diagnosis of kidney disease may be made exactly from these data at least to
a sufficient extent to furnish operative indications. While this is to a certain
extent true, the surgeon who in addition catheterizes the ureters will acquire
additional and valuable data, and may save himself from grievous errors.
Moreover, as already suggested, the ureteric mouths may appear normal in
the presence of tuberculosis of the kidney. Thus, Brown relates three instances
where no abnormality was noticeable in the condition of the mouth of the
ureter while a catheter introduced withdrew urine containing tubercle bacilli
and the operation confirmed the diagnosis of tuberculous kidney. The results
of ureter catheterization in bleeding from the kidney are often very valuable,
although at times disappointing. It is of course possible by this means to
determine the source of the bleeding, but its pathological causation sometimes
remains obscure. The three most common conditions other than trauma which
lead to hemorrhage of the kidney are stone, tuberculosis, and malignant new
growths of the kidney. In the absence of tubercle bacilli we cannot, as a rule,
exclude tuberculosis without frequently repeated tests. With a negative X-ray
finding and the absence of inflammatory products in the urine we are some-



METHODS OF EXAMINING THE KIDNEY



335



times able I" exclude renal calculus. The iiexl mosl probable diagnosis is
malignant tumor, and this type of renal hematuria will, of course, in time be
accompanied by the formation of a palpable tumor. Other conditions to be
described later al length are congenital cystic degeneration of the kidney,
bilharzia bematobium, and 9ome other conditions to I"- mentioned.

For a more complete description <>t" the cystoscope and of its use the reader
is referred to the publications of NTitze, Berkeley Hill, Hurry Fenwick,
Thompson, Boisseau dn Rocher, Casper, Albarran; ami. in America. Taylor,
Ayres, Brown, Otis, Bransford Lewis, Valentine, Bierhof, and others.

Some Hints in Regard to tin-: Technic of Catheterization of the Ureters,
Adapted from F. T. Brown's Article on this Topic



In order that the examination shall he conducted successfully, it i- necessary
that the surgeon should have everything he is likely to need within easy reach of
his right hand, so that the left hand may he left constantly free to retain the
cystoscope quietly in position after it has been introduced into the bladder. The
steadiness with which the cystoscope is held and the gentleness with which it is
moved have much to do not only with the comfort of the patient, hut also with
the success of the entire procedure.

The operation of cystoscopy with catheterization of the ureters is at best a try-
ing one for the patient, and hence it is important that he should be so placed and
supported upon the table that all his muscles may be
at rest. To this end it is desirable to use a table
fitted with leg rests, such that both the legs ami
thighs may be well supported. The leg rests may be
made in the form of double-inclined coni-
cal gutters, the apices of which conform to
the flexures of the knees. The patient
should be so placed upon the table that the
buttocks are as close to its edge as possible.
It is desirable to use a table of such a char-
acter that the parts supporting the patient's
hack can be elevated to any desired degree, and such
that the entire back, including the lumbar region.
receives support. After the patient has emptied his
bladder voluntarily, the specimen passed is preserved
for comparative examination with those withdrawn
through the ureteral catheters. The patient having
been comfortably placed upon the table, a little
cocain solution (two- to four-per-cent) is introduced
into the urethra. After a few moments a soft-rubber
catheter is introduced into the bladder, and any re-
sidual urine is withdrawn. The bladder is then

irrigated, if the urine has been at all purulent, with a two-per-ceni warm boric-
acid solution, or with equal parts of 0.9-per-cent salt solution ami four-per-cent
of boric acid. This fluid is also used to distend the bladder during the cysto-




Fio. 7. r >. — I'i.tzmaw's II wr> Syr-
is..! IND IrRIG LTING < A THK-
TK.H.



