1 COLUMBIA LIBRARIES OFFSITE SBHtK^^i^^^^m^m^^mm^^m RC920 .L97 1918 A treatise of cystos H^^^^^^^^^M p^ p" A^ tk, ^^ ' "^HHhBbH '^, . 'i.t-','.JIEK, ASSj^AXT IX THE Df:PAKTMKXT OF URINARY DISEASES AT THE LARIBOISIERE IICaPITAL ; LAUREATE OF THE FACULTY OF THE ACADEMY OF MEDICINE. . TRANSLATED AND EDITED WITH ADDITIONS BY ABR. L. AVOLBARST, M.D., NEW YORK CYSTOSCOPIST, BETH ISRAEL HOSPITAL; CONSULTING UROLOGIST, CENTRAL ISLIP AND MANHATTAN STATE HOSPITALS ; GENITO-URINARY SURGEON, WEST SIDE GERMAN DISPENSARY AND HOSPITAL ; AUTHOR OF * ' GONORRHEA IN THE MALE, ' ' ETC. rVITH 217 FIGURES IN THE TEXT AND 24 CEEOMOTTrOGI^APniC PLATES OUT- SIDE THE TEXT, INCLUDING 76 DRAWINGS FPOM ORIGINAL WATER COLORS. ST. LOUIS C. A\ MOSBY COMPANY 1918 Copyright, 1918, By C. V. Mosby Company Press oi C. V. Mosby Company Sf. Louis PREFACE The iiii])()rtaiu'(' of ui-t'lJii-<-il ;iih1 vesical endoscopy is universally recognized. Physicians and surgeons are in constant need of the light shed by this science, which is one of the principal reasons for the existence of the modern urologist. But in order to apply the art skil- fully and thereby derive all the advantages it is able to offer, it is necessary to attain considerable practice and skill in urethroscopy and cystoscopy. Tlianks to the jDerfection of modern instruments, it is easy to obtain clear and distinct pictures; on the other hand, it is often dif- ficult to interpret the image which is presented, at first sight. For tliat reason, it is necessary to acquire considerable familiarity in j^rac- tical endoscopy, in order to attain that indispensable experience which gives one a mastery of the subject and the ability to make a correct diagnosis. This work is the result of fifteen years of practical endoscoi^y. Its object is to present to the medical profession the procedures and methods which have been so well perfected as to enable us to deter- mine the condition of the urethral and the bladder mucosa, and also of the ureters, pelves and kidneys. Its object is to meet the needs, not only of students, who must be guided gently step by step into this wonderful science, but also of those who, though quite familiar with the practice of cystoscop}" and urethroscopy, are not acquainted with all of its useful applications. Undoubtedly many urologists are thor- oughly acquainted with the ordinary urethroscopic an^l cystoscopic technic; nevertheless, there are but few who full>' realize all the ad- vantages that can be derived from the most recent progress in urothros- cop3^ and cystoscopy. It is the purpose of this work to illustrate and i)oi)ularize the science of direct vision cystoscoi)y and the marvelous ai)plications which it renders possible. The treatment of i)rostatic hypertr()i)liy endourethrally, the endovesical treatment of l)ladder tumors, the re- moval of foreign bodies from the bladder, and biopsy of the liladder, are just so many ccuupiests, as yet too little known, and Avhicli it is well to make known to the medical world. Since the onset of the present AVorld AVar, sclent ilic activity has 9 10 PREFACE diminished everywhere, owing to tlie more serious duties with which scientific men find themselves preoccupied. Doctor Wolbarst, of New York, who has undertaken to translate my work into English, and whom I have given sole authority, with the greatest pleasure, is perfectly qualified to do the subject justice: for the large experience which this well-known urologist has acquired in his specialty has fitted him perhaps better than anyone else to understand and interpret my work. It has been a great satisfaction to me to know that in the work that he has done he has almost always reached the same conclusions and found the same therapeutic indications as I have in my own practice. I am glad to state that this important translation which he has undertaken this year, has been brought up to date, and that the reader will find all the information necessary, not only as to the technic of cystoscopy and urethroscopy, but also in the therapeutic applications of these instruments. The book consists of six chapters. Urethral and vesical endos- copy are first studied historically and in a general way. This is fol- lowed by a chapter on urethroscopy proper, and another on the use of urethroscopy in catheterization of the ejaculatorj^ ducts and in the endoscopic treatment of prostatic hypertrophy. The remainder of the work, that is, its major portion, is devoted to the stud}^ of cystoscopy. Cystoscopy in general, jDrismatic (indirect) cystoscopy, and direct vision