i^e^'z.- o U^^ Columbia Winitxttf^itp mtbeCitpotlltto^orfe ^Atfnmtt Htbrarg CYSTOSCOPY AND URETHROSCOPY LEWIS and MARK 'l:^^^ f' ), \ K <> '-M'^'^ .^> " Authors' case of multiple calculi (over 1700) and enlarged prostate. See page 9 (Froniis piece.) Cystoscopy and Urethroscopy FOR General Practitioners BY BRANSFORD LEWIS, B.S., M.D., F.A.C.S. PROFESSOR OF GENITQ-URIXARY SURGERY, MEDICAL DEPARTMENT OF ST. LOUIS UNIVERSITY, ST. LOUIS, MISSOURI, GENITO-URINARY SURGEON TO ST. JOHN'S HOSPITAL, ETC. AND ERNEST G. MARK, A.B., M.D., F.A.C.S. PROFESSOR OF GENITO-URINARY AND VENEREAL DISEASES IN THE UNIVERSITY MEDICAL COLLEGE, KANSAS CITY, MISSOURI, ETC. WITH A CHAPTER BY WILLIAM F. BRAASCH, M.D. ATTENDING PHYSICIAN TO THE MAYO CLINIC, ROCHESTER, MINNESOTA WITH 113 ILLUSTRATIONS, 23 OF WHICH ARE PRINTED IN COLORS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET Copyright, 1915, by P, Blakiston's Son & Co. THE. MAPLE. PRESS-TORK. PA PREFACE * Developments in cystoscopy and urethroscopy have been so rapid and far-reaching in recent years that there has been ample room and need for the several excellent text-books on these subjects that have appeared during the same period. These books have but comported with the kaleidoscopic changes in methods, technique and instrumental equipment which they have described. A similar demand has impelled the production of the present contribution. Views on pyelography, on local anesthesia of the urinary tract, on the technical and other features of cystoscopy and urethroscopy have been modernized to a degree that demands the attention and accurate description that have been accorded them. While no large share of the book is devoted to historical considerations, certain features and events are made clear that have been the subject of confusion and error in genito-urinary literature. The facts related are based on historical data that are irrefutable and are confirmed by references accessible to anyone interested in attesting them. It has been the desire of the authors to portray the technique of cystoscopy and urethroscopy so graphically, by both text and illustration, that the book might prove of real value to the novice in furthering his endeavors in this line, as well as of ad- vantage to the experienced who may be interested in studying the methods of others besides his own. Who may not learn something by studying the work of his confreres, no matter how skilled or original he may be? In harmony with this aim, resort is had to photography in numerous instances, and to diagrams where necessary. The steps and phases of cystoscopy, ureteral vi PREFACE catheterization and of urethroscopy are depicted from every angle conceivable; so that the student can hardly escape a fair understanding of these, even if he does nothing more than follow and study the illustrations. It is felt that the need of plain teaching in this regard is greater because of the relative lack of opportunities provided in this country for personal instruction and clinical demon- stration. Europe has been the Mecca of students in this department, but scientific Europe is now otherwise engaged and bids fair to be thus diverted for some time to come. It would seem opportune, therefore, for our country not only to make its own cystoscopes and allied appliances, as it has been doing so successfully, but also to foster and develop its own literature along these lines. The Authors. TABLE OF CONTENTS PART I CYSTOSCOPY CHAPTER I ANATOMY OF THE BLADDER Pages Pedersen's anatomical divisions of bladder for purposes of cystoscopy. . . . 1-3 CHAPTER II THE CYSTOSCOPE. A HISTORICAL REVIEW Bozzini, Lichtleiter, Segalas' Urethro-cystic Speculum; Bruck's stomato- scope; Rutenberg's air-inflation cystoscope; Nitze's cystoscope; First use of incandescent lamp; Boisseau du Rocher's cystoscope; Brenner's direct catheterizing cystoscope; Albarran's lever device; Low amper- age lamp; Tilden Brown's cystoscope; Bransford Lewis' cystoscope; Brown-Buerger cystoscope; Pawlik-Kelly cystoscope; Cystoscopic Armanentarium; Selection of a cystoscope; Cystoscopic acces- sories; Care and sterilization of instruments 4-21 CHAPTER III OPERATIVE TECHNIQUE Preparation of the patient; Cystoscopy of the normal bladder; Technique of air-inflation cystoscopy; The Pawlik-Kelly method; The appear- ance of the normal bladder; The coloring of the normal bladder; The vascularity of the normal bladder; The luster of the normal bladder; The trigone; Fallacies in cystoscopic findings; The inter- pretation of the cystoscopic picture 22-36 CHAPTER IV URETERAL CATHETERIZATION Various methods for segregation of the two urines; Purposes of ureteral catheterization in diagnosis and treatment; Selection between direct and indirect methods; Technique of the two methods; Selection of ureteral catheter; Catheterization under forced air-inflation; Pawlik- Kelly method; Difficulties encountered in ureteral catheterization; Dangers of infection and traumatism; Tests for kidney functionation. 37-70 vii Vlll TABLE OF CONTENTS CHAPTER V URETERO -PYELO GRAPHY Pages Technique of; Pathologic conditions of kidney and ureter; Normal pelvis; Hydronephrosis; Inflammatory pelvic dilatation; Tumor differentia- tion in upper lateral abdomen; The cystic kidney; Localization of renal shadows; Identification of intra- and extrarenal shadows; Renal tuberculosis; Congenital malformations; Supernumerary ureters; Solitary kidney; Ureteral dilatation; Contraindications to uretero-pyelography 7i~93 CHAPTER VI CYSTOSCOPY OF THE DISEASED BLADDER Congestion of bladder; Various forms of cystitis; Stones; Tumors; Cystos- copy of. Contraindications to cystoscopy in tumors; Cysts; Bilharzia disease; Varices; Tuberculosis; Lymphoid tubercle; Edema buUosum; Diverticulation and trabeculation; Tabetic trabeculation; Ureteric meatoscopy; Eversion or prolapse of ureteral orifices; Cystic dis- tention of lower end of ureter 94-121 CHAPTER VII OPERATIVE CYSTOSCOPY Purposes of, in the bladder and ureter; Various operative cystoscopes; Nitze's technique; Bransford Lewis' instruments and technique; Cauterization; Fulguration of bladder growths; Fulguration appara- tus; Methods of application; Ureteral stricture; Ureteral calculus . 122-154 PART II URETHROSCOPY CHAPTER I ANATOMY OF MALE URETHRA 155-161 CHAPTER II DEVELOPMENT OF THE URETHROSCOPE Desormeaux' urethroscope, Griinf eld's urethroscope; Nitze-Oberlander's instruments; The exposed platinum-loop urethroscope; The low amperage lamp; Various types of modern urethroscopes; Air-inflation urethroscopes; KoUmann's operative urethroscope; Mark's operative urethroscope; Water inflation instruments of Walker, Goldschmidt, Buerger and McCarthy; Care and sterilization of instruments. . . 162-169 TABLE OF CONTENTS IX CHAPTER III URETHROSCOPY OF THE NORMAL URETHRA Pages Urethroscopy of the anterior urethra; Technique of; The points to be observed in the central figure; The elasticity of the urethra; The vas- cularity of the mucosa ; The luster of the mucosa ; The appearance of the lacunae of Morgagni and the glands of Littre; The value of air- inflation in tirethroscopy ; Urethroscopy of the posterior urethra; Urethroscopy of the female urethra 170-185 CHAPTER IV URETHROSCOPY OF THE DISEASED URETHRA Chronic urethritis; Oberlander's classification; The changes in elasticity; Modifications in vascularity ; Changes in luster ; Appearance of lacunae of Morgagni and the glands of Littre; Chronic posterior urethritis; Stricture; Valves and diverticula; Tumors of the urethra; Varices of the urethra; Tuberculosis of the urethra; Herpes of the urethra; Chancroid of the urethra; Syphilis of the urethra; Leukokeratosis of the urethra; Calculi of the urethra; Cysts of the prostatic utricle; Argyria 186-221 CHAPTER V OPERATIVE URETHROSCOPY Air-inflation practically indispensable; The treatment of cystic follicles and suppurating glands; Stricture, methods of treatment in cases of extreme difficulty; Papilloma, Oberlander's method; Schwartz' method; Author's method; Removal of other tumors; Removal of the verumontanum ; Treatment of strictures of the ejaculatory ducts; Treatment of valves and diverticula by author's method; Removal of foreign bodies; Warning against over air-inflation 222-229 Index 231 LIST OF ILLUSTRATIONS Fig. Page 1. Floor of bladder and urethra (Pedersen) 2 2. Roof of bladder and urethra (Pedersen) 2 3. Boisseau du Rocher's cystoscope 8 4. Brenner's cystoscope 9 5. Tilden Brown's modification of Brenner's cystoscope 10 6. Bransford Lewis' universal cystoscope 12 7. Buerger's indirect- view cystoscope 14 8. Convenient plan and equipment of cystoscopic room 19 9. Application of local anesthetic 23 10. Introduction of cystoscope 24 11. Author's urethral tablet depositor for male 25 12. Author's urethral tablet depositor for female 26 13. Anterior cystoscopic view showing normal vesical mucosa (Facing page) 32 14. Anterior cystoscopic view showing transitional mucosa between sphincter and vesical membrane (Facing page) 32 15. Schematic bottom of Valentine's box phantom 35 16. Valentine's box phantom 35 17. Irrigation of bladder through cystoscopic sheath 41 18. Irrigation of bladder. Thumb removed, water escaping 42 19. Observ^ation cystoscopy. With bladder fuU of water 46 20. Ureteral catheterization (direct method), insertion of catheter into left orifice 47 21. Ureteral catheterization (direct method), insertion of catheter into right orifice 48 22. Showing inaccessibility of ureteral catheterization by direct method in the presence of precipitate bladder or enlarged prostate 49 23. Direct catheterization, side view 49 24. Direct catheterization, side view 50 25. Direct catheterization, cystoscopic view 51 26. Direct catheterization, catheter inserted into left ureter 52 27. Direct catheterization, both catheters in place 53 28. Indirect catheterization, side view 54 29. Indirect catheterization, catheter inserted into left ureter 54 30. Indirect catheterization, side view, control of catheter by lever .... 55 31. Indirect catheterization, side view, showing angulation of cystoscope. . 55 32. Indirect catheterization of left ureter. Approach of catheter 56 33. Indirect catheterization, catheter inserted into left ureter 57 34. Indirect catheterization, beak pointing downward 58 35. Withdrawal of lens system leaving catheter in place 59 36. Cystoscope sheath is being withdrawn with one hand, while catheters are fed in by the other 61 xi XII LIST OF ILLUSTRATIONS Fig. Page 37. Cystoscope withdrawn, catheters draining into sterile test-tubes. ... 62 38. Lavage of left kidney pelvis 65 39. Irregtilar, tortuous outline of the right ureter caused by blood clot falling pelvis and upper ureter 72 40. Irregular inflammatory dilatation of the pelvis of kidney caused by bleeding pyelitis 73 41. Dilatation of right ureter caused by stone lodged in that part of the ureter at entrance of bladder 74 42. Beginning of small hydronephrosis 76 43. Outline of normal pelvis 78 44. Dilated ureter and pelvis caused by stone in lower ureter 79 45. Colloidal silver outlining right ureter rules out shadow which might have been taken as stone 80 46. Three-ureter case of author 87 47. Post mortem specimen probably analogous to the condition shown in Fig. 46 88 48. Radiogram of duplicated ureter and pelvis 89 49. Comparison of sound and cystoscope for detection of stone 98 50. Multiple stones (over 1700) removed through cystoscope . 99 51. Cystoscopic view of tumor of bladder (Facing page) 100 52. Cystic granulosa or lymphoid tubercle (after Kneise) 113 53. Cystic granulosa (after Kneise) 113 54. Edema buUosum in connection with bilateral hypertrophied prostate (Facing page) 117 55. Trabeculation and diverticula of bladder wall (Facing page) 119 56. Constricted ureteral orifice and resulting uretero- vesical cyst (Knorr) . 121 57. Side view of above, catheter introduced (Knorr) 121 58. Bransford Lewis' operating cystoscope 126 59. Accessories to Lewis' operating cystoscope 126 60. Bransford Lewis' air cystoscope 129 61. Appurtenances to Lewis' universal operating cystoscope 131 62. Combined universal and operating cystoscope (191 4) 131 63. Dr. Leo Buerger's ureteral dilator 131 64. Bransford Lewis' induction rheostat 135 65. Bransford Lewis' electric controller 136 66. Bransford Lewis' fulguration apparatus 139 67. Mode of fulguration of papilloma, direct method 140 68. Mode of applying fulguration of papilloma, indirect method 141 69. Benign papilloma (Facing page) 142 70. Benign papilloma after 5 fulgurations (Facing page) 142 71. Benign papilloma after 8 fulgurations (Facing page) 142 72. Dilated ureter due to stricture 145 73. Stone in orifice of left ureter 147 74. Removing stone by alligator forceps 148 75. Stone lodged in mid ureter 151 76. Showing cystoscope, X-ray catheter and stone in lower end of ureter, after descent from position shown in Fig. 75 152 77. Ureteral stone removed from J. S. F 153 78. Showing strictured right ureteral orifice retaining stone 154 LIST OF ILLUSTRATIONS XIU Fig. Page 79. Ureteral scissors cutting strictural orifice of ureter 154 80. Orifice widened by scissors 154 81. Ernest G. Mark's aero-urethroscope 166 82. Patient in position for urethroscopy 171 83. Introduction of urethroscope 172 84. Urethroscope introduced and obturator withdrawn 173 85. Attaching observation window preUminary to forced air-inflation ... 174 86. Window attached and observation carried on 175 87. Introduction of urethroscope into posterior urethra 176 88. Urethroscope introduced for intra-urethral operative procedure . . . .177 89. Intra-urethral operation under forced air- inflation 178 180 180 180 188 188 188 190 190 190 190 190 191 191 191 90. Normal urethra with vascular mucous membrane .... (Facing page 91. Normal urethra with anemic mucous membrane (Facing page 92. Soft infiltration (acute urethritis) (Facing page 93. Glandular urethritis (Facing page 94. Same form as Fig. 93 (under treatment) (Facing page 95. Same form as Figs. 93 and 94 (nearly cured) (Facing page 96. Mixed urethritis. Hard infiltration second degree .... (Facing page 97. Dry urethritis, infiltration of the second degree (Facing page 98. Dry urethritis, hard infiltration of the first degree . . . . (Facing page 99. Dry urethritis showing large submucous nodosities . . . (Facing page 100. Dry urethritis, infiltration second degree (Facing page loi. Membranous urethra, in normal state (Facing page 102. Normal prostatic urethra (Facing page 103. Urethritis of the prostatic portion (Facing page 104. Floor of the proximal portion of the supramontanal region 193 105. Normal colliculus with prominent posterior frenula 193 106. Normal colliculus viewed from front 193 107. Atypical colliculus with peculiar utricle 193 108. Small cysts in roof of the supramontana 193 109. Fosstda prostatica and declive 193 no. Inflammatory excrescences on the colliculus ,. . 193 111. Small papilloma lying against colliculus 193 112. Enlarged prostatic duct in depressed scar tissue 193 CYSTOSCOPY AND URETHROSCOPY PART I CYSTOSCOPY CHAPTER I ANATOMY OF THE BLADDER The bladder is a hollow muscular organ whose function it is to temporarily hold the urine. It is composed of a serous peritoneal layer which only partially covers it, a muscular covering which is made up of practically three layers, and a mucous lining. Of its external layers or its relations to neigh- boring structures we are, from a cystoscopic standpoint, con- cerned but little. Aberrations in such neighboring structures may involve changes in the contour of the bladder as observed through the cystoscope but it is unnecessary to enter into a detailed discussion of such changes. The mucous coat is covered with a stratified pavement epithelium and richly supplied with blood vessels. The blood supply is finer and more closely woven on the trigonal area, or that area which is formed by the interuretic fold, or ridge, as a base and the internal vesical meatus as an apex. Viewed through the cystoscope the mucosa has a characteristic luster and the branching vessels give it a marked retinal appearance, except on the trigone. Here the fine interweaving of the vessels gives to this area a reddened or a reddish-pink appearance as contrasted with the delicate straw color of the mucosa in other parts of the bladder. Forming the base of the trigone is the interuretic fold or ridge at the ends of which are situated the orifices of the ureters. Normally, these openings appear as slits or dimples, marked by some increase in vascularity. CYSTOSCOPY AND URETHROSCOPY The sides of the trigone are about one and a quarter inches long, though this is variable within normal limits. Any one of the sides of the trigone may be lengthened or shortened, the variation depending upon the point at which the ureter enters the bladder. Figs, i and 2. rLUUK ROOF Fig. I. Fig. 2. •Anatomical divdsions of bladder for purposes of cystoscopy. Pedersen.) (After In a condition of distention, the bladder assumes a globe-like shape. In collapsing the mucosa falls in numerous folds. For the purposes of the cystoscopist the bladder has been divided by Dr. V. C. Pedersen,* into four segments or quadrants. * Topography of the Bladder with Especial Reference to Cystoscopy, V. C. Pedersen, N. Y. Med. Jour., Aug. 23, 1913. ANATOMY OF THE BLADDER Our division is obtained by an imaginary plane being passed transversely through the bladder just posterior to the point at which the ureteric folds disappear into the bladder wall. This divides the bladder into superior and inferior halves. Another imaginary plane passed vertically through the bladder and urethra divides the bladder into anterior and posterior halves. The bladder is thus divided into four quadrants or segments, which form excellent divisions for cystoscopic classification and study (see Figs, i and 2). Pedersen has denoted these divisions as follows : "First, the posterior lower quadrant, or, better, the uretero- trigonal quadrant, containing the right ureter and its fold, the interureteric fold, the left ureter and its fold, trigonum, and the posterior half of the neck. "Second, the posterior upper quadrant, or by choice the sub- peritoneal quadrant, which lies beyond the ureteric and inter- ureteric folds, and is not infrequently called the deep base or deep fundus of the bladder. "Third, the anterior upper quadrant, or preferably the urachal quadrant, inasmuch as this contains the true apex of the bladder with the remnants of the implantation of the fetal struct- ure, the urachus. This quadrant might also be well known as the apical zone. "Fourth, the anterior lower quadrant, which might suitably be noted as the retropubic, inasmuch as it lies immediately behind the symphysis pubis and contains the anterior half of the neck of the bladder. " The importance of the neck of the bladder, and the fact that it is best explored with the retrovision telescope, or with the urethroscope, might be regarded by many as reasons for making it a fifth subdivision for ofhce records and the like." For the purposes of cystoscopic study and topographical classification these divisions of the bladder are excellent and are to be recommended. CHAPTER II THE CYSTOSCOPE. A HISTORICAL REVIEW The history of cystoscopy and endoscopy in general dates from the pioneer work of Bozzini of Frankfort. Bozzini's instrument, which he termed a "Lichtleiter," was first described by him in the Journal der praktischen Heilkunde, Bd XXIV, 1806. The vesical speculum, which was a part of Bozzini's instrument, was intended only for the female bladder as observa- tion of the male bladder was considered out of the question. This speculum resembled a funnel. The spout of this funnel was one and a half inches long and about one-sixth inch in diameter. A metallic elastic spiral near the distal extremity of the tube permitted some degree of mobility of the bladder end of the tube. A shaded stand contained the source of light — a candle. The report of the Medical Faculty of Vienna and the Josephine Academy that were appointed by the Austrian government to investigate the claims of Bozzini in behalf of his instrument was distinctly unfavorable both as to the invention as it stood and the possibility of its future development. This pessimistic view discouraged further advance in cyst- oscopy until December, 1826, at which time Segalas of Strasburg presented his " Urethro-cystic Speculum" before the Royal Academy of Sciences of France. The shape of Segalas' speculum was similar to that of Bozzini's. The endoscopic tube was separable from the funnel which was in reality a conical mirror. A second mirror, concave in shape, through the center of which was a hole for the introduction of an ocular tube, was used as a reflector for the two candles that formed the source of illumination. The instrument had little of practical value to recommend it. 4 THE CYSTOSCOPE The following year, 1827, John Fisher of Boston described in the Philadelphia Journal of the Medical and Physical Sciences quite a complicated instrument for the purposes of endoscopy. It consisted of three tubes and two mirrors, one of them concave for the purpose of reflecting the light of the candle. It will be readily understood that this instrument found no adherents. From this time up to the year 1853, very little was accom- plished. Avery, Cazenave, Gessler, Malherbe and Espezel were endeavoring to forward the progress of endoscopy but their efforts were without definite results. In 1853, Desormeaux, to whom has been given the title, "the father of endoscopy,'^ following the ideas of Fisher, produced his endoscope and two years later this instrument was presented before the Imperial Academy of Medicine in Paris. The instrument of Desormeaux was in reality the first to receive practical acceptance at the hands of the medical profession, and in recognition of his labors Desormeaux was awarded a portion of the Argenteuil Prize. In Germany, Furstenheim, and in America, Robert Newman, did much to popularize endoscopy as proposed by Desormeaux. In 1865, Cruise of Dublin developed the efficacy of Desormeaux's instrument to a marked degree by improving the reflecting apparatus and the vesical specula. In 1862, August Haken of Riga proposed in the Wiener medizinische Wochenschrift, March 22, 1862, the use of metallic tubes blackened on the inside and into which the light was reflected by means of a head mirror. Dating from the work of Desormeaux, endoscopy steadily advanced and with the invention of the Stomatoscope by Dr. Julius Bruck of Breslau in 1867 a new era was inaugurated — the platinum loop period. It seems rather remarkable that the difficulties presented in the exposed platinum loop were not overcome for a period of ten years following its introduction. In 1874, Grlinfeld, acting on the principles suggested by Haken, presented his vesical specula. These tubes were closed at their vesical extremity by glass windows which allowed the 6 CYSTOSCOPY AND URETHROSCOPY bladder to be distended with water. By means of the view so secured he was enabled to locate the ureteral orifice and suc- ceeded in inserting a small bougie passed alongside the tube into the ureter. Two years later, 1876, Rutenberg of Vienna (Deutsche Zeitschrift fiir prakt. Medizin, Feb. 12, 1876) presented his cumbersome female vesical speculum to the profession. It deserves mention only by reason of the fact that in its use Rutenberg employed forced inflation of the bladder with air, a principle which remained neglected for a number of years before it was finally accorded a permanent place in cystoscopy. In 1877, Dr. Max Nitze of Berlin, utilizing Bruck's idea of the incandescent platinum loop devised the first electric cysto- scope. This instrument embodied the three principal factors of modern cystoscopy — the electric source of illumination, the placing of the source of light in the instrument near the field to be examined and the use of a lens system. The efforts of all previous laborers in the field of endoscopy pale into insignifi- cance when compared with the signal achievement of Nitze. The first lens system of Nitze was made for him by Beneche, an optician of Vienna, and was composed of a series of telescopic lenses. This telescopic lens system was pushed down till its distal extremity presented at a window placed at the convexity of the angle of the shaft with the beak of the instrument. The view obtained was direct and was limited to the posterior wall and base of the bladder. The instrument as a whole was the work of Diecke, a Dresden instrument maker, and many of the valuable suggestions toward its building emanated from Ober- lander who was one of its earliest exponents. Later, Nitze placed the manufacture of the cystoscope in the hands of Leiter of Vienna and the masterly mechanical skill displayed by the latter evolved the Nitze-Leiter cystoscope as it was presented before the Medical Society of Vienna on March 9, 1879. The instrument was presented in two forms — one similar to THE CYSTOSCOPE 7 the Nitze cystoscope of 1877, and one in which by means of the intervention of a prism in the lens system, a view was obtained of the neck, anterior wall and sides of the bladder. The window in the latter form was placed on the shaft of the instrument at the concavity of the angle formed between the beak and shaft. The aperture for the exit of the light-rays in the back was closed by a piece of rock-crystal. On account of the great heat generated by the platinum loop, an arrangement for the purpose of keeping a stream of cold water circulating in the instrument was essential. This was accomplished by means of two channels in the shaft which united in the beak. During cystoscopy a constant flow of cold water was maintained. The complicated character of the instrument required the services of a competent electrician for its management and, even in the most skilled hands, the platinum wire became fused so frequently as to place the instrument beyond the pale of practicability. But with all of its drawbacks its use was urged by practically all of the leading workers in the field of gen- itourinary surgery. Roswell Park of Buffalo was among the first to advocate its use in this country. The application of the Edison incandescent lamp, devised in 1880, to other forms of endoscopy was advocated for some time previous to its introduction into cystoscopy. On January 18, 1883, David Newman of Glasgow used the first incandes- cent-lamp cystoscope and yet it was not until March, 1887 — over four years later — that this form of cystoscopic illumination was presented to the general profession. At this time two in- candescent-lamp cystoscopes appeared — one made by Hartwig of Berlin after the suggestions of Nitze (Illustrirte Monatsschrift der arztlichen PolytechnLk, March, 1887), and the other by Leiter of Vienna (Konig. Gesellschaft der Aerzte zu Wien, March, 1887). By means of the use of the incandescent lamp, three distinct factors of advantage were obtained: The dis- carding of the cumbersome cooling device, the enlargement of 8 CYSTOSCOPY AND URETHROSCOPY the lens system with a consequent enlargement of the cystoscopic field, and the far greater reliability of the source of light. With these advantages there ensued much greater interest in cystoscopy and its far wider acceptance in the field of urology. In the same year (1887) Dittel (ref. Casper's Handbuch der Cystoscopie, 1898, pp. 16-17) modified Nitze's model by placing the illumination lamp on the tip of the beak instead of within the beak. In 1885 Boisseau du Rocher of Paris showed the first model of his indirect- view, incandescent-lamp " megaloscope, " or A SKeaXvT TeUbCope (mega\oscop?) Fig. 3. cystoscope, by which he claimed to give a larger field of vision through his lens system. In 1889 he had further developed and changed the instrument so that, as described* by him in that and succeeding years, it represented the first completed model of composite cystoscope (Fig. 3) presenting the first cystoscope built on the separable sheath-and- telescope plan; the first and original attainment of double, synchronous catheteri- zation of the ureters (by two independent ureteral catheters at the same sitting); the first to afford free irrigation facilities through the cystoscope itself. The two models of the instru- * Du Rocher, Annales des Mai. des Org. Gen.