ASEPSIS IN URETHRAL VESICAL, AND URETERAL EXAMINATIONS.
Examples of general septic infection starting in the lower urinary tract and travelling up, infecting bladder, ureter, renal pelvis, and kidney, and from thence the system at large, are sufficiently abun dant in medical literature to require no demonstration here to prove the possibility of such an accident. In the male, the ascending cases of gonorrhoea and the cystitis and pyelitis following the introduction of a catheter, are the most familiar examples, while in the female the occasional outbursts of cystitis in the gynecological and obstetrical wards are unquestionably due to septic catheters. I remember, when I was a resident in a large general hospital, a man with a broken back whose urethra was literally torn to pieces by the repeated intro duction of a flexible catheter from which the shellac coating was peel ing off in thousands of little flinty, jagged scales, all over its surface. The consequence was an intense purulent urethritis, cystitis, and death.
In the same way one catheter in careless hands in an obstetric ward has repeatedly been the means of infecting one patient after another.
Too great care cannot therefore be taken in observing rigid aseptic rules throughout the manipulations necessary for the investi gation of the urinary tract.
The instruments must be thoroughly washed with hot water and soap after every investigation, and in inflammatory and infected cases, the dilators, cystoscopes with obturators, searcher, catheters, and evacuator, must be boiled in a one-per-cent soda solution, and then pre ferably laid away between sterilized towels. The hands of the operator and his assistants must under no circumstances come directly into con tact with those portions of the examining instruments which are intro duced into the urethra and bladder. There is no necessity for man ual touching of the end of the cystoscope, the searcher, the ureteral catheter, or the little sterilized pledgets of cotton with which the resid ual urine is taken out of the bladder.
The urethral orifice must always be carefully cleansed before a speculum is introduced, and if the case is one of gonorrhoeal infec tion it will be safer first to empty Skene's glands, removing any pus they may contain. If there is any acute inflammatory trouble in the urethra there will be some danger of carrying up septic material into the bladder in pushing in the speculum. This ought, therefore, not to be done without first washing out the urethra with a short catheter so constructed that the water passing out at the point is directed back ward into a tube a short distance behind it and thus allowed to es cape. If there is any inflammatory trouble in the bladder the ureteral orifice ought first to be wiped off with a saturated boric acid solution before passing in the ureteral catheter.
In severe catarrhal diseases of the bladder catheters should not be left in the ureters to drain off the urine for any considerable time.
unless an urgent necessity exists.
Estimate of the Vague of this illethod of Examination.—The pro cedure described above presents many points of advantage over other means of examining these organs. In the first place, we are enabled, by means of a speculum S to 10 mm. in diameter, to examine all parts of the bladder and ureteral orifices without anesthesia, with out pain, and without injury to the urethra.
This method is analogous to the investigation of the posterior pharynx, with a reflected light and tongue depressor, and quite as simple. It is more direct than the examination of the larynx or the eye. It has, however, much in common with ophthalmoscopy, being the examination of the inner surface of a spherical body through a circular opening in one of its sides. It has a material advantage over ophthalmoscopy in that we are able to see all parts of the sphere equally well, even those lying anteriorly near the opening. We have also here the further advantage of being able to investigate the condition of distant organs such as the ureters and kidneys. An analogous condition in eye diseases would be the power to examine the optic tracts in the brain and draw important conclusions as to brain disease.
We also possess a certainty in diagnosis, and a large number of affections hitherto not recognized are brought within the reach of topical treatment. I have found, for example, that affections which were wont to be considered general diseases involving all parts of the bladder mucosa may in reality involve only a small part, or are often distributed in patches with intervening healthy parts.
I have found also that so-called irritable bladder in women is a mild inflammatory affection involving either a small part of the tri gonum or a part of the urethra, and is a disease readily amenable to treatment.
The method does away forever with the incision of the bladder for diagnostic purposes, or the incision and dilatation of the urethra for the purpose of introducing the finger into the bladder.
By catheterizing the ureters in the simple manner described we do away with the necessity of fishing for them with a catheter intro duced through the urethra, guided by the eye watching its point playing over the anterior vaginal wall. This method of Pawlik is always more or less uncertain, is quite difficult, and attended with injury to the bladder, and in inflammatory cases is particularly dangerous.
We can by this means exclude renal disease where pus is found in the urine, or we can diagnose unilateral or bilateral renal disease.
We can also always readily ascertain the sources of hemorrhage.
We are thus enabled to treat pyelitis and pyo-ureter and stricture of the ureter in its lower part.
Treatment can be applied directly to the parts affected without unnecessarily treating the sound surfaces.
We may also follow up the method of treatment from week to week without discomfort to the patient, and with certainty as to results.