cystoscopy are considered, not so much from the instrumental standpoint, which would only constitute a tedious recital, as from the point of view of the practical results obtained with the use of these instruments. The chapter on the cystoscopic appearance of the nor- mal and pathologic bladder has been treated with special detail be- cause of its very great importance. Direct vision c^^stoscopy is de- scribed in all its details in the succeeding chapter. Further on, catheterization of the ureter w^ith its technic, its indi- cations, difficulties, and accidents is taken up fully; likewise the oppor- tunities offered by ureteral catheterization, such as the search for ureteral calculus, the treatment of renal colic, the exploration of the renal pelvis, the treatment of pyelitis by jDclvic lavage, also radiog- raphy and pyelography. The next chapter considers the practical applications of cystos- copy^; that is, the endovesical treatment of bladder tumors by gal- vanocauterization, the cold or hot snare, electrocoagulation, electrol- ysis and radium. PREFACE 11 The hist cliaiotcr is devoted to tlie treatment of foreign bodies in llie l)laddor and of the cystitos. Tliere is also a consideration of the instrumental exploration of the lower end of the ureter and of vesical biopsy. Particular attention has been given to the illustrations. The 247 illustrations in black together with the 24 colored plates appeal directly to the eye of the reader. In the study of endoscopy nothing is so im- l)ortant as to establish a clear, reliable picture in the mind's eye, so that the reader may remember it and be able to make a correct diag- nosis in cases occurring in his practice. AVith pleasure, I express to the publishers, Messrs. 0. Doin & Son, gratitude for the care they have exercised in the publication of this work; I also thank M. Dupret, draughtsman, for the consummate art, as well as the untiring patience, which he has been so good as to exhibit in the detailed endoscopic work which Avas entrusted to him. Georges Luys Paris, France. January, 1918 TRANSLATOR'S PREFACE Tliis Irniislation of Tjiiys' woi-k on "Cyslosc()i)y and Uretliros- copy" was undertaken with a twofold purpose in view: First, to l)rini;' to American and other English-speaking urologists the message which Luys' book bears; and secondly, to express in concrete form the love and affection which the translator feels for France. This work was undertaken, in the first weeks of the great "World War, — weeks in which the fate of glorious France and the rest of the civilized world hung in the balance. And when, as if by a miracle, Paris was saved and the invader's progress arrested at her very gates, and all lovers of France breathed once more, it seemed to be a sacred duty and a pleasure, as well, to bring this fine book by one of her greatest urologists within easy reach of his confreres in America. Lu3^s' work is frankly a plea in behalf of direct vision cystoscopy and urethroscop3^ In America this method has not received the wide- spread and almost universal welcome that has been accorded the indi- rect method. Nevertheless, whatever the reason may be, it is felt that American urologists will w^elcome this thorough exposition of the direct method, so that they may at least compare it with the method with which they are more familiar. Several features stand out strikingly in contrast with usual works of this kind: First, the extensive and illuminating historical data, showing the origin and development of cystoscopy and urethroscopy; secondly, the discussion of topics that are not strictly urologic, but closely affiliated, such as the sections on uterine cancer and pregnancy. The translator has striven faithfully to transpose the author's lyric French into plain English, — frankly, a difficult task. There is always a fear of failure to express the author's exact meaning; but the effort has been made honestly, and it is hoped, successfully. Xo attempt has l)iH'n nuuh' to alter the tyineal French character of the work. Whatever additions or amendments have been made, have lieen inserted either for the purpose of bringing the subject matter uj) to the minute, as it were, or in order to make the subject more practical for American readers. I would take advantage of this oj)portunity to thank Dr. William E. Ciould, and my staff assistant. Dr. S. Steiner, for valuable assistanc(^ 13 14 translator's preface rendered in the translation; also Dr. William F, Braascli, of the Mayo Clinic, for his fine little article on "Direct Cystoscopy;" and lastl}'^, but by no means least, The C. V. Mosby Company, that has undertaken the publication of the translation in this inauspicious time of high cost of production, simply, to use its own words, as its ' ' contribution to France." It is a jDleasure, as well as a privilege, to subscribe to that sentiment. Abr, L. Wolbarst New York City May, 1918. CONTENTS PAOK Chapter I. — History ok Ukk/i'iikai, a.