METHODS OF EXAMINING THE FEMALE URINARY ORGANS.
The female bladder, urethra, and ureters are open to investigations by three principal methods : (1) by the examination of the secre tions; (2) by palpation; (3) by inspection.
1. Examination of the Secretions.—The methods employed in the examination of secretions relate to the various chemical changes in the urine, such as increased acidity and marked oxaluria, having an irritating effect upon the bladder walls and the ureters, and alkalinity of the urine with decomposition and the formation of ammonia salts and deposits of phosphates. The presence of more or less mucus in the urine is also an important evidence of the existence of inflammation. Blood is significant either of disease of the kidneys, or of some abrasion or neoplasm within the bladder itself. Various inflammatory affections are caused by the presence of gonococci, staphylococci, streptococci, tubercle bacilli, and the colon bacillus.
Bits of tissue in the urine, such as epithelial cells, little pieces of tumors, etc., are indicative of inflammation and neoplasms. These considerations, which might be greatly amplified, apply equally to the male urinary organs, and belong more to a general than to the special consideration of the subject which we have undertaken.
2. Palpation.—Much valuable information can be gained in dis eases of the urethra, bladder, and ureters by the sense of touch alone. An investigation of the parts with the index finger, if the tactile sense is not blunted, reveals to us a normal as contrasted with a .patulous urethral orifice. In one of my cases, at the first examination my assistant passed the finger directly into the bladder without the slightest resistance, discovering in this way an extreme relaxation due to coitus per urethram. The finger will also detect a rolling out of the urethra, a dropping of the bladder, or a pro lapse in which the bladder forms part of the sac; sensitiveness of the base of the bladder, and more especially around its neck, may also be detected in this way. About half-way up the vagina, and curving out from the base of the bladder toward the posterior and lateral pelvic walls, in the direction of the cervix uteri, the finger will detect a flattened cord-like body which can be traced for about 10 cm. (4 in.)
of its course, losing itself behind the cervix; this is the right or left ureter.
If the ureter cannot be readily felt and hooked down by the end of the finger in this way, it will be detected upon displacing the va ginal wall upward and outward until the end of the finger touches the lateral wall of the pelvis just below the superior strait. The fin ger is then drawn downward and backward, stroking the pelvic walls and carefully estimating the size and consistency of each structure touched. As soon as the observer thinks he has felt the ureter, he catches the cord again with the hooked finger, draws it down a little, and slides the finger along it toward the bladder, where it is felt leaving the pelvic wall, as it passes toward the base. It can be caught again and traced back until it loses itself alongside the cervix. About 8 cm. (3 in.) of the ureter can be felt in this way. It is never hard like a whipcord or a goose-quill, except under pathological conditions ; it is rather a soft, flat, yielding band. In some cases, instead of lying close to the pelvic wall, it is farther out in the cellu lar tissue and is then not so easily felt with one hand.
In the later months of pregnancy, the ureter is often felt with re markable distinctness against the head of the child. It appears then to be larger and of firmer consistency than at other times.
The examiner must avoid mistaking the upper margin of the levator ani muscle, the obturator nerve or artery, or the edge of the obturator foramen for the ureter.
That portion of the ureter which lies in the posterior part of the pelvis can often be felt from the rectum. It is particularly accessible to touch when enlarged by disease. The normal ureter can always be felt here when a bougie or catheter is introduced through the urethra into the ureter as far as the brim of the pelvis. The land mark in the rectum is the internal iliac artery, close to which the ureter lies on one side or the other during the first part of its course. By these means, it will be seen that the whole of the pelvic portion of the ureter is accessible to touch.