouth of the speculum so as to throw its light into the bladder with out interfering with the field of vision, as in the Otis urethroscope. I prefer, as the simplest and most easily attainable light, a common electric drop-light, with a short handle, connected with the bracket on the wall by a long cord. Where this is not attainable I take with me to the place of examination a small portable battery consisting of three storage cells. This is capable of running a mignon lamp for fifteen hours consecutively. The only objection to this form of illumination is the expense of the outfit, and its liability to be out of order just when wanted for use. An Argand burner held by an assistant may be used, or a lamp or candle in case of necessity. Daylight will also sometimes be serviceable, but cannot of course be depended upon.
An important point to be borne in mind, in reflecting the light from its source into the bladder, is to make the angle formed by the pencil of light striking and leaving the mirror, as small as possible. The best arrangement from this standpoint is the little electric lamp held immediately in front of the reflector attached to the forehead, as shown in the figures. The electric light resting on the sacrum is for this reason far better than a lamp or candle, which must be held so as to make a considerable angle.
The first part seen is about the middle of the posterior wall. The groundwork of the bladder appears of a dull whitish color, everywhere divided up by a network of branching vessels. The inner vessels, almost like capillaries, can be traced to their trunks, and these again to larger trunks one or two millimetres in. diameter, of a dark or light red color which seems to come up to the mucous sur face from the deeper layers where the vessels lie hid from view. Occasionally an artery can be distinctly seen to pulsate. Sometimes little glistening points appear along the vessels. By elevating and depressing the handle of the speculum and moving it from side to side, all parts of the posterior hemisphere are brought successively into view. The size of the area viewed at any one time depends upon the calibre of the speculum, its closeness to the bladder wall, and the distance of the examining eye from the external opening. By mark edly elevating the speculum the vault of the bladder is seen with the same distinctness. As a rule, the residual urine to the amount of 6 or 8 c.c. (1- to 2 drachms) will have to be removed by the suction apparatus before all parts are brought into view. If the handle of the speculum is dropped a little the floor of the bladder will come into view. This is more or less in the plane of the eye of the observer, and must be examined with greater care to detect all the peculiari ties of its surface. In order to bring special parts of the base more clearly into view, the speculum can be pushed until its edge rests upon the part, and then by dropping it a few millimetres and ad vancing it just a little, the area in question will be made to lie directly over the end of the speculum, at right angles to its former position.