\d Vksical Endoscopy 25 History of Eiidoscoj^y 25 History of Urethroscopy 27 Urethroscopes with External Ilhimination 27 Urethroscopes with Internal Illumination 36 Luys' Urethroscope 43 Urethroscopes for the Posterior Uretlira 47 History of Cystoscopy 54 History of Direct Vision Cystoscopy 50 Chapter II. — Urethroscopy 65 Technic of Urethroscopy 70 Contraindications to Urethroscopy 81 Urethroscopy of the Normal Urethra 82 Urethroscopy of the Pathologic Urethra 88 Urethroscopy in the Female 110 Chapter III. — Practical Application of Urethroscopy 115 Catheterization of the Ejaculatory Ducts 115 Eiidourethral Treatment of Prostatic Hypertrophy 135 Chapter IV. — Cystoscopy 139 .Anatomic Considerations 147 Ureteral Meatotomy 150 Ureteral Ejaculation 158 Errors in Cystoscopy 162 Dangers of Cystoscopy : 105 Vesical Phantoms 167 Chai'ter V. — PmsMATic (iKDUtEcr Vision) Cystoscopy IfiS Nitze 's Cystoscope 168 Modification of Nitze 's Cystoscope 172 Technic of Indirect Vision Cystoscopy ISl Diflficulties of Indirect Vision Cystoscopy 189 Normal Bladder as Viewed through the IiKliicd X'isimi Cystoscojie 198 Pathologic Bladder as Viewed tlirougli tlie liidiiect \'isi(iu ('yst()S(M)|H' 199 Acute Cystitis 199 Chronic Cystitis 200 Cystoscopy in Tumors of the BhuliiiT 205 Cystoscopy in Anomalies of the Biaddci- 20() Cystoscopy in Cancer of the Uterus 207 Cj'stoscopy in the Cancerous Biaddci- 20S 15 16 CONTENTS PAGE Chapter VI. — Direct Vision Cystoscopy 218 Conditions Necessary for Direct Vision Cystoscopy . 218 Description of Luys' Direct Vision Cystoseope 225 Teclmic of Direct Vision Cystoscoiay 229 Advantages of Direct Vision Cystoscopy in Examination of the Bladder 234 Objections to Direct Vision Cystoscopy 242 Comparative Eole of Indirect and Direct Vision Cystoscopy . . . 243 Direct Vision Cystoscopy During Pregnancy 248 Chapter VII. — Catheterization of the Ureters 254 Ureteral Catheterization with the Indirect Vision Cystoseope 254 Technic of Ureteral Catheterization with the Indirect Cystoseope 263 Ureteral Catheterization with the Direct Vision Cystoseope 267 Technic of Ureteral Catheterization with Luys' Cystoseope 269 Choice of Method in Ureteral Catheterization 285 Indications for Direct Cystoscopy in Ureteral Catheterization 285 Indications for Indirect Cystoscopy in Ureteral Catheterization 290 Difficulties, Accidents, and Errors in Ureteral Catheterization 291 Accidents Associated with Ureteral Catheterization 293 Errors Associated with Ureteral Catheterization 298 Ureteral Catheterization in Children 306 Chapter VIII. — Information Derived through Ureteral Catheterization .... 307 Exploration of the Ureter 307 Detection of Ureteral Calculi 307 Treatment of Nephritic Colic 312 Exploration of the Eenal Pelvis 313 Ureteral Catheterization in Kidney Function Tests 319 Treatment of Pyelitis by Pelvic Lavage 320 Ureteral Catheterization — a Demeure 324 Radiography of the Ureteral Catheter 326 Pyelography 326 Chapter IX. — Practical Applications of Cystoscopy 329 Treatment of Bladder Tumors 329 Endovesical Treatment of Bladder Tumors 330 Galvanocauterization 330 Nitzc's Method 331 With the Direct Vision Cystoseope 332 Technic of the Endovesical Treatment of Bladder Tumors with Luys' Operating Cystoseope 333 Treatment of Bladder Tumors with the Cold or Hot Snare 342 Electrocoagulation of Tumors of the Bladder 347 Endovesical Treatment of Bladder Tumors by Electrolysis 354 Endovesical Treatment of Bladder Tumors by Radium 355 Chapter X. — Treatment of Foreign Bodies in the Bladder 357 Actual Foreign Bodies 357 Treatment of Vesical Calculi 354 Treatment of Cystitis 374 Instrumental Exploration of the Inferior Extremity of the Ureter 374 Vesical Biopsy 37g ILLUSTRATIONS kk;. pack 1. T)('s()iitu';uix 's ur('tlni>s('()]u> • 27 '2. Iliir1('|(ni|i 's iii('11ii(iscu|i(' 28 'A. Lc'ilci 's paiiclcctioscopc 28 4. Scluitzo'.s (lia])hotoseo]ie 29 5. Xyrops' oleftrnuiotliioscopo 20 (). Laiiy 's iii'('tlirosc()|)o 29 7. Otis' uioHnoscope ."