-Urin., 1890, pp. 65-93. THE CYSTOSCOPE 9 merit of that year (1889) furnished both the direct and the in- direct view of the interior of the bladder; and the successful use of the catheterizing features was reported by Poirier, a surgeon of Paris.* Nine years later (1898), Boisseau du Rocherf had combined the several original features of his instru- ment into one combination cystoscope the first composite sheath-and- telescope instrument of the kind ever devised, the features of which have since been utilized in the produc- tion of a number of the composite cystoscopes now on the market. In 1889, Brenner modified Leiter's direct view cystoscope for the purpose of irrigation during cystoscopy. The modifica- tion consisted of the addition of a small tube on the shaft of the instrument, as is shown in Fig. 4. It was but a step from the y^ yf ^ Breooer Fig. 4. utilization of the tube for purposes of irrigation to its adaptation as a catheter channel; the same year (1889) thereby furnishing another ureter-catheterizing cystoscope to the profession. By its means, Zuckerkandl and others were enabled to catheterize successfully the ureter in the male. James Brown of Baltimore is credited with being the first in America to accomplish ureteral catheterization in the male, making use of this instrument. Following the application by Brenner and du Rocher of the catheterizing principle to the cystoscope, Casper (1894), Nitze (1894), and Albarran (1897) caused the construction of cysto- scopes having a similar end in view. To Albarran must be given the credit of originating the lever-device, adopted in so * Poirier, An. d. Mai. des Org. G.-Urin., 1889, p. 625. t Du Rocher, An. d. Mai. des Org. G.-Urin., 1898, p. 485. lO CYSTOSCOPY AND URETHROSCOPY many subsequent instruments, for controlling the angle or direction of the ureteral catheter as it leaves the cystoscope to go to the ureteral orifice, in the indirectcatheterizing instru- ments. In 1898 Charles Preston of Rochester, New York, invented his ''cold" lamp, used first in the Valentine urethroscope, and later in the Koch air-cystoscope. In connection with the latter there were sheath and telescopes affording both direct and indirect vision; and a separate tube for carrying a ureteral catheter. In the same year (1898) Casper provided for flight angle vie*/ C direct Cattieterizing Fig. 5. double synchronous ureteral catheterization by having a sliding, removable cover for the catheter groove. In 1899 F. Tilden Brown* modified the Brenner instrument by adding two ure- teral catheter tubes instead of the one it possessed, emu- lating the plan of Boisseau of ten years before, and retaining the direct view only. In 1900 Bransford Lewisf presented his first model of cystoscope (Fig. 60) for both male and female; fixed ureter catheter channel, at first single, shortly afterward * F. Tilden Brown, Annals of Surgery, 1899, p. 668. t Bransford Lewis, Jl. of Cutan. and G.-U. Dis., Sept., 1900. THE CYSTOSCOPE II double; to be used with air as a distending medium. In 1901 Tilden Brown* presented his first model of composite cysto- scope (Fig. 5), with sheath, direct and indirect- view tele- scopes, and double ureter catheter channels by the direct method only; setting the lamp at the tip of the beak, after the plan of Dittel of 1887. In 1902 Bierhoff submitted a modification of the Nitze catheterizing instrument that was of materia] advantage, making the sheath and telescope separable, for permitting the removal of the cystoscope from the bladder while the two catheters were left in the ureters — something impracticable with the indirect catheterizing instruments then existing. In 1903 Schlagintweitf introduced a new idea into cys- toscopy by affording a retrospective view (of the neck of the bladder and the prostate) by means of a movable lens. This instrument was non-catheterizing. In 1904 Bransford LewisJ reported the use of his operative cystoscope (Fig. 58), adapted not only to use within the bladder but also in the ureters. The direct-vision air cystoscopes of Luys,§ and of CathelinU were submitted in 1904 and 1905, and attracted considerable attention in France. In i9o6# the first model of the Universal cystoscope of Bransford Lewis was presented — at first (March 22) before the Chicago Urological Society, and later before the American Urological Association (June 4). Its distinctive features were: the fenestration of the beak on both concavity dna convexity, with the setting of the cold lamp upside down in the beak, throwing the light to best advantage where desired; free irriga- tion provided for, both for cleansing the bladder and for the exchange of fluids during the cystoscopic work, even while any * F. Tilden Brown, Med. and Surg. Reports of Bellevue Hosp., Jan., 1905. t Schlagintweit, Ctralbl. f. d. Krkhtn. d. Harn.-u. Sex. Org., 1900, p. 130. t Lewis, Trans, of Miss. Valley Med. Assn., Oct. 11, 1904. § Luys, Trans, de I'Assn. Francaise d'Urol., 1904, p. 522. II Cathelin, Trans, de la Soc. de Chir. de Paris, May 24, 1905. # Lewis, American Jour, of Urology, December, 1906. 12 CYSTOSCOPY AND URETHROSCOPY Fig. 6. — Bransford Lewis's Univer sal Cystoscope (1906). THE CYSTOSCOPE 13 of the several telescopes were in place or during efforts at catheteri- zation; the application of three different observation telescopes, direct, right-angle, and retrospective, for the one sheath. At this time the direct method of catheterization (double, synchro- 14 CYSTOSCOPY AND URETHROSCOPY nous) was the only one provided for, but plans were soon com- pleted (1907) for another telescope affording double ureter catheterization by the indirect method, so that, from the stand- point of mechanics, the two methods of ureteral catheterization, the direct and the indirect, were executed with the same degree of precision and satisfaction; and further, as provided for by the present universal instrument (Fig. 6), both telescope and sheath are removable with equal ease, while leaving the two catheters within the ureters. In 1907 F. Tilden Brown (Transactions of the American Association of Genito- Urinary Surgeons, 1907, p. 371) presented his new model of composite cystoscope, in which the lamp was removed from the tip to the interior of the beak, set upside down; and three observation and two catheterizing telescopes were provided, as in the Lewis model of 1906. The Brown-Buerger cystoscope (Fig. 7) was introduced by Dr. Buerger in 1909. It possesses the following features: A short beak, set at a very obtuse angle with the shaft, adding to the ease of introduction and manipulation; two removable telescopes, one for observation and the other for double ureteral catheterization, by the indirect method only. For those who prefer to work by indirect vision only this is a very convenient and serviceable instrument. Our universal cystoscope was made, from 1906 to 1907, by the Wappler Company, of New York; from 1907 to 19 14 by the Kny-Scheerer Co. of New York. The newest model, combining the examining, catheterizing and operating features (Figs. 61 and 62), is being made by the Wappler Company. * Many other ingenious modifications of the modern cysto- scope have been made by various workers in the field of cysto- * The historical incidents and chronological data of the developments in modern cystoscopes are given in extenso in the following papers by the author: "Resum6 of Progress in the Development of Modern Cystoscopes," Transactions of American Urological Assn., 1908; "Originality and Priority in Modern Cystoscopes," Buffalo Medical Journal, August, 1908. THE CYSTOSCOPE 1 5 scopy among whom may be mentioned Follen Cabot, Winiield Ayres and Buerger in this country; Newman of Glasgow; Casper in Germany, and Albarran in France. The apparatus of Newman for determining the accurate location of lesions seen through the cystoscope deserves especial mention, as does his binocular attachment which makes it possible for both demonstrator and student to observe the cystoscopic field at the same time. The labors of Kelly of Baltimore in popularizing the method of himself and Pawlik in cystoscopy in the female are deserv- ing of great credit. By his advocacy of the method and his untiring energy in this field, Kelly did much toward awaken- ing interest in cystoscopy and catheterization of the ureters in the female. His cystoscopic tubes are of service in some of the cystoscopic maneuvers in the female bladder but for cysto- scopy per se or for ureteral catheterization they are not to be compared to the modern types of cystoscopes. Consideration of the various instruments designed for in- travesical operative procedures will be taken up later when dealing with operative cystoscopy. The Cystoscopic Armamentarium. — The cystoscopic arma- mentarium is dependent upon the amount of work to be done. If serious and systematic cystoscopy is to be attempted, instru- ments answering several requirements are essential. These essentials may be summed up as follows: (i) A direct view of the base and posterior wall of the bladder; (2) a right- angle view of the sides, apex and trigonal area; (3) a retrospective view of the area surrounding the internal urethral orifice; (4) simultaneous catheterization of both ureters by the direct method; (5) simul- taneous catheterization of both ureters by the indirect method; (6) free irrigation of the bladder through the cystoscope during the cystoscopic examination. It is unnecessary to possess both long and short shafted cystoscopes for use in either the male or female. In fact the long shafted instruments are to be preferred on account of the l6 CYSTOSCOPY AND URETHROSCOPY distance placed between the face of the cystoscopist and the genital organs of the patient. Realizing the importance of these essential points and the discomfort to the patient and the delay occasioned by the with- drawal and introduction of separate cystoscopes during the cystoscopic seance, the Bransford Lewis Universal Cystoscope was devised. With the one sheath it fulfills all of these require- ments. The different cystoscopes of Bierhoff, Casper, Nitze and Albarran each combine some of these essential requirements but in none of them are all of the essentials present. The necessity for the possession of direct, right angle and retrospective view instruments is readily understood and re- quires no explanation. When possible, catheterization of the ureters by the direct method is preferable to the use of the indirect but there are numerous cases in which it is impossible or impracticable to utilize the former, thus making it necessary to possess both types of instrument. In pronounced hematurias and pyurias, the fluid used as a distension medium may cloud up so quickly as to make success- ful cystoscopy impossible in the absence of free irrigation through the cystoscope during cystoscopy. With an instrument in which such free irrigation is practicable, this source of failure is eliminated. While formerly we were of the opinion — basing this opinion on the use of the so-called irrigating cystoscopes then extant — that in cases of active hemorrhage from the bladder, kidneys, or posterior urethra, successful cystoscopy was im- possible with the use of a fluid distending medium, we have since modified these views and with the exception of its occasional use in operative cystoscopy, consider that air-inflation is to be re- legated to the past. The Choice of Cystoscopes. — While the selection of the necessary cystoscopes is, in a degree, dependent upon the individual preference of the cystoscopist, still such instruments must fulfill certain requirements. (i) They must be of perfect workmanship, must not be THE CYSTOSCOPE 1 7 complicated or cumbersome, and their individual parts must be readily replaceable in case of accident. This latter require- ment applies especially to the cystoscopic lamp. The lamp must be capable of a maximum of light with a minimum of heat production. (2) They must permit of facility in cleansing. Ease in cleansing is readily possible in instruments of the "sheath" type. Catheter channels which cannot be thoroughly cleansed are an obvious source of danger. (3) The lens system must give for its caliber the largest possible cystoscopic field with the least loss of light. In this respect, the American, or hemispherical, lens system has not been equaled. (4) The caliber of the shaft must be the smallest compatible with the requirements of the instrument. The shaft must be sufficiently long for cystoscopy in the presence of an elongated prostatic urethra due to hypertrophy. (5) The beak must be long enough to facilitate its intro- duction with a minimum of discomfort and yet not so long as to interfere with easy intravesical manipulation. The angle of the beak with the shaft should be about 135°. (6) It must permit of free irrigation during cystoscopy. (7) It must permit of an indirect view, a retrospective view and a direct view through the same sheath. This necessitates the fenestration of the beak on both the concavity and the convexity. (8) It must permit of double synchronous catheterization of the ureters by both the Brenner and Nitze methods. It should permit of the use of not less than a No. 6 French catheter. Cystoscopic Accessories. — The electric current used may be that from a dry or wet cell battery or the dynamo-generated current controlled by a suitable rheostat. For office and hos- pital work the latter form of current is preferable on account of the instability of the battery. In the use of the dynamo-gen- erated current, one source of great annoyance may be frequently 10 CYSTOSCOPY AND URETHROSCOPY encountered, especially if the floor of the room used for cysto- scopy be of tile, stone or concrete. The current may become grounded through the patient or operator and while this ground- ing is not necessarily accompanied by danger, it is a source of great discomfort and is a factor opposed to successful cystos- copy. This grounding may be avoided in various ways, the most simple of which is the intervention between the operating table and the floor of a rubber mat, sufflcently large for the operator to stand upon. The use of rubber gloves and a rubber- castered table provides fair non-conduction. Where a special room for cystoscopy is to be constructed, the tile floor may be insulated against grounding by means of an asphalt base, surrounded with rubber (see also p. 135 relating to Rheo- stats') . For the injection of the bladder with the fluid used for dis- tension, a syringe of known capacity should be employed. We have for some time past been using a Politzer bag for irrigation and distension and have found it thoroughly practicable and satisfactory. The Janet syringe having a capacity of one- hundred and fifty cubic centimeters is a most excellent instru- ment. It is readily sterilizable. In making cystoscopic examinations, the use of a table espe- cially adapted to the purpose is a source of much comfort and satisfaction to both patient and operator. The catheters used in ureteral catheterization should be of the finest quality of woven silk. They should be of varying sizes and coloring. The zebra catheters, graduated into centimeters, alternately black and yellow or red are an invaluable addition to the armamentarium of the cystoscopist. The subject of ureteral catheters will be more fully considered in discussing catheteriza- tion of the ureters. Care and Sterilization of Instruments. — The care and sterili- zation of cystoscopes and ureteral catheters are points of con- siderable importance. The cystoscope is essentially an instru- ment of delicate construction and on account of this delicacy THE CYSTOSCOPE 19 20 CYSTOSCOPY AND URETHROSCOPY and its high cost it requires especial attention. Fortunately, in its development, while it has lost nothing of intricacy, improved methods of modern manufacture have eliminated the earlier defects of its construction so that it has become a stable and dependable instrument not requiring the constant services of a skilled electrician. While formerly the European instruments, in case of accident to any essential part of their mechanism, had to be returned to their makers for repair, they are now so con- structed that their parts are readily replaceable. It is to the credit of American manufacturers that this feature of stability and ready repair has always been kept in view in American made instruments. In the construction of the lens system, a cement is used which does not withstand a high temperature. The silvered surfaces of the prisms and hemispherical lenses are very promptly clouded and permantly impaired by boiling, making this ordinary method of sterilization out of the question. As some reliable method is essential, especially in instruments constructed for puposes of ureteral catheterization, the asepticizing quali- ties of formaldehyde vapor have been utilized with such com- plete success that it has come to be considered the method of choice. The cystoscopes may be suspended in a glass jar or air-tight case in the bottom of which are placed tablets of hexamethylen-tetramin or gauze saturated with a solution of 40 per cent, formalin. If the latter is used, calcium chloride must be suspended in the jar in order that it may, by its hygro- scopic qualities, absorb the moisture from the evaporation of the formalin solution, or tablets of formalin are placed in the bottom of such a cabinet. Instruments so treated are thoroughly sterile. Before using, the cystoscopes should be washed in sterile water to remove the irritating formaldehyde. Washing in ethereal soap and alcohol, while not as effective as the method described above, may be used with a fair degree of satisfaction, but it is less to be com- mended in catheter-carrying instruments. THE CYSTOSCOPE 21 The woven-silk catheters used for ureteral catheterization must have a perfectly smooth, varnished exterior and the lumen of the catheters must be thoroughly patent. On account of the length of the catheters and their delicate lumen, coupled with the fact that formaldehyde sterilization has a tendency to soften and destroy the varnish, this method is unsatisfactory. After a thorough trial of the different methods which have been sug- gested we have finally adopted the one advocated by Casper — steam sterilization. The sterilization is carried out as follows: Each catheter is wrapped separately in gauze, care being taken that the wrapping is so carried out that no part of the varnished surface of the catheter can come in contact with any other part. In other words, the catheters are enclosed full length in a gauze wrapping of about three layers. The catheters so wrapped are placed in a steam sterilizer and the steam sterilization contin- ued for a period of two hours. At the end of this time, the steam is cut off and hot-air sterilization continued for fifteen minutes. The object of the latter, which is an addition to the method of Casper, is to drive out the moisture deposited by the steam. The catheters are removed from the sterilizer and placed in sterile glass jars, thus completing the technique. Where quick sterilization is required, boiling for five minutes in a supersaturated solution of ammonium sulphate is fairly satisfactory. Washing the catheters with an ethereal soap and immersing them for a few minutes in a 3 per cent, formalin solution, which is also injected through the catheters, is a fairly reliable method where steam sterilization is impracticable. The catheters, of course, must be thoroughly rinsed in sterile water before using. CHAPTER III OPERATIVE TECHNIQUE Subacute or chronic symptoms indicating involvement of the bladder, coupled with urinary findings corroborative of this involvement, in which there exists the slightest doubt as to the character and extent of the responsible factor or factors, form a direct and positive indication for cystoscopy. We are well aware that this rather sweeping statement is at variance with the teachings of former writers on the subject, but we can con- ceive of no conservative means other than cystoscopy by which accurate and comprehensive knowledge of such conditions may be obtained. With this rule as a working basis, sound surgical judgment and careful attention to technique will obviate a detailed and exhaustive resume of indications pro and con. The Preparation of the Patient. — In the preparation of the patient for cystoscopy, preliminary urinary antisepsis should be insisted upon where feasible, a well-recognized principle in all urethral instrumentation. The lack of such antisepsis forms no contraindication to cystoscopy. The position the patient should assume during cystoscopy should be that which is comfortable for the patient and which will permit of ease in manipulation on the part of the operator. Probably the most satisfactory position for both patient and operator is that illustrated in Fig. 9. This position is applicable in normal cystoscopy with water distention instruments. Where air-inflation is used, the Trendelenburg position is of great service, if not absolutely essential. The external genitals should be thoroughly cleansed and contiguous parts isolated from the field of operation by means of sterile towels. The bladder should then be catheterized. OPERATIVE TECHNIQUE 23 While general anesthesia is seldom necessary, local analgesia, though not absolutely essential in the majority of cases requiring Fig. 9. — Application of local anesthetic (tablet of alypin) through tablet depositor. Position of depositor in reaching posterior urethra. -cystoscopy, is a source of much comfort to the patient and greatly facilitates these measures. Indeed, we consider in- sufficient analgesia to be probably the most potent factor 24 CYSTOSCOPY AND URETHROSCOPY operative against satisfactory cystoscopy. The personal equa- tion naturally plays an important role. For obtaining local analgesia many methods have been sug- FiG. lo. — Introduction of the cystoscope into the anesthetized urethra. Patient in proper and comfortable position. gested and many drugs used. The deep urethra being the most sensitive part of the tract is that part which requires the most analgesia. To obtain this the instillation of some analgetic OPERATIVE TECHNIQUE 25 solution may be employed or the author's method of using alypin tablets, one and one-eighth grain, deposited in the deep urethra through his tablet depositor, may be made use of. We have caused two different forms of this depositor to be made (Fig. 11), one for the male urethra and one for the female. In our hands this method has proved by far the most satisfactory one. The method is as follows: The depositor is inserted within the urethra to the required depth, the obturator is re- moved and any accumulated urine allowed to drain away. The tablet is placed in the tube and the obturator is inserted, push- ing the tablet before it into the urethra. By gently pushing in and pulling out the depositor with the obturator fully in place the softened alypin tablet is smeared over the surface and analgesia is readily obtained. This procedure may be repeated as often ^^yjuJSiiiSiii Fig. II. — Author's urethral tablet depositor for male. as is necessary to obatin the required degree of analgesia, as we have never seen the slightest ill effects follow the use of al}'pin. Analgesia having been obtained, the cystoscope is introduced and an irrigator containing clear sterile water is attached to one of the stop-cocks on the sheath. The obturator is with- drawn and the bladder flushed out through the sheath, the flow being controlled by means of a stop-cock on the sheath. This flushing is carried out until the washings return as clear as may be possible under the conditions present (Figs. 17 and 18). Where there is pronounced hematuria it may not be possible to obtain an entirely clear medium for cystoscopy and we must depend upon the irrigating cystoscope to clear up this obscurity of the distention medium. 26 CYSTOSCOPY AND URETHROSCOPY With cystoscopes of a non-irrigating type, with a fixed lens- system, the above technique is not possible. In such cases it will be necessary after analgesia has been obtained to insert the catheter and to irrigate through it, after which the cystoscope is introduced. The amount of distention medium used depends upon the capacity of the bladder to be cystoscoped, about six or eight ounces being used in bladders having a normal capacity. It is perhaps better to distend the bladder with a telescope inserted in the sheath, for if the bladder be under- or over-distended certain distortions in the cystoscopic picture occur which Fig. 12. — Author's urethral tablet depositor for female. may prove misleading to the cystoscopist of small experience and tend to an incorrect interpretation of the cystoscopic findings. Distention therefore carried out with the cystoscope in place and under ocular observation is the more accurate procedure. Before inserting the cystoscope, and indeed before preparing the patient, the cystoscopic lamp should be tested and the rheostat turned to the proper point for good illumination. This preliminary procedure is important and will often save much embarrassment to the operator and loss of time in replacing OPERATIVE TECHNIQUE 27 burned out lamps or correcting other details. The switch is then turned off and is not again turned on until the cystoscope is in the bladder and the operator is ready to begin the examination. In the selection of a lubricant, we are guided to a certain extent by the type of cystoscope used. If instruments of fixed lens-system type are used, a combination of glycerin and gum arabic is by far the best emollient on account of its thorough miscibility with water and from the fact that it in no way tends to cloud the lenses. Where sheath instruments are used, a sterile preparation of Iceland moss may be used. The Normal Bladder. — For purposes of systematic ex- amination we may divide the bladder into the two sides, the apex, the base and trigonum, the posterior wall and the region im- mediately surrounding the internal meatus. While, practically, most of the lesions of interest are to be found on the base and trigonal area and in the region around the internal urethral mea- tus, systematic search must include all of the areas mentioned. In using cystoscopes of the indirect or prismatic view type, the first area under observation would naturally be that of the apex and it is well to examine this area before proceeding further. By pushing in and withdrawing the cystoscope and by elevating and depressing the instrument each point will be brought into focus. The cystoscope is now slowly rotated until one of the sides is brought into view when, by maneuvers of the same character as those described above, each point is accurately observed. Further rotation brings into view the base and trigonum and the orifices of the ureters, first one and then the other coming into the field of vision. Still further rotation brings into view the other side of the bladder. For observation of the posterior wall, a direct-view instru- ment may be substituted for the indirect* and for observation * We cannot agree with Fenwick who decries the necessity for a direct-view instru- ment, saying that by proper manipulation it is possible to obtain a satisfactory view of the posterior wall through the right-angle view cystoscope. 28 CYSTOSCOPY AND URETHROSCOPY of the area immediately surrounding the internal urethral meatus an instrument having a retrospective lens must be used. In using cystoscopes having a fixed lens-system these changes necessitate the withdrawal of the instrument already in place within the bladder, the changing of the conducting-cords from the rheostat to the cysloscope, the readjustment of the rheostat and the introduction of another instrument into the bladder. These changes consume valuable time and this time is all the more valuable should the patient be under a general anesthetic or the distention medium evince a tendency to become rapidly turbid. The use of the sheath-type instrument minimizes the time lost in changing from one lens-system to another, as it is only necessary to withdraw one telescope from the sheath and replace it by another. The cystoscopic examination having been completed, the cystoscope is withdrawn and the bladder flushed out with or without a full-sized soft-rubber catheter. If a freely irrigating or sheath instrument be used this may be accomplished through the instrument. Technique of Air-inflation Cystoscopy.