Seneca (New York) has lately described a new urethral dilator, which figured in the 111ustr. Mona'schrift der Arid. Polytechnik, 1882, part 7, which consists of four rounded steel rods, each one of which is united to a central axis by a cross arm. The dilating part is four inches long, and the highest degree of dilatation attainable is two inches, which may be read off upon a graduated quadrant. Similar, but covered with a rubber hood, is the dilator of Kurtz.' Neither instrument possesses any advantage over that of Simon; in fact, they are not so good, since they do not dilate the whole uterine periphery evenly.
If urethral dilatation does not suffice for the accomplish ment of our object, we must have recourse to the method of vagino-cystic incision, which has also been recommended by Simon. By this means we can invert the bladder in the vagina and even between the vulva, and can employ not only palpation. but inspection for its examination. Simon's cysto tomy with artificial inversion is done by making an incision of an inch in front of the anterior lip of the os uteri in the anterior vaginal wall. and some inches in length. From its middle a cut + of an inch long is made to the urethra, giving a T-shaped incision. A thin double hook is inserted into the bladder through the cut, and is hooked into the mucous membrane; at the same time the other hand depresses the bladder forcibly above the symphysis. The incisions are best done when the vagina is dilated by a Simon's di lating instrument, or a Bozeman's speculum, and the bladder wall is tightly stretched; or it may be accomplished by dragging down the uterus and the upper part of the vesico-vaginal wall. The bleeding is stopped by ligature or torsion, and after the operation upon the internal surface of the bladder is finished, the cut edges are united with thread. Union takes place easily, since the parts fit together well.
Simple dilatation of the urethra is of service principally in the diagnosis of diseases of the vesical mucous membrane, and in the detection of for eign bodies and stones, and in their extraction. It is also useful in the cure of fissures of the urethra, for the recognition of defects in the vesico vaginal wall, when the vagina is closed, for the diagnosis of the seat and extent of growths and tumors of the bladder wall, for their extirpation, and for the cure of vesico-intestinal fistubt by the atuterization of the vesical mouth of the fistula. Besides this it has been recommended for the treatment of obstinate vesical catarrh by local application of concen trated caustics (Heath), for the finding anti extraction of renal calculi in the vesical end of the ureter, and finally for the opening of luematometra, whose evacuation between the bladder and the rectum is impossible or dangerous (as Spiegelberg and others have used it). The method is,
therefore, of great diagnostic and therapeutic value. If Silbermann (1.c.) in 48 cases of rapid dilatation of the female urethra, found incontinence occurring 8 times, this was because most of his operations were not done in accordance with the rules laid down by Simon, nor with his instru ments; and they cannot reflect upon the value of Simon's method.
In cases of very large stone with considerable vesical tenderness, or in the extirpation of tumors situated so high up on the lateral vesical wall that they cannot be reached through the dilated urethra, and in cases of operation for vesico-intestinal fistula, the T-shaped incision above described will be necessary. Sims, Emmet, Bozeman, Simpson, Hegar, and Simon have employed it also in cases of obstinate vesical catarrh with ulceration of the mucous membrane, to prevent the stagnation of decomposed urine in the bladder. Simon remarks, however, that the results obtained from the operation for this indication, were such as to cause him to regard it as being yet sub judice.
After dilatation of the urethra to the extent of admitting a finger and instrument into the bladder, a further exploratory method, also intro duced by G. Simon, may be undertaken. It is the sounding and catheter rization of the ureters, which may be of use in diseases of the ureters and kidneys. The orifices of the ureters will be found about 1 inch from the vesical orifice of the urethra in the so-called lig. interuretericum (Fig. 7). They may be felt as prominences about half an inch from the median line. These prominences being fixed with the index finger of the left hand, the head of a small sound is carefully guided to the spot; the hand is now carried to the side opposite to the one of the ureter that is being sounded, and against the arcus pubis, and by a gentle pressure the sound is inserted in the ureter. With the finger tip the entrance of the sound is to be guided. With instruments of suflicient length the pelvis of the kidney may be attained. The sound must first be carried some three inches from within outwards; and when the bony margin of the true pelvis is reached, the handle must be depressed and carried towards the thigh on the same side. Thus the anterior portion of the sound is held parallel to the spinal column, and its head is directed somewhat towards the anterior ab dominal wall, and easily reaches the pelvis of the kidney. Simon has provided two instruments, a urethral sound, and a urethral catheter, for this purpose. (Figs. 8 and 9.) They are t,en inches long, and inflexible, since a flexible metallic instrument could not straighten out the curve which the ureter takes in its passage from the bladder to the margin of the pelvis.