With these instruments Simon accomplished the operation 17 times in 11 different women, introducing the sound 9 times, and the catheter 8 times; and in no case did he do the slightest damage by the operation. It is true that he had no further opportunity to use catheterization of the ureter; but he believed it to be possible by this means to ascertain the presence of calculi in the ureters, and even in the pelves of the kidneys. He also claimed an especial advantage in obtaining urine direct from the kidneys without its having passed through the bladder. Stones found in the vesical end of the ureters could be cut out or extracted; or if they were near the renal mouth of the ureter, they might possibly be crowded back into the pelvis of the kidney. Strictures also might be dilated; and hydronephrosis occurring as it commonly does, with a pervious ureter, might be evacuated by means of the urethral catheter. These anticipa tions, however, were a little too sanguine. The operation would certainly not always be harmless. The straightening of the bend above-mentioned, would necessitate a more or less extensive laceration of the mucous mem brane, at least. Nay, perforation of the ureters might occur, es pecially when strictures of the ureters, or changes of position from tumors of the uterus, vagina, ovaries, pelvis, etc., were present.
Even sudden movements of the deeply narcotised patient, as of vomiting, might cause an accident of so serious a nature as to ren der us very cautious in view of the problematical advantages of the exploration. Luckily the diseases calling for catheterization are rare. Indeed I must admit, that although I have tried in every case in which I have dilated the urethra, I have never, in spite of the greatest patience, been able to introduce a sound into a ureter.
The attempt has been made in the past to illumine the female urethra and bladder, and so lay them open to inspection. Grunfeld used a straight tube of varying diameter with a funnel-shaped mouth, and pro vided with a reflecting glass at its inner end. He clahned to be able to • recognize with this instrument the most delicate changes of color of the mucous membrane of the bladder and urethra. Ultzmaun and Fiirth confirmed his assertions. With the aid of a gas or oil flame we can, with Simon's mirrors, obtain a good view of the posterior and lateral bladder walls. But the anterior and antero-lateral portions of the vesical mucous membnine min not be readily brought into the field of view; nor can we in this mode of examination fix our position, since the posterior bladder wall is applied to the opening of the speculum. Rutenberg, therefore, suggested the stretching of the bladder, and first tried to do so with water; but he was soon satisfied that air, being more transparent, was more appropriate, and constructed the apparatus figured on Fig. 10. This apparatus consists of the speculum itself, with a stopper, a part to be screwed to this with a fenestrum, and the mirrors. In order to obtain
the greatest possible amount of light with a certain diameter, the specu lum is made not of hard rubber, like that of Simon, but of German sil ver. It is of the same size front and rear, and has an internal diameter of 1-715- of an inch, the metal being -316 of an inch thick. It is inch longer than Simon's instrument, so as to leave room to handle the instrument when the other piece is screwed on. This latter part is Li inches long, and has a glass fenestrum I inch long; the glass is of the purest, and is one line in thickness. There is also a tube I inch in diameter, to which is attached a rubber tube for the purpose of inflation. The patient, un less her urethra has been previously dilated, must be deeply narcotized, and must be kept so during the whole examination. Since inflation of the bladder is extremely painful, and may cause disturbing contractions of the abdominal and vesical muscles, it is advisable to narcotize the pa tient even in those cases in which the urethra has been already dilated. The patient is placed in the dorsal position, with thighs flexed and fixed by two assistants. After dilating the urethra up to Simon's largest spe culum, the bladder is emptied of urine, and the silver tube is introduced. The upper part is now screwed on, without the mirror, the fenestrum having been heated in the flame of a spirit lamp to prevent the condensa tion of moisture. One of the assistants then inflates the bladder by a powerful expiratory effort applied to the rubber tube, or a bellows may be employed for that purpose. Using the Rutenberg apparatus in this manner I have once seen the bladder immediately blown up upon intro duction of the mirror. The other assistant holds the light above the symphysis, which is reflected by a concave mirror like that used in laryn goscopical examinations into the bladder. By moving the speculum in various directions, a large part of the posterior and lower bladder wall 11P can be plainly seen. If we wish t,o see the remaining portions, the mirror must be introduced, the upper piece being of course unscrewed, and the glass warmed. Examining the living subject Rutenberg found the pos terior bladder wall before inflation to be of a dirty, grayish-red color; but little was to be seen save the larger folds and indistinct vessels. But when the air entered the gray color gave place to an increasingly vivid red, and through the stretched and transparent epithelial coat the finest vascular net-work can be seen, running along the muscular bundles. Towards the base of the bladder the color of the mucous membrane became darker, the vascularization richer, and through the mucous mem brane could be seen the interlaced bundles of muscles. Without using the urethral sound Rutenberg was never able to find the urethral opening.