EXAMINATION OF THE URETERS. 
BY 
HOWARD A. KELLY, M.D., 
ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OP PENNSYLVANIA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN GYNECOLOGICAL SOCIETY, 
YOL. XIII. 1888. 
PHILADE LT HI AT 
WM. J. DOMAN, PRINTER. 
1888. PALPATION OF THE URETERS IN THE 
FEMALE. 
By Howard A. Kelly, M.D., 
Philadelphia. 
By palpation of the ureters the gynecologist has at his 
command a new and valuable adjuvant in the correct diagnosis 
of renal and bladder diseases and their sequelae, as well as 
the possibility of recognizing intrinsic diseases of the ureters 
hitherto only discovered on the post-mortem table. Such is 
the specialization of specialties, that I have been asked by 
surgeons if the ureters are prone to disease of any sort or 
variety. It is but necessary to consult the works of Rayer, 
Cruveilhier, and others on renal diseases, and especially the 
plates of the former, to recognize at once the extent to which 
the ureters are often associated with the kidneys, participating 
in processes of inflammation, ulceration, and tuberculosis. 
Here invariably the ureteral disease is secondary, descending, 
and the condition of the ureters discovered by a vaginal 
examination may be the first clear point in determining the 
nature of the disease above, and the only possible means, short 
of operation, of determining on which side the disease exists. 
Again, inflammatory diseases of the bladder, particularly gon- 
orrhoeal, often have a fatal tendency to travel upward, result- 
ing in pyelitis and pyelo-nephritis. Here the affection of the 
ureter invariably precedes that of its pelvis and the kidney, 
and may at once put a careful observer on his guard as to 
possible consequences, even of an apparently mild inflammation. 
Calculus resting in the pelvis of the kidney or lodged in the 
ureter, occasions an inflammatory condition of the whole of 
the tract below, easily distinguished by palpation. 4 
PALPATION OF URETERS IN THE FEMALE. 
When we recall the immense quantities of excrement dis- 
charged daily through these delicate tubes, from two organs 
absolutely essential to life, one or other of which may be dis- 
eased, or both in different degrees, and associate with this the 
anatomical relation of the pelvic portion of the ureter in the 
female, placing it within easy reach of the examining finger, 
we see at once the importance of a careful routine consideration 
of their condition and function in every case coming under 
observation. It is but necessary to bear in mind the cases of 
hydro-nephrosis which have been caused by pressure of uter- 
ine tumors, ovarian tumors, retroflexion, and even prolapsus 
uteri, and the constriction of parametric scars, caused also in 
one case by a retroperitoneal sarcoma observed by the writer, 
and to remember the possible effects of pressure by the gravid 
uterus, as well as the large number of cases of carcinoma uteri 
which die of uraemic coma, from involvement and obstruction 
of the ureters, not to cite cases in which the ureters have been 
tied in enucleating the cancerous uterus per vaginam, as com- 
municated to me by Dr. H. C. Coe, and observed by others, 
as well as cases in which a ureter has been cut in opening a 
pelvic abscess, to realize the clinical importance of ureteral 
pathology. I may also here mention the fatal results which 
have followed the neglect of Dr. Emmet’s precaution, in the 
operation of vesico-vagiual fistule, of rolling out the edges and 
hunting for the ureteral orifices, a neglect which has in many 
instances resulted in death and in more in a failure in the 
operation. This brief statement of the important facts serves 
to show how extended a field is here open for the gynecologist, 
connecting him often with practical medicine, just as the 
abdominal surgery of to-day closely links his work with that 
of the general surgeon. In fact, with a more careful study 
of bladder troubles, now the bete noir of gynecology, with a 
differentiation of bladder and ureteral diseases up to this time 
impossible, and with an association of a careful study of renal 
diseases as connected with or to be disassociated from the last, 
a new realm seems to be opening to the scientific gynecologist. HOWARD A. KELLY. 
5 
Methods of Examination.—The ureters can be 
examined in several ways : 
inspection. 
catheterization. 
By palpation, or by either or all three methods 
combined. 
Inspection is the method proposed by Dr. T. 