^O S. Casper's electroscope ^'>0 9. Antal's aorouretliroscope •"''1 1 (). Fenwick 's aerourethroscope 32 n. Clar's photophore 33 12. Urethroscopie tul)e and its iil)turator 33 13. Griinfeld's tul)(^ witli wimlow and iiiiri'or 34 14. Horteloup's bivalve speculum 34 15. Kollmann-Wiehe tubes 35 Ki. Nitze's urethroscope 37 17. Oberlaender's urethioscope 37 18. Valentine's urethroscopie lamp 38 19. Valentine 's lamp carrier 38 20. Oberlaeuder-Kollmann urethroscopie tube 38 21. Valentine's urethroscopie outfit 39 22. Kollmaun's photographic urethroscope 39 23. Handle of Kollmann-Wiehe 'a urethroscope, provided willi an dptic ap[iaratus ... 40 24. Wasserthal 's aerourethroscope 40 25. Gordon's endoscope 41 2G. Handle and telescope of Kaufmann's uretlirosco|)e 41 27. Luys' long cystoscopie tulie and its obturator 43 28. Luys' short urethroscopie tulie and its lamp 43 29. Handle of Luys' urethroscope 45 .'!0. Improved model of the handle of Luys' uretludscojie 45 31. Profile view of Luys' urethroscope ( complete ) 40 32. Illustrating liow the prominence of tlie veramontanum aiK^sts aiul nbstrucls tiu^ ex- tremity of the urethroscopie tube 47 33. Le Fiir's urethroscopie lamp 48 34. Le Fiir's uretlu'oscope 48 '.)'). (ioldschmidt 's j^osterior urethioscope 48 .">(). (ioldschmidt 's anteiior urethroscope 49 37. Buerger's cystoui('throsco])e 50 38. Wossidlo's posteiior urethroscope . . * 51 ;i9. Kelly's cndo.-coiiir tulie 57 4(1. Mcthoil of liolding Kelly's endnscoiiic tube 57 41. I'awlicU's eiidosco|ii(' tulic :inil ohluratoi- 58 42. Ptiwlick's endoscope with its lam|i and ii'rigaliiig a|i|iaiatns 58 4.'!. Gaireau's endoscopic tube with its uiin<' asiiiralor 59 -14. ('ulli'ii's cysloscope GO 17 18 ILLUSTRATIONS FIG. ** PAGE 45. Urethroscopie examining table (author's model) 71 4G. Rheostat for light and cautery adapted for city cun-ent 72 47. Rheostat for light and cautery, using city current 72 48. Rheostat for light, using city current 73 49. Light controller 73 50. Pocket battery . . " 73 51. Sigurta's portable battery for electric illumination 74 52. Wooden cotton carrier 74 53. Special forceps for intraurethral work ■ 74 54. Examination of the anterior urethra 75 55. Examination of the posterior urethra .75 56. Ten cubic centimeter syringe . 76 57. Introduction of the urethroscopie tube into the posterior urethra •. 76 58. The Urethroscopie tube having been introduced, the obturator is withdrawn and the handle is attached to the collar of the tube (lamp pointing downward) ... 77 59. In the examination of the posterior urethra, the' handle of the urethroscope is turned upward, the lamp also upward 78 60. Intraurethral manipulation; drying the mucosa with cotton swabs ....... 79 61. Urethroscopie view of the "prostatic fossette" 85 62. Anatomic view of the "prostatic fossette," comprised Ijotween the posterior margin of the verumontanum and the bladder neck 85 63. Normal verumontanum, the orifice of the prostatic utricle not visible 86 64. Normal verumontanum, the orifice of the prostatic utricle visible 86 65. Normal verumontanum, without a median prostatic utricle , 87 66. Kollmann's pipette, for aspirating the glandular secretions 90 67. Little polypus situated at the bottom of a lacuna of Morgagni 91 68. Urethroscopie lesions of the prostatic fossette, behind the verumontanum .... 101 69. Glandular lesions of the anterior surface of the prostate, seen with the urethroscope . 102 70. Polypus on the summit of the verumontanum 107 71. Long eel-shaped polypus on the anterior aspect of the verumontanum ...... 107 72. Long phallus-shaped polypus on the superior aspect of the verumontanum . . . . 108 73. Hypertrophied verumontanum, the result of a chronic inflammation 110 74. Luys' direct vision cystoscope, female model, complete . Ill 75. Large pediculated polypus in the female urethra __ 112 76. Classic arrangement of the ejaculatory canals 116 77. Verumontanum without any visible orifice 117 78. Ejaculatory canals opening on the lips of the prostatic utricle 117 79. No prostatic utricle visible; the ejaculatory canals open on the lateral walls of the verumontanum, resembling a diver's helmet 118 80. The ejaculatory canals open on the lateral walls of the verumontanum but at dif- ferent levels lis 81. Urethroscopie view in which the prostatic utricle is visible 119 82. The ejaculatory canals made visible only after incision of the utricle 119 83. Gun-barrel aspect of the ejaculatory canals 120 84. A stylet introduced into the orifice ' of the ejaculatory canals, enters the seminal vesicles, and not the vas deferens ■ 123 85. ''Vesicular casts," obtained by massage of the seminal vesicles 123 86. Metallic bougies for catheterization of the ejaculatory canals 130 87. Star-shaped cicatrix resulting from a perforation of the bladder, due to an abscess of the right iliac fossa I43 88. View of a vesical perforation of an adjacent abscess I44 89. The floor of the bladder '.'