336 THE KIDNEY AND T7EETER

scopic examination. For irrigating the bladder one may use an TJltzmann or a
Janet syringe, or the bladder may be irrigated by means of a glass irrigating jar,
the fluid being permitted to flow into the bladder by gravity. After the washing
fluid has returned quite clear the posterior urethra may be rendered anesthetic by
the introduction through the catheter, or by means of the Ultzmann drop syringe,
of a solution of cocain (four-per-cent). From -4 to 10 c.c. of this solution, intro-
duced into the posterior urethra, are usually sufficient to produce a satisfactory
degree of anesthesia. When the posterior urethra is anesthetic a soft-rubber cathe-




Fig. 76. — Ultzmaxx's Syrevge for Ixsttllatton in the Deep Urethra. The shaft of the instru-
ment must be made of silver: its caliber is of such a size that one of the divisions on the shaft of
the piston is equal to the fluid contents of the entire shaft.

ter may be passed into the bladder, and through it a quantity of the solution may
be introduced which will vary somewhat in different cases. Four ounces is a
moderate quantity, but more may be used in case it does not produce a sensation
of distention and discomfort. In cases where the urine is quite clear or nearly so,
it will not always be necessary to irrigate the bladder before introducing the
cystoscope. Under such circumstances the cystoscope. with its obturator in posi-
tion, is carefully introduced into the bladder. The obturator is then withdrawn,
and if it is desired to substitute fresh clean solution for that which is in the
bladder a rubber catheter may be inserted through the sheath of the instrument.
Such a catheter may be surrounded by a movable rubber belt, which acts as a cork
to prevent the solution from running out between the catheter and the sheath of
the instrument. Before the cystoscopic examination is commenced boric-acid solu-
tion may be added by attaching the catheter to a syringe or an irrigator. When
the bladder is believed to contain a sufficient quantity of fluid any one of the
several telescopes of the instrument may be introduced through the sheath in place
of the catheter, the lamp may be illuminated and the examination of the bladder
commenced. "Whether or not it is desired to introduce catheters into the ureters, it
is not a bad plan to introduce first the direct observation telescope, which gives a
larger field and more brilliant illumination, or the right-angled observation tele-
scope, since through these instruments the interior of the bladder may be studied
and the situation of the mouths of the ureters may be determined. In order to
substitute one telescope for another the following procedure is recommended by
Brown : " When any of these telescopes is withdrawn a trifle so that the vesical
end has come wholly within the sheath, the latter can itself be slightly withdrawn
until the heel opening comes just to the internal meatus; by now raising the
ocular end to more or less of an angle with the plane of the patient's body,
the distending medium in the bladder will be prevented from escaping, while the
telescope is wholly removed, and the next telescope, when well within the sheath,
calls for a lowering of the ocular end, so as to prevent the impact of its vesical



METHODS OF EXAMINING THE KIDNEY

(mkI upon the neck of the bladder. After a little practice one can make such
changes with perfeci success, and thus save the time otherwise required for a
renewed introduction of distending medium with each succeeding telescope/' The
interior of the bladder having been studied, oi r other of the telescopes con-
taining ureteral catheters is introduced. As already stated, the direct telescope
renders it easier to pass the ureteral catheter when the papilla has once been located,
but, on the other hand, the indirect telescope permits one to see the ureteric
orifice more easily. Whichever one is used, the task of the surgeon is first to
find the papilla, and then to introduce into the ureteric orifice of one side the
ureteral catheter. Here ii must be said that considerable practice is necessary to
do this readily. All the manipulations should be made with extreme gentleness
from beginning to end. II' the slightesl roughness is used in the manipulations,
the surgeon will be pretty sure to find himself looking through a blood-stained
medium, and will identify the orifices of the ureters with difficulty, if at all. In
the cystoscopes of Brown, arrangements are made for continuous irrigation of the
bladder with fresh solution, if such is required; ami thus the medium may be kept
reasonably clear throughoul tin' examination. When the surgeon has succeeded in
engaging one of the catheters in the mouth of a ureter, the instrument i- gently
pushed inward a distance of about two and a half indies. The cystoscope is
maintained by the left hand at precisely the same inclination to the horizontal,
and the ocular end is slowly moved in a lateral direction through an arc of thirty
or forty degrees, until the orifice of the other ureter comes into view. It is im-
portant to make this movement very slowly and gently, since otherwise the catheter
already passed may cause undue tension and traumatism on the mouth of the