Emmet, and is conducted by splitting the vesico- 
vaginal septum and everting the edges of the wound 
until the ureteral orifices are exposed, when the 
ureters may also be catheterized, and their secretions 
compared. This method resembles the practice of 
introducing a catheter into the exposed orifices of the 
ureters in the margin of a vesico-vagiual fistule. It 
is one of value in serious cases warranting operative 
interference; nor is the operation, skilfully conducted, 
to be estimated as in any way grave. The edges of 
the incisions can be brought together after the ex- 
amination and the wound healed at once. Griinfeld 
attempted to reach the same result by means of a 
catheter attached to an endoscope, introduced per 
urethram and carried thus into the ureter under con- 
trol of the eye, while G. Simon gave great impulse 
to the whole subject of catheterization by his well- 
known paper, “ Ueber die Sondirung des Harnleiters 
beim Wei be.” His method, in brief, was to cut the 
tight external orifice of the urethra, to dilate the canal 
by a series of plugs, slowly and carefully introduced, 
until it would admit the index finger (his finger 
measured almost six centimetres in circumference), 
which sought out the little ureteral prominence in 
the bladder, and thus guided a catheter or sound in- 
troduced alongside the finger into the ureter. This 
method I have practised for the sake of estimating 
its value. It is too circumstantial to be of any 
general applicability, and, owing to the varying 
sizes of index fingers, one of considerable danger; 6 
PALPATION OF URETERS IN THE FEMALE. 
in addition to which is the fact that in the very cases it is 
most desirable to catheterize, the ureteral orifices are often 
most difficult or even impossible to find. The method of 
Prof. Karl Pawlik, of Prag, of catheterizing the ureters free- 
handed, without preliminary preparation of the patient, be- 
yond the occasioual distention of the bladder with a bland 
fluid, is the one deserving most attention. This method I 
have both practised and seen at the hands of Prof. Pawlik 
during the past summer. The patient is placed in the dorsal 
position, with legs strongly flexed on the abdomen, and a 
Simon or Sims’s speculum introduced retracting the posterior 
vaginal wail. The eye at once observes a series of divergent 
folds starting just back of the neck of the bladder and sweep- 
ing laterally and back toward the cervix uteri, corresponding 
very closely at their point of union to the inter-ureteric ligament, 
and following in general outline the course of the ureters. A 
delicate catheter, of which the cut is here shown, loaned me 
by Prof. Pawlik, or one similar to that exhibited here, which 
I have used myself, is then carried into the bladder, distended 
with about four ounces of urine, and poised between thumb and 
index finger. The position of the end of the catheter is plainly 
noted by the eye observing its movements in the vagina as the 
point sweeps gently along the floor of the bladder. The ureteral 
orifice is to be sought for about an inch back of the neck of the 
bladder, and about a half or three-quarters of an inch from the 
median line on either side. This position of the ureter, how- 
ever, is not constant, and cannot be relied upon alone. Far 
more characteristic is the slight tripping sensation given to the 
point of the catheter as it glides over the ureteral prominence. 
As soon as this sensation is perceived, the catheter must be at 
once brought back to the place where it was felt, and gentle 
attempts made to engage its point by repeatedly carrying the 
handle upward and outward, and the point consequently in 
the opposite direction. Once caught, the catheter sweeps 
readily in, and if lightly held directs its own course, the 
fingers simply following. It thus passes some distance un- HOWARD A. KELLY. 
7 
restrainedly, parallel to the pelvic wall, and the eye observes 
the anterior vaginal wall being lifted up in advance and to 
one side of the cervix, forming a distinct pocket on the side 
on which the ureter is catheterized. This is a point to which 
my attention was specially called by Prof. Pawlik. 
On withdrawing the stopper in the end of the catheter, a 
few drops of urine run out, when the flow ceases; after a few 
seconds a few more drops run out and then cease, keeping up 
in this way an intermittent discharge entirely characteristic. 
The catheter cannot with safety be pushed beyond the brim of 
the pelvis. On withdrawing it the sudden drop of the anterior 
vaginal wall is very characteristic. I have found, as Pawlik 
states, that very slight force in the cadaver is apt to make false 
pockets in the mucosa of the bladder. This was especially 
marked in a subject upon which I experimented this summer 
in Prof, Virchow’s laboratory. The ureters were displaced 
backward to an extreme degree, and, in spite of the fact that I 
knew exactly where they were, and the catheter would con- 
stantly glide over the orifices, it was almost impossible to 
introduce it. I have at other times succeeded in introducing; 
c 5 
it at the very first attempt, and yesterday morning in my 
office catheterized the right ureter of a patient who did not 
know that I was doing more than making an ordinary vaginal 
examination. I have made a change in Pawlik’s catheter, 
substituting a series of holes for the long fenestrum, which 
caught and cut the mucous membrane of the urethra in intro- 
ducing it into the bladder. 
Palpation of the Ureters. 
