those cases in which it appears as a mere slit in the vesical mucosa. Quite the contrary is true in the free-hand catheter

ARNOLD

SONS, BALTO.

ization of the ure

ter by Pawlik's method.

A valuable aid for the beginner searching for the ureteral orifice is

FARNOLD & SONS, BALTO

FIG. 8.-Speculum and obturator (two-thirds natural size).

the following: A point is marked on the cystoscope five and a half centimetres from the vesical end, and from this point

FIG. 9.-Direct inspection of bladder by reflected light; electric bulb with reflector held above symphysis pubis; hips in moderate elevation.

two diverging lines are drawn toward the handle with an angle of sixty degrees between them (Fig. 13). The speculum is.

introduced up to the point of the V, and turned to right or left until one side of the V is in line with the axis of the body; then by elevating the endoscope until it touches the floor of the bladder the ureteral orifice will usually be found within the area covered by the orifice of the speculum. The ureteral orifice can often be found by an adept at once, and almost instinctively, by a single movement of the speculum after its introduction into the bladder.

In order to ascertain whether it is the ureter which lies within the field, I use as a searcher (Fig. 14) a long, delicate sound with a handle bent at an angle of 120°, which is introduced through the speculum into the suspected ureteral orifice (Fig.

FIG. 10.-Suction apparatus (three-fourths natural size) used for withdrawing residual urine.

ureter, and the lateral walls of the orifice are slightly raised, appearing as distinct folds with a dark pit between them. The searcher may be withdrawn and a ureteral catheter at once introduced, if it is desirable to collect the urine direct from the kidney. The ureteral catheters which I use for direct catheterization are quite different from those heretofore employed. They are straighter, and either have no handle or only a small one which will readily pass through the No. 10 speculum (Figs. 16, 17, 18). The catheter may be left in place some minutes or an hour or more. The urine which accumulates in the meantime in the bladder necessarily represents the discharge of the opposite kidney; in this way the urine of both kidneys may be isolated by simply introducing one catheter.

By placing the patient in the genu-facial posture (Fig. 19) an

extreme distention of the bladder is obtained in the form of a flattened ovoid. In this posture the interureteric ligament also comes sharply into view, but the ureters are not so readily seen, as they are concealed by the outer extremities of the fold. The genu-facial posture is indispensable in some inflammatory cases when the bladder will not balloon out in the ordinary posture owing to its thickened walls. A satisfactory inspection can also be made in many cases in the left semi-prone position by elevating the pelvis on a pillow.

Simple Direct Catheterization without Elevation. -After some practice it is possible even to catheterize the ureters with the patient simply in the dorsal position without elevation of the pelvis. The success of such an attempt depends upon the examiner's familiarity with the position and appearance of the ureteral orifice on the posterior wall of the bladder. The manipulation necessary to expose the ureteral orifice becomes with practice almost instinctive. The bladder is emptied by catheter, the ureter is dilated, and the speculum, No. 10 or 12, introduced from five and a half to six centimetres, and its outer end elevated until the base of the bladder appears, when it is turned thirty degrees to the right or left, and with a little patience in searching the ureteral orifice is found. To prevent the residual urine from obscuring the field the speculum is gently pressed against the mucous membrane; it is then only necessary to take up the urine with pledgets of cotton as it flows from the ureter into the speculum.

An anesthetic is not necessary for cystoscopy or catheterization of the ureters, unless the urethra is to be dilated up to No. 14, 15, or 16. In nervous women it is often best to make a thorough examination first under anesthesia. Subsequently a satisfactory illumination of the bladder can be made, and the ureters catheterized and any ordinary treatment readily applied through the No. 10 ed forceps (threespeculum without anesthesia. I have succeeded

FIG. 11. Delicate mouse-tooth

fourths natural size).

repeatedly in passing the No. 12 speculum in nervous women

FIG. 12.-Speculum inclined 30° to left, exposing right ureter, searcher being introduced.

without causing marked discomfort. Anesthesia will be em

5.5cm

FIG. 13.-Speculum marked for finding ureter automatically.

ployed less frequently as the examiner gains skill and confidence.

in manipulating the instruments. A pledget of cotton saturated with a five-per-cent cocaine solution, inserted into the urethra

seven minutes beforehand, greatly facilitates the dilatation and is often the best form of anesthesia.

Four specula, Nos. 8, 10, 12, and 14, and dilators Nos. 7 and 8, 9 and 10, 11 and 12, 13 and 14, 15 and 16, mousetoothed forceps, aluminum applicator, ureteral searcher, and one ureteral catheter are practically the only instruments required for general purposes of diagnosis and treatment.

FIG. 15.-Left ureteral orifice exposed and searcher engaged.

A wide field is opened to the gynecologist by these simple means of diagnosis and treatment. It is an enormous stride forward to be able to expose all parts of the bladder walls so