EXAMINATION BY THE URETHRA AND THE BLADDER.
Only in exceptional cases is it possible to penetrate through the urethra into the bladder with the finger without precedent dilatation. Here and there it happens, generally unintentionally, where,—because of narrowing or impermeability of the vagina, or some error in development,—cohabi tation has taken place through the urethra, and such instances are not as infrequent as is believed. As a rule, vesical touch must be preceded by dilatation of the urethra as a preparatory measure. The urethra cannot be stretched as readily as the sphincter ani without resulting incontinence, Exact figures as to dilatability cannot be stated, although the maximum would appear to be, with few exceptions, about two and three-quarter inches. In only a single case, in a woman who had cohabited per rethram, have I been able without preliminary dilatation to insert the index and the middle finger into the urethra to the extent of over one and three-quarter inches, which necessitated a distension to the extent of three and a half inches, without resultant incontinence.
For purposes of dilatation I use the hard rubber dilators which will be described under the heading of rapid dilatation of the uterus. By means of these the urethra may be sufficiently dilated in a few minutes, to enable the index finger to be inserted. If the borders of the urethra are too tense, then we may nick them slightly. Simon was in the habit of doing this before proceeding to dilatation, making an incision to the depth of one eighth of an inch right and left with the scissors. Slower dilatation by means of tents, the fingers or more or less complicated instru ments is of less value, and is inferior to rapid dilatation. Simon's second method of making an artificial fistula is rarely used for purely diagnostic purposes.
Dilatation and examination are best accomplished with the patient in the dorsal position. Anesthesia is induced, and the smallest, well-oiled, hard rubber dilator is gently inserted into the meatus, and slowly pushed forward. After the lapse of one to two minutes the instrument is re moved and the next size inserted, and so on until the largest number has been introduced. As soon as this has been accomplished, the index finger is at once passed into the bladder. The rule as to the choice of hand is the same as in case of the vaginal examination. The remaining fingers
are either flexed, or else, what is preferable, the middle finger is inserted into the vagina. When the finger has passed through the meatus, the narrowest part of the urethra, it easily reaches the neck of the bladder, and thence the cavity of the organ itself, and it feels the trigonum, where the expert examiner is able to detect the openings of the ureters, into which Simon often inserted the sound, a procedure which has latterly been carefully studied by Pawlick. If we next perform the bimanual, we feel through the bladder the anterior surface of the body of the uterus, the fundus, the broad ligaments, with great ease. The vesico-vaginal septum is best examined between the thumb in the vagina and the finger in the bladder.
If the vesical examination were accompanied by as few untoward after effects as that by the rectum, it would without question be frequently resorted to, for the results as regards the anterior pelvic space are as valuable as those noted under the rectal examination for the posterior pelvic space.
The vesical examination is resorted to in case of diseases of and for eign bodies in the urethra and bladder, in cases of diseases of and anom alies in the urethro- and the vesico-vaginal walls, in case of anomalies of the round ligaments, and of the anterior portion of the broad ligaments, in case of tumors which occupy the anterior wall of the uterus, and in case of defects of this organ, in case of ante-uterine hematocele, and ex ceptionally of hematometra, in case of defects in the vagina which inter fere with the touch, or where there exists a rudimentary state of the vagina or uterus, in conjunction with examination by the rectum. In the latter instances it may suffice to pass a catheter into the bladder, by means of which the vesical wall is pressed down against the finger in the rectum, which is then able to determine the rudimentary state of the bladder and of the uterus.
Although the vesical examination does not result in permanent incon tinence, and is not accompanied by hemorrhage worthy mention, still it is an operation only to be resorted to in case the other exploratory routes are impassable. Generally the examination by means of the cathe ter in the bladder, and the finger in the rectum should be favored as the preferable method.