Since a visit made to Dr. M. Sanger, of Leipzig, in 1886, 
when he demonstrated the possibility and the practicability of 
palpating the female ureters in their lower pelvic portion, it 
has been my routine practice to examine the ureters in all 
gynecological cases coming to me for treatment, and in my 
case-book I have a printed form, in which any deviation from 
the normal is noted under the heading “ ureters.” When 8 
PALPATION OF URETERS IN THE FEMALE. 
there is no disease, both ureters can usually be felt with 
facility, as more or less flat cords about three millimetres 
in diameter, movable to an extent of one or two centi- 
metres, in the loose pelvic connective tissue. One or both 
hands may be used in palpating, the right hand inside most 
readily finding the right, and the left hand the left ureter. 
Method.—The finger is passed into the vagina behind the 
internal orifice of the urethra, at the end of the rugose pro- 
montory on the anterior vaginal wall, and carried with some 
exertion up toward the brim of the pelvis, displacing the 
vaginal wall upward and outward until the pulp of the finger 
reaches the highest point it can touch, often as high as the 
brim, but varying according to the greater or less laxity of 
the tissues and their fixation by pelvic pathological processes. 
It is then carried downward, stroking the pelvic wall, care- 
fully estimating the character of all structures felt rolling 
under it. As soon as the observer thinks he has felt a ureter, 
he catches the cord again with the hooked finger and pulls it 
down a little, and then slides the finger first toward the blad- 
der, where the ureter is felt to lose itself at the trigonum, 
and then backward, where it loses itself sweeping around 
the cervix. I have found that in a certain number of cases 
the ureter can be felt most distinctly in this position just in 
advance of the cervix, by placing the patient on her left or 
right side, when the vagina balloons out and applies itself closely 
to that side of the pelvic wall which lies undermost; here 
the ureter can, by a slight effort displacing the vaginal vault 
upward, be hooked and brought down under the finger, felt 
with the utmost distinctness, and compressed. 
Bimanual Palpation.—l found after examining a certain 
number of cases in which it was impossible to displace the 
vagina sufficiently to feel the ureter against the pelvic wall, or 
to feel the ureter with one hand lying like a cord in the connec- 
tive tissue alongside the vagina, it was still possible to outline 
its whole course with distinctness by a bimanual examination, 
when it could be picked up between the tips of two fingers, HOWARD A. KELLY. 
9 
and traced from cervix to bladder. In speaking of this to 
Dr. Sanger this summer, he called my attention to the fact 
that he had mentioned the bimanual examination, and stated 
that he was daily more fully appreciating its possibilities. 
The best position to feel for the ureters at the beginning of 
the bimanual examination is in the oblique diameters of the 
pelvis, bringing the tips of the fingers as closely as possible 
together, and rolling them to and fro, keeping near the pelvic 
wall, watching for the characteristic sensation, when the cord 
may be traced in either direction. In late pregnancy the 
ureters are especially distinct, and seem often to be enlarged. 
Under favorable circumstances, a thickened ureter can be felt 
through thin abdominal walls as it leaves the pelvis and 
crosses the brim. 
The following brief notes are a series of cases from a general 
gynecological practice in which I jotted down in ray case-book 
a statement as to the condition of one or other ureter : 
S. I). Chronic gonorrhoea. Left ureter distinctly felt as a 
tense painful cord, exciting ardor urines on pressure. 
M. R. Five months pregnant; ureter distinctly enlarged, felt 
best close to cervix. 
M. G. Prolapsus uteri. Ureters felt in dorsal position; in 
left lateral position left ureter distinctly felt after crowding vagina 
high up and hooking it down on finger; obturator artery felt 
parallel to course of ureter. 
M. W., very stout woman. Ureters felt with difficulty in the 
dorsal position; fibres of obturator muscle easily to be mistaken 
for ureter; in semiprone position, left ureter brought down and 
felt with ease. 
M. D. Appendages removed; left ureter not felt, owing to 
fixation of vaginal wall on that side; right felt with ease. 
Illegitimate pregnancy, three months. Ureters not enlarged, felt 
distinctly, best bimanually, in loose connective tissue. 
M. G. Severe ardor urinse; cannot feel ureter; mistook sharp 
border of obturator foramen for ureter. 
M. F. Cannot feel ureter with unaided vaginal hand; bimanu- 10 
PALPATION OF URETERS IN THE FEMALE. 
ally felt distinctly in loose connective tissue at a distance of four 
centimetres behind pubis, and traced around toward cervix. 
M. C., three months pregnant; ureter only to be felt bimanu- 
ally, not enlarged, but distinct, and cord-like. 
