SOUNDING AND CATHETERIZING THE FEMALE URETERS.
The passage of a catheter, sound, or bougie into the ureter is as easily accomplished as the inspection of its orifice, and, if gently conducted, is a simple, painless, and harmless procedure. I have found it necessary under a variety of conditions, the most important of which may be classified under the following headings : First, for the collection of urine directly from the ureter, without contamination with the bladder, in order to determine the presence or absence of renal disease, or of one kidney and not of the other.
Second, to determine the existence of ureteral disease, such as hydro-ureter and pyo-ureter.
Third, in order to lay a solid bougie in the ureter, so that it can be kept constantly under touch and recognized throughout any ab dominal or pelvic operation in which it was in danger of being cut or tied.
For a ureteral catheter, I use a simple metal tube about 25 cm. (10 in.) long, gently curved at its outer end, which is held in the hand, so as not to obstruct the view during its introduction. The end is also enlarged a little, so as to hold a fine rubber tube slipped over it in washing out the ureter and kidney. The ureteral end of the catheter has a rounded point with three or four holes in it, and a very slight curve at the end.
To introduce the catheter, the ureteral orifice is brought to about the centre of the field of the speculum, and the mirror and light are adjusted so that the head of the observer is not in the way as he intro duces the catheter into the speculum and slides it on, until its point rests in the ureteral slit. On pushing it in a little, the sides of the opening separate, and it appears as a hole, with the catheter lying in one side of it. The catheter must now be pushed out gently toward the side, stopping at once if the slightest resistance or obstruction is met. When it has reached the pelvic wall, 4 or 5 cm. (1 to 2 in.) from the orifice, it must be firmly held while the speculum is slowly drawn out, disengaged from the urethra, and pulled over its end. It is usually necessary for an assistant to pull open the buttock of the side on which the handle lies, to keep it from making such undue pressure upon the ureteral catheter as may injure the ureter. The patient who has been in the knee-breast position may now raise her Self up on her elbows or hands, while the urine is being collected as it flows from the catheter. A. minute or two, or more, often elapses be fore the flow begins. It is easy to tell whether the catheter is filling by stopping up its end with a little drop of water, which blows out in the form of a little bubble as soon as there is any movement within. The urine escapes intermittently by three, four, or five drops, one after the other, followed by a pause of from a few seconds to a half minute or more. The average amount of the flow should be a half
cubic centimetre (-1- drachm) per minute. It is often less than this, but rarely more, unless there is some disease. I have in a number of instances seen the urine escape from the catheter in a steady stream, but they were all cases of hydro-ureter.
For a prolonged drainage of the ureter, or in order to drain both ureters, permitting no urine whatever to enter the bladder, it is nec essary to introduce two short ureteral catheters, with fine rubber tub ing on the ends, in the following manner: The catheters are about 6 cm. long (21 in.) and 2 mm. in.) in diameter, slightly curved, and with holes in the end, like the ureteral catheter just described. The outer end of the catheter is a little enlarged, and over it is passed a piece of fine rubber tubing about 15 cm. (6 in.) long. A stylet with a strongly bent handle is coated with vaseline and introduced into the catheter through the tube. This gives the requisite stiffness and length for the introduction of the catheter into the ureter after the manner previously described. The catheter is pushed well on until its outer end lies within the bladder 1 or 2 cm. (4- to 1 iu.) from the ureteral orifice. The stylet is now withdrawn, and after it the specu lum, very slowly, taking care not to drag the rubber tubing with it. The speculum is again dipped in sterilized vaseline, and re-entered into the bladder, beside the rubber tube. The opposite ureter is now exposed and catheterized in like manner and the speculum again withdrawn. The rubber tubes now lie in the vulvar cleft emerging from the urethra, conveying the urine from right and left kidney into separate vessels. Care must be taken to mark the tubes, distinguish ing right from left.
I have also been able to catheterize both ureters in this way without withdrawing the speculum, by catheterizing one first and pushing several centimetres of its rubber tube into the bladder so that it would not be pulled upon, while turning the speculum to the opposite side to catheterize the other ureter.
I have had flexible bougies made 2i- mm. in.) in diameter and 40 mm. (14- in.) in length with well-rounded ends. These are kept cool so as to be stiff when wanted for use. If too flexible they can not be introduced into the ureter. The bougie is inserted into the ureter by passing it along the tube, which is elevated until the end of the bougie lies in the urethral orifice. The bougie is then slowly pushed on 2 or 3 cm. (1 to 14- in.) at a time, grasping it close to the speculum. There is no difficulty in this manner in carrying it all the way up to the kidney.