— For purposes of simple cystoscopy, air-inflation of the bladder in either the male or the female has but little to commend it and is to be condemned. As a distention medium air is, as a rule, distinctly uncomfortable to the patient and the position which must be assumed by the patient is both awkward and uncomfortable. On account of the absence of the lens-system, the caliber of the cystoscope is decidedly larger than where water-distention in- struments are used ; and the size of the cystoscopic field is greatly decreased. The presence of a foreign medium, air, in the viscus modifies the appearance of the mucosa so that the picture obtained under air-inflation is essentially different from that where water is used. Lastly, it is impossible under air-inflation to observe the anterior wall or the region around the internal orifice. In the female, the shortness and laxity of the urethra permit of a limited observation of the apex. OPERATIVE TECHNIQUE 29 In. favor of air-inflation cystoscopy it may be said that there are certain cases of extreme hemorrhagic conditions in which air-inflation facilitates the examination. But even in cases of extreme hemorrhage, free irrigation through the irrigating cysto- scope is practically always sufficient to do away with this source of annoyance. In operative cystoscopy, which will receive consideration in another chapter, air-inflation is often valuable. The position to be assumed by the patient in air-inflation cystoscopy must be that which will permit of ready ballooning of the bladder by the air and which will at the same time drain the accumulating urine away from the distal end of the cysto- scopy In the male these essential points are best obtained by the exaggerated Trendelenburg position and in the female by the same position or by the genupectoral posture. In these positions the weight of the abdominal viscera is thrown away from the bladder and the accumulating urine gravitates toward the apex. The bladder is catheterized to assure its being thoroughly empty and the sensibility of the posterior urethra is thoroughly obtunded. This thorough analgesia is essential for the reason that any spasmodic efforts on the part of the bladder or involun- tary movements on the part of the patient interfere materially with the examination. A little air mixed with urine and ex- pelled into the cystoscopic tube by a spasmodically contracting bladder fills the tube with air-bubbles which must be removed with the aspirator and cotton- tipped applicators before the exami- nation can proceed. In very many cases general anesthesia will be required to secure the relaxation necessary for a successful cystoscopy by means of air-distention. The urethral sensitiveness having been obtunded, the bladder is drained of any fluid which may have accumulated during the production of anesthesia. The patient is placed in position and the cystoscope, well lubricated, is introduced into the bladder. The light, having previously been tested and adjusted, is turned 30 CYSTOSCOPY AND URETHROSCOPY on. In the female, and sometimes in the male, the bladder will be seen to balloon from atmospheric pressure. By means of a suitably constructed aspirator, any remaining fluid is aspirated from the bladder. If forced air-inflation is necessary, the bevel window is inserted on the cystoscope, the air-inflation apparatus is attached and air is forced into the bladder. After some experimentation a few years ago we found that heated air was much better borne by the bladder than air at the ordinary room-temperature. We secured this necessary heat by placing the intake of the inflating bulbs over the flame of an alcohol lamp. The Pawlik-Kelly Method. — This method, which is only applicable to the female, was first devised by Pawlik, of Prague, and popularized by Kelly, of Baltimore. Its simplicity appeals to the general surgeon and gynecologist; and while it is not to be commended in cystoscopy per se, it is of value in certain intravesical procedures in the female. The instruments necessary for this method of cystoscopy are the vesical speculum with obturator and a conical dilator. Formerly, the bladder was illuminated by means of the rays of light reflected from a head-mirror or a Washington-Isaac lamp, but since the introduction of the low-amperage mignon lamp into endoscopy, the source of illumination is contained within the tube. For the disposal of the accumulating urine in the bladder, Garceau, of Boston, has added an aspirating attachment to the speculum. The bladder is emptied and the urethra anesthetized. The conical dilator is introduced into the urethra and by a rotary motion the urethra is gradually dilated up to the mark of lo on the dilator. This means an average dilatation of the urethra of one centimeter. The patient is placed in the dorsal-hips-elevated or knee- chest position. In ordinarily thin subjects the dorsal posi- tion will be sufficient for the atmospheric ballooning of the OPERATR'E TECHNIQUE 3 1 bladder, but in fat women the knee-chest posture will prove necessary. The speculum with obturator in place is introduced and after removal of any accumulated urine, inspection or other maneuvers are carried out. The Pawlik-Kelly method may be satisfactorily carried out without preliminary dilatation by the use of the short anterior urethroscopic tube. We have utilized the Mark aero-urethro- scope for this purpose with perfect satisfaction, as it combines with this method the possibility of forced air-inflation. The objections to the Pawlik-Kelly method as a purely cystoscopic procedure are (i) the necessity for preliminary dilatation of the urethra, (2) the uncomfortable position of the patient and (3) the incompleteness of the view obtained. The Appearance of the Normal Bladder. — The elements which enter into the cystoscopic picture and which require especial observation as being of clinical importance are (i) the coloring, (2) the vascularity (3) the normal luster of the epithelial layer, (4) the trigonum and (5) the ureteral orifices. The Coloring.^ — The normal coloring of the distended bladder, which in reality is dependent upon the vascularization and the integrity of the epithelial layer, is a pinkish-straw color in all parts of the bladder except the trigonal area. Here it is reddish, sharply marked off from the remainder of the mucosa. The Vascularity. — Scattered over the mucosa of the bladder are numerous arborescent vessels whose minute branches anastomose with great constancy.* Undue distention of the bladder with fluid obliterates this anastomosis, making it unob- servable, but it is present in every normal bladder. These vessels arise from no particular points, seemingly springing from general trunks situated deeply underneath the mucosa. They vary as to size and intensity of coloring. Some * Fenvvick incorrectly states that these vessels evince no tendency toward anas- tomosis. 32 CYSTOSCOPY AND URETHROSCOPY are deeply red, enough to suggest their being venous branches. The retinal appearance suggested by Fenwick is marked. It will be noted that there are considerable areas in some bladders which are apparently devoid of these branching vessels. In other bladders, this vascularization is fairly evenly distributed. It is, as a rule, more marked on the posterior wall. The vas- cularization of the trigone and the area immediately surround- ing this portion of the bladder is of interest. Often the trigone is seen to be bordered with numerous delicate vascular branches very closely grouped. In fact, these branches seem to lose themselves in the greatly increased vascularity which character- izes the trigone. Undue distention of the bladder by an excess of fluid in the viscus has a tendency to cause a disappearance of these vessels and a consequent anemic appearance. The Normal Luster. — Covered by its normal epithelial coat- ing and with a normal vascularization, the mucosa of the bladder has a characteristic luster which reflects the rays of light in such a manner as to give a general and even illumination in the viscus. Any destruction of this epithelial layer dulls this reflecting surface to such an extent that the illumination is markedly interfered with and we have the so-called "light- absorbing" bladder. The Trigonum. — This area, placed at the anterior portion of the bladder base, varies greatly in different individuals. The sides of the trigonum vary in length normally from one to one and a half inches. Though usually uniform in shape, this area is by no means always so. These departures from the uni- formity of shape of the normal trigonum have been classified as "short" and "long" trigona by Viertel. To these common quasi-normal conditions may be added that one in which, with an irregularly formed trigonum, one ureteral orifice opens almost directly behind the meatus internus. The trigonal area is very slightly elevated above the sur- rounding mucosa, this elevation being more marked at the Fig. 13. — Anterior cjstoscopic view, showing (upper portion) normal vesical mucosa; (lower portion) half-moon view of normal internal vesical sphincter. (Kneise.) Fig. 14. — Anterior cystoscopic view, showing transitional mucosa between sphincter and vesical membrane. Fine radiating arterioles. (Kneise.) OPERATIVE TECHNIQUE T^;^ angles, the two proximal angles being raised at the entrance of the ureters to form the montes ureteri and the distal angle being heaped up to form the uvula. This elevation of the trigonal angles is more marked in the incompletely distended bladder. Between the points of entrance of the ureters and forming the base of the trigonum is the interureteric ridge or fold. This may be so pronounced as to form a distinct ridge, though ordinarily it is marked by but slight elevation. Very often its presence is unmarked by any sign of elevation. The appearance of the ureteral orifices is by no means constant. They vary from fine, hardly discoverable slits in the mucosa to readily perceptible depressions, and this variation may be noted between the ureters of the two sides. Their edges may be marked by a finer vascularization, which is more noticeable when the ureter gapes and discharges its swirl of urine. The localization of the ureteral openings may be greatly facilitated by the administration of methylene-blue or indigo- carmine which impart to the urinary jet a characteristic coloring. The coloring of the trigone varies with the vascularity. Ordinarily of a uniform pinkish-red, contrasting strongly with the surrounding mucosa, this area is readily outlined, but in anemic individuals and under decided distention this differentia- tion becomes more difficult. The classical description of the trigonum found in text-books and in monographs describing the cystoscopic appearance of the bladder serves rather to confuse the beginner in cystoscopy than to aid him, and for this reason we have avoided it. It is thor- oughly impracticable to describe in its great variations of shape, elevation and vascularity, a "normal" or ''typical" trigonum. A recognition of these variations within normal limits must result from thorough training in practical cystoscopy. Fallacies. — Under certain conditions of over- or under- distention of the bladder with fluid, or of spasmodic contraction of the detrusors, cystoscopic findings which are apparently pathological may be noted and are very often misinterpreted by 34 CYSTOSCOPY AND URETHROSCOPY the beginner in cystoscopy. In an over-distended bladder or in a normally distended bladder in which the detrusors are con- tracting strongly a trabeculated appearance of the bladder surface is found with great frequency. The explanation of this condition is obvious. Such apparent trabeculation is un- associated with accompanying pathological changes. In a condition of under-distention, the angles of the trigone become prominent and under an improper focus the prominence caused by the heaped- up uvula may assume a form analogous to certain forms of prostatic hypertrophy. It has even been mistaken for a neoplasm. In an under-distended bladder, the mucosa becomes wrinkled and dimpled. This dimpling may be mistaken for diverticula- tion or for misplaced ureteral orifices. Blood flowing back into the bladder from a traumatized prostatic urethra and clotting may deceive the novice into be- lieving he is observing a neoplasm. A stream of water directed against the supposed new-growth through the irrigating cysto- scope will dispel this illusion. In introducing the fluid used for distention into the bladder, a little air is often forced in. The air-bubble attaches itself to the mucosa and will be noted as a glistening grape-like body apparently fixed to the surface of the bladder at the apex or anterior wall. It should offer but little difficulty to proper interpretation. The Interpretation of the Cystoscopic Picture. — It must not be forgotten by the beginner in cystoscopy that in using' the prismatic or hemispherical lens-systems, the object, or field, under observation is seen as an inverted image. This in- version of the image is quite confusing at first and an improper interpretation of the picture is unconsciously made. To over- come this, it is necessary that the cystoscopist should thoroughly familiarize himself with the picture as seen through the lens- system. This proper recognition of the angles can be readily secured by the use of the cystoscope in the phantom^bladder OPERATIVE TECHNIQUE 35 in which various articles such as calculi, hairpins, etc., have been used. Valentine devised an exceedingly simple and in- genious apparatus for studying the inverted image without the use of the cystoscope. This apparatus, to which he has given the name of Box Phantom, consists of a small square box at the bottom of which (Fig. 15) is a schematic circular device, sepa- rated into four segments. " At the extreme of each radius is a figure just as it appears on a watch dial. In two segments are depicted arrows pointing in various directions, a key and a hairpin. Near the front of the picture are two holes intended to simulate the ureteral orifices. Fig. 15. — Schematic bottom of Valen- Fig. i6. — Valentine cystoscopic box tine cystoscopic box phantom. (New phantom. (New York Med. Jour.) York Med. Jour.) The right side of the box has a metal support to hold the lid at an angle of forty- five degrees to its open surface. The inner surface of the lid has a mirror. In the front of the box is a hole, representing the urethral lumen."* A late improvement in the Universal cystoscope consists of an ocular lens fitting at will on the eye-piece of each telescope * Ferd. C. Valentine: Aids to Cystoscopic Practice, N. Y. Med. Jour., June 6, 1903. 36 CYSTOSCOPY AND URETHROSCOPY and correcting the inversion and placing all images in their correct position.* The phantom is used by holding it in the hand and ob- serving the reflected image on the mirrored lid. Various man- ipulations may be tried by means of a probe or similar instrument introduced through the hole representing the urethral opening. The operator is guided in his manipula- tions by the reflection noted in the mirror. In studying the size of the image, as observed through the cystoscope, the cystoscopist must keep in mind the fact that the area under observation increases in size as the lens-system is carried away from it. With this increase in observed area there is a proportionate loss of detail. Vice versa, if the lens- system is moved toward the area under observation, the details become larger and more distinct. According to Casper, the natural size of an object is seen at a distance of about two centi- meters, but this necessarily depends upon the telescope used and its focal distance. In order to properly interpret the size of objects observed cystoscopically, the cystoscopist must avail himself of practical experience in observing objects of known size. By carefully observing the ratio between the size and clearness of detail of the object observed, subsequent distortion of the image in actual cystoscopy is avoided. *In the latest model (19 14) of the same instrument the image is corrected in all telescopes, obviating the necessity of applying a correcting eye-piece. CHAPTER IV URETERAL CATHETERIZATION While the necessity for the segregation of the two urines had long been recognized, it was not until 1874 that the first practical attempt at segregation was made. In this year, Tuchman, of the German hospital in London, utilizing an instrument somewhat resembling a lithorite was enabled to compress the vesical extremity of one ureter and collect the urine com- ing from the opposite kidney. The crudity and uncertainty of this procedure was sufficient to condemn it as impracticable. In the following year, Simon endeavored to catheterize the female ureter by guiding the catheter along a finger introduced into the bladder through the previously dilated urethra. The over-stretching of the sphincter necessitated in this procedure resulted in quite severe tears and incontinence in some cases. About this time, Hegar proposed temporary ligation of the ureter, the ligature to be applied through the anterior vaginal wall. Some years later, a method of ligating the ureter for the purpose of segregation was devised by Sanger. In this method the hgation was applied through an abdominal incision such as was employed for ligating the common iliac artery. Hegar' s method w^as again taken up in 1886 by Warkalla who proposed to pass a threaded needle under the ureter and to occlude the ureter by traction upon this ligature. In 1 88 1, Griinfeld utilized his vesical endoscope and under the guidance of the eye passed a catheter alongside the speculum into the bladder and thence into the ureter. Two years later, 1883, Newman of Glasgow utilized an incandescent lamp cysto- scope for the same purpose. In 1880, Pawlik devised his method of "fishing" for the ureteral orifices in the female bladder without endoscopy or 37 ;^S CYSTOSCOPY AND URETHROSCOPY dilatation of the urethra. Pawlik's method was based upon certain anatomical landmarks observed on the stretched anterior wall of the vagina. These landmarks were prominences on the mucosa corresponding to the boundaries of the vesical tri- gone. Having recognized these landmarks both by sight and touch, the catheter, which was of metal, was passed through the urethra into the bladder which was distended with two hundred cubic centimeters of fluid. The tip of the catheter was directed against the angle of the trigone and the ureteral orifice was fished for. Later, about 1886, Pawlik devised his method of catheteriz- ing the femiale ureter through an open endoscopic tube. By means of the exaggerated Trendelenburg or genupectoral posi- tion air entered the tube and distended the bladder from atmospheric pressure. Howard Kelly, of Baltimore, took up the method of Pawlik and by his earnest advocacy of it did much to popularize and advance catheterization of the ureters in the female. Various other methods for segregation have been suggested and later discarded. It suffices to mention the methods of Sands, Wier, Heuser and Silberman. In Sand's method the ureter was compressed by digital pressure exerted through the rectum in the male and the vagina in the female. Wier proposed to compress the ureter against the pelvis by means of a Davy's rod introduced into the rectum. Heuser proposed by means of a sort of padded vise to compress the ureter through the abdominal wall — a thoroughly absurd and unsurgical procedure. Intravesical compression of the ureteral orifice by means of a rubber balloon attached to a catheter, through which quicksilver was introduced into the balloon, was the basis of the method of Silberman. The modification of the lens-system cystoscope for the purposes of ureteral catheterization has received attention in the preceding chapter. In 1898, Harris, of Chicago, devised his "segregator" by means of which a sort of water-shed was created on the base of URETERAL CATHETERIZATION 39 the bladder, from each side of which was collected the sepa- rate urines from the two ureters. In the past few years two other separators have appeared — those of Luys and Cathelin of France. The fallacies of the segregator are many and its use as an accurate diagnostic measure is not to be countenanced in the face of the overwhelming evidence in favor of ureteral cathe- terization. Some of the most potent arguments against its employment follow: (i) Its use is attended with more discomfort than ureteral catheterization. (2) With the kidney infection there may be a vesical in- volvement trailing over to the opposite side which may readily confuse the investigator. (3) A bladder stone or new-growth may prevent segregation of the ureteric areas with a consequent mixing of the two urines. The same result may ensue in a trabeculated bladder or in intravesical prostatic encroachment. (4) The ureteral orifices may be congeni tally misplaced. Kiimmel reports a case in which urine was secured from the right side by the use of a Luys segregator though the right kidney had been previously removed. The Purposes of Ureteral Catheterization.^The indications for and the purposes of ureteral catheterization as outlined by us in the Annals of Surgery* for January, 1903, are sufficiently comprehensive. They are as follows: Diagnosis. — A. To locate the origin of pus, blood, tuberculous products or bacilli, the various pyogenic infections, abnormally desquamated epithelium, etc., as to whether they come from (i) the bladder, (2) the right ureter, (3) the left ureter, (4) the right kidney, (5) the left kidney, (6) the right or the left peri- renal space, and communicating with the corresponding kidney or ureter. * Ureter Catheterization: Its Purposes and Practicability. Bransford Lewis, Annals of Surgery, Jan., 1903. 40 CYSTOSCOPY AND URETHROSCOPY B. To recognize and locate obstructive conditions in the right or left ureter from (i) stricture, (2) stone, (3) adjacent tumors, (4) bend or kink in the ureter from movable or dis- located kidney, (5) valvular junction of ureter and its pelvis. C. To determine (i) the presence of two kidneys; (2) if only one, which is absent. D. To determine the number of ureters present. E. To determine the functional activity of each kidney separately and relatively, with respect to its excretion of urea, albumin, quantity of urine, the specific gravity, etc. F. To determine the size and capacity of each kidney pelvis with respect to (i) hydronephrosis, (2) pyonephrosis, (3) total obliteration of kidney secreting tissue. G. If there be kidney disease present, to determine (i) if only one kidney is affected or both; (2) if only one, which the affected one; (3) if both, which is the one more affected; (4) if removal of the worse one be advisable, is the other one able to carry on kidney function sufficiently? (5) if removal of one be advisable, and the other is capable of supporting life, will the operation remove the infection from the body, removing the possibility of dissemination or recontamination? Treatment. — A. To enlarge narrowings or stricture at (i) the ureter openings or (2) in the channels of the ureters. By facilitating drainage through the increased ureter caliber, thus ob- tained, to assist in the improvement of pyelitis or pyonephrosis, unilateral or bilateral. B. To irrigate and medicate (i) the ureters, (2) the kidney pelvis of one or both sides. C. To assist, by anesthetizing and enlarging the ureter opening, the passage through it of a calculus or a plug of pus, blood, etc., and by such analgesia to relieve renal colic. D. To use the ureter, after it is catheterized, as a guide in certain abdominal and pelvic operations. E. By prolonged catheterization of a ureter to assist in the cure of a ureteral fistula. URETERAL CATHETERIZATION 41 The Choice of Method. — Whether the ureters are to be catheterized by the direct (Brenner) or indirect (Nitze) method is, in the majority of cases, a mere matter of the operator's Fig. 17. — Irrigation of bladder through the cystoscope sheath. Thumb covering the escape, water flowing into the bladder. personal preference based upon his training in the technique of the two methods. In a general way it may be said that cathe- 42 CYSTOSCOPY AND URETHROSCOPY terization with the direct lens-system is the method of choice where applicable, but there are cases in which one is com- pelled to resort to the indirect method Fig. 1 8. — Irrigation. Thumb removed and water escaping. Patient comfortable. The reasons for giving preference to the direct method have been very ably presented by Kolischer and Schmidt (Jour, of A. M. A., June 4, 1904). Summed up they are as follows: URETERAL CATHETERIZATION 43 (i) The distance between the opening of the catheter channel of the cystoscope and the orifice of the ureter is much less in the direct method than in the indirect (Figs. 24 and 29), and the direction of approach of the catheter is in the same line as the ureteral canal. On account of the extreme flexi- bility of the ureteral catheters, the shortness of the space to be bridged over in using the direct method is a distinct advantage. (2) The tension on the suspensory ligament and the genitalia is much less when the ureteral opening is in view with the Brenner type of instrument. (3) The withdrawal of the direct lens-system cystoscope with the ureteral catheters in place is readily accomplished without disturbing the catheters. Bierhoff's modification of the Nitze-Albarran instrument has made this withdrawal pos- sible where the indirect method of catheterization is pursued. In the later models of our new Universal Cystoscope, the with- drawal of the indirect lens- system and the removal of the sheath leaving the catheters in place is readily accomplished. In favor of the indirect method, there is but one argument which holds good in normal catheterization of the ureters: The ureteral openings are more readily discoverable in cystos- copy by the indirect method. In some forms of prostatic hypertrophy or in precipitate bladders (Fig. 22) and in some diseased conditions of the ureteral meatus catheterization by the indirect method becomes necessary. Kolischer and Schmidt, in discussing the first two of these conditions, say that the necessity for using the indirect method may be obviated by intrarectal lifting of the bladder base. While this may be accomplished in some cases, we question its utility in the majority of cases of this character and certainly prefer not to subject our patients to such an awkward and uncomfortable procedure. Selection of Ureteral Catheters. — The catheters for catheter- izing the ureter should fulliU certain requirements. 