M. McC. Ureter felt distinctly in left lateral position; not 
felt in dorsal position. 
M. C. Ureters felt doubtfully; sharp line of fascial origin of 
levator ani readily taken for a ureter. 
M. A. Dorsal posture, ureter felt as large as little finger, 
exquisitely sensitive; not so well felt in lateral posture. 
E. S. Ureters distinct, firm cords from bladder to cervix ; 
d.esire to urinate on pressing on them. 
M. U. Gonorrhoeal cystitis. Right ureter sensitive. 
M. O. Large and stout woman. Ureters felt doubtfully. 
M. T. Ureters flat bands ; parallel to origin of levator fibres 
and obturator artery. 
M. P. Bright’s disease. Retroflexion; ureters remarkably 
distinct, cord-like. 
M. S. Puerperal fever. Left ureter very large and distinct. 
M. R. Left ureter felt by hooking finger up and under left 
pubic bone; it cannot, however, be pressed against the pelvic 
wall; felt more distinctly bimanually with the left forefinger 
close to the left side of the cervix, and the right hand meeting 
it through the abdominal wall; the tissues glide from under the 
hands as they are brought forward until the ureter slips like a 
tense whip-cord; this lies at least one and a half centimetres 
from and parallel to the pelvic wall in the connective tissue. 
M. A. Ureter felt distinctly as it courses high up under the 
upper margin of the obturator foramen, and then sweeps down 
toward the cervix, 
M. G. Ureters distinct throughout their course ; particularly 
distinct in fornix by cervix. 
F. B. Left ureter as large as quill; very tender, and produces 
intense desire to urinate on pressure. 
M. McF., ten months pregnant; left ureter large as goose-quill. 
The ureter must be felt distinctly and its course traced, to 
determine with certainty its identity. It may be mistaken 
for the obturator artery, the obturator nerve, which is some- HOWARD A. KELLY. 
11 
times very distinctly felt, the upper margin of the obturator 
foramen, the line of origin of the levator ani muscle, bundles of 
fibres of these muscles, notwithstanding their different course, 
and bundles of connective tissue. While the ureters cannot 
be discovered in all cases, with perseverance and practice a 
marvellous facility will be developed for their detection. 
With this brief summary of the methods of examination, 
particularly of palpation of the ureters in the ordinary cases 
as they mount the gynecological table, I will close by citing 
four cases in which the patients had been sufferers for years 
from disease of the ureters, and under the most varied kinds 
of treatment for bladder and uterine diseases which never 
existed. Two had had severe operations upon the bladder 
for cystitis; in all, I found nothing more than an inflamma- 
tory condition of the pelvic ends of the ureters—a ureteritis. 
Case I. Ureteritis.—Mrs. W. came to me in 1886, aged 
twenty-eight years; has had two children, six and four years 
ago. First labor instrumental; second natural and easy. 
Recovery after last rapid, until three weeks post-partum, when 
she lifted a heavy wash-boiler from the stove to the floor. She 
felt something snap inside, and was unable to straighten her- 
self, feeling at once an intense desire to urinate; she managed 
to crawl to the closet, where she remained some hours strain- 
ing in a vain effort to pass water. She succeeded finally in 
forcing out only a few drops. Since that time, four years ago, 
she has never urinated easily, but has remained a confirmed 
invalid, suffering from a constant ardor urinse, which it is 
impossible to quench, and a dribbling which keeps her person 
wet and odorous, rendering it impossible for her to assume the 
care of any duties, beyond the constant necessary attention to 
her person. She had been treated continuously ever since the 
accident for various bladder diseases. I found the bladder per- 
fectly free from disease, and after removing- a large dermoid cyst, 
performed Dr. Emmet’s buttonhole operation, under the false 
impression that the trouble might be due to some traction at the 
neck of the bladder, teasing it. Shortly after this I discovered 
that the whole difficulty lay in the ureters, that both ureters 12 
PALPATION OF URETERS IN THE FEMALE. 
were enlarged to the thickness of my little finger and exquisitely 
tender. The least impression made her cry out with pain and 
an irresistible desire to urinate, which she did upon my exam- 
ining hand. The course of the ureters was similar to that of the 
normal, sweeping in a well-marked curve from the base of the 
bladder, behind the pubis, outward to the pelvic wall, skirting 
this in a gentle curve downward to the cervix uteri, behind which 
they rose to disappear from the examining finger. 