.'.'. 148 90. Normal ureteral orifice projecting like a papilla I5I TTJJJSTRATTONS 1^ PIG. PACK ill. XiiiiiNil iii'clci'il iiiilii-i' ill llir sliii|i(' III' ;iii iilili(|ii(' clcCt 151 ill'. L:ii-f, (i[i(Mi inclcrnl orilirc 151 il.'l. rictt'i'iil (uKicc sliiipcil liUc llu' licak of v. claiiniicl tc . 151 !t4. Uiclcral orifice IciigtlKMicd into ;i sliar|i line 151 !t5. NiiTiow ui'Ptoral orifice with thiclveiicil lips, iiulii-iitixi' nt' :i inilij pvclilis .... 151 9(5. Arch-sluipcd orifice indicative of a ureteral dilatation 151 07. Golf-hole-shaped lU'eteral orifice, indicatinaL;'ul:itinn 348 li04. View of a bladder tumor situated in median line nf the trijione 351 -05. 8ami> as Fig. 204. First application of electroco;iuulation 351 •200. Same as Fig. 204. Eight days after the application of el(>c1 rocnagulatiou . . . 352 '207. Same as Fig. 204. Second application of electrocoagulation 352 20S. Same as Fig. 204. Fifteen days after the application of electrocoagulation . . . 353 209. Celluloid hairpin, after having lain in the bladder nine days 359 210. Forceps for the extraction of foreign bodies through the direct vision cystoscope . o59 211. Fragment of a Pezzer catheter, broken off in the bladder 360 2] 2. View of the bladder mucosa in bullous cystitis 362 21.'". Thti'e strands of silk thread the ends of which, project into the bladder .... 363 214. Three additional strands of thread, with a knot projecting into the bladder . . . 363 215. View of a phosphatic calculus seen through Luys' direct vision cystoscope . . . .365 216. Extraction of a phosphatic calculus through Luys' direct vision cystoscope . . . 367 217. Silver nitrate stick for endovesical cauterization 373 COLOR PLATES l>LATK PAGE I. The verumoutiimim 5L II. Eel-shaped and phallus-shaped polvpi on tlic vcnmioiitaiiimi 66 III. Glandular lesions of the uictliia and prostate 89 IV. Pathologic lesions on the verumontanum and prostate 92 V. Lesions of the verumontanum; also showing the ejaculatory ducts 104 VI. Prostatic cavern in chronic prostatitis ; urethroscopic view of a urethral stricture 122 VII. Endoscopic views of the anterior urethra 132 VIII. Pathologic lesions of the male urethra ; enormous polypus of the female urethra . 146 IX. Papillomatous tumor of the bladder 160 X. Normal and pathologic views of the bladder 176 XL Silk thread in the bladder; syphilis of the bladder 188 XII. Normal and pathologic views of the bladder and ureters 202 XIII. Normal ureteral orifice; same in pregnancy; ureteral emission; trabeculatcd bladder; urethrovesicovaginal fistula 214 XIV. Chronic cystitis; vesical herpes 228 XV. Vesical leucoplakia; cluonic cystitis 240 XVI. Tubei'culous ureteral orifice and vesical ulcerations 258 XVII. Polypi on the vesical neck 270 XVIII. Phosphatie vesical calculi; tul)erculous vesical ulcerations 284 XrX. Cancerous tumors of the bladder 300 XX. Inflammation and localized abscess of the vesical neck 310 XXI. Bullous edema of the vesical fundus 322 XXIL Tumor of the roof of the vesical neck ; vesical fistula 336 XXIII. Edema of the ureteral orifice 344 XXIV. Vesical tumor; vesical cancer; bullous edema; purulent ureteral ejaculation . . 358 CVSTOSCOI^Y AND Uin:rHliM)SC()PV CHAPTER I liiSTUliY OF UliETHRAL AND M^:hICAL ENDOSCOPY HISTORY OF ENDOSCOPY Ever since ancient times, physicians liave made efforts to inspect the natural ca^T.ties of the body mth special instruments. Even aniono- the ancient Hebrews^ the use of the vaginal speculum was alread}' known; and in the surgical arsenal which was discovered in the excavations at Pompeii, instruments designed for the exploration of the rectum were found. Naturally, instrumental examination could I)e made only of the large body cavities which are easy of access, such as the mouth, vagina, and rectum. Efforts to penetrate a ca^^ty A\itli a hmien as narrow as that of the urethra or the bladder, were in vain, and tlie first solutions of this difficult problem l^egan to show themselves only as we approach modern times. Historically considered, it appears tliat endoscopy only goes as far back as the beginning of tlie nineteenth century, and it was Bozzini, of Frankfort, who in 1805 was the first to attempt the direct inspection of the cavities of the body. He constructed tubes of different shapes and lengths, chiefly for the study of the urethra. To illuminate the interior of his