ureter. The mouth of the second ureter having been found, the sec 1 catheter

is inserted to a distance of about two inches. The caps which have previously cov-
ered the outer ends of the catheters are now removed, and the urines are collected
in bottles marked "Bight " and " Left." If it is desired to make cultures from
the urine, live or six drops may he allowed to fall from either catheter upon suit-
able culture media in labeled "culture tuhes." During the time when the urines
are being collected, some of the water contained in the bladder may he allowed to
escape through the outlet in the cystoscope provided for the purpose. The patient
will thus he rendered more comfortable. While many surgeons prefer to remove
tin' cystoscope and to leave the catheters in position. Dr. Brown informs me that
he is in the hahit of leaving the cystoscope in the bladder while the urine is being
collected, holding it constantly in position with his left hand. If it is desired,
however, to remove the cystoscope, it may he done when using the direct method
of catheterization without much trouble. In order, however, to remove the cysto-
scope with the catheters in position, when using the indirect instrument, not a
little skill is required in order to prevent an undue amount of traumatism to the
ureters, and the consequent contamination of the specimens with microscopic or
gross quantities of blood, thus in many instances invalidating the purpose of the
whole procedure. The source of electric illumination for cystoscopes may he one
or other of the forms of "electric controllers" now on the market attached to the
street current, or, on the other hand, dry-celled batteries or storage batteries may
he used. The voltage of (he cold electric lamps now in general use is very small,
and a dry-celled battery of ten cells furnished with a small rheostat furnishes a

current satisfactory in every way.

74



338



THE KIDNEY AND UEETEE



From six to twelve cubic centimeters of urine should be collected from each
kidney, for purposes of analysis and microscopic examination. For taking the
specific gravity of such small quantities of urine the Westphal balance is the most
convenient instrument.

For the purpose of practicing the operation of ureteral catheterization Dr.
Brown recommends the use of bladders removed from the bodies of human beings




Fig. 77. — Gtstoscope for Direct Examination of the Blad-
der in the Male with Obturator Coude. (After Luys.)



of both sexes and suspended in a two-per-cent solution of formalin, 5 or 6 ounces
of the same being used to distend the organ. In removing a bladder, one inch
of urethra and three or four inches of each ureter are suitable portions to leave
attached. Very small bougies should be passed through the ureter stumps, so that
the orifices may remain a little patent ; otherwise they will be difficult to recognize
and impossible to enter with a catheter. In order to have the bladder retain a
steady position while manipulating the cystoscope, it is well to pin the viscus
with small staples to a wooden block, which has had a concavity made in it for
the reception of the base of the bladder. A series of such bladders will illustrate
very well the many changed conditions one has to expect in performing cystoscopy
and ureteral catheterization on the living subject.

Catheterization of the Ureters through a Straight Tube by Direct Vision. —
Gustav Simon, and later Pawlik, catheterized the ureters of the female suc-



Fig. 78. — Cystoscope for the Direct Examination of the
Bladder with Lamp Inserted and Magnifying Lens.
(Luys.)




cessfully in a good many cases by the direct method or by the sense of touch.
Simon showed that the female urethra might be dilated quite widely without



METHODS OF EXAMINING THE KIDNEY



339



serious injury, but it remained for Howard Kelly, of Baltimore, to develop
the method to its presenl state of usefulness. While generally only applicable
lo women, catheterization of the ureters in the male through ;i straight tube,
by direct vision, has been accomplished successfully by Kelly and by Roberl
T. Morris, Bransford Lewis, and
others. It is certain, however, that
this method for the catheterization

of the ureters in the male can never

be employed except by a few highly
skilled specialists. Tn the female
the catheterization of the ureters by
the direct method is so easy that
any surgeon of average skill can ac-
complish it. in simple eases at the
first trial. The use of Kelly's meth-
od is very general at the present
time, and while in highly skilled
hands the ureters can be catheter-
ized in the female through the elec-
tric cystoscope with comparative ease,
this method also will always remain
chiefly in the hands of specialists.
The following are the principles of
Kelly's method: The atmospheric dis-
tention of the bladder by the posture
of the patient — i. e., the knee-chest
posture or the lithotomy position with
elevation of the hips, the introduction
of a simple cylindrical speculum into
the bladder, illumination of the inte-
rior of the bladder by means of ;i head
mirror or of an electric headlight, and
the subsequent inspection of the in-
terior of the bladder, finding of the
ureteral orifices, and the introduction
into them of catheters.

The instruments which are used for catheterization of the ureters are an
electric headlight or other strong source of artificial light, ;i 32-candle-power
lamp — set. in a white enamel reflector, for examph — and a head mirror, a
series of vesical specula with obturators, a urethral calibrator and dilator,
an evacuator for removing the urine from the bladder, although this may
in many instances be dispensed with, a pair of long mouse-toothed force])-.
a ureteral searcher, a metal ureteral catheter, and flexible varnished silk long
and short ureteral catheters, occasionally solid ureteral bougies, and for the




o] :~.



Fig. 70. — Catheterization- of the Ureter
through a Straight Tubs. (After Luys.)



340 THE KIDNEY AND URETER

purpose of detecting stone in the ureter a ureteral bougie coated near its end
with wax. Personally I have always found it much easier to catheterize the
ureters in the female by using as a source of illumination a good electric head-
light, run by a suitable storage battery or the modified direct street current,
with the interposition of Wappler's electric controller, or the controller of the
Electrosurgical Instrument Company of Rochester, UST. Y. Sunlight and a
head mirror may also be used, although not always available. Gas or oil
lamps are undesirable. When using a head mirror, it should be such a one
as is ordinarily used for the examination of the throat and larynx, with a focal
distance of twelve inches.

The specula which are introduced through the urethra are metal cylin-
ders made of German silver, nickel-plated, about three inches and a half
in length, set upon a strong handle with a conical expansion at the outer end
of the tube. Each speculum has an obturator, with a large, strong handle
and a bluntly conical vesical end fitting snugly into the vesical end of the
speculum, which should be so constructed that no sudden, sharp shoulder exists
which might injure the urethral mucous membrane during its introduction.



Fig. 80. — Urethral Calibrator and Dilating Instrument for the Female Urethra. (Kelly.)

The specula are made in sizes ranging from 5 to 20 mm. in diameter. The
sizes ordinarily used are from 7 to 12, it being rarely necessary to use a
larger instrument for mere purposes of inspection of the interior of the blad-
der or catheterizing the ureters. The instrument known as the urethral
dilator, which also serves to measure the caliber of the urethra, is a solid cone
of metal, having a large, strong handle at its base ; it is three inches in length,
and gradually increases in size from a diameter of 3 mm. at its blunt tip to
16 mm. at its base. A series of numbers placed at intervals on the surface
of the cone indicate its diameter at several different points. The evacuator as
used by Kelly is a small, hollow, perforated metal ball, connected by a slender
rubber tube a foot or more in length with a rubber bulb. Somewhere in the
course of the rubber tube a bit of glass tubing may be inserted, so that the
operator can tell when the urine is being sucked out of the bladder. When
using the knee-chest position for the examination the evacuator is rarely
necessary. When the woman is examined upon her back the urine tends to
gravitate away from the urethra and collect in a pool in the base of the blad-
der, and must occasionally be removed during the examination. Any simple
aspirating device, such as will occur to the mind of any practical surgeon, may
be used for keeping the bladder dry during the examination. A long, slender
pair of mouse-toothed forceps are used to hold bits of cotton or gauze and to



MKTIlohS OF RXAMINING THE KIKN'KV



.111



wipe away adherenl mucus, blood, or pus which may cover and obscure the
mucous membrane. A long, slender probe with a large handle benl to nearly
a right angle with the shaft of ili<' instrument i- convenient when searching
for the mouth of the ureter, although a slender metal ureteral catheter may
lie used for the same purpose. Tin- metal ureteral
catheter is twelve inches in length, slightly curved near
its blunt point, corresponds in tin- middle "t its shafl
to the diameter of a No. 7 ~<>und <>f the French scale
( -J mm. in diameter), and jusl behind i'- tip r., a X... t.
There are three small eves near the tip of the catheter.
This instrument is often exceedingly useful, ami may
be made to engage in a ureteral orifice which is -trie-



T-



I'n,. 82.— Kelly's Tube for Examin-
ing ihk Interior <>?- the Female
Bladder and Catheterizinq the
Ureter.