Case 11. Ureteritis.—Sarah McK., aged twenty-eight years, 
single, virgin ; was regular in all her functions until nine years 
ago, while in Ireland, at work on a hand-loom, when she began 
to have a desire to go more frequently to urinate. For a year 
this continued, growing worse, until the desire became almost 
constant. This continued eight years without pain, during 
which time she had taken work as a waitress. She then began 
having pains down the bladder, which she described as “jagging.” 
She was obliged at this time to rise three or four times in the 
night, at well as to go almost incessantly throughout the day. 
From this beginning the pain has always continued, increasing 
in severity, until it has finally assumed a darting, stabbing char- 
acter, seeming to travel from the vagina upward. Besides these 
pains she had at intervals throughout the day distressing bearing- 
down feelings in the lower part of the abdomen. For five years 
she has never been a half hour on her feet without urinating; 
her greatest distress is in the left ovarian region ; the only relief 
experienced is for three or four minutes after passing water; lat- 
terly she cannot sleep more than half an hour without being 
called by a painful desire to micturate. She is pale and worn, 
with an anxious expression, and describes herself as utterly 
wretched. I found the urine clear, at times cloudy, but no evi- 
dence whatever of disease of the bladder; the left ureter was 
felt at a point three-quarters of an inch below the sharp upper 
margin of the pubic origin of the adductor, as she lay on her 
back, as a large, hard cord, so sensitive that she cried out on the 
least pressure; this grew larger and irregular in size as it swept 
around toward the cervix to lose itself behind the retroposed 
uterus. In this position, beside the cervix, the ureter was so 
large and tender, and so distinct to palpation, that it was mis- 
taken at first for an enlarged tender ovary. I opened the base HOWARD A. KELLY. 
13 
of the bladder a year ago, securing perfect relief; and she so 
much fears a return of the old symptoms that she prefers the 
discomforts of the fistule, and will not yet let me close it. 
Case 111. Ureteritis.—Mrs. C. is a mother of four children, 
the youngest six months old; her husband had gonorrhoea before 
marriage, but states he was well when married. When three 
months pregnant with her second child she had a violent cystitis, 
passing blood and pus from the bladder. A doctor dilated the 
urethra by introducing the linger, and since that time, in addition 
to her constant suffering, she has been unable to control her urine, 
which runs from her, soaking the bed to which she is confined. 
I find now no signs of any disease of the bladder, but on either 
side a ureter as large as a goose-quill, hard, and so tender to the 
touch that they cannot be thoroughly examined without an 
anaesthetic; the uterus is retroposed. 
Case IV.—Mrs. H., a widow, aged forty years, came to me in 
1886 with a statement that she had been for eleven years a suf- 
ferer from inflammation of the bladder. During the day she 
urinated every fifteen minutes to every half hour, and at night 
arose every hour. She had a haggard expression, and a trans- 
parent, waxy skin. She suffered constantly from a burning sen- 
sation in the lower abdomen, which was frequently aggravated 
by the great ease with which she took cold; she was always 
worse at the menstrual period. She had chills, which were fol- 
lowed by pains all through the lower part of the abdomen, after 
which the urine would, at times, stop flowing for several hours, 
and she felt as if the “ channel from the kidney to the bladder was 
closed.” At this time she would be consumed with a high fever, 
and a burning extending into the left hip bone; she suffered at 
the same time from palpitation and dyspnoea. Gradually under 
pressure of severe straining she would be able to pass a little 
urine by gushes and driblets, when the attack would wear off. 
I found the urine with a sediment, containing no pus and no 
albumen. The uterus lay retroposed, as in the other cases; 
resting in the sacral hollow, as if sitting in a rocking chair. The 
cervix lay one inch behind the pubis, and halfway between cervix 
and pubis on the left is the large, exquisitely tender ureter, 
moderately movable as it lies in the loose connective tissue of 14 
PALPATION OF URETERS IN THE FEMALE. 
the pelvis. Urine flows in gushes during the examination, as the 
desire on touching the ureters is so great she cannot control it. 
I performed the operation of hysterorrhaphy upon this 
patient, hoping that by taking the twist out of the tissue sur- 
rounding the cervix and by lifting the uterus up, a possible 
mechanical cause of the ureteral obstruction would be removed. 
Her condition after four months is marked improvement in 
the number of times she is obliged to urinate, especially at 
night, and considerable general improvement, but no change 
in the condition of the ureters as determined by vaginal touch. 
I have purposely refrained from attempting more in these 
cases than to point out the fact that many cases being treated 
for functional disease, irritable bladder, or even cystitis, are 
purely and simply diseased ureters, which can readily be 
detected by vaginal touch.