But beautiful as may be the effect of lighting up the vesical mucous membrane in this manner, it is questionable whether or not there is danger in it. Firstly it may be feared, that under the heavy pressure which is upon the air in the bladder, some of it might enter the ureters, reach the pelvis of the kidneys, and possibly cause pyelitis, or pyelonephritis, an affection which in many cases endangers life. I have used Rutenberg's method in ten cases, and in several of them repeatedly. Instead of a gas lamp I used an ordinary round, low oil lamp, which, as I demonstrated to a num ber of physicians at the Naturforscherversammlung at Hamburg, gives a. sufficient volume of light. My experience is that Rutenberg's method of exploration is absolutely harmless, that it gives splendid results, is. easy to exercise, and I therefore welcome it as a. valuable addition to our means of diagnosis in diseases of the bladder.
But the question has been asked as to tne necessity for any such method of exploration, since the entire inner surface of the bladder can be pal pated with the finger, and the speculum exposes to view fairly large por tions of the vesical mucous membrane. But wherever we can use both touch and sight in our examinations, the latter becomes undoubtedly more exact. And all anomalies cannot be felt; hyperaamias, superficial ulcerations, diphtheritic sloughs cannot, though they can be rea,dily recog nized with the eye. Palpation of the bladder surface presents consider able difficulty; the speculum shows us only a single fold of the mucous membrane; and if we introduce a small mirror through the cylinder to inspect the anterior wall of the organ, the mucous membrane falls down on all sides, and covers the surface of the mirror. It is necessary to dilate the bladder if we desire to obtain a clear picture, especially of the anterior wall. Besides this, the mirror may be moved around in all directions, without in any way injuring the mucous membrane.
So far I have not succeeded in seeing the orifices of the ureters by nienns of the mirror in the dilated bladder. Further, it is possible to fasten a small sponge or brush to the metal rod that carries the mirror, and so to apply medicaments directly to the diseased spot, without at the same time involving all the rest of the organ. Certainly Rutenberg's method has a future before it.
Matthews Duncan uses ord.inary glass specula of large size, with oblique ends, for inspecting the vesical mucous membrane.
W. Noeggerath is the only one among the authors who have studied the methods of bladder inspection after urethral dilatation, who claims that there is always a reaction after opening the urethra in the manner described. He claims that retention of urine, sensations of burning and heat in the urethra and labia, occasionally cystitis, sometimes abdominal pain, and even perimetritis may occur. I have often noticed a burning pain and dysuria, and once a distinct vesical catarrh, after these ex aminations; but I can very positively assert that these ill consequences may be easily remedied by washing out the bladder for a few days with lIegar's funnel. Though the method has some drawbacks, they are not to be feared in ordinary cases; they are avoidable, and are of little weight in comparison with the advantages to be obtained. Bridge's so-c,alled case of peritonitis, after rapid dilatation of the female urethra, is note worthy in that incontinence occurred, although Simon's rules were exactly followed, the patient dying in a typhoid condition a month later. I have recorded a case in my Pathology of the Rmale Sexual Organs, Leipzig, 1881, p. 407, in which, in a woman fifty-four years old, who had suffered for eighteen months from violent dysuria, and whose urine is said to have often been mingled with mucous and blood, a fatal acute double nephritis with anuria was caused by palpation of the bladder after rapid dilatation.
The patient had a uterine myoma and a tubo-ovarial cyst, and bladder trouble was suspected, but not found. Hence exploration of the bladder may evidently, under certain circumstances, be dangerous.
One more explorative instrument remains to be mentioned, by means of which the abnormal contents of a bladder may be appreciated without dilating the urethra. We refer to W. Donald Napier's sound, the beak of which is covered with a coating of pure lead, which is to be polished so highly with a piece of leather as to become extremely sensitive to the touch of any hard substance. The beak is then dipped in a 1 per cent. solution of nitrate of silver, and is thus provided with a coat of black so delicate that the slightest touch of a foreign body makes a perfectly dis tinct impression. A magnifying glass must be used before the instru ment is introduced to make sure that there are no impressions upon its tip.
The exploration of the bladder with the manometer, first described by Schatz, has recently been revived by Hegar, Odebrecht, and Dubois.' Dubois, following Schatz, introduced a metallic or elastic catheter into the bladder, and united it by means of a rubber tube to a glass tube some 60 inches long. The 0 point of the graduated index was placei at the symphysis, and the height of the column of urine gave the pressure. But he soon found that the level of the top of the bladder did not always coincide with the symphysis, in one case reaching that point only when it contained 23 cubic inches of urine. It was ascertained that the bladder pressure is nearly a constant one, and is independent of age and sex. It rises to 1 inch with each ordinary expiration, and falls again with expira tion. In the recumbent position, it amounts to 4 to 6 inches; standing it is 12 to 16 inches; while laughter, coughing, or voluntary effort increases it to 20 to 60 inches. Dubois believes that the pressure of from 4 to 6 inches is not due to the weight of neighboring organs, but marks the tension exerted by the elastic muscular bladder upon its contents. In proof thereof he demonstrated that after removing the organs from the abdominal cavity of a suitable subject, a pressure of 4 inches was attained by the tension of the bladder alone. He also found that the pressure in the rectum is independent of that in the bladder, since it remains the same while the bladder pressure is being diminished by emptying the organ. In a case where the pressure in the abdominal cavity sank to nothing after the evacuation of a considerable amount of ascitic fluid, that of the bladder remained at 8 to 10 inches. Finally, in a case of cystocele vaginalis with prolapsus uteri, in which the influence of the abdominal pressure was excluded, since even the deepest inspiration had no influence upon the height of the column of water, the pressure of the bladder, which con tained 9 cubic inches of urine, was 4 inches. Of course the intra abdominal pressure influences the bladder, and is increased by ascites and meteorism. In myelitis and in fractures of the spinal column, Dubois proved that there was a distinct diminution of vesical pressure. But he always found a positive pressure even with absolute paralysis of the blad der and the abdominal muscles. And he could never, by sudden and intermittent pressure, cause a negative pressure, as Odebrecht claims to have done. Dubois explains the entrance of air into the bladder through the catheter, as being due to variations in pressure of the stream of urine, by which bubbles of air pass between it and the walls of the catheter, and then ascend into the bladder. Hence the important practical rule in catheterization, not to depress the handle of the catheter too much; and if manual pressure upon the abdomen is used to promote evacuation, the catheter must be withdrawn before that pressure is relaxed.