THE EXAMINATION OF THE FEMALE URETHRA AND BLADDER.
Formerly we had to content ourselves with the inspection of the mouth of the urethra and the anterior vaginal wall, and could only use touch and sight in the diagnosis of abnormal conditions of the bladder wall in those cases in which traumatism exposed its surface; and were in other cases confined to the use of metallic catheters and sounds. We are now able to examine with the finger and the eye almost the whole surface of the vesical mucous membrane. To G. Simon belongs the merit of having elaborated a method for the rapid and certain dilatation of the female urethra, and of having given exact rules as to the amount of dilatation which is permissible, and of proving its safety. From the oldest times, indeed, it had been customary to dilate the female urethra for the extraction of stone. (See page 2 et seq.) The Italian surgeon Benevieni (1502), and after him Marianus Sanctus (1506), de,scribed it; and Franco (1561) used a special dilating instrument for the purpose. In the earlier years of this century dilatation was effected by compressed sponge, by laminaria, or by Weiss's metallic dilators. Nevertheless Hybord in 1872 could only find recorded twelve cases of bloodless dilatation for the extraction of stone, and the exploratory rnethod was but very seldom used.
Simon's method begins by making an incision /10- inch long with the scissors at each side of the mouth of the urethra, which is the most re sisting part, and another -1 inch deep down through the urethro-vaginal wall. The specula are inserted, one after the other; they are made of hard rubber, and are hollow; each is fitted to a mandrin. (See Figs. 4 and 5.) Simon has 17 different numbers, ranging from /80- of an inch to -e6- of an inch in diameter. After the thickest has been introduced, the index finger is inserted into the bladder, the corresponding middle finger being in the vagina, the other hand pressing the vault of the bladder against the index finger. Every portion of the bladder save the highest corners can be explored in this way; and the narrowest urethrie can be dilated in from 5 to 7 minutes. While Heath, when he dilated with his
finger alone, always found the mucous membrane of the urethra torn under the arch of the pubis, and usually had twenty-four hours of incon tinence of urine, by Simon's method ruptures of the mucous membmne rarely occur, and the patients can retain their urine completely after the operation. Simon has laid down exact rules as to the extent to which dilatation may be carried without causing incontinence. He found that in the full-grown woman, plugs of 2/ inch circumference, = / inch diameter, can be used without danger; and that in extreme cases, where somewhat hazardous means are justifiable, dilatation up to 2.6 or even 2.8 inches might be done. In young girls the diameters must be propor tionately diminished. With this degree of dilatation incontinence need not be feared, and it is amply sufficient in most cases for diagnostic and therapeutic purposes. I have had. occasion often to make use of Simon's method, and can vouch for the accuracy of his statements. In spite, how ever, of the prescribed incisions made at the edges of the external orifice, one or other of them has always torn further, and a lesion has occurred at the base of the clitoris. But from the pressure exercised upon the parts by the speculum, the bleeding has been usually insignificant, and has soon stopped after withdrawal of the instrument. These incisions, therefore, are not always necessary; and they should, with all other fissures, be sutured immediately after the operation with fine silk. In continence has never occurred in my cases. I must add that while I was unable after the ordinary dilatation of the urethra, for the extirpation of a papilloma vesica, to introduce an instrument into the bladder, alongside the index finger of the left hand, I could easily do it after dilatation with Simon's specula. Nor is this instrumental dilatation tiresome for the operator. As I show in my gynecological operative course, the dilatation of the urethra, and the palpation of the internal surface of the bladder can be well demonstrated and practised on sub limate preserved subjects.