tubes, lie ('mi)loyed reflected light; but this form of iiisti'umentation was certainly too primitive and defective, and bis ffuitless efforts wei-e quickly forgotten. Similar efforts of Fisher, of Boston, in 1824, met with (Mpial lack of success. Later, in 1826, Segalas- presented to the Academy of Sciences of X^aris a urethrocystic speculum, designed for tlie examination of the urethra and bladder. This, too, Avas soon foi-uotten. He employed two coneenti-ic metal tubes, the innei' perniilting a \ie\v of the blad- der while the outer allowed the light from two candK's to enter, th'- light being i-eflected by a concave mirror. The real beginnings of endoscopy wei-e made, however, in France, and should be put to the ci-edit of Desormeaux. who in 1853, was the 25 26 CYSTOSCOPY Al^B URETHROSCOPY first to examine the uretliral and vesical mucosa in the living subject through an endoscopic tuhe in the urethra. The works of this author actually establish the beginning of endoscopic study, and he fully de- serves the title of "Father of Endoscopy" which has been bestowed on him. He was fully justified, too, in writing on the covers of his treatise on endoscopy, this cry of triumph: ''Nos quoque oculos erudi- tos habemus." (Cic). In 1865 he published an important work in which he made public the results of his experience.' Desormeaux's instrument consisted of a series of tubes of different calibers and lengths which were introduced into the urethra. The source of light was a petroleum lamp; the illumination was brought into the interior of the tube by a reflecting mirror pierced in its center and inclined to an angle of 45 degrees to the tube. This apparatus was based on the same principle as that of Bozzini. Desormeaux's endoscopic researches became well laioA^m and at- tracted the attention of other investigators to such an extent that under this stimulus, similar efforts were soon multiplied in number ; the first that appeared were those of Hacken* in 1862, and of Cruise' in 1865. At that time, the principal aim was to increase the intensit}^ of the light, in order to illuminate the lower end of the endoscopic tubes. AYith this object in mind, Furstenheim, of Berlin,^ substituted gas for the petroleum light, and Andrews,^ in 1867, and later Stein^ employed a magnesium light. Up to the time of Desormeaux, all the attempts to inspect the urethra and the bladder may be considered together; since his time, however, a clear difference must be established between those who de- voted themselves especially to the studv of the urethral mucosa and those who attempted to inspect the bladder particularly. It is there- fore proper to make a separate study of the history of urethroscopy^ as distinguished from that of cystoscopy. REPEEEISJ'CES iKasenelsolin : Die aSTormale imd Pathologisehe anatomie des Talmua, in Eoberts' Historische studien aus dem Pharmakolgisclien Institute zu Dorpat, 1896, v, p. 276. 2Segalas: Trans. Acad. Sc, 1826. Traite des retentions d 'urine, Paris, 1828. sDesormeaux: De 1 'endoscopic et de ses applications au diagnostic et au traitement des maladies de I'uretre at de la vessie, Paris, 1865. *Hacken: Dilatatorium urethrge zur Urethroscopie, Wien. nied. Wchnschr., No. 12, 1862. sCruise: The Utility of tlie Endoscope, Dublin, Quart. Jour. Med. Sc, May, 1865. ePurstenlieim: Berl. klin. Wchuschr., 1870, Nos. 3 and 4j Oesterreich Zeitschr. fiir Jahresb. Heilkr., No. 25, 1870. ^Andrews: The Urethra Viewed by Magnesium Light, Med. Eec, New York, 1867, ii, p. 107. sStein: Das Photoendoscop, Berl. klin. Wchnschr., 1874, No. 3. HISTORY OF URETHROSCOPY 27 HISTORY OF URETHROSCOPY Numerous models of Tirctliroscopes have already been suggested, and allliougli ilic list ol' existing iiistruinciits is a long one, it is still far from complete, and avo nmst expect new ones to appear continually. AVe may classify all existing uretliroscopes into two quite distinct gi'oups: 1. Urethroscopes with external illumination; that is, whose source of light is situated outside of the urethroscopic tuhe. 2. Urethroscopes with internal illumination; that is, with tlie source of light situated inside of the tuhe. Urethroscopes with External Illumination This group itself comjjrises two distinct types of instruments: 1. Those in which the source of light is attached to the urethroscope. 