44 CYSTOSCOPY AXD URETHROSCOPY (i) They must be of the best grade of woven silk. Their surface must be without flaw or roughness. (2) They must be flexible, yet stiff enough to be readily threaded through the catheter channels in the cystoscope with- out evincing a tendency to bending. (3) Their lumen must be thoroughly patent and of suf- ficient caliber to assure drainage. The eye of the catheter must be of sufficient size. (4) They must be long enough to permit their introduction into the ureter as far as the kidney pelvis if such procedure is desirable. As regards the size of the catheter, the shape of the tip and the placing of the eye, we must be guided by the character of the work to be done and the conditions met with in the ureter. The size of the catheter should be as large as compatible with the catheter channels in the cystoscope and the ureter to be catheterized. Thus, in an unobstructed ureter and with the average catheterizing cystoscope, a No. 6, French, may be used. It is possible in some cystoscopes to use a No. 7, French. In the vast majority of instances in which catheterization of the ureter is demanded, a catheter having the ordinary blunt, rounded tip is preferable. In some cases of stricture of the ureter, the olive-tipped catheters are of service. For ordinary diagnostic measures, a laterally placed eye fills all requirements. Where lavage of the kidney pelvis or ureter is desirable, a catheter having a centrally placed eye is preferable though not absolutely essential. The so-called "whistle-tip" catheters have proven excellent for both diagnosis and lavage. For determining ureteral length or the accurate location of obstructions in the ureter, the zebra ureteral catheters are of great service. These catheters are graduated into centimeters, alternately black and yellow or orange, and by observing the catheter as it is pushed up into the ureter, an accurate idea of distances may be obtained. Ayres, of New York, has caused URETERAL CATHETERIZATION 45 such catheters to be constructed having each fifth centimeter colored red, making the measurement more easily observed. For X-ray work, a catheter containing a wire stylet may be utilized. Leaded ureteral bougies and hollow catheters filled with insoluble bismuth salts have been made use of for the same purpose. Lately, hollow catheters having bismuth in- corporated in their walls have been used with satisfactory results. TECHNIQUE Direct Method. — The cystoscope and catheters are sterilized in accordance with the technique described in aprevious chapter. The cystoscope is inserted and with the bladder distended, the catheters in place in the catheter channels of the cystoscope, the interureteric ridge is searched for and followed to one angle of the trigonum. It is in this neighborhood that we may expect to find the orifice of the ureter. In the hands of the practised cystoscopist, this methodical search for the orifice of the ureter is seldom necessary. If a slit or dimple in the mucosa is observed it is kept under observation to determine whether or not it is the ureteral meatus. If we are observing the orifice, in a few seconds the mons ureteris, upon which the orifice is located, will be seen to swell up, the slit gapes and a swirl of urine issues forth. To facilitate the finding of the ureteral orifices, different drugs which impart a character- istic coloring to the urine, such as methylene-blue or indigo- carmine, may be employed. The colored urine is emitted in a greenish-blue or purplish swirl which is readily noted in the clear distention medium. Keeping this slit under observation, the catheter corresponding to the orifice is pushed on until it is seen to emerge into the cystoscopic field. The tip is made to penetrate the ureteral orifice and the catheter is now slowly pushed onward with a slight rotary motion until it has traversed the desired distance within the ureter. The catheter must be kept constantly under observation during this maneuver in order 46 CYSTOSCOPY AND URETHROSCOPY that we may be assured that it is pursuing its course up the ureter and that it has met no obstruction. This is important. The catheter having been pushed in the desired distance, Fig. 19. — Observation cystoscopy. With bladder full of water, telescope inserted, light turned on, operator views the interior of the organ and its contents. search is now made for the orifice of the other ureter and the same procedure carried out. It is usually a very easy matter to URETERAL CATHETERIZATION 47 locate the other orifice by the simple process of following the interureteric fold directly across from the ureter which has Fig. 20. — Ureteral catheterization (direct method). Insertion of the catheter into left orifice by right hand; cystoscope held by the left. Both catheters supported by an assistant. already been catheterized, but the possibility of an asymmetrical placing of the orifices must be always kept in mind. 48 CYSTOSCOPY AND URETHROSCOPY With both catheters in place, the cystoscope is withdrawn, leaving the catheters in situ. The manner in which this Fig. 21. — Ureteral catheterization (direct method). Insertion of catheter into right orifice by left hand. Catheters may be supported on the shoulders of operator, if a sterile gown be worn. maneuver is accomplished depends upon whether the cathe- terization is done with a fixed lens-system instrument or with URETERAL CATHETERIZATION 49^ the sheath tj^De of cystoscope. In the former, the catheters must be threaded in at the same rate that the cystoscope is removed Fig. 22. — Showing inaccessibility of ureteral catheterization by direct method in the presence of precipitate bladder or enlarged (overhanging) prostate. Fig. 23. — Direct catheterization, side view. Left ureteral orifice in range of view of direct catheterizing telescope. in order that their position in the ureters may remain un- changed. With the sheath instruments, the lens-system con- 4 50 CYSTOSCOPY AND URETHROSCOPY taining the catheter channels may be withdrawn sHghtly from the sheath and the catheters disengaged from their channels (see Fig. 36) and left lying loose within the sheath. The distention fluid is allowed to run out through the sheath which can now readily be withdrawn without disturbing the catheters. The ends of the catheters are now cleansed with a moist piece of gauze, dried with a piece of sterile gauze and the first few drops of the drainage are allowed to escape. If drainage is not Fig. 24. — Direct catheterization, side view. Catheter inserted into left ureter. established within a reasonable time, the eye of the catheter is probably occluded by the ureteral mucosa or a plug of mucus or pus or a clot of blood. The injection of one or two cubic centimeters of sterile water through the catheter serves to es- tablish the flow. The catheter from the right ureter is drained into a sterile bottle or test-tube marked "Right" and that from the left ureter into a similar bottle or tube labeled "Left." If the eye of the catheter lies within the ureter, the drainage has the peculiar characteristics of the ureteral spurt. There will be the expulsion of a few drops of urine at fairly regular intervals, varying from four seconds to as many minutes. If the. eye of the catheter lies within the kidney pelvis, this intermittent URETERAL CATHETERIZATION 5 1 spurt is absent, the urine coming in a steady drop, drop, drop. The two catheters do not discharge their contents synchronously, nor are the intervals between spurts the same on both sides. In order to avoid any possibility of confusing the two cathe- ters, they should be of different colors. It is w^ell to establish a jQxed rule of using a certain color for the right ureter and a certain color for the left. By adhering to this rule, all possible Fig. 25. — Direct catheterization; cystoscopic view. Approach of catheter. confusion arising from this cause is obviated. We have made it a rule to use a light-colored catheter for the left side and a dark catheter for the right. Before the catheters are placed in the lens-system, it is our practice to fill their lumen with sterile water and the catheters, so filled, are plugged at their external opening with ordinary commercial pins. These plugs are not removed until the cathe- ters are in the ureters, thus preventing any contamination from the bladder fluid. 52 CYSTOSCOPY AND URETHROSCOPY Kolischer and Schmidt have suggested lubrication of the ureteral catheter with glycerin or a preparation of tragacanth in order to facilitate its passage up the ureter and to reduce trauma. The idea of lubrication is an excellent one but the use of either of the above lubricants is fallacious as they are thor- oughly miscible with water and in the passage of the catheter from the cystoscope into the ureter it must pass through the water used for distention and the lubrication becomes practically Fig. 26. — Direct catheterization. Catheter inserted into left ureter. nil. We have made use of sterile oil for this purpose but the oil has the disadvantage of contaminating the drainage and is open to the objections urged against oily lubricants. When sufficient urine has been obtained through the cathe- ters, they are withdrawn from the ureters. It is a wise precau- tion to inject a few cubic centimeters of a 5 per cent, solution of argyrol through the catheter as it is being withdrawn. Indirect Method. — If it be of the Nitz type the cystoscope containing the catheters within the channels provided for them URETERAL CATHETERIZATION S3 is inserted into the distended bladder and, the light being turned on, the cystoscope is turned until the angle of the trigonum comes into view. The ureteral orifice is located and the cor- responding catheter is made to emerge into the cystoscopic field. By manipulation of the lever controlling the angle of the catheter it is made to take the direction of the orifice of the ureter and inserted in the manner described under catheteriza- tion by the direct method. Fig. 27. — Direct catheterization. Both catheters in place, ready for withdrawal of cystoscope. The catheter having been inserted the desired distance, the other ureter is located and similarly catheterized. In using the Casper slide-bar principle, the catheter after its insertion into the ureter, is thrown out into the urethra and the second catheter inserted. Both ureters being catheterized, the second catheter may be thrown out into the urethra and the 54 CYSTOSCOPY AND URETHROSCOPY cystoscope, being turned until its beak presents upward, may be withdrawn from the bladder. This cannot be accomplished Fig. 28. — Indirect catheterization, side view. Left ureteral orifice in view, catheter emerging from ureteral channel and coming into view of operator. Fig. 29. — Indirect catheterization. Catheter inserted into left ureter. without disturbing the position of the catheters in the ureters to a certain degree. It is often found difhcult to effect this maneuver. URETERAL CATHETERIZATION 55 Where the Nitze or Albarran instruments are used, it is usually necessary to leave the instrument in situ while the cathe- FiG. 30. — Indirect catheterization, side view. Catheter about to enter left ureteral orifice; direction controlled by (a) angle of cystoscope, and (b) the lever. Fig. 31. — Indirect catheterization, side view. Catheter inserted into left ureter. Angulation of cystoscope shown by dotted lines (first position) and solid lines, second position — for catheterization. ters are draining, on account of the impracticability of turning the cystoscope without materially disturbing the catheters. 56 CYSTOSCOPY AND URETHROSCOPY Bierhoff's modiii cation makes this turning and the subsequent withdrawal of the cystoscope possible. In using the indirect catheterizing telescope of our universal cystoscope, the catheterizing telescope may be withdrawn from the sheath as in the direct catheterizing instrument, leaving the catheters undisturbed within the ureters. Fig. 32. — Indirect catheterization of left ureter. Approach of catheter. The subsequent technique is the same as that employed in catheterization by the direct method only it must be remembered that the beak is turned downward and must be again turned upward before the sheath is removed. In removing the indirect telescope after the catheters are in place within the ureters the following steps must be employed: (i) Lower the lever to its lowest point; remove the telescope sufficiently to grasp the catheters and disengage them from the proximal ends of the catheter channels letting them lie loose within the sheath and then complete the removal of the cystoscope; (3) rotate the URETERAL CATHETERIZATION 57 sheath upon its own axis so as to bring the beak upward and remove the sheath as in direct catheterization. Catheterization under Forced Air-inflation. — This method of catheterization which did much to popularize the procedure — especially in America — has practically been relegated to the past. Catheterization is by the direct method. The cystoscope containing the ureteral catheters in the catheter channels is inserted into the bladder, previously Fig. z$. — Indirect catheterization. Catheter inserted into left ureter. emptied by use of a catheter. The obturator being withdrawn, any remaining urine is removed from the bladder with an aspirator especially adapted to the purpose. The light is turned on, the bevel window attached and the bladder is in- flated with air. The orifices of the ureters are sought for and catheterized. The window is removed and the air allowed to escape from the bladder. The cystoscope is removed, the 58 CYSTOSCOPY AND URETHROSCOPY catheters being threaded in at the same rate as the removal of the instrument. Fig. 34. — Ureteral catheterization (indirect method). Beak of cystoscope pointing downward in bladder (see also Fig. 29); insertion of catheter into left orifice with right hand. The Pawlik-Kelly Method. — Cystoscopy is employed as described for this method in a previous chapter. The orifice URETERAL CATHETERIZATION 59 of one ureter is located and a metal catheter, or a woven-silk catheter armed with a stylet is inserted through the open tube Fig. 35. — Withdrawal of cystoscope, leaving the catheters to drain the ureters: the sheath is being steadied by an assistant. The telescope is first withdrawn by the left hand, while the catheters are fed in by the right. Patient comfortable. the desired distance into the ureter. The same procedure is employed for the other ureter. The tube is now withdrawn and the catheters are allowed to drain. 6o CYSTOSCOPY AND URETHROSCOPY The simplicity of this method is appeah'ng but it is open to the objections of necessary previous urethral dilatation, a dis- agreeable posture and more trauma and pain. While it is ordinarily only applicable in the female, Luys has employed a similar procedure in the male. We have used the short anterior tube of our aero-urethroscope for catheterization of the ureters in the female. It can be utilized as in the Pawlik-Kelly method or with forced air-inflation. We have added to the usual ure- throscopic accessories a catheter carrying tube (Fig. 8i,F), which may be employed through the operating window. Difficulties. — Of the causes operative against successful catheterization of the ureters, insufficient obtunding of sensa- tion is the most common. Insufficient distention of the bladder, lack of space for manipulation in greatly contracted bladders, profuse hematuria, new-growths of the bladder, obstruction of the ureteral lumen due to stone, stricture, kinking or extra- ureteral pressure and malposition of the ureteral orifices are all factors which may present themselves as opposed to catheteri- zation. It must not be forgotten that in bladders which are comparatively normal, the interureteric fold and the ureteral eminences may not be observed. In very anemic cases the intensity of the coloring which characterizes the trigonum may be so reduced as to make the recognition of this area ex- tremely difficult. Conversely, in a bladder which has been the seat of pronounced cystitis, the mucosa may be of a uniform red color throughout the bladder, thus making the differentia- tion of the trigonal area from the surrounding mucosa difficult, if not impossible. Only the practised cystoscopist will be able to surmount these difficulties and this ability results only from long and painstaking experience. The correct interpretation of the findings obtained by ureteral catheterization is of extreme importance. Even where the utmost care has been observed to avoid trauma, blood cells are almost constantly found under the microscope. The total urinary picture must be the basis for diagnosis. URETERAL CATHETERIZATION 6i Occasionally, the urine obtained through the catheter, though at first clear, becomes suddenly macroscopically bloody. Casper Fig. 36. — Cystoscope sheath is being withdrawn by one hand, while catheters are being fed in by the other — while maintaining their same relative position in the ureters. suggests that if this is due to trauma produced by the catheteri- zation, that the catheter should be pushed farther up into the ure- ter. We are of the opinion that the hematuria of this character 62 CYSTOSCOPY AND URETHROSCOPY is due to a congestion of the ureteral mucosa dependent upon the presence of the catheter and the peristaltic contractions Fig. 37. — Cystoscope withdrawn, catheters draining into rubber-capped sterile test tubes (marked R and L as shown in Fig. 38). of the ureter. Where the cystoscope is removed, leaving the catheters in situ, the procedure suggested by Casper cannot be carried out. URETERAL CATHETERIZATION 63 Dangers. — The dangers of infection and traumatism which have been urged against catheterization can, we believe, be discussed in a very few words. Albarran, Casper, Kiimmel and Landau, whose experience is based upon several thousand cases, are unanimous in saying that these supposed dangers do not exist. In our experience, which has been fairly extensive, we have never encountered a case of infection arising from this procedure. With sterile instruments and careful atten- tion to technique, we may dismiss these objections as having no existence in fact. Kidney Fimctionation. — In the diagnosis of relative kidney functionation, catheterization of the ureters plays an important part. It is not sufficient to know that a supposedly healthy kidney is secreting a normal amount of urine. The ability of each kidney as an excretory organ must be determined. The nitrogen output of each kidney varies greatly at different times and it is necessary to have the total excretion for a period of twenty-four hours or longer, in order that the excretory ability may be determined. As it is both inadvisable and impracticable to leave the ureteral catheters in place for so long a time, differ- ent methods for a rapid determination of the functional activity of each kidney have been devised. We have at our disposal four distinct methods: Chromocystoscopy, the Phloridzin Test, Urinocryoscopy and Hemocryoscopy, and the Phenolsulphone- phthalein Test. Chromocystoscopy. — In 1853, Beauvaire remarked the ab- sence of the characteristic odor of asparagus, after its ingestion, from the urine of nephritic patients. It is upon this selective elimination of certain substances by the healthy kidneys, that both Chromocystoscopy and the Phloridzin Test are based. As indicated by the term "Chromocystoscopy," this test depends upon the ability of the kidneys to eliminate certain dyes. Methylene-blue and indigo-carmine have been made use of for this purpose. If methylene-blue be administered in a normal dosage, the characteristic greenish-blue tinge may be 64 CYSTOSCOPY AND URETHROSCOPY noted in the urine excreted by a healthy kidney in from fifteen to thirty minutes after ingestion. Any pronounced delay in the elimination of this drug is considered to be very suggestive of crippled functionation. Ackard and Castaigne believe that a delay of one hour or longer, indicates pronounced disease. Further investigation by Walker and others has proved these findings to be fallacious, so that no dependence can be placed upon the elimination of methylene-blue as an accurate test of kidney functionation. In pronouncedly alkaline urine, no coloring is to be observed. The methylene-blue may be ad- ministered hypodermically, about twenty to thirty minims of a I per cent, solution being used. The use of indigo-carmine seems to be more dependable. Following the injection into the gluteal muscles of sixteen centi- grams of indigo-carmine, Velcher and Joseph have observed the elimination of purple-tinted urine from normal kidneys in from fifteen to thirty minutes. Any marked diminution in color is held to be due to disabled kidney functionation. The pub- lished results of different investigators bear out this contention. By filling the bladder with a dilute solution of hydrogen peroxide to which starch has been added and by the internal administration of iodide of potassium, the same authors (Velcher and Joseph) have observed the bluish discoloration which takes place when the urine ejected from the ureters comes into contact with the starch solution. The diminution in color reaction is said to be diagnostic but the reliability of the test has not been very strongly urged. The Phloridzin Test.^While Von Mehring first established the fact that the administration of phloridzin is followed by a glycosuria without a hyperglykemia, Klemperer was the first to study the elimination of sugar in phloridzin-glycosuria in its relation to kidney functionation. In Klemperer's experiments the phloridzin was administered by the mouth and he found, as the result of his investigations, that glycosuria did not occur in contracted kidney. Magnus Levy, in subsequent experimenta- UEETERAL CATHETERIZATION 65 tion, proved that phloridzin, if ingested, was subject to such chemical change as to nullify the conclusions of Klemperer. He Fig. 38. — Lavage of left kidney pel\-is. Drainage having been completed, medicated solution is being injected through the corresponding catheter. Ureteral syringe fits over the end of the catheter. obtained a glycosuria following the hypodermic administration of phloridzin in granular atrophy and other pathologic conditions 5 66 CYSTOSCOPY AND URETHROSCOPY of the kidney. Following other French investigators, Casper and Richte'r undertook an exhaustive study of phloridzin- glycosuria in its relation to kidney functionation. They found the relative elimination of sugar by each kidney to be of excep- tional value in determining functional activity. The work of Krotoszyner, of San Francisco, has been of much value in estab- lishing the reliability of this procedure. From fifteen to twenty-five minims of a ^ to a 4 per cent, solution is injected hypodermically. The solution must be fresh and warm. Krotoszyner insists upon the impor- tance of these points and traces certain failures in the work of other investigators to old or cold solutions. Elimination begins, as a rule, thirty minutes after injection and is at its height about one hour after injection. Larger dosage has a tendency to decrease the time elapsing between the injection and the begin- ning of elimination. While the Phloridzin Test is of unquestioned value, it must not be forgotten that the discrepancy between the amounts of sugar eliminated by the two kidneys must be greatly marked before any reliance can be placed upon its diagnostic value. An absence of sugar from both urines would, of course, establish the fact of crippled functionation in both kidneys. Cryoscopy. — While cry oscopy was first suggested by DeCoppet in 187 1 and extensively investigated by Raoult, who published the results of his researches in 1882, it was not until 1898 that Koranyi employed this physiochemic procedure to determine the clinical significance of the difference in the osmotic pressure of the urine and the blood. This work was later taken up by Senator, Klimmel, Casper and Richter, Albarran, Tieken and others. To take up in detail the physiochemic explanation of this pro- cedure and the exhaustive studies of those who have developed cryoscopy, is beyond the purpose of this work. It suffices to say that cryoscopy is based upon the fact that the more concen- trated the solution, the lower is the freezing point. The freezing URETERAL CATHETERIZATION 67 point of normal urine varies from —1.2° to —2.3° centigrade (Lindemann). When the molecular concentration diminishes to the point that the freezing point is raised above —0.9° centigrade, it is indicative of renal insufhciency. Urinocryoscopy is of little value unless the freezing points of the two urines obtained by ureteral catheterization and the freezing point of the blood are taken into consideration as the basis for diagnostic and prognostic reasoning. The normal freezing point of the blood is considered to be — 0.56 centigrade (Dreser). With renal insufhciency there is a retention of waste products in the blood and a consequent lowering of its freezing point. Lindemann has pointed out that so long as the pathological involvement is limited to the pelvis of the kidney, no deviation from the normal freezing point is noticed. This deviation only occurs when the disease involves the kidney parenchyma. The fact that in the use of cryoscopy a most expert knowledge of physics and chemistry is absolutely requisite for the observ- ance of the essential technique and that even under the strictest technique sources of error may creep in, must necessarily limit the field of usefulness of this procedure. Carried out under painstaking technique and in the hands of a competent physicist it is of undoubted value, but even Rumpel, Kiimmel's most enthusiastic assistant, suggests that its use should be combined with Chromocystoscopy, and the Phloridzin Test in order that accurate deductions may be made. In connection with cryoscopy, the electrical conductivity of the urine has been utilized as a test of functionation. This method, however, has not been developed to the degree that we are justified in drawing conclusions as to its value in determining kidney functionation. THE PHENOLSULPHONEPHTHALEIN TEST This test which has been put upon a thoroughly definite basis through the studies of Geraghty and Rowntree, is, in the opinion 68 CYSTOSCOPY AND URETHROSCOPY of those who have used the method extensively, the most depend- able of all tests for determining renal functionation. The tech- nique is relatively simple. As given by its authors in a com- munication read before the New York Academy of Medicine it is as follows: "Twenty minutes to half an hour before administering the test, the patient is given 300 to 400 cubic centimeters of water in order to insure free urinary secretion, otherwise delayed time of appearance may be due to lack of secretion. "Under aseptic precautions a catheter is introduced into the bladder, and the bladder completely emptied. Noting the time, one cubic centimeter of a carefully prepared solution of the phenol sulphonephthalein containing six miUigrams to the cubic centimeter is accurately administered subcutaneously, intra- muscularly or intravenously by means of an accurately gradu- ated syringe. (We have used a two cubic centimeter syringe, which is graduated in fifths of a cubic centimeter.) "The urine is allowed to drain into a test-tube in which has been placed a drop of 25 per cent, sodium hydroxid solution, and the time of the appearance of the first faint pinkish tinge is noted. "In patients with urinary obstruction, the catheter is with- drawn at the time of the appearance of the drug in the urine, and the patient is instructed to void into a receptacle at the end of one hour, and into a second receptacle at the end of the second hour. "A rough estimate at the time of appearance can be made by having the patient void urine at frequent intervals, without the use of the catheter. In prostate cases it is wise to have the catheter in place until the end of the observation. "When a catheter is to be employed, it is well, previously, to have the patient under the influence of hexamethylenamin. "Sufficient sodium hydroxid (25 per cent, is added) to make the urine decidedly alkaline in order to elicit the maximum color. The color displayed in the acid urine is yellow or orange, URETERAL CATHETERIZATION 69 and this immediately gives place to a brilliant purple-red color when the solution becomes alkaline. This solution is now placed in a liter measuring-flask and distilled water added to make accurately one liter. The solution is then thoroughly mixed, and a small filtered portion taken to compare with the standard which is used for all of these estimations. "Recently the Hellige hemoglobinometer, especially modified for use in connection with the phthalein work, has been utilized. A standard alkaline solution, six grams to a liter, is placed in the wedge-shaped cup. The urine collected is diluted to a liter and a small filtered portion poured into the rectangular cup. The wedge-shaped cup is now manipulated by means of the screw until the two sides of the color field are identical. The percent- age on the scale is now noted. This instrument is much cheaper than the Duboscq and approximately accurate. Fairly accurate estimations, however, can be obtained by means of graduated cylinders — equal quantities of the standard solution and of the diluted urine being used in separate cylinders, and the denser solution being diluted until the colors become identical. The amount of the drug in the solution being known, the amount in the urine can be readily calculated. "When the collected urine has been made strongly alkaline, it is necessary to estimate the phthalein within a few hours, as the red color fades gradually under these conditions. When it is desirable or necessary to defer the estimation for some hours or days, it is better to make the urine distinctly acid, under which condition the phthalein remains unchanged. It should, of course, be made alkaline again when the estimation is made. "Excretion in Normal Individuals. — The excretion has been studied in several hundred normal individuals. In our earlier work subcutaneous administration was used exclusively, the drug appearing in the urine in from five to eleven minutes, 38 to 60 per cent, (average 50 per cent.) being excreted in the first hour after its appearance in the urine, and 60 to 85 per cent, for two hours. In health the elimination is practically complete in two yo CYSTOSCOPY AND URETHROSCOPY hours, only a trace being present during the third and fourth hours. "Recently intramuscular and intravenous injections have been employed. The time of appearance following the intramuscular administration is practically the same as that after the sub- cutaneous, but the output averages 5 to lo per cent, more for the first hour. Following the intravenous injection, the drug normally appears in from three to five minutes, and from 35 to 45 per cent, of the drug is eliminated in the first fifteen minutes, 50 to 65 per cent, in the first half hour and 63 to 80 per cent, dur- ing the first hour. This rapidity of the excretion, following the intravenous administration, is exceedingly striking, and when this method is employed, observations for a quarter hour or half hour period only should be employed. For general use, however, we advocate the lumbar intramuscular method (the latter particularly when the edema is present), as the technique involved is much simpler and the results obtained are reliable. The technique of the test is exceedingly simple. The injection is given, time of appearance noted, and collection of urine made for one or two hours. To each sample sufficient sodium hydrate is added to insure alkalinity and maximum intensity of color; then the urine is diluted to one Hter, a small amount is filtered, the reading made, and the percentage of the drug excreted is calculated."