Li



Fig. SI. — L.ONG AND SLENDER MotTSE-

rooTHED Forceps for Holding

PlEDQI re i >r COT I '< IN OH GA1 ' I

Used n> Wipe aww Pus, Blood,

OR< Mm R M \ P] RIAl WHIl bCaTHI -

TERIZING nil I'ki rERSOF nil I l -

m m i throvoh Kelly's Tubes.
(Kelly.)



tured, or may be used to dilate
the ureter at a higher point when
a silk instrument might fail to
pass. It is convenient to have
one or more of these catheters
constructed of some flexible met-
al, such as tin. Solid ureteral
bougies, 2 mm. in diameter, hav-
ing a blunt point constructed
either of flexible metal or of
hard rubber, are sometimes useful in detecting the
presence of stone in the ureter or for dilating a stric-
ture. The metal ones arc usually made twelve
inches in length with an enlarged handle; the
long ones for passing up to the kidney are
made twenty inches in length. For the pur-
pose of detecting stone these bougies may be
tipped with wax. so that the contact with the

stone will make scratch marks upon the sur-
face of the wax visible when the bougie is
withdrawn.



342 THE KIDNEY AND URETER

For dilating strictures of the ureter Kelly also uses dilating catheters
of metal ten inches in length, in sizes from 2^ to 6 mm. in diameter. The
metal catheters are conveniently constructed, like a Thompson's searcher, with
a flat surface on the handle, indicating the direction of the tip of the catheter,
ending in a small, curved tube, Avith a little metal plug, such that the flow of
urine from the ureter may he stopped temporarily if desired. In inspecting the
interior of the bladder or catheterizing the ureters of the female by Kelly's
method, the patient should be prepared by a thorough evacuation of the bowels,
the external genitals should be thoroughly cleaned and disinfected, as for a
surgical operation. The patient should empty her own bladder in the squatting
or sitting position immediately before the examination.

In very nervous patients, in young girls, in case the operator is inexperi-
enced, or where the urethra appears very narrow and to require considerable
dilatation, the examination may be under a general anesthetic. The applica-
tion of a ten-per-cent cocain solution, introduced into the urethra by means of
Ultzmann's drop syringe, followed by the introduction of a pledget of cotton
into the urethral orifice, saturated with the same solution, and left in place
ten minutes before the examination is made, is usually sufficient to prevent
undue pain and suffering. One of two positions may be chosen for the exami-
nation, according to the peculiarities of the individual case: If the patient



Fig. 83. — Ureteral, Probe for Sounding the Ureter in the Female. (Kelly.)

is distinctly stout, the knee-chest position will usually be necessary;
otherwise the bladder will not properly distend with air. If the patiei
is thin, the lithotomy position, with the buttocks elevated from ten
twelve inches above the surface of the examining table, by means of i
able cushions or by tilting the table to a sufficient degree, will give sufficient
distention of the bladder. In either of these positions, if the patient is prop-
erly placed, the abdominal viscera tend to gravitate toward the diaphragm, and
after the speculum is introduced into the urethra and the obturator withdrawn,
the bladder distends with air by atmospheric pressure.

Kelly recommends that if the bladder does not distend, and if the pa-
tient is unable to stand the fatigue and the discomfort of an examination in
the knee-chest position for a considerable time, first placing her in the knee-
chest position, introducing a small speculum, so that the bladder distends with
air, withdrawing the speculum, turning the patient over into the dorsal posi-
tion, and then making the examination. It is desirable during the change of
posture to keep the hips elevated. The knee-chest position is the one which
renders the examination easiest for the surgeon, and insures the distention of
the bladder with air. The patient may be held in this position by assistants,
the most comfortable way, or if she bo under a general anesthetic a suitable




METHODS OF EXAMINING THE KIDNEY



343



harness attached to uprights al the fool of the operating table Bupporte the
abdomen and the buttocks respectively, h is importanl i" keep the buttocks
as high as possible, and the head and face as rial upon the table a- may be.
The Burgeon then proceeds with the examination, using all aseptic precautions,
such as would be used in a surgical operation: Sterilized instruments, sterile
rubber gloves, etc Lubrichondrin, " K Y" or Bome other [celand-moss prepa-
ration, sterilized, is the besl Lubricant for the instruments. In mosl cases
before introducing the speculum it will be necessary to dilate the urethral ori-
fice with the conical dilator. This is the narrowest part of the female urethra.

The remaining portion usu-
ally dilates very readily, and
the urinary meatus once passed
the speculum glides easily into
the bladder. The conical di-
lator is introduced gently into
the urethra, and its caliber
noted. In sonic instances the
instrument passes in readily
to a diameter of 8 or 9 mm.,
and in these cases no further
dilatation is necessary. In