2. Those in Avhich the light is independent of the urethroscopic tuhe. 1. Urethroscopes With External Illumination Attached to the Urethroscopic Tube. — The first apparatus of this kind was constructed by Desormeaux, the originator of. the method. Fig. 1 is self-explana- tory. This j)rimitive urethroscope was soon improved upon, for the Fig. 1. — Desonneaux's urethroscope. illumination A\'hich was furnished by an oil lamp and later by a petro- leum lamp, was quite insufficient for its purpose. The electric light eventually gave to this method of examhiation the position it deserves. This important im])rovement to Desormeaux's urethroscope was con- tributed by Horteloup (Fig. 2). In this 'same group of instruments nmst also be mentioned the following : (a) The panelectroscope of Leiter (Fig. 3). This instiiunent con- sists of tubes of varying calibers and lengths, corresponding to No. 28 CYSTOSCOPY AND URETHEOSCOPY 18 or No. 20 Cliarriere, which are introdnced into the urethra by tlie aid of an obturator or stylet. Illumination is furnished by an electric lamp (B), placed in a semicylinder open on its upper sur- Fig. 2. — Horteloup's urethroscope. The cyl- inder containing the lamp is closed; there is a concave mirror at ^; at C a strong lens in- creases the intensity of the light which is reflected upon an inclined mirror F, thence carried into the speculums, which are held to- gether by a metal ferrule E ; at the extremity of the telescope D, is a group of lenses. face; the light is thrown upon the mirror (D), and thence reflected into the urethroscopic tube (A). A lens (C), which can be adjusted accord- ing to one's vision, magnifies the field, in order that one may see more ^ Fig. 3. — Leiter's panelectroscope.^ — It is open above; the light is reflected upon the mirror D, into the specu- lum A; a lens C, magnifies the image. clearly at the distal end of the tube. This instrument has been again taken up by Heitz-Boyer, who presented it to the Surgical Society.^ HI.STORY OV IMtlCTIIltOSCOPY 29 Fig. 4. — Schutze's diaphotoscope. Fig. 6. — Lang's urethroscope. 30 CYSTOSCOPY AITD URETHROSCOPY 'V\w only important niodiiication wliicli lias been made consists in the illuinination whicli is similar to that which Brnnning has applied re- ('(•iil!\- to the csophagoscope. Fig. 7. — Otis' urethroscope. This instrument is open to the same criticisms which may he directed against all nrethroscopic instrmiients having external illmni- nation (see page 35). An attempt based on the same plan was made recently by Wyndham Powell,^ who constructed a urethroscope with Fig. 8. — Casper's electroscope. external illumination which provided parallel rays of light. With this instrument, examination of the urethral mucosa requires air dilatation. Horteloup' gave up the use of Leiter's panelectroscope because of niSTOFiV OF ri;i:Tiii;os('r)Tv 31 lis iii('()ii\-('iiiGnces aiKi rciiiiiKMi i iiK'niix, iiii[)i'OVOcl ^\'\\\\ ;iii elect lic ())) The diaplioioscoix' of Scliulzc, (Fi^-. 4). ((0 Tlio electroiirotliT()S('()i)o of Nyi'0})s ( Kii;'. r) (d) TliG urethroscope of Lang (Fig. G). (o) Tlie uvotliroseope of Otis (Fig. 7). (f) ^Hic electroscope of Casix-r (Fig. S). he |illlllil i\ I' Ill>1 lllllielil of I )<'sor 111). Fig. 9. — Antal's aerourethroscopc (g) The aerourethroscope of Aiital (Fig. 9). Thi.s instruiiu'iit contributed another iniprovenient. It Avas designed to separati' and distend the urethral walls to their iiiaxiiiiiim exleiil. 1'lie invthroscopic tube is closed at its proximal end by a movable AviiuU)\v acting like a valve, which permits air to be forced into the canal of the urethra by means of a bulb. During the examination, the window retains the air ill the tube, without interfering witli vision in tlie least: meanwliile nii 32 CYSTOSCOPY AXD UEETHKOSCOPY assistant makes pressure on the urethra either at the level of the )„Min.'iiin ()!• at the membrauons urethra through the rectum. By this ,n..11i,.- metallic tube in the Fig. 11. — Clar's photophore. lateral wall of which was an opening of V/2 to 2 centiineters, covered with a little glass window. The urethral extremity of tlie tube Avas closed with a metallic tip, to which was attached a little minor at an angle of 45 degrees. The light rays which penetrated into the tube were reflected by this mirror upon the lateral window of the tube and the operator Avas enabled in this way to make an examination of the urethral walls. Urethroscopic tubes have been modified since by numerous authoi-s. Fig. 12. — Urethroscopic tube and its obturator. Posner has recommended glass tubes varnished l)lack inside, to i)i-evfnt the reflected ligiit in the tube from dazzling the observer. Tulx's of gum and hard rubber have also been reconmiended. AVith the object of enlarging the field of vision, Ausi)itz