* * Jour. A. M. A., Sept. 2, 1911, Vol. LVII, pp. 811-816.. CHAPTER V URETERO-PYELOGRAPHY* Attempts to render the urinary tract opaque to the X-ray through the injection of various media have been made repeat- edly in the past decade. The different substances used include lime water, bismuth, collargol (Voelcker and Lichtenberg^), argyrol (Keyes-), cargentos (Uhle'^), air and oxygen (Lich- tenberg and Dietlen"^). To Voelcker and Lichtenberg must be given the credit of first demonstrating a radiogram of an injected renal pelvis in the living. Subsequent investigators have demonstrated that the radiogram following injection is of considerable practical aid in the diagnosis of numerous con- ditions in the urinary tract. Technique. — Of the various media injected, colloidal silver seems to be the most satisfactory. That medium which can be used in the weakest solution, casts the clearest shadow, and is the least irritating, should be the one of choice. Colloidal silver, which at present seems to fulfil these requirements best, when used in a lo per cent, aqueous solution, will outline the ureter and renal pelvis quite definitely. The following technical precautions should be observed: (i) The colloidal silver crystals^ should be ground in a mortar when put in solution and then fil- tered in order that undissolved crystals may not be deposited in the renal pelvis and cause irritation. A solution too thick to easily pass through a fine needle should not be used. (2) The solution should be carefully warmed just before using and not boiled. (3) As a routine procedure, injection of the solution by gravity*^ is preferable in order to obviate over-distention. (4) Unless evidence of ureteral obstruction is at hand from two to * Written by William F. Braasch, Mayo Clinic, Rochester, Minn. 71 72 CYSTOSCOPY AND URETHROSCOPY eight cubic centimeters of the solution will suffice to outline the pelvis. Care must be taken not to inject the medium too rapidly because of the possibility of over-distending the pelvis and Pjc^ 39.— Irregular, tortuous outline of the right ureter caused by the blood clot filling the pelvis and upper ureter. Normal pelvis and ureter on the left side. causing renal colic. A short radiographic exposure is preferable because respiratory movement and slight change of position may render the pelvic outline indistinct. URETERO-PYELOGRAPHY 73 Fig. 40. — Irregular inflammatory dilatation of the pelvis of the kidney caused by a bleeding pyelitis. Upper ureter involved as far as the first point of narrowing. 74 CYSTOSCOPY AND URETHROSCOPY Excluding possible errors in radiographic technique, failure in obtaining a satisfactory radiogram may be due to any of the Fig. 41.— Dilatation of right ureter caused by stone lodged in that part of the ureter where it enters the wall of the bladder. following conditions: (i) Old and weakened solutions; (2) return of injected solutions because of an occluding ureteral URETERO-PYELOGRAPHY 75 obstruction; (3) obliteration of the pelvis by tumor, stone or inflammatory changes; (4) dilution of the injected solution by retained fluids; (5) immediate colic following over-distention of the pelvis. The Normal Pelvis. — The outline of the normal pelvis will vary greatly depending on the number, depth, breadth and con- tour of its calices as well as the extent to which the free wall distends. In order to correctly interpret actual abnormality one should first become familiar with this wide range of normal pelvic contour. The variation from the normal outline must be marked in order to recognize it as pathologic. The pelvis should not be over-distended while being radiographed, other- wise the resulting contraction of the pelvic wall may leave but a narrow irregular slit. On the other hand in order to demon- strate pelvic deformity of moderate degree the pelvis should be well filled. Should the kidney move while the radiogram is being made, the outline may become blurred and appear abnor- mally large. Evident detachment of calices is a peculiarity which may occasionally be found confusing. It is best there- fore to make several successive pyelograms with slightly in- creasing pelvic distention in order to obtain an accurate pelvic outline. Hydronephrosis. — Distention of the renal pelvis as the result of ureteral obstruction can be clearly demonstrated in the pyelo- gram providing a sufficient amount of the injected medium reaches the pelvis. The dilatation will be readily recognized by the increased size of the pelvic lumen as well as by the broad, knobbed shape of the calices ("Derby hat" — Keyes). The greater the distention the shallower and broader will the calices appear. In extreme cases they may be completely effaced from the pelvic outline and but a rim of cortex remain. Occasionally the free pelvic wall may be prevented from much distention because of peri-pelvic inflammatory changes and the distention may be confined within the border of the kidney. As a result the parenchyma is flattened and the dilated calices will be the diag- 76 CYSTOSCOPY AND URETHROSCOPY Fig. 42. — Beginning small hydronephrosis showing broadening of the calices of the terminal irregularities. True pelvis small. This type of dilatation is typical of obstruc- tion in the lower ureter. Moderate dilatation of the ureter visible. URETERO-PYELOGRAPHY 77 nostic features. The etiologic factors can often be interpreted from the contour of the distention. The mechanical or retention dilatation is distinguished from the inflammatory distention by the comparative regularity of its outline as seen in the even lines of the free wall and rounded ends of its broad calices. Elon- gated or pear-shaped distentions are usually due to constriction a short distance below the uretero-pelvic juncture, very often anomalous renal blood vessels. When the obstruction exists in the lower portion of the ureter, distention of the individual calices is usually proportionally greater than that of the free pelvic wall. The ureter may be markedly distended with but moderate dilatation apparent in the calices and little or none in the true pelvis. In order to render the outline distinct with extensive dilatation it may be necessary first to drain away as much of the retained fluid as possible before injecting. Pyelog- raphy is of particular value in ascertaining the existence and extent of early hydronephrosis (twenty to fifty cubic centi- meters). The earliest changes consist in broadening of the cali- ces and flattening of the fine terminal endings. Not infre-y quently, however, the normal pelvis will show broadening of several calices and an exceptionally large pelvic outline that may be difiicult to differentiate from the changes of early hydro- nephrosis. To be of practical value, therefore, the pelvic de- formity must be considerable. The Inflammatory Pelvic Dilatation. — The outline of the inflammatory distention is characterized by its marked irregu- larity. The degree of irregularity will vary with the extent of the inflammatory process. Pyelitis when recent and of moderate severity will show but slight and often indistinguishable changes. Chronic pyelitis with scar tissue changes in the pelvic wall may show considerable irregular distention. Pyelitis resulting from stones within the pelvis is often characterized by the marked irregularity of individual calices, although the general outline will depend largely on the degree of mechanical obstruction. In cases where the inflammatory process has extended into the peri- 78 CYSTOSCOPY AND URETHROSCOPY pelvic tissues we frequently find the upper ureter involved. The resulting dilatation may be consequent to mechanical obstruc- tion of peri-pelvic scar tissue changes or to the cicatricial retrac- tion of the ureteral wall itself. In exceptional cases the pelvic Fig. 43. — Outline of normal pelvis of both sides. Note terminal irregularities of minor calices which prove them to be normal. The irregular dim shadows adjacent to the right pelvis are caused by gall-stones. Their extra-renal situation is proved by the absence of inflammatory changes and relation to the calices. distention may show the characteristics of both the inflammatory and mechanical distention. With the extensive inflammatory changes accompanying pyonephrosis the irregular wide calices may be seen extending into the farthest limits of the cortex. URETERO-PYELOGRAPHY 79 Frequently the pelvis will be seen fringed with detached shadows of varying size which are caused by cortical abscesses connected with the pelvis. Fig. 44. — Dilated ureter and pelvis caused by stone in the lower ureter. Note lateral insertion of the ureter. Congenital anomaly occasionally seen in association with horseshoe kidney as in this case. Tumor Deformity. — On account of the wide variation in size and shape of the normal reno-pelvic outline the tumor must 8o CYSTOSCOPY AND URETHROSCOPY show considerable deformity in order to interpret it as abnor- mal. The majority of renal tumors removed at operation will show, on section, considerable abnormality in the pelvic contour. This deformity results from the retraction of the various calices Fig. 45. — Colloidal silver outlining right ureter rules out shadow which might have been interpreted as being stone in the ureter if the stilet alone were used. or encroachment into the pelvic space by the surrounding tumor tissue. In case of tumor retraction the following ab- normalities may be demonstrated in the radiogram after injection: (i) Irregular dilatation of the entire pelvis; (2) re- URETERO-PYELOGRAPHY 8l traction or distention of one or more calices, often to a consider- able extent; (3) retraction of the pelvis and upper ureter at the uretero-pelvic juncture. In case of tumor encroachment but very Httle of the pelvic lumen need remain in order to identify actual deformity. Irregular narrow streaks at either side of the protruding tissue may outline the remaining pelvic spaces. If the pelvis is largely obliterated by the tumor the small amount of colloidal silver that enters the remaining pelvic lumen is often obscured by the shadow of the tumor tissue itself, and only the adjacent catheter or ureteral shadow may be visible in the radiogram following injection. With marked retraction of the individual calices bizarre shapes of the pelvic space are frequently seen. In such cases the injected medium occasion- ally may not drain away readily, as the remaining shadows will demonstrate in a radiogram taken several days after in- jection. Another point of corroborative value in suspected tumor of the kidney is to find the pelvis situated in unusual posi- tions such as over-lying the vertebral column or laterally dis- placed. With necrosis and degeneration of the tumor tissue the pelvic outline may become very irregular, even resembling that of a purely inflammatory process. However, it will not be possible to make a radiographic demonstration of distinct pel- vic deformity in every renal neoplasm. A large number will not have enough deformity to be of diagnostic value. Further- more, because of obstruction to the ureteral catheter from various abnormalities in the course of the ureter, external pres- sure or even ureteric metastasis, it will often be found impossible to reach the pelvis with the injected fluid. Organized blood clots may exist in the pelvis and ureter even though the urine from the affected kidney appears normal. A pyelogram made of a pelvis containing these clots gives a pecu- liar outline consisting of a series of irregular streaks simulating marked deformity sometimes observed with tumor. Tumor Differentiation. — The clinical identification of tumors in the upper lateral abdomen is frequently very difficult. Large 6 82 CYSTOSCOPY AND URETHROSCOPY tumors of the peri-renal organs with indefinite symptoms and clinical findings may be easily confused with tumors of the kid- ney. The frequent absence of any urinary symptoms or findings with renal neoplasms leaves us no localizing data. The demon- stration of pelvic deformity in the radiogram following injection would identify the tumor, while the absence of any evident abnormality would in most instances exclude its renal origin. Again, if the radiogram made after injection locates the pelvis high and the tumor is felt well below the costal margin, the two could hardly be adjacent. Finally, the tumor- mass itself will frequently cast a faint diffuse shadow in the radiogram and if at some distance from the injected renal pelvis will further exclude its renal nature. The Cystic Kidney. — Pelvic deformity as the result of changes in the parenchyma of the polycystic kidney may fre- quently be rendered visible in the radiogram following injection. As a result of the usual increase in extent of the renal parenchyma consequent to cystic changes the pelvic space is encroached upon to a varying degree. In contradistinction to the retraction of calices occurring with renal neoplasm we usually find marked shortening or complete effacement of calices. As a result the pelvic outline will often appear roughly oval in the pyelograph with one or more irregular indentations representing former calices. Occasionally, however, with large cystic kidneys evident retraction of the general pelvic outline may be seen. With marked secondary infection the resulting outline may as- sume the characteristics of a pyonephrosis. The cystic degen- eration will not affect the pelvic outline enough to render any abnormality apparent in more than two-thirds of the cases. If the renal tumor be clinically regarded as possibly polycystic, it is well to make a bilateral pyelogram even though but one kidney can be felt enlarged. Localization of Renal Shadows. — While it is true that with good radiographic technique the kidney-shadow can usually be fairly well outlined, nevertheless, for various reasons, in the URETERO-PYELOGRAPHY 83 course of routine examinations it will frequently happen that the renal outline is quite indefinite or will not show at all. Furthermore, a distended gall-bladder, displacement, enlarge- ment or anomaly of the liver, abdominal tumor, a large fatty capsule, etc., often cause a shadow to appear in the radiogram which may easily be mistaken for the kidney- shadow. While it is very often possible approximately to localize renal stones in the shadow of the kidney if well defined, it can usually be done more accurately with the aid of the pyelogram. A small stone deep in the calyx may, in the original radiogram, appear to be in the cortex, while in the pyelogram the shadow of a cortical stone would be seen in the pyelogram separated from the pelvic shadow and its relative position in the parenchyma quite accu- rately ascertained. Stones within the pelvis will either be ob- scured entirely by the colloidal silver shadow or show faintly through it, depending on the comparative densit}^ It is true that cortical stones just beyond a calyx may, in exceptional cases, appear to be continuous with the calyx-shadow and in it. Furthermore, dilated ends of calices may appear detached and may simulate cortical stones. Again, a stone in the lateral renal cortex in direct line with the pelvis might appear to be within the pelvic shadow, depending on the comparative density of the stone and pelvic shadow. Such a lateral position is, however, rather infrequent. Another possible source of con- fusion may arise when extrarenal shadows are in direct line with the pelvis and may appear included within it. Unless there is much pelvic distention the injected solution should be com- paratively weak in order that the stone- shadow may remain visible in the injected pelvis. The relative position of the shadow may be rendered more certain by making the radio- gram at various angles or stereoscopic. Pyelographic localiza- tion of a renal stone several centimeters or more in diameter and easily felt at operation, would, as a rule, be unnecessary and may even be contraindicated. With a small stone, however, 84 CYSTOSCOPY AND URETHROSCOPY data which would previously have localized the stone may be of considerable aid in finding it at operation. Identification of Intrarenal Shadows. — Stones within the pelvis will cause variable degrees of distention more or less irregular in outhne. The dilatation may be due either to ob- struction at the pelvic outlet, to inflammatory changes within the pelvis, or individual calices. Not infrequently the pelvic outline will assume the characteristics of both mechanical and inflammatory dilatation. Small stones may occasionally not cause enough changes in the pelvic outline to be recognized as abnormal. Occasionally dilatation of but a single calyx results when a small stone obstructs the outlet of the calyx. Distention of the calices or pel vie wall resulting from previous inflammation may be apparent even though no pus nor blood is found in the urine. Small cortical stones may exist without symptoms or urinary findings and may not affect the pelvic outline. Cortical stones with inflammatory changes and necrosis in the surround- ing tissue will cause more or less inflammatory distention of the pelvis. Identification of Extrarenal Shadows. — Although extrarenal shadows can usually be identified as such in the radiogram it is at times difficult to do so. The relation of the injected renal pelvis to an adjacent shadow is often an aid to its identification. Extrarenal shadows which may confuse interpretation in the region of the kidney are caused by a variety of conditions; those commonly misinterpreted are calcareous deposits in adja- cent glands and blood vessels. The absence of inflammatory changes, the intervening distance between the shadows and the pelvic outline, and peculiarities in relation to the calices if near the pelvis will usually enable us to identify the shadows as extra- renal. With the development of the radiographic technique gall-stone shadows are being found more frequently and must be considered in the interpretation of shadows in the right kidney region. Peculiarities in the character of gall-stone shadow and negative cystoscopic data are frequently suggestive of its iden- URETERO-PYELOGR.AJ'HY 85 tity. The distance between the gall-stone shadow and the in- jected renal pelvis should usually identify the former as extra- renal. When the gall-bladder lies low and overlaps the area of the kidney the gall-stone shadow may appear to be intrarenal. Peculiarities in its relation to the injected pelvis and absence of inflammatory changes within the pelvic outline should suffice to identify its extrarenal position. Stereoscopic radiograms may, in favorable cases, be of some practical value in their differentiation. Renal Tuberculosis. — Not infrequently a unilateral pyelitis is associated with an ulcerated bladder and on cystoscopic examination will simulate a tuberculous infection. On the other hand, renal tuberculosis may infect the bladder but little and the cystoscopic data may be suggestive of a simple pyelitis. When the tubercle bacillus cannot be found after repeated micro- scopic examinations of the urine and guinea-pig inoculation is neither available nor practical, the pyelogram may be of consid- erable value in differential diagnosis. With tuberculosis the following changes may be noted in the pyelogram : (i) Moderate inflammatory irregularity of calices; (2) one or more calices merging with the outline of a connecting cortical abscess; (3) irregular distention of the entire pelvis; (4) irregular destruction of pelvis and calices. With simple pyelitis the pelvis usually shows but moderate inflammatory changes. Needless to say, a pyelogram should be made only when the question arises whether or not the condition is surgical and not when the kidney is manifestly destroyed or when guinea-pig inoculation is available. Congenital Malformations. — The existence of various con- genital anomalies in the kidney and ureter can frequently be definitely determined in the uretero-pyelogram. The position of the ectopic or pelvic kidney is clearly demonstrated in its relation to the surrounding bony structure. The fused kidney with its adjacent pelves and converging ureters can be distinctly traced to its exact location. When the lower pelvis of a fused 86 CYSTOSCOPY AND URETHROSCOPY kidney lies over the sacrum, the resulting pyelogram might eas- ily be confused with that accompanying an ectopic kidney and an adjacent normal kidney. As a rule, however, the distance sepa- rating the two pelvic outlines will enable us to differentiate between the two conditions. DupHcation of the renal pelvis is readily demonstrated in the pyelogram. It may be either appar- ent or true according to the point of union of the calices. The individual calices may be so large and so situated that they resemble separate pelves, particularly so if the calices do not unite until just beyond the hilum. When, however, there are two distinct pelves within the hilum and each has its separate calices and ureter the condition must be considered as an actual duplication of the pelvis and become of surgical impor- tance. It is of considerable practical value to determine whether the two pelves are independent or continuous. If united, the calyx connecting the adjacent pelves can usually be outlined. Evidence of failure in rotation of the kidney may be apparent from peculiarities in insertion of the ureter and situation of the renal pelvis. Lateral instead of median insertion of the ureter is suggestive of fused kidney and the position of the other kid- ney should always be determined. The combined use of the metal impregnated catheter in one side and the pyelogram in the other may occasionally be indicated. Complete duplication of the ureter from pelvis to bladder is easily demonstrated by the impregnated catheter; partial duplication and division of the ureter is frequently better outlined by the ureterogram. Since it is usually the surgical complication which calls our attention to the congenital anomaly in the kidney or ureter, the pyelo- gram will be found of particular value in determining the nature and extent of the complication. Author's Three-Ureter Case. — This was remarkable in several respects. So far as known, it was the first in which three different urines were drawn from one living individual; the first in which one of three ureters was demonstrated to be the unique source of recurrent gonorrhea; and the first in which URETERO-PYELOGRAPHY 87 LEFT SIDE RIGHT SIDE Fig. 46. — Three-ureter case of Author, in which one of the three ureters had been for five years the source of recurrent {gonorrheal infection of the lower urinary tract CYSTOSCOPY AND URETHROSCOPY Fig. 47.— Post-mortem specimen probably analogous to the condition shown in Fig. 46 of the living individual. URETERO-PYELOGRAPHY 89 such a condition was permanently relieved by direct ureteral antiseptic irrigation. The patient, a male, aged 24 years, was referred by Dr. J. L. Crook, of Jackson, Tenn., on Feb. 3, 1906. There had been many recurrences of urethral gonorrhea since 1900, notwith- standing the approved methods of treatment for that condition Fig. 48. — Radiogram of case of duplicated ureter and pelvis, catheters and collargol in place. Case of Dr. R. C. Bryan. that had been administered by several capable physicians dur- ing that time. Cystoscopy and ureteral catheterization, together with radiography, developed the following: 1. That three ureters were present, giving urines of three different specific gravities and other characteristics. 2. That two of the urines gave clear healthy urine, while Qo CYSTOSCOPY AND URETHROSCOPY the third (issuing from the median opening) gave purulent urine, the subject of pure culture gonococcus infection in abundance. 3. A few irrigations of this ureter with argyrol solution disinfected it completely, permitting the patient to go home shortly afterward, entirely and permanently relieved. Since then he has married and become the father of children, without ever having had a recurrence of the infection that had lasted for five years.