ureter I have frequently observed little jets of urine ejected at short intervals, like a miniature fountain; in pathological cases FIG. 7.-No. 16 speculum (natural size). This speculum is usually the cystoscopy or catheterization of ureters. I have seen pus and blood flowing from one ureter while the other discharged normal urine. The ureteral orifices and their surroundings are not constant in appearance. Sometimes the orifice appears as a dimple or a little pit, or, in inflammatory cases, as a round hole in a cushioned eminence; at other times as a with the point directed outward; again it may be scarcely visible even to a trained eye, appearing as a fine crack in the mucosa, and occasionally is so obscure as to be recognized only by the jet of urine as it escapes, or by a slight difference in the color of the mucous membrane at that point. In rare cases it has the form of a truncated cone with gently sloping sides; this appearance is most apt to be developed in the knee-breast position. The bladder mucosa is usually of a slightly deeper rose color around the ureter, and in the presence of an inflammatory process it even appears deeply injected. In one instance the left ureteral orifice was marked by a large vessel which emerged directly from its lumen and then divided. My observations upon the appearance of the female ureteral orifice coincide closely with the clear description given by E. Hurry Fenwick, of London, in his work on the male bladder.' In the direct inspection the ureteral orifice always appears to lie nearer the urethra than maximum size used in one would anticipate. This is a result of the illusion produced by the foreshortening of the base of the bladder; the foreshortening also accounts for the difficulty in finding the orifice immediately in 'British Medical Journal, June 16th, 1888. those cases in which it appears as a mere slit in the vesical mucosa. Quite the contrary is true in the free-hand catheter ARNOLD FALTO 12 ization of the ure ter by Pawlik's method. A valuable aid for the beginner searching for the ureteral orifice is F ARNOLD & SONS, BALTO FIG. 8.-Speculum and obturator (two-thirds natural size). the following: A point is marked on the cystoscope five and a half centimetres from the vesical end; and from this point FIG. 9.-Direct inspection of bladder by reflected light; electric bulb with reflector held above symphysis pubis; hips in moderate elevation. two diverging lines are drawn toward the handle with an angle of sixty degrees between them (Fig. 13). The speculum is introduced up to the point of the V, and turned to right or left until one side of the V is in line with the axis of the body; then by elevating the endoscope until it touches the floor of the bladder the ureteral orifice will usually be found within the area covered by the orifice of the speculum. The ureteral orifice can often be found by an adept at once, and almost instinctively, by a single movement of the speculum after its introduction into the bladder. In order to ascertain whether it is the ureter which lies within the field, I use as a searcher (Fig. 14) a long, delicate sound with a handle bent at an angle of 120°, which is introduced through the speculum into the suspected ureteral orifice (Fig. 15). If it be the ureteral orifice which is under inspection, the searcher passes easily from two to six centimetres up the FIG. 10.-Suction apparatus (three-fourths natural size) used for withdrawing residual urine. ureter, and the lateral walls of the orifice are slightly raised, appearing as distinct folds with a dark pit between them. The searcher may be withdrawn and a ureteral catheter at once introduced, if it is desirable to collect the urine direct from the kidney. The ureteral catheters which I use for direct catheterization are quite different from those heretofore employed. They are straighter, and either have no handle or only a small one which will readily pass through the No. 10 speculum (Figs. 16, 17, 18). The catheter may be left in place some minutes or an hour or more. The urine which accumulates in the meantime in the bladder necessarily represents the discharge of the opposite kidney; in this way the urine of both kidneys may be isolated by simply introducing one catheter. By placing the patient in the genu-facial posture (Fig. 19) an extreme distention of the bladder is obtained in the form of a flattened ovoid. In this posture the interureteric ligament also comes sharply into view, but the ureters are not so readily seen, as they are concealed by the outer extremities of the fold. The genu-facial posture is indispensable in some inflammatory cases when the bladder will not balloon out in the ordinary posture owing to its thickened walls. A satisfactory inspection can also be made in many cases in the left semi-prone position by elevating the pelvis on a pillow. Simple Direct Catheterization without Elevation. -After some practice it is possible even to catheterize the ureters with the patient simply in the dorsal position without elevation of the pelvis. The success of such an attempt depends upon the examiner's familiarity with the position and appearance of the ureteral orifice on the posterior wall of the bladder. The manipulation necessary to expose the ureteral orifice becomes with practice almost instinctive. The bladder is emptied by catheter, the ureter is dilated, and the speculum, No. 10 or 12, introduced from five and a half to six centimetres, and its outer end elevated until the base of the bladder appears, when it is turned thirty degrees to the right or left, and with a little patience in searching the ureteral orifice is found. To prevent the residual urine from obscuring the field the speculum is gently pressed against the mucous membrane; it is then only necessary to take up the urine with pledgets of cotton as it flows from the ureter into the speculum. An anesthetic is not necessary for cystoscopy or catheterization of the ureters, unless the urethral is to be dilated up to No. 14, 15, or 16. In nervous women it is often best to make a thorough examination first under anesthesia. Subsequently a satisfactory illumination of the bladder can be made, and the ureters catheterized and any ordinary treatment readily applied through the No. 10 ed forceps (threespeculum without anesthesia. I have succeeded FIG. 11. Delicate mouse-tooth fourths natural size). |