devised a urethroscopic tube with two movable valves opening into the urethra, so as to obtain the maximum view of the urethral nuu-osa witiiout at 34 CYSTOSCOPY AND URETHROSCOPY the same time dilating the urinary meatus. This idea has also been utihzed by Oberlaender and by Horteloup (Fig. 14). By separating the arms of the tube by means of the screw D, the field of examination in the urethra is increased. Finally, Janet suggested a double endoscopic tube. It is composed of two tubes, one sliding into the other. The inner tube has a Avindow Fig. ;13. — Griinfeld's tube with window and mirror. which permits inspection of the bladder neck. The outer is an ordinary urethroscopic tube open at both extremities. When the inner tube is removed, the outer enables the observer to examine the urethra in the usual manner. Quite recently tubes have been constructed according to the sug- gestions of Kollmann and Wiehe (Fig. 15). ' Their object is to permit (^ Fig. 14. — Horteloup's bivalve speculum. By removing the branches, by means of the screw D, the vis- ual field at the bottom of the urethra is increased. the dilatation of the distal portion of the tube by means of a screw situated at its outer extremity, in a manner similar to the dilatation of the horn of a bagpipe. But this method, while very ingenious, really gives but a very slight enlargement of the visual field and the slight advantages which are thus secured hardly compensate for the incon- veniences of the method which are due to its complexity. n I STORY OF URETHROSCOPY 35 Advantages and Disadvantages of Urethroscopes Having Exter- nal Illumination. — Tlie oulstandin^' advaiila^'c of iii-elliroscojH's willi external illumination is that manipulation or iiilcrveiitioii in the in- terior of the tuhe is simplified. The cotton carrier- and the instruments Avhicli are introduced into the tube are freely nioval)le and do not interfere with the source of light. Besides, the field of vision is cei-- tainly somewhat greater than in the case of internally ilhiiiiiiia1' oi' ri;i IIOSCOPY 30 iiH'iil lias doeidod (lisadxanla^cs, Ihc principal hcinu' its lack oi' siiii- ])li('ity (tlio first essential of a good iiistriuneiit) ; in addition the handle is diflicnlt to control 1)ecause of its large size. A second disadvantage Fig. 21. — Valentine's urethroscopic outfit. is fonnd in the reversed pictnre, which does not give a view of the objects as they really are. All in all, this instrnment is too complicated and cumbersome to be practicable. From a practicable point of view, Valentine's instrnment actiiall\- had several distinct disadvantages. Whenever a lamp l)roke oi- Inii-iicd (Hit, it took great care and mnch time to replace it: the lam]i itself was ^2^ mmitittudisiiim^^ mumtw tT ' ■•'■ Fig. 22. — Koliiiiann's photographic urethroscope. short-lived, for if a dro]i ol' linid got inside of its little metallic sheallu a short circuit was established, which burned it out ; though the ui-ethral lesions could be seen clearly, they might, nevertheless, occasionally remain undiscovered because the field was not magnified; lastly, the 40 CYSTOSCOPY AND URETHROSCOPY little lamp and its holder made an appreciable projection into tlie Imnen of the tube, thereby diminishing the visual field considerably. In the hope of remedying these disadvantages, I have devised a number of important modifications of this instrument, the first of which was presented before the Surgical Society on December 24,- Fig. 23. — Handle of Kolluiaiin-Wiehe's urethroscope, provided with an optic apparatus. 1902, and later shoAoi to the Academy of Medicine by my teacher, Le Dentu.'' 1. I added to the urethroscope an adjustable lens, the focus of which corresponded with the length of the urethroscopic tube. The urethral lesions are thus magnified and none of them can possibly be Fig. 2-1. — Wasserthal's aerourethroscope. overlooked. In order to observe the picture clearly, the presence of the magnifying glass is really very useful, and makes possible the study of interesting details Avhich can readily escape the unaided eye. The urethroscope being an instrument designed especially to afford an exact diagnosis, the great value of magnification in outlining th,e^ ji is'i'oi;^' oi' riii'rniijoscoi'v 41 details and cliaractcr oi' tiu! urethral mucosa can bo readily coniprc- iicndcd. It is therd'orc stra]i,ij,'e, to say the least, tliat certain iii,<;('nuous observers ai-e unwillin,"- to avail themselves of this important im- provement, on llie ,i;r()uii(l that tliey are obliged to i-ea