* Three-ureter case of Dr. R. C. Bryan (Fig. 48): Female, 35 years of age, complained of bloody urine. Cystoscopy showed three ureteral orifices, two on the right side. From the mesial one bloody urine containing tubercle bacilH issued. Catheteri- zation, collargol injection and x-ray photography gave the ac- companying excellent result. It probably indicated two ureters and two pelves draining the one tuberculous right kidney. Operation was not accepted. Solitary Kidney. — The pelvic outline of the solitary or asymmetrical kidney differs from the normal only in its extra- ordinary size which is commensurate with its parenchyma. In the pyelogram the pelvis will appear unusually large, but with its calices and papillae normal in outhne. With an acquired single kidney, on the other hand, although its parenchyma may show considerable hypertrophy, the pelvis may either appear normal in size and contour, or show moderate elongation of the pelvis and calices. Ureteral Dilatation. — Ureteral dilatation may result from either mechanical obstruction or inflammatory retraction. The outline of the dilated ureter can usually be demonstrated in the radiogram after injection. The dilatation may vary in degree from a scarcely recognizable distention to sacculation of several inches in diameter. The ureterographic demonstration of ure- teral dilatation above a questionable stone-shadow is more accu- rate than the ureteral stilet or impregnated catheter in identify- *For full report of the case, see Medical Record, Oct. 6, 1906. URETERO-PYELOGRAPHY 9I ing ureteral stone. A small percentage of stones in the ureter of recent origin will not cause sufficient distention above to be recognized as such in the pyelogram. However, such stones may be recognized as being intraureteral by a nodular enlarge- ment of the ur et er at the si te of the shadow in question . Appr ox i- mately 25 per cent, of the stones in the ureter (particularly when in the bladder segment) will so occlude the ureteral lumen as to prevent the injected fluid from getting by. Stone in the kidney and upper ureter with but few exceptions will cause inflammatory changes in the outline of the pelvis and ureter below. The inflammatory ureteral dilatation may occasionally be the only data at hand to identify the intrarenal nature of a doubtful shadow. Cicatricial constriction of the ureter follow- ing inflammation or trauma frequently causes marked mechan- ical distention of the ureter above it. Mechanical dilatation of the ureter is usually greater in extent than that caused by inflam- matory changes in the ureteral wall. With low-lying constric- tion we may find considerable dilatation of the ureter above with but little change in the outline of the pelvis. The pelvis will dilate last. The first pelvic changes to be noted are the broaden- ing of the isthmus and flattening of the terminal irregularities of the individual calices. A peculiarity occasionally noted is that with low ureteral obstruction the first part of the ureter may remain undistended with pelvic distention above and ureteral dilatation below it. The dilatation accompanying inflammatory changes in the ureter may be general or localized. With descending infection the entire ureter is usually involved uni- formly, whereas with ascending infection the process is usually localized to a short distance above the bladder. Localized inflammatory dilatation may be the result of a peri-ureteral process such as is seen in the upper ureter with peri-pelvic inflam- mation. Ureteral dilatation may be consequent to retraction from surrounding tumor tissue, as may be seen with renal neo- plasm involving the upper ureter or with retroperitoneal growths along the course of the ureter. Physiologic obstruction to the 92 CYSTOSCOPY AND URETHROSCOPY ureteral catheter, such as is caused by acute angulation in the course of the ureter as it leaves the wall of the bladder or by folds of a flaccid ureter and loose ureteral mesentery, will show no ureteral dilatation above it. The ureterogram may be the only method with which such a condition can be clinically iden- tified. With marked ureteral distention one should first endeavor to drain as much of the retained fluid as is possible before injecting the colloidal silver solution. Profuse return flow alongside the catheter in a flaccid ureter may give the appearance of moderate distention. It can easily be differen- tiated, however, since the broadening caused by return flow is evident only in areas giving an irregular outline to the ureter. Occasionally ureteral dilatation, particularly when ascending or the result of chronic bladder retention, may be demonstrated in the radiogram after filling the bladder with colloidal silver solu- tion, and then placing the patient in the Trendelenburg position. Contraindications to Uretero -pyelography. — Although ure- tero-pyelography, like cystoscopy, is not to be used as a routine procedure in abdominal diagnosis, there is no objection to its correct employment whenever a doubtful radiogram, cysto- scopic examination or abdominal tumor leaves the diagnosis uncertain. In a series of over looo cases where uretero-pyelog- raphy was employed the author has noted neither fatality nor any permanent injury resulting. While occasionally the exami- nation may cause pain, a severe reaction is usually the result of error in technique or lack of care in the selection of cases. Unless the procedure is strongly indicated the markedly hyper- sensitive individual should not, as a rule, be subjected to uretero- pyelography . Pyelography is distinctly contraindicated in cases of large hydronephrosis where the dilatation can usually be determined merely by ureteral catheterization. Cystoscopy and the ureteral catheter alone will usually aid the interpreta- tion of large radiographic shadows sufficiently to identify them. Previous localization of large stones easily felt in the kidney at operation is unnecessary. Whenever the drainage of the kidney URETERO-PYELOGR.APHY 93 pelvis is impaired it should be injected with caution. However, the long list of conditions in the urinary tract which would remain undiagnosed without uretero-pyelography justifies its use. REFERENCES 1. Voelcker, F. and von Lichtenberg, A.: ''Pyelographie (Rontgenographie des Nierenbeckens nach KollargolfuUung)," Miinchen. med. Wchnschr., 1906, liii, 105. 2. Keyes, E. L., Jr.: "Radiographic Studies of the Renal Pelvis and Ureter," Tr. Am. Urol. Assn., 1909, 19 10, iii, 351-357, I Pl- 3. Uhle, A. A. and Pfahler, Geo. E. : "Combined Cystoscopic and Rontgenographie Examination of the Kidneys and Ureter/' Ann. Surg., 1910, H, 546-551. 4. Von Lichtenberg, A. and Dietlen, H.: "Der Darstellung des Nierenbeckens und Ureters inRontgenbile nach Sauerstoffiil- lung," Miinchen med. Wochnschr., 1911,^11,1,1341-1342. CHAPTER VI CYSTOSCOPY OF THE DISEASED BLADDER The study of the diseased bladder and the proper interpreta- tion of the pathological conditions found therein by cystoscopy must be based on a thorough knowledge of the cystoscopic appearance of the bladder in a condition of health. Acting on the supposition of such knowledge we shall endeavor in this chapter to describe as accurately as possible the lesions and abnormalities of the pathologic bladder, though we are keenly aware that any description, no matter how exhaustive and pains- taking, must be inadequate as compared with clinical in- vestigation. Congestion. — Occasionally, the cystoscopist will observe a fine and closely woven increase in vascularity on the bladder wall. This congestion is the precedent stage of a cystitis. By preference, these congested areas are located in the immediate neighborhood of the ureteral orfices or on the posterior wall. Infection or irritating sand-like particles draining down from the kidneys will explain the congested areas about the orifices of the ureters, while the patch observed on the posterior wall is very ingeniously explained by Fenwick in his consideration of "Inoculation Cystitis," i.e., that the patch is caused by the posterior wall coming in contact with the infected internal meatus in the collapsed or empty bladder. We have observed this congested area after catheterization, caused apparently by the vigorous contraction of the bladder wall on the tip of the catheter. This congestion is readily made out and is seen to consist of a thickly- woven net-work of very fine vessels. There is no appreciable loss of epithelial luster. If this precystitic stage continues to the point of infection a cystitis supervenes. 94 CYSTOSCOPY OF THE DISEASED BLADDER 95 Cystitis. Acute Cystitis. — While an acute cystitis is, as a rule, a contraindication to cystoscopy, it occasionally becomes necessary to secure ocular observation of the acutely inflamed bladder. This inflammation may be generalized, though as a rule, it is confined to the trigonum and the immediate surround- ing area. While of not particularly common occurrence, the cystitic area or areas may be localized on any part of the mucosa. Fenwick has noted a cystitis which involved but one-half of the bladder, the other hemisphere remaining absolutely free from infection. The infected area is seen to be a uniform turgescent red.\ There is a distinct loss of the epithelial luster noted on the normal \ mucosa. The elasticity of the infected area is greatly impaired. ' giving rise to a rugose appearance. The infected zone is bor- dered by a thickly woven net-work of fine vessels, which lose their individuality as they merge into the turgescent zone of infection. Submucous hemorrhages are often noted, and these small areas of extravasation are often noticeable some time after the acute inflammation has subsided. A filmy veil of muco-pus may be observed slightly hazing over the inflamed mucosa. The whole picture is one of acute inflammation. If the infected area is noted to immediately surround or trail away from one or both ureteral orifices, the infection may ' safely be considered to be a descending one. ' If in conjunction with a trigonal cystitis, a cystitic patch is noted on the posterior wall, this patch may be explained as an ''inoculation cystitis" (Fenwick, vide supra). Such localized patches may be the result of infection from contiguous pelvic inflammation. Subacute and Chronic Cystitis.^ — Chronic cystitis may pre- sent in varied forms, somewhat dependent upon the etiologic factor. In the subacute form where epithelial destruction has been extensive there is an almost entire loss of epithelial luster, so that with a perfect illuminating power in the cystoscope, the 96 CYSTOSCOPY AND URETHROSCOPY picture may appear vague and blurred, the so-called "light- absorbing" bladder. The mucosa is a uniform dark red. Rugosities are observed with great regularity and the bladder evinces a tendency toward stiffness, i.e., loss of elasticity. Here and there a film of mucopus is seen clingmg to the mucosa. Sloughy looking white patches may be observed attached to the dark-red back ground, a form of cystitis to which the terms "diphtheritic," "desquamative" and "membranous" have been applied. In the severer grades of vesical inflammation, large grayish areas of sloughing mucosa may be noted. In the chronic stage which sometimes supervenes on a pro- nounced acute cystitis, areas of ulceration may be observed. These ulcerative areas are usually at the site of submucous hemorrhages, a condition mentioned above in considering acute cystitis. In the extremely chronic form of such ulcerations a deposit of lime salts occurs, forming a thin phosphatic cap. To the untrained observer, these phosphatic deposits may be taken for true calculus and by the click elicited by a searcher may easily deceive the surgeon who depends entirely upon this instrument for the diagnosis of stone. Ulceration, while by no means pathognomonic of vesical tuberculosis, should lead to a strong suspicion of its probable presence. The cystoscopic appearance in a chronic cystitis of long standing is essentially different from that of the grades men- tioned above. The mucosa is almost sclerotic looking. The epithehal luster is lost but the "light- absorbing" characteristic noted in the subacute form is no longer present. Against the back ground of sclerotic- white, which has lost the pinkish-straw coloring that seems to underlie the normal mucosa, an occasional vessel is seen. The beautiful arborescence and delicate anas- tomoses which characterize the vascularity of the normal bladder are no longer observed. The few scattered vessels seem to be isolated and to have lost their small branch-like terminations. Occasionally, a cicatrix may be noted, the aftermath of an espe- cially severe invasion. CYSTOSCOPY OF THE DISEASED BLADDER 97 Stone. — The importance of the cystoscope in the diagnosis of vesical stone cannot be over-estimated. Erroneous findings, both positive and negative, are made with such frequency as to make even the skilled surgeon chary of a diagnosis made by the searcher which has not cystoscopic confirmation. In the comprehensive diagnosis of stone we are confronted by the following questions: (i) Is a stone present? (2) If present, have we to deal with single or multiple calculi and how many? (3) What is the character of the stone or stones, i.e., are they of the soft or hard variety and of what size? (4) Is the stone encysted, enclosed in a diverticulum or impacted in and protruding from the ureter? (5) If a click is elicited by the searcher, have we to deal with a stone or a phosphatic-capped neoplasm or ulcerated area? That a knowledge of the above conditions is important, especially if litholapaxy is contemplated, and that such knowledge can be obtained only by means of careful cystoscopy, will hardly be denied. In the detection of vesical stone, the searcher may and does often fail for the following reasons: (i) The stone may be caught in a diverticulum. (2) It may be held between the rugosities caused by conges- tion. (3) It may lie in a deep bas fond behind an over-hanging prostatic ledge. (See Fig. 49.) Fenwick has described an atonic sacculation of the bladder occurring just behind the interureteric fold which may im- prison the calculus and render its detection by means of the searcher extremely improbable. Under such circumstances a positive diagnosis can be made only by cystoscopy, and the frequency of such conditions is such as to deserve much greater recognition than is given them by the general profession. The appearance of stone presented under cystoscopy is 7 98 CYSTOSCOPY AND URETHROSCOPY striking and characteristic. The coloring and shape vary with the composition of the calculus. Kidney stones which have but recently entered the bladder are grayish-brown (uratic) or reddish-brown (oxalate). They may be smooth or spiculated. Stones which have remained in the bladder for a long period or which have formed in this viscus are phosphatic and vary from a grayish-white to a dead-white color. Their surface is usually smooth and if multiple calculi are present irregular facetted surfaces appear. Partially encysted stone or stones which are impacted at the orifice of the ureter will be noted as projecting apparently Fig. 49. — Comparison of sound and cystoscope for detection of vesical stones: Visible by cystoscope, but beyond reach of sound. (Keen's Surgery.) from the bladder wall. If the stone is old it may have a mush- room appearance. Stones which have recently become lodged in diverticula do not completely fill the cavity. If the diverticulum be large and the stone comparatively small, the phonophore devised by Follen Cabot and later modified by Eaton is of service in the detection of the calculus. If the stone has remained in the diverticulum for some time it may probably completely fill the cavity or may mushroom out into the bladder cavity. Case illustrated by Frontispiece: Multiple stones in the bladder. CYSTOSCOPY OF THE DISEASED BLADDER 99 F. J. C, aged 64: referred by Dr. J. C. Parrish, Vandalia, Mo . Extremely debilitated from prolonged suffering and urinary sepsis; with bilateral hypertrophy of the prostate and obstruc- tion (12 ounces of residual urine, alkaline, purulent). History of ten years standing. Frequent efforts at urination day and night, with occasional passage of small stones. Probably a hundred had passed out this way, with voluntary urination. After pro\dding rest and restora- tive measures for several days, we introduced the cystoscope and met with the remarkable view presented in the frontispiece. A multitude of calculi of varying sizes, ranging from that of a grain of sand to a pea; distributed over the reddened and trabeculated bladder in singles, in groups and in masses. After a good view had been taken by everyone available, the task of removing the stones was begun. They were washed out through the sheath of the Universal cystoscope, about a thousand being thus re- moved at the first sitting, and the remainder of over 1700 at the two successive similar sittings (Fig. 50). Radiograms of both kidneys and ureters were taken and showed no stone shadows in either. Later, when the patient had sufficiently recuperated, the obstructing prostate was removed by the suprapubic route, under novocaine-spinai anesthesia, with prompt and satisfactory recovery. In the cystoscopic diagnosis of stone, it seems hardly neces- sary to warn against mistaking a phosphatic-incrusted neoplasm for a calculus. The incrustation of a growth is thin and is readily Fig. 50- -Multiple stones (over 1 700) removed through cystoscope. lOO CYSTOSCOPY AND URETHROSCOPY fragmented by tapping with the beak of the cystoscope. The growth is usually readily observable and careful cystoscopy will establish the differential diagnosis. TUMORS Tumors. — The use of the cystoscope has demonstrated the fallacy of the older teachings as to the rarity of tumors of the bladder. Vesical neoplasms occur with a fair degree of frequency and their study has formed an important part in the remarkable advance made in urological diagnosis. Unfortu- nately their classification by the different investigators has given rise to much confusion. Kiister and Albarran have proposed a classification based upon the prevailing histological elements, epithelial, connective tissue and muscular. From the stand- point of histo-pathology, the classification is as follows: I Papilloma* I Carcinoma t Adenoma Cysts Epithelial Group Connective Tissue Group Sarcoma Myxoma Fibroma Angioma Muscle Group { Myoma Cystoscopically considered we may broadly divide bladder growths into two classes: (i) Pedunculated and (2) sessile. The pedunculated growths may present as villous- covered tu- mors or as smooth polypi. The sessile tumors may have a rough- ened, warty, or excoriated surface or be comparatively smooth or "bald" (Fenwick). It is quite often impossible to more than * In Kiister's classification papilloma is included in the connective-tissue group but Davis (Primary Tumors of the Urinary Bladder, Annals of Surgery, April, 1906) logic- ally places it in the epithelial group. fDewitski (Medicinsche Woche., Aug. 7 and 14, 1905) has recorded a case of syn- cytioma malignum. Fig. 51. — Cystoscopic view of tumor of bladder. Papilloma. CYSTOSCOPY OF THE DISEASED BLADDER lOI guess at the histo-pathology of the growth from its appearance through the cystoscope. As a fairly reliable rule it may be stated that slender-stalked growths are usuall}' benign while sessile tumors are generally malignant. Apparently benign villous-covered growths may exhibit malignant changes, this tendency toward malignancy being usually found at the base of the tumor. In the cystoscopy of bladder growths the cys- toscopist is concerned principally in determining the presence of a neoplasm, the number of growths present, their appear- ance and location, their mode of attachment to the bladder wall, i.e., w^hether they are sessile or pedunculated, and the ex- tent of the involvement of the wall in the base of the growth, all of which are important from the standpoint of subsequent treatment and prognosis. Cystoscopy. — Fenwick has divided the progress of vesical new-growths into tliree stages: (i) The latent stage; (2) the hematurial stage; (3) the stage of infection. The opportunity for examining the bladder cystoscopically in the first or symp- tomless stage is practically never presented and the cystoscopist is, therefore, forced to examine in the presence of free bleeding and infection. The clouding of the distention medium incident to the hemorrhage is operative against a comprehensive cystos- copy and requires changes in and additions to the technique usually observed in cystoscopy. To control the hemorrhage, st^-pticin may be administered internally and a i-iooo solution of adrenal extract injected into the bladder immediately before cystoscopy. Lately we have made use of normal horse serum hypodermically for the control of hemorrhage. The tendency of much intravesical instru- mentation to give rise to bleeding must be kept in mind and preliminary manipulations should be reduced to a minimum. Within a few minutes after the injection of the adrenal solu- tion the cystoscope should be introduced — and it is impor- tant that an instrument of the freely irrigating type be used — and the solution allowed to discharge through the sheath on I02 CYSTOSCOPY AND URETHROSCOPY the withdrawal of the obturator. The required amount of clear distention medium should be rapidly but gently in- troduced, the lens-system inserted, the light turned on and a rapid search for the growth instituted. In the event of copious hemorrhage quickly obscuring the distention medium, free irrigation through the instrument should be utilized. Even in extreme bleeding, a constant stream of irrigating fluid will keep the field under immediate observation sufficiently clear for accurate cystoscopy. Cystoscopy of a bladder which is the seat of a new-growth should be carried on with much gentleness and strict adherence to aseptic technique. Any intravesical manipulation under such conditions has a decided tendency to produce bleeding. If cystoscopy is done during the hematurial stage and previous to the supervention of infection, it is a safe rule to be prepared to operate immediately following the cystoscopic examination. Fenwick considers a history of sudden painless "blocking" of the urinary stream in vesical tumor to be indicative of marked back- pressure effects and favors immediate operation as soon as the cystoscope has confirmed the diagnosis. Unilateral renal pain is held by the same author to demand the greatest gentleness and cleanliness in cystoscopy. Contraindications to Cystoscopy.- — If, in the presence of a pronounced hematuria, manual or digital examination reveals infiltration of the bladder wall, cystoscopy is both unnecessary and contraindicated. The diagnosis of an infiltrating malignant neoplasm may be considered as established and the discomfort, trauma and danger of added infection incident to cystoscopy under such circumstances should be studiously avoided. A pronounced persistent cystitis supervening upon a history of profuse hematuria is contraindicative to cystoscopy unless followed by immediate operation. The indications are rather for suprapubic drainage, at which time exploration of the bladder may be accomplished. CYSTOSCOPY OF THE DISEASED BLADDER IO3 Location of Growths. — While the position a tumor occupies in the bladder is influenced in a great degree by the character of the growth, the area immediately surrounding the trigonum forms probably the most frequent location. The lateral and posterior wahs are quite frequently the site of bladder growth while it is extremely exceptional to find the anterior wall the seat of tumor. It is often difficult in long pedicled growths — and especially in those whose villi are long and tenuous — to locate readily the site of attachment of the pedicle. A growth springing from the lateral wall may appear under careless cystoscopy to be occupying the base or even the opposite lateral wall. It is always the part of wisdom to cause a swirl of irrigating fluid to be directed against the growth through the irrigating cystoscope causing it to float off and up in the distention medium and thus disclosing its site of attachment. Fenwick* has suggested change of position on the part of the patient during cystoscopy, thus causing the growth to gravitate to different parts of the bladder. In thickly covered villous growths, it is often difficult to determine the size of the pedicle or the condition of the mucosa surrounding the area of implantation. As these two points are of great diagnostic and prognostic importance, their determina- tion is important. Resort may be had to the irrigating cysto- scope {vide supra) which procedure will clear up the difficulty. Papilloma. — Of this form of vesical neoplasm, there are two distinct clinical types (i) the villous-covered growth having a definite pedicle and (2) the sessile warty patch. The latter is, in reality, made up of a number of thickly grouped papillae springing directly from the mucosa. These two forms will be described together. The appearance of the pedicled villous-covered growth — the so-called fimbriated papilloma — is one of the most beautiful and interesting pictures presented to the cystoscopist. The delicate fibrillae float freely in the distention fluid and are * Tumors of the Urinary Bladder. I04 CYSTOSCOPY AND URETHROSCOPY readily agitated, by any movement which disturbs the fluid, much resembUng the movements noted in deUcate sea-moss waving in its watery environment. Their color is a yellowish- pink, looking very much like small slender pieces of normal bladder mucosa which have become detached. Careful observa- tion of these fibrillae will disclose the presence of minute blood vessels coursing along their length. These villi differ greatly in size and contour. They may be of extreme tenuity and delicacy or they may present a shorter, thicker appearance. The villi are occasionally so stunted as to be hardly observable and the tumor may then appear to be of the "bald" epitheliomatous type. The viUi often present branchings or off -shoots. If bleeding be present, small streams of blood will be noted issuing from various parts of the growth. If hematuria has been pronounced, clots may be observed adhering to the tumor. If cystitis has supervened, a film of mucus may partially obscure the growth. It may be the seat of deposit of phosphatic grit. On observing the base, or pedicle, of villous-covered benign tumors, it will be noted to be in most instances slender and its point of attachment to the bladder wall has no surrounding zone of infiltration. A thick, stunted pedicle or infiltrated ap- pearance of the mucosa surrounding the base should immediately arouse a suspicion as to malignancy, as it is in the pedicle and base that malignant changes in apparently benign growths are observed. A slender pedicle and long villous processes are prognostic of benignancy. The fact that benign villous-covered growths occasionally occur as purely sessile tumors must not be overlooked, the villi in such instances arising directly from the vesical mucosa without any common pedicle. Sessility must, however, be always viewed with suspicion. Benign growths are almost invariably single, though a malignant tumor may be surrounded with benign papillomatous "splashings" or "tuft- ings" (Fenwick). The location of papilloma is usually in the neighborhood of the CYSTOSCOPY OF THE DISEASED BLADDER I05 trigone but outside of it. We have observed one case of long slender -stalked tumor in the male whose point of origin was the urethral angle of the trigone. Carcinoma. — Carcinoma of the bladder is observed as a smooth, sessile, infiltrating growth or as a pedicled villous- covered growth. These will be considered separately. The Sessile Growth. — The one pronounced characteristic of this form of tumor is its absolute sessility. It is usually found posterior to the interureteric fold but in its extension may involve the trigone. It is but slightly raised above the surrounding surface and its edges merge gradually into the surrounding mucosa. Its surface, comparatively smooth in the early stages of the growth, becomes later cracked and roughened and devoid of its epithelial covering. From these cracks blood oozes and mixes with the distention medium. White flakes of phosphatic deposit may be noted on its surface and often this phosphatic incrusta- tion is almost complete. If cystitis be present (and it is usually a factor before cystoscopy is undertaken) a veil of muco-pus covers the surface and floats up in the distention medium. The color of these sessile growths, at first reddish and marked by a net-work of dilated vessels, becomes later a reddish-gray, the color varying in different portions of the surface. The periphery of the tumor is marked by clusters of glandular translucent vesicles. These vesicles often extend up and over the surface of the growth, imparting to it a roughened mam- millated appearance. The extension of these vesicles for any distance from the growth is indicative of wide submucous infiltration and is an extremely bad prognostic sign. The Villous-covered Malignant Growth. — It is sometimes exceedingly difficult to make a cystoscopic differential diagnosis between this form of villous-covered growth and the benign villous-covered tumor. In the main, the malignant tumors of this class are characterized by shorter, denser villi, and a tend- ency to sessility and multiplicity. If the tumor is pedicled, Io6 CYSTOSCOPY AND URETHROSCOPY the pedicle is short and thick and is devoid of the peculiar freedom of movement noted in the slender pedicle of the benign growth. Satellite " splashings " are often found m the immediate neighborhood and these "splashings" are usually benign in character. A careful observation of the area immediately surrounding the site of attachment of the pedicle is of great importance. The mucosa, instead of presenting the normal appearance noted in the benign tumors, is injected with dilated vessels. Grape- like, vesicular bodies, formed from distended glands, often sur- round the base and Fenwick considers these as evidential of deep iniiltration. Sarcoma. — Sarcoma of the bladder is a comparatively rare member of the group of vesical neoplasms, though quite a goodly number of cases have been reported. Senftblen,* in 1861, recorded the first case and Wilder,! in 1905, reviewed fifty cases compiled from the literature. To these he adds four others, a total of fifty-four recorded instances. Of these cases, twenty- six were over forty years of age and only sixteen under twenty. The site of origin of the great majority of these tumors was in the immediate neighborhood of the ureters or the posterior wall. In the cases of Butlin, Williams, Fenwick, Whitehead and Bunce, practically the entire bladder was involved. In the cases of Siewert, Eve, Chaffey, Baker, D'Arcy, Power, Nicolich and Hinterstoisser, the growth sprang from the anterior wall. Such a large percentage of tumors originating in the anterior wall — a most unusual location for bladder growth- — should be kept in mind as a significant fact in the cystoscopy of vesical tumor. Fenwick concludes from his studies of sarcoma of the bladder that in children there is a tendency toward multiplicity and that in the adult the single growth is the rule. There is no rule as to the gross appearance of these tumors or as to their * Archiv f. klin. Chir., Berlin, 1861, Bd I, page 128. t Amer. Jour, of the Med. Sciences, Jan., 1905. CYSTOSCOPY OF THE DISEASED BLADDER I07 mode of attachment to the bladder wall. They are most often sessile or subsessile, though pedunculated growths occur with a fair degree of frequency. Their growth is rapid. The cystoscopy of sarcoma shows nothing that can be con- sidered characteristic. Wilder emphasizes the importance of the cystoscope in the early diagnosis of the presence of sarcoma and points to the case of Stankiewicz as being the only one in which recurrence had not taken place within one year subsequent to operation. In this case the diagnosis of the presence of a tumor was made by cystoscopy and the growth was no larger than a small cherry. Cysts. — Cysts of the bladder, with the possible exception of those of the mucous follicles found in the trigonal area, are of extreme rarity. Dermoid cysts have been observed as have those caused by the echinococcus. Follicular Cysts. — Cysts of the mucous follicles are not infrequently observed. They usually accompany a condition of submucous infiltration and are of about the same size and appearance as the cysts of Littre's glands of the urethra. They appear as small translucent vesicles, about the base of which careful observation will disclose a zone of infiltration. Fenwick has observed them at the edge of tuberculous patches and around the base of infiltrating epithelioma. They are not uncommon in chronic cystitis. Dermoid Cysts. — This rare form of vesical neoplasm usually presents as a sessile growth. In the case observed by J. Block,* a girl of eighteen years, the growth was located posterior and to the outside of the trigone. It was about the size and ap- pearance of a half of a small raspberry. Several fine hairs were seen emerging from small depressions on the surface. It was a pedicled growth, having a distinct fibrous pedicle. In its incipi- ency, it was undoubtedly sessile or subsessile. Bilharzia Disease. — This disease, fairly common in Egypt and Africa, is of the most extreme rarity in this country. In * Amer. Jour, of Med. Sciences, April, 1905, Io8 CYSTOSCOPY AND URETHROSCOPY England quite a number of cases have been observed in soldiers who have been on duty in Africa and Egypt. The cystoscopy of Bilharzia disease is inconstant and pre- sents nothing which may be considered characteristic. Fenwick states that the ova may be deposited in the mucosa without provoking marked disturbance and appear "as small clumps of white rice grains scattered over the bladder in patches." Griesinger, quoted by Fenwick, states that the earliest observable changes are scattered hyperemic spots. These spots of hyperemia, in all probability, mark the points of lodg- ment of the ova in the capillaries. With the emergence of the ova, small hemorrhagic spots are noted. In chronic cases, papillomatous growths are often observed. Fenwick considers the continued irritation caused by the dis- toma hematobia to be a cause of epithelial cancer and Goeber* con- cludes, from his exhaustive study of Bilharzia disease, that cancer forms fully 50 per cent, of the tumors arising from this cause. Echinococcus. — This form of parasitic invasion of the bladder has been observed, but it is of exceptional rarity among English- speaking peoples. Cystoscopically it presents nothing char- acteristic and we shall therefore dismiss it without further comment. Varices. — The existence of varices in the bladder, while denied by some writers and entirely ignored by others, has been established beyond any doubt. They are unquestionably rare but have been observed by Casper and others. We have ob- served one such case in which there were present pronounced varicosities. The patient was a middle-aged woman suffering from a marked cystocele. The cystoscopic appearance is typical. The bluish, dis- tended veins pursue a tortuous course over the mucosa. View- ing them laterally they are seen to project quite prominently above the surrounding mucosa. They are almost always found in the trigonal area or immediate neighborhood. * Goeber: Zeitschrift f. Krebsforschung, last index XLIV. CYSTOSCOPY OF THE DISEASED BLADDER IO9 Myxoma. — This is essentially a tumor of childhood, being rarely, if ever, encountered after the age of six years. It is extremely rare. In 222 cases of microscopically examined tumors observed by Nitze, myxoma occurred five times. Myxomata are markedly pedunculated and are quite often multiple. They spring from any portion of the bladder. In the female they may protrude from the urethra. Cystoscopically, they present a smooth well-vascularized surface and are semi-translucent, their degree of translucency depending upon the preponderance of the mucous element in their structure. They have no infiltrated area surrounding their site of attachment and closely resemble the mucous polypi found in the nose. Several mj-xomata may arise from a single pedicle. Fibroma. — Pure fibromata of the bladder are rarely, if ever, found. They practically always present the mixed t}^e of tumor, the papillary fibroma (Virchow), the fibro- myxoma and the fibro-myoma. The last form may be considered a surgical curiosity. Casper considers them the forerunners of myxoma, myoma and adenoma, but with this statement we cannot agree. Their cystoscopic description is that of papilloma and myxoma. Myoma. — The occurrence of myoma in the bladder, while especially rare, has been demonstrated as a possibiHty by Belfi eld's case. They occur as sessile growths and may attain a large size. They demand no especial cystoscopic description. Adenoma. — This rare form of vesical neoplasm has been observed twice by Nitze. He states that the tumor is usually sessile and may occur in any portion of the bladder, having been observed in the vertex where there is normally no glandular structure. The mixed type — adeno-carcinoma — is more com- monly observed than pure adenoma. Tuberculosis. — In taking up the cystoscopic stud}^ of urinary tuberculosis our consideration is practically limited to that form which is a descending infection from a tuberculosis of the upper urinary tract. That form of infection which is simply an exten- no CYSTOSCOPY AND URETHROSCOPY sion of tuberculous involvement of the prostate and adnexa affords no indication for cystoscopy and indeed, in such involve- ment, instrumental investigation of the bladder is distinctly contraindicat ed. While the possibility of primary vesical tuberculosis cannot be denied, its occurrence must be of the greatest rarity, if, in reality, such a condition ever exists. The cystoscopist, there- fore, may expect to find the tuberculous lesion in that location most liable to be attacked by a descending infection, i.e., the orifices of the ureters. It seems apropos at this point to sound a warning against careless cystoscopy in suspected tuberculous cases and especially in that class of cases in which the element of mixed infection is slight or absent. A comparatively latent tuberculous infection of the bladder may develop most virulent characteristics under trauma and introduced infection. The utmost precautions of aseptic technique and gentleness must be observed or most regrettable sequelae may follow. The appearance of vesical tuberculosis depends upon the stage of infection observed as well as upon the degree of involve- ment. In the extremely early stage — the stage of congestion which precedes the development of the tubercle^the appearance is not characetristic. Small areas of congestion, characterized I by an extremely delicate vascularization, will be noted immedi- ately surrounding one or other of the ureteric orifices, possibly trailing away from it on to the adjacent mucosa. This extension is practically always on to the trigonum or posterior to the inter- ureteric ridge. Later, these areas of congestion become the seat of minute extravasations and the appearance is that of small submucous hemorrhage. In the center of these hemorrhagic areas small grayish-yellow tubercles* will be noted. Each hemorrhagic * Fenwick's observations are not in accord with the description given here, but care- ful personal observation of proven cases justifies our description which seems to coincide with that of the majority of observers. CYSTOSCOPY OF THE DISEASED BLADDER III area may be the seat of a single tubercle or of multiple deposits. The further course of these tubercles is analogous with that of tubercles of any other mucous surface and the appearance va- ries with the stage of development. The natural course is toward ulceration and in the final stage of progress of the tuber- cle, ulcers are observed. These ulcerations call for especial description. The size and shape of such ulcers depend upon whether the ulceration is formed from the breaking down of a single tubercle or from the coalescence of a multiple deposit. In the former instance the ulcer has a fairly regular outline. In the latter, the outline is irregular and the ulcer is, of course, of greater dimensions. The edges are slightly raised above the surrounding mucosa. The base is grayish and necrotic. There is a peripheral zone of extravasation and the line of demarcation from the surrounding healthy mucosa is sharply defined. The appearance of the ureteral orifice in a descending tuber- culous infection which has involved the bladder is dependent upon whether the infection has travelled by continuity along the ureteral mucosa or whether the bladder has become infect ed from the infection- bearing urine without involvement of the ureter to any pronounced degree. In the latter instance, the changes in the orifice of the ureter are not particularly marked. There may be some slight puffi- ness of the orifice which may be touched by extravasated areas. But beyond changes similar to those characterizing the tuber- culous deposits in the mucosa, nothing characteristic is to be observed. Where the infection has been by continuity along the ureter, marked distortion of the ureteral orifice occurs and this distortion is characteristic. In the pronounced infiltration which accompanies the tuber- culous process in the ureter, there ensues a thickening and con- sequent shortening of the ureter — the so-called "bow-string 112 CYSTOSCOPY AND URETHROSCOPY ureter." With this shortening of the tube, the orifice becomes retracted and crater-like. The normal ureteral slit becomes widened and stiffened by infiltration until finally an irregular crateriform opening results. Ulceration may attack this thick- ened unyielding ring with the result that the edges of the orifice become ragged and covered with a grayish-yellow slough. Casper describes a bullous edema with the formation of numer- ous translucent vesicles surrounding the ureteral orifice which he considers peculiarly typical of a descending tuberculosis. Where the extension has been by continuity, another change which is quite characteristic will be noted. With the retraction of the ureteral orifice, the distance from the vesical meatus to the retracted orifice becomes correspondingly elongated. A possible congenital irregularity of the trigone must be taken into con- sideration, and without easily recognizable changes in the orifice of the ureter, the elongation of one of the ureteral sides has no pathologic significance. In the diagnosis of tuberculosis of the upper urinary tract, there is need of great caution. It quite often happens that the kidney and ureter may be markedly involved without any in- volvement of the bladder. In such instances, the only diagnostic sign to be observed cystoscopically is the retraction of the ureteral orifice. This, to the trained observer, is characteristic, but ureteral catheterization with a careful microscopical exami- nation will make the diagnosis certain; and we are convinced that careful technique in the urinary examination will reveal the tubercle bacillus in every instance of urinary tuberculosis. Lymphoid Tubercle.- — A condition which occasionally accom- panies bladder tuberculosis, and is also observed in non- tubercu- lous bladders which are the seat of cystitis, is a deposit of lymph in the form of lymphoid tubercle. On account of the possibility of confusing this condition with tubercle of the bladder, we have considered it best to describe lymphoid tubercle in connection with the consideration of tuberculosis in order that the differ- entiation may be readily understood. CYSTOSCOPY OF THE DISEASED BLADDER 113 The question as to whether there exists in the mucosa of the normal bladder lymphatic follicles is a mooted one, with the pre- ponderance of opinion favoring a negative view. The investiga- tions of Kretschmer,* whose review of the literature has been exhaustive, are of interest. He has compiled the findings of different investigators as follows: "S. Alexander describes the occurrence of lymphoid nodules or formations in the urinary bladder under the name of nodular cystitis "Stoerck and Zuckerkandl recently, in describing their Fig. 52. — Cystitis granulosa or lym- phoid tubercle (non-tuberculous). (After Kneise.) Fig. 53. — Cystitis granulosa. Kneise.) (After cases of cystitis glandularis, found, besides the presence of glands, areas of lymphoid cells which presented a follicle- like arrangement. "In regard to the presence of lymphoid tissue in the bladder normally, there are those authors who maintain that lymphoid tissue is not a normal constituent of the urinary bladder. "For example, Piersol in his book on Normal Histology says that simple lymphatic nodules or solitary follicles are found in almost all mucous membranes, those of the bladder and sexual organs excepted. * Surgery, Gynecology and Obstetrics, Nov., 1908. 114 CYSTOSCOPY AND URETHROSCOPY " Stoerck says that he examined a large number of bladders in infants in large series, and from various parts of the bladder for the presence of follicles, with the same negative results as were obtained by other authors. "According to Chiari, the mucous membrane of the bladder does not normally contain lymphoid tissue. That lymphoid tissue in the form of small masses occurs in the urinary tract he does not deny, but he says that their origin is in direct relation with the chronic catarrh of this mucous membrane. "Przewoski takes a similar view of this subject and says that, as they are absent at times, in adults, they cannot be looked upon as a normal part of the bladder mucosa. He thinks they can develop at any period of life, and draws attention to the fact that they occur in a mucous membrane which shows all the signs of inflammation, and that the catarrhal conditions of the mucous membrane give the best conditions for its develop- ment "Taking a directly opposite view of the ideas expressed by the above-mentioned authors, there are those who believe that lymphoid tissue is a normal part of the bladder. "Stohr says that the tunica propria sometimes contains solitary nodules. "In describing the histology of the pelvis, ureter, and blad- der, Bohm and Davidoff state that the mucosa often contains diffuse lymphoid tissue which is more highly developed in the region of the renal pelvis. "Bailey is very positive, for he says that the stroma (of the bladder) consists of fine, loosely arranged connective tissue containing many lymphoid cells and sometimes small lymph nodules. "S. Alexander says that the presence of lymphoid tissue may be looked upon as the rule and its absence as the exception. " Weichselbaum found these formations in five individuals, varying from twenty to twenty-three years of age, who never had had a gonorrhea. He is of the opinion that normally lymph CYSTOSCOPY OF THE DISEASED BLADDER II5 follicles may be present, but very sparingly, and that, not until they become swollen and enlarged by pathological changes do they become visible microscopically. " Ziegler holds a somewhat similar view, for he says that when the mucous membrane of the bladder contains small aggrega- tions of lymphoid tissue, which are not uncommon about its neck, these are apt to protrude from the injected bladder surface as grayish- white nodules. "Aschoff found numerous follicles in one new-born female." Sabotta and McMurrich state that there exists in the mucosa of the bladder lymph nodules but no true glands. In the case investigated by Kretschmer apparently true lymphatic follicles were found, but he concludes that such findings must be consid- ered abnormal. The peculiar formation of lymphoid tubercles has been termed by Fenwick "adenoids of the bladder" though he recognizes their true character. They exhibit a pronounced predilection for the trigonal area. In a case examined post- mortem by F. J. Hall and described in a personal communication to us, the tubercles were scattered over the entire bladder mucosa, but this must be considered most unusual. Commonly, they are noted on the trigone or in its immediate neighborhood. This statement is borne out by the observations of Fenwick and ourselves. Lymphoid tubercles are of a peculiar yellowish, gelatinous appearance and are distinctly raised above the mucosa. The surrounding mucosa has no reddish zone of extravasation. The absence of hemorrhagic periphery and the relatively large size of the lymphoid tubercle serve to differentiate it from true tubercle.* SIMPLE ULCER Non-tuberculous Ulceration of the Bladder. — Ulceration of the bladder is usually noted as an accompaniment of severe * Fenwick cautions against mistaking lymphoid tubercles for actual tuberculous deposits in the presence of a vesical tuberculosis. Il6 CYSTOSCOPY AND URETHROSCOPY cystitis and has been given sufficient consideration in connection with the study of cystitis. There is, however, one form of vesical ulcer that deserves especial mention, the non- tuberculous ulcer, the etiology and symptomatology of which are extremely obscure. It is appar- ently idiopathic in its origin, the basis of which is probably an arterial or trophic disturbance, followed by a localized necrosis. It has been observed, as a rule, in males between the ages of twenty and thirty, though females and persons of other ages are by no means exempt. It is usually noted posterior to the interureteric ridge and adjacent to and to the inner side of one or the other ureteral orifice. It is a comparatively rare form of bladder lesion. There is nothing characteristic in its appearance and it may readily be confounded with tuberculous ulceration, from which it can only be differentiated by the absence of coexisting tuber- culous lesions. The tubercle bacillus is, of course, not present in the urine. The ulcer varies in size from one-half inch in diameter to one and one-half inches, averaging in size three-quarters of an inch and has a fairly regular outline. The surface is depressed. Its coloring is grayish and necrotic and there is the tendency noted in all forms of vesical ulceration to the formation of phos- phatic crust. The lesion is markedly chronic in its course and is unaffected by anti- tuberculous measures. Occasionally the edge of the ulceration is undermined presenting the appearance found in chancroid. Careless or rough instrumentation occasionally traumatizes the vesical mucosa to such a degree that ulceration follows. Before the advent of the low- amperage lamp in the cystoscope, burns of the bladder mucosa from the hot beak of the instrument were not uncommon. These burns were followed by subsequent sloughing and ulceration. Traumatic ulceration yields slowly but certainly to rational treatment. Fig. 54. — (Above) edema bullosum, in connection with (below) bilateral hyper- trophied prostate. CYSTOSCOPY OF THE DISEASED BLADDER II7 Edema Bullosum. — Albarran, Casper and others have noted the presence of a submucous serous exudate occurring in the form of blebs or bullae accompanying inflammatory processes of the bladder and to this submucous effusion they have given the name of Edema Bullosum. Bierhoff'* has. given a most excellent description of this condition. The formation of bullae may occur in any form of cystic irritation. Casper considers their presence surrounding the orifice of the ureter characteristic of a descending tuberculosis. The cystoscopic appearance of bullous edema is fairly typical. The bullae present as semi-translucent vesicles, varying in size from that of a pea to a grain of wheat. Their coloring and trans- lucency vary in direct proportion to the amount of inflammatory hyperplasia which has taken place in their mucous covering. Their protrusion above the surrounding surface is occasionally so pronounced as to give them a pedunculated appearance. Bullous edema 's practically limited to the trigonal area, being seldom encountered elsewhere. The bullae seldom, if ever, occur singly and usually present as a group of "heaped-up" vesicles. Diverticulation and Trabeculation.— Diverticula of the bladder are congenital or acquired. The former are usually single while the latter are almost invariably multiple and are associated with trabeculation. For this reason we shall consider them together. Congenital Diverticula. — Congenital diverticula are com- paratively rare. By predilection they are usually situated justbe- hind the interureteric ridge though they may present in any part of the bladder. Cystoscopically they appear as round or oval open- ings. The size of the opening is varied. The mucosa, in the ab- sence of infection or of contained stone, has a normal vasculari- zation and appearance. They are much deeper than the acquired variety and it is usually impossible to see the distal end of the sac. Acquired Diverticula. — Acquired diverticula are practically * Medical News, Vol. LXXVII, 1900. Il8 CYSTOSCOPY AND URETHROSCOPY always multiple and, being the result of sacculation, or extrusion between trabeculae caused by long-continued muscular spasms to overcome obstruction at the vesical meatus, their edges are formed by trabecular bands and their orifices are, therefore, irregular in shape. They are comparatively shallow so that the entire surface of the sac may be seen during cystoscopy. The changes in their mucous lining partake of the same character as the changes noted in the rest of the bladder mucosa. True trabeculae must be differentiated from that condition which is often observed during cystoscopy in well distended bladders in which considerable muscular spasm is taking place. In the latter condition, muscle bands will be seen to stand out prominently upon the mucous surface of the bladder. To the uninitiated, these muscle bands may be taken for true trabeculae but the absence of vascular and epithelial changes and of diver- ticula will readily serve to differentiate this condition from true trabeculation. Tabetic Trabeculation. — Nitze was the first to call attention to the fact that even in the earlier stages of tabes there occurred a trabeculation of the bladder wall due to incoordination between the detrusors and the sphincters. This condition is in some cases quite marked and we beHeve with other observers, notably Koll, that it is often possible to make a diagnosis of tabes through the cystoscope even before the classical symptoms of the disease have developed. The trabeculation is the result of atonicity and resembles the apparent trabeculation which is sometimes observed during cystoscopy, as the result of over- distention of the bladder accompanied by a certain amount of spasm. The difTerentiation between these two conditions is important and trabeculation which is observed in the absence of distinct obstructive conditions in the lower urinary tract should always lead to a suspicion of a possible cord involvement. Leukoplakia. — The formation of thick dead-white plaques — the result of epithelial proliferation — upon the bladder mucosa has been occasionally noted as the sequence of prolonged cystic Fig. 55. — Trabeculation and diverticula of bladder wall. (Knorr.) CYSTOSCOPY OF THE DISEASED BLADDER II9 irritation. As in leukoplakia, or leukokeratosis, taking place on other mucous surfaces, these plaques may be considered as the possible forerunner of epithelioma. Cystoscopically, they ap- pear as irregular dead-white patches slightly raised above the surrounding mucosa in which there is a sparse vascularization and diminution of epithelial luster. They must be differentiated from phosphatic "incrustations" of flat infiltrating new-growths. This differentiation can be readily made by tapping the patch with the beak of the cysto- scope and by the fact that these patches are absolutely lusterless. Occasionally they themselves may be the seat of phosphatic deposit but there should be no difficulty in differentiating them from infiltrating malignant growths. Ureteric Meatoscopy. — The diagnostic importance of the changes which are sometimes noted at the orifices of the ureters consequent to disease of the upper urinary tract has been much insisted upon by certain writers on the subject of cystoscopy, notably Fenwnck. We cannot share in their advocacy of this form of cystoscopic diagnosis and while positive findings of diseased ureteral orifices are of value in indicating the presence of pathologic changes in the corresponding kidney and ureter, negative findings cannot be considered as contraindicating a kidney lesion. We are of the opinion that ureteric meatoscopy without exploration of the ureter and the collection of the separately catheterized urines must be considered of minor importance. The retracted crater-like orifice due to a descending tuber- culosis, the everted or prolapsed orifice, the so-called cystic distention of the ureteric orifice and the edematous swelling of the orifice due to stone lodged in the vesical end of the ureter are all worthy of consideration from the standpoint of cystos- copy. The first-named condition has been sufficiently described under vesical tuberculosis. Eversion or Prolapse of the Ureteral Orifice. — Eversion of the ureteral orifice is comparatively infrequent. It is probably I20 CYSTOSCOPY AND URETHROSCOPY the result of long-continued expulsive efforts on the part of the ureter. It varies markedly in degree. In the lesser degrees it may be present at one cystoscopy and absent at another exami- nation. In one case which we have been enabled to cystoscope quite frequently, eversion of one ureter orifice was well marked on some examinations and absent at others. A catheter inserted into the prolapsed orifice would reposit the everted mucosa very readily. The urine coming from this side was normal in every particular, the other kidney being the seat of disease. True prolapse of a severe grade is rare. It has been mistaken for new-growth of the bladder and at least one case has been operated on under this mistaken impression with fatal results. This case is fully reported by Colley* and occurred in an infant of eighteen months. There should be no difiiculty in the cystoscopic diagnosis of this condition. The eversion of the ureteral mucosa through an enlarged orifice has much the appearance of an anal prolapse. Fenwick considers many of the reported cases of eversion to have been examples of cystic distention or "ballooning" of the ureteral orifice and says that cystoscopic differential diagnosis must be made between the two conditions. The dissimilarity in the appearance of the two conditions is so marked that we consider any mistake in classification to be due to confused terminology rather than to actual error in diagnosis. Cystic Distention of the Lower End of the Ureter. — While infrequently met with, this condition has been reported a suffi- cient number of times to accord it cystoscopic description. It is dependent upon congenital atresia or narrowing of the ureteral orifice. The expulsive force of the ureteral peristalsis gradually forces out the mucosa of the orificial end of the ureter and it becomes ballooned (Figs. 56 and 57). Afterword. — It hardly seems necessary to mention here the fact that uterine tumors and exostoses from the pelvis may impinge upon the bladder to the degree that they may cause a *Path. Trans., 1879, Vol. XXX, page 310. CYSTOSCOPY OF THE DISEASED BLADDER 121 bulging or distortion on the inner side of the viscus. Malposi- tions of the uterus may give the same cystoscopic appearance. From the standpoint of cystoscopy these changes in the shape of the bladder as observed through the cystoscope are rather Fig. 56. — Constricted ureteral orifice and resulting uretero-vesical cyst. (After Knorr.) Fig. 57. — Side view of the same, with catheter introduced. (Knorr.) unimportant. There is a possibility of their being mistaken for vesical tumors but the absence of vascular changes in the mucosa and of evidences of infiltration should serve to obviate any pos- sible error. We do not consider them of enough importance to award them any further discussion. CHAPTER VII OPERATIVE CYSTOSCOPY In view of the excellent and comprehensive work already accomplished, as well as that prospective, through the instru- mentality of the several operative cystoscopes on the market, due consideration of this subject is appropriate. Operative cystoscopy is indicated in all cases in which it can accomplish the surgical purpose in view — the removal of a for- eign body or the remedying of a surgical condition — that can be accomplished otherwise only by opening the bladder. It goes without saying that this mode, if successful, is less heroic and more readily acceptable to the patient than a cutting opera- tion would be. But there are various factors and conditions that have a bear- ing on the appropriateness of operative cystoscopy to a given case: The tumor or lesion or foreign body itself, its size, location, nature; the extent of involvement of the vesical structures; the capacity of the bladder and its tolerance of instrumentation; the fortitude of the patient; the caliber of the urethra, etc., and finally, the skill of the operator and his familiarity with the technique of such work. If the nature of a growth or its extent of involvement is such as to indicate that removal by this method will not give the last- ing results offered by the more radical cutting measures, the cystoscopic method is not to be chosen. But it is not yet deter- mined that the cutting methods do give more lasting results or greater freedom from recurrence in cases of adventitious vesical growths. That question is still under discussion. It is estab- lished* that Nitze removed by cystoscopic methods 150 non- *Knorr, Cystoscopy, 1908, page 168. OPERATIVE CYSTOSCOPY 1 23 malignant tumors from the unopened bladder, with only one death and three recurrences. The records of open operative methods do not furnish anything to compare with these figures, which make an overwhelming argument for operative cystos- copy in non-malignant growths where it is practicable — both from the standpoint of operative mortality and of freedom from recurrence. . It is further established that open operations, with the ex- tensive handling and manipulation required in removing vesical growths, are prone to contribute to further inoculation and dis- semination of such growths at other points in the vesical mucosa. Even excessive care in the handling of such tumors, by means of forceps alone, etc., has not furnished exemption from such sur- gical inoculation; so that operations have been devised with the especial object in view of preventing this unfortunate occurrence — such as the transperitoneal mode of attack, as recommended by Harrington (Annals of Surgery, 1893) and popularized by Mayo. It cannot be conceded that lack of equipment, of skill or ability in cystoscopic methods, on the part of the surgeon, furnishes legitimate reason for withholding the benefits of opera- tive cystoscopy where it is demanded. Tracheotomy and in- tubation bear a similar relationship. The safer and more con- servative method is the one to be applied when it is demanded, and it is incumbent on the surgeon who accepts such cases to prepare himself for applying the approved method. Such a choice may stand between the life and death of a patient; as, witness the large difference between the death-rate of litholapaxy and that of the open methods of removing calculi from the bladder, i.e., approximately 2.4 per cent, for litholopaxy, and from 10 to 13 per cent, for the lithotomies — showing the strikingly greater number who die from cutting methods as compared with the non-cutting ones. While possibly not always justified by actual conditions, it is a fact that patients are habitually influenced by fear and appre- 124 CYSTOSCOPY AND URETHROSCOPY hension when, contemplating a cutting operation, and are prone to procrastinate and postpone measures for relief until serious secondary complications are established, the kidneys involved, etc. It is probable that many of these would more readily accept the cystoscopic methods of relief if presented to them, especially when accompanied with an explanation of their freedom from the necessity of general anesthesia and of lying in bed for one, two or three weeks in convalescence from a cutting operation. It may reasonably be asserted, therefore, that where opera- tive cystoscopy is appropriate and applicable it should be given the position of choice. The field of operative cystoscopy has heretofore been con- fined almost exclusively to the bladder and its contents, but the experience of the authors in operative cystoscopy of the upper urinary tract has been sufficiently encouraging to justify the division of the subject into: I. Operative Cystoscopy of the Bladder; II. Operative Cystoscopy of the Ureter. The objects to be accomplished in the first of these divisions are the following : 1. Crushing and removal of stones. 2. Removal of foreign bodies: hairpins, twigs, catheters, ligatures, etc. 3. Removal of pieces of growth for investigation. 4. Removal of tumors and cauterization of their bases. 5. Fulguration or application of the high-frequency current to vesical tumors. 6. Fulguration or cauterization of ulcers or ulcerated areas in the vesical mucosa; of varices, cysts, etc. 7. Curettement of ulcerated areas, and the topical applica- tion of strong solutions to the site affected. The second of the divisions embraces the following objects for accomplishment: I. Dilatation, divulsion or incision of a strictured ureteral orifice. OPERATWE CYSTOSCOPY 1 25 2. Removal of stone from the ureter, 3. Gradual dilatation of stricture at any point of the ureter. 4. Securing the closure of a fistula of the ureter at any point. 5. By dilatation, irrigation and the injection of oil into the ureter to promote the descent of a stone or stones impacted high up in the ureteral channel or even in the renal pelvis. OPERATIVE CYSTOSCOPES To meet the varied requirements of operative cystoscopy much ingenuity has been displayed in the production of the several instruments on the market. First in the lists were the instruments of Nitze and of Casper; later, others were introduced, exhibiting more or less individuality in their objects or their construction. The operative cystoscopes of Kolischer,* of Mainzer, Mirabeau,t and of Latzko| were purposed for the female bladder only, and were based on the ''direct" plan of access, after the manner of Brenner. Kelly and Pawlik's instruments were for females only, and were used with air distention, secured by postural methods (knee-chest position). The operative cystoscope of Bransford Lewis, § pre- sented in 1904 (Fig. 58) was capable of being used in either male or female, with either air or water distention, under control of rubber bulb for the former, and hydrostatic pressure for the latter; thus affording freedom from reliance on posture to secure distention of the bladder. Similar instruments were introduced in 1905 by Luys and by Cathelin, appropriate for both male and female bladders For vesical operative cystoscopy the cystoscope of Nitze is the one best known and most highly esteemed, that fact being based both on the large experience of its author with this instru- * Wiener med. Presse, 1897, No. 52. t Centralbl. f. Gynecologic, 1900, No. 36. t Wiener klin. Rundschau, 1900, No. 37. § Trans. Miss. Valley Med. Assn., Oct. 11, 1904. 126 CYSTOSCOPY AND URETHROSCOPY Fig. 58. — The Bransford Lewis Operating Cystoscope (1904); SH., sheath; OB., obturator; H., lens-telescope, with perforated collar for passage of the acces- sory instruments. =^^ THE KNY-SCHEERER CO.N.Y. <... u THE KNY- SCHEERER CO.N.Y. Fig. 5q. — Accessories for author's operating cystoscope: i, alligator forceps; 2, ureteral scissors; 3, ureteral dilator; 4, flexible ureteral forceps; 5, bulb-aspirator; 6, cautery; 7, catheter carrier. OPERATIVE CYSTOSCOPY I 27 ment and on its individual merits. Its main objects are, the ensnaring and removal of a pedunculated vesical tumor (papil- loma) ; the cauterization of the base after removal; the crushing and removal of stones of moderate dimensions; the grasping and removal of foreign bodies. The Nitze operative cystoscope consists of an inner telescope, and an outer sheath. The telescope contains the lamp and the prism for observation. The sheath is made in several forms, according to whether it contains a platinum wire snare or a cau- tery mounted on porcelain. The sheath has an irrigating channel and rubber tubing for the purpose of running water in and out of the bladder after the introduction of the cystoscope. To the sheath that bears the wire snare is attached the apparatus for moving the wire, one strand at a time, back and forth, in- creasing or decreasing the size of the loop. Technique. — First, unscrewing the beak, the particular sheath desired for use is slipped over the shaft of the telescope and the beak is replaced. With these two parts closed tightly, the whole instrument is passed into the bladder. The telescope is pushed forward through the sheath, which exposes the lamp and prism and permits a view of the vesical contents, including the inner end of the sheath itself, whence, at will, the wire loop is made to emerge by means of the mechanism before mentioned. If a pedunculated polyp is the object of the attack, it is brought into view, encircled with the snare, when, with or with- out the addition of galvanic heat, the loop is contracted, the pedicle compressed and finally severed. Unless the resulting hemorrhage is too severe, the sitting may be completed with cauterization of the base or stump of the tumor; for which a sheath with porcelain-covered cautery is appropriate. When the tumor is too large to be removed all at one time several sittings may be required, a portion only being remo\ed by the loop each time, until finally the base is reached and the terminal cauterization applied. In other instances, where the attachment is sessile or there 128 CYSTOSCOPY AND URETHROSCOPY are ulcerated areas, the cautery itself is the agency utilized. To meet the demands of differing locations and sizes of tumors, several sheaths have been constructed, with beaks of differing lengths. With the lithotriptor not only may calculi of fair size and density be seized under observation and crushed for extraction by subsequent washing, but the fragments left over after ordi- nary litholapaxy may be detected, seized and removed or further crushed and removed; thus rounding out an operation which, though brilliantly executed, is sometimes marred by leaving in a flake or fragment of stone, that later acts as a nucleus for further stone formation and recurrence. The Casper model of operative cystoscope is composed of sheath, irrigating tube, galvano-cautery, and cold snare. Casper does not deem it necessary or desirable to heat the snare but prefers the cold one. With the same instrument there are also a sharp curette, and forceps for the removal of foreign bodies. Although the operative cystoscopes of Mirabeau, Mainzer and Kolischer are built on the Brenner direct-vision plan, they are supplied with lenses and are used with water as a distending medium. For vesical operative cystoscopy all instruments adopting the direct-vision plan labor under a certain definite disadvantage: They are incapable of working at a right- angle or "around the corner." The direct (forward) view is the only one furnished by them, and this does not permit access by them to the anterior wall of the bladder. It is true that most adventitious growths and pathological conditions of the bladder are located at the trigone or on the posterior wall in the neighborhood of the ure- teral orifices, within reach of the direct-vision models, but a certain small proportion of them do not follow this rule but are located on the anterior wall, outside of their sphere of activity. While relatively few in number, such cases must be reckoned with in operative cystoscopy. The air cystoscopes of Pawlik, Howard Kelly, Luys, Cathelin OPERATIVE CYSTOSCOPY 129 and Bransford Lewis may be classed as similar in their main features yet with points of essential difference. Those of Pawlik and Kelly are designed for females only, are used with external illumination (head mirror), and the air distention of the bladder is obtained by postural methods; while the other instru- ments mentioned are adapted to both males and females, are equipped with cold lamp internal illumination, and their air- cocks and insufflation arrangements for effecting forced inflation make them independent of postural necessities. In males it is inexpedient to try to secure distention of the bladder by knee- GZfe;e= Fig. 60. — Bransford Lewis air cystoscope. 1900. chest posture; it occasions too much of a strain on the patient, both generally and locally, and the bladder does not usually dilate satisfactorily. Neither is the view obtained at all satis- factory. In females the knee-chest posture usually secures sufficient dilatation of the bladder, but at most it is awkward and embarrassing for the patient and uncomfortable for the operator; and does not offer any advantages not possessed by the patient lying on her back or in the lithotomy position — a much more natural and acceptable one. While it is a fact that in most women the exaggerated lithotomy position, with eleva- tion of the pelvis, will produce dilatation of the bladder sufffcient 9 130 CYSTOSCOPY AND URETHROSCOPY for use with the cystoscopes of Kelly and Pawlik (unequipped with forced inflation bulb, etc.), it also is a fact that there are numerous exceptions to this rule; exceptions in which the bladder is too inflamed and tender and its tonicity too great to permit of satisfactory dilatation through this comparatively mild (and in such instances, inefflcient) means. Therefore it is of much advantage to be in position to control the dilatation by means of forced inflation with air-bulb, if air is used, or by hydrostatic pressure if water be the distending medium. Moreover, it is of equally great technical advantage to work with the internal illumination of a cold electric lamp, carried in the beak of the instrument, as compared with the endeavor to use the unstable head mirror as a source of illumination, with its ever-changing distances and alignment. The Bransford Lewis Operating Cystoscope. — Regarding its sphere of action, the following considerations apply to this instrument: For general intravesical operative work, its scope is not as great nor as broadly serviceable as the Nitze or Casper instruments; but on the other hand, it is very much simpler in its construction and in its use; while for intraureteral work it presents advantages not possessed, it is thought, by any of the other instruments. In fact, it has been developed with this kind of work particularly in view; and ten years' use has brought the conclusion that it has well fulfilled the mission designed for it. Instrument and Technique. — This instrument (Fig. 58) con- sists of a tubular sheath, Sh, with a cold lamp throwing its light from the convexity of its beak only, as this is a direct- vision instrument and requires no lateral illumination. Air-cock i connects with the large interior channel of the sheath, and is used to supply additional air or water to the blad- der as desired, during manipulation or observation. Cock 2 connects with the smaller tube 2-3, which is utilized for aspir- ating excess of fluid or blood, etc., from the bladder during man- ipulation. The obturator, Ob, fills out the sheath during its OPERATIVE CYSTOSCOPY 131 A>=°^ B-^^ WnrVLtX ELECTMC Mrg. CQ uvc. /I/SW YORK ex D Fig. 61. — Appurtenances to Bransford Lewis universal and operating cystoscope, model 1914. A. Flexible biting forceps; B, scissors; C, stone forceps; D, ureteral dilator; E, volcellum forceps. V/APFllR ELECTFIC MFG. CO. INC. NEW YORK Fig. 62. — The Bransford Lewis combined universal and operating cystoscope latest model 1914. A, Forceps in use by direct method; £, Same, by indirect method. 4^ © e IJ { 12 14 16 18 20 1 Fig. 63. — Dr. Leo. Buerger's ureteral dilators. 132 CYSTOSCOPY AND URETHROSCOPY introduction into the bladder; after which the obturator is withdrawn and is replaced by the perforated ocular window. The perforation in the window may be closed by a metal plug (not shown in the illustration) when the cystoscope is in use for observation only; or it permits the passage of the several acces- sories, forceps, etc., when in use for operative purposes. The adjustment of accessories to the perforation and to the window is such that the distending medium, water or air, is retained in the bladder during the work. When in place for use, the several accessories hug the floor of the inner channel, leaving the greater part of the space above for vision. The field of view is not large at one time, but the survey is made by moving the instru- ment in various directions; by which, successively, the trigone, the base, the posterior and lateral walls and some of the apex are brought into view. If water be chosen as the distending medium, the field of vision may be enlarged considerably by using the direct lens telescope, H, which also passes through the perforation in the window. Lenses are impracticable when air is used, as they tend to become smeared with mucus and obscured. As the instrument is capable of being used with either water or air as a distending medium the operator is in position to exercise his preference. In using air-distention it is desirable to keep the field as free from fluid, urine, blood, etc., as possible, to which end the accessory aspirating tube, 2-3, is utilized. Accessories. — The several instruments accessory to the operating cystoscope are shown in Fig. 61. They consist of: 1. A straight alligator forceps, i, for use either in the ureter or bladder, for grasping and removing a small stone or foreign body. 2. Flexible ureter forceps. 4, that may be opened and closed at will, even though in a curved or double-curved position; to be passed into a ureter for one or two inches, following the pelvic curve of that organ, and made to grasp a ureteral stone impacted there. It is made like a bullet forceps, both for the purpose of OPERATIVE CYSTOSCOPY I33 obtaining a better grasp of a ureteral calculus and also to avoid injury to the ureteral mucosa when opened up within the channel. In a number of instances the author has succeeded in passing it as far as two inches up the ureter. If the ureter is dilated the forceps may be passed even further than that. 3. Ureteral scissors, 2, for snipping the orifice of a strictured ureter. 4. Ureteral dilator, 3. It is introduced into a stenosed ureter closed and is then stretched widely as it is withdrawn or while remaining in one position. 5. Galvano-cautery point or blade, 6. 6. Ureteral catheter-carrier, 7, for transmitting ureteral sounds or catheters. 7. Suction bulb, 5. 8. Lens telescope, H, for direct observation. Mode of Use. — To facilitate operative work with this instru- ment the patient should be on a well-arranged cystoscopic table, capable of giving marked elevation of the pelvis when required, and supporting the legs in comfortable leg-crutches, rather than foot rests. Ample anesthesia must be provided, to secure entire relaxation and non-resistance of the bladder, as well as quietude on the part of the patient. (For remarks on anesthesia, see page 23). One must determine whether he is to use air or water as a distending medium for the bladder. If there is much hemor- rhage, or reason to believe there will be such incident to the procedure — as often occurs in connection with vesical work of this kind — it may be best to resort to air-inflation. Whereas, water may be readily clouded and the view obscured by such influences, when used as a distending medium, air is not so affected. With the patient in the exaggerated lithotomy posi- tion any accumulating blood or pus wiU tend to gravitate toward the summit of the bladder, if distended with air, thus keeping a clear field for operative work in the neighborhood of the trigone, the ureteral openings, the base, etc. If the fluid accumulation 134 CYSTOSCOPY AND URETHROSCOPY becomes sufficient to interfere with the operative field it may be drawn out by use of the aspirating bulb, or by opening the cock leading to the vacuum bottle, the beak end of the cystoscope being held, meanwhile, in the pool of fluid. As the air tends gradually to escape during manipulations, it is advisable to have an assistant keep up regular and moderate insufflation with the double rubber bulb supplied for the purpose. Care must be exercised lest too great air pressure be supplied. While, if used with due regard to this precaution, no harm can result, cases have been reported in which a break in the continu- ity of the mucosa at some point has permitted the passage of air into the tissues and given rise to emphysematous accumulations that caused annoyance and anxiety. We are not aware that any such accident has proved fatal, and probably there will be no fatality from such a cause, but it is just as well to avoid any such possibility by remaining within the limits of reason and modera- tion in all manipulations within the urinary tract. It must be remembered that water is a medium more natural and more acceptable to the bladder than air, and arouses much less irritation or resistance than does air. When the work is to be done in the ureter, or will probably be unattended by severe bleeding or clouding of the fluid, water may be chosen as a dis- tending medium. It is best supplied by gravity from a glass irri- gator, about two feet above the level of the patient. When used, the direct- view lens telescope may be used with it, or, if pre- ferred, the ocular window only; in which case an unbroken column of water must be maintained between the window and the interior of the bladder. The smallest bubble in the cysto- scope sheath will obscure the view. Therefore the window should be adjusted while the water is running, thus expelling all bubbles. With conditions properly adjusted an excellent and clear view is obtained in this way, though the field is not a large one, as previously mentioned.* *The latest model (1914) of the author's cystoscope (see page 1:31) is used only with water-distention, because of the many advantages and fewer objections per- taining to it. OPERATIVE CYSTOSCOPY 135 Cauterization. — This may be accomplished in two ways with this instrument: By direct applications of chemical cauterants, nitric acid, nitrate of silver, etc., on a cotton- tipped probe or applicator, or by means of the alligator forceps, passed through the window and sheath of the cystoscope; or the cautery blade, 6, Fig. 59, may be brought to livid heat by the galvanic current. In using the electric current for the double purpose of illu- mination and cauterization, it must be remembered that when using the ordinary rheostats or controllers for illumination two separate and independent sources of electricity should be utilized; for instance, while the street current is passed through the current controller and serves for illumination, a storage bat- tery should supply electricity for the cautery current, with a large cable adapted to cau- tery purposes. Occasionally, under the circumstances just mentioned, or indeed during the performance of an ordinary cystoscopy or endoscopy, the operator or patient receives an electric shock of more or less severity by the grounding of the current through a moist tile, wood or granitoid floor. A medical friend of the author's was knocked to the floor uncon- scious by such an occurrence, on one occasion, and it was several days before he fully recovered from the effects of the stroke. For the purpose of avoiding the possibiUty of such an accident, Mr. Wm. A. Phillips, of St. Louis, has made for the author an induction rheostat (Fig. 64) which not only gives complete security in this respect but supplies gradations of light-regulation so finely drawn as to completely avoid the jump-increase incident Fig. 64. — Bransford Lewis' Induction Rheostat. 136 CYSTOSCOPY AND URETHROSCOPY to regulation by successive buttons. The security against shock or grounded current is attained by having the rheostat composed of two separate coils of wire, one within the other, affording an induced current from one to the other, with no direct connection between them; so that it is impossible for the street current to be transmitted directly to the operator or the patient when this rheostat is in use. Fig. 65.— The Bransford Lewis electric controller (for direct or alternating current). This rheostat can be used only in connection with the alter- nating current. If the direct current is the only one available a motor generator may be interposed to develop the desired alternating current, which is then led into the rheostat. All of the fulguration or high-frequency apparatuses on the market that are furnished for use in connection with the direct current are supplied with such a motor generator. It converts the direct OPERATWE CYSTOSCOPY 137 current into the alternating one; and the current so supphed may be utihzed with the rheostat under discussion, affording the safety mentioned. Under these circumstances it is not necessary to provide two independent sources for the electricity used; it is perfectly safe and proper to use the one source (street current) for both lighting and f ulguration and no danger of short- circuiting ensues. Another controller which Mr. Phillips has supplied for the author is one shown in Fig. 65, adapted either to direct or alternating current, and furnishing current for diagnostic lamps, for cauterization, for galvanism, and for sinusoidalism. A pilot light indicates when the current is on or off. The controller is made either as a wall plate or table plate. It has long been diffi- cult to obtain a controller providing both cauterization and light- ing purposes in connection with both direct and the alternating currents; and the convenience of this arrangement is easily appreciated. Fulguration. Cauterization with the High-frequency Cur- rent. — