I have twice been able to palpate with perfect distinctness the normal ureter through the abdominal walls, for a short distance up ward from the brim of the pelvis. Both of these cases were women who had just been confined, and the abdominal walls were lax and the recti muscles separated. Not infrequently a ureter enlarged by disease can be detected as a round cord through the abdominal walls. Almost always in ureteral inflammatory disease, marked tenderness can be elicited on pressure at points about 3 cm. (1 in.) to the right and left of the promontory of the sacrum, which is first located by deep palpation. By a bimanual examination, with one or two fingers in the vagina, and one hand pressing down into the pelvis from above, the ureters can always be found, even when it has not been possible to locate them with one finger in the vagina as described. The object of the hand above is twofold, to displace the ureter slightly down ward, making it more accessible to the vaginal finger, and to keep up an even pressure affording a plane of resistance against which the ureter can be palpated.
Another method of palpating the bladder, much in vogue in the early part of this century and up to within a few years ago, is the examination by means of a finger introduced into the bladder through the dilated urethra, or through an incision in the base of the bladder from the vagina. The details of this method need not be dwelt upon, as the perfect means of investigation now at our command enable us to dispense entirely with a procedure so distressing and fraught with ill consequences to the patient. Many of the victims of this mode of examination suffered afterward from a life-long incontinence.
Lastly, a mode of palpation of some value in a preliminary in vestigation is the sense of touch conveyed by a sound introduced into the bladder through the urethra, striking a stone or coming in contact with a tumor, or rugous surfaces of the bladder. Hemor rhage thus easily excited is significant of an inflammation or new growth.
3. inspection is the method which yields the most immediate and positive results in examining the bladder and urethra for diagnostic purposes.
Inspection is able to teach us much about the bladder and ure thra, even when confined to the external parts. By inspection of the external urethral orifice, we can determine its integrity or diseased condition, and in the latter case often see the mouths of the urethral tubules. Conditions of hyperininia, inflammation, and caruucles are at once visible. Pus will sometimes be seen exuding from the ure thral orifice. A displacement of the urethra downward and outward with the vaginal wall is evident. The displacement of the bladder together with the anterior vaginal wall, known as cystocele, and the more marked displacement of a diverticulum of the bladder into a prolapses sac, are also easily determined by inspection. The long
ovoid, over-distended bladder pushing out the lower abdominal wall has a characteristic appearance. Since I propose to describe a new method of inspection which I consider superior to all its predeces sors and free from their difficulties and dangers, I feel it necessary to premise my description with a brief consideration of the various other methods employed. I shall also show that by the same means by which we inspect the bladder and urethra, we are able to treat their affections topically.
For the inspection of the interior mucous surface of the bladder some seven methods, more or less widely differing from one another, have been proposed.
Professor G. Simon, of Heidelberg, examined the parts of the bladder which came into contact with the end of a straight speculum and covered its lumen. By sliding the speculum about, different parts of the bladder came into view. He estimates the value of endoscopy in these words : " The value of this procedure is much less than by palpation, as one can never illuminate more than a small area of the bladder, and thus only by chance discover papillary enlargements, ulcers, etc." As to the discovery of the ureteral orifics by such a means, he says, " Even with the magnesium light we have endeavored in vain to discover the ureteral orifice. Endoscopy is useful in illuminating all points that have been discovered by touch, and for the illumination of small areas is of great service in the female, as well as in the male." Simon speaks of the practical results of his method of catheteriz ing the ureters in these terms : "As to the assurance of being able to introduce a sound or catheter—in my practice on corpses and the seventeen attempts on living subjects, I have not succeeded in per fecting my method to such an extent that I can feel confident of in troducing the sound into the ureter at every sitting, but I believe I could do it in the majority of cases. I have had no opportunity to catheterize the ureter in disease." Dr. Skene, of Brooklyn, examined the bladder through a specu lum carrying a test-tube. Inside of this again a thin silver plate the length of the tube, and occupying about one-third of its circumfer ence, was introduced. At the end of this plate a mirror was attached at an angle of about 100 degrees, and at the outer end a delicate handle projecting at an obtuse angle. By moving the mirror back ward and forward and turning it around when the tube was intro duced into the bladder and urethra, various portions of the mucous surface are brought into view, light being thrown into the tube by the aid of a concave mirror. Skene sometimes used sunlight, but on account of its uncertainty preferred gaslight, taking his illumination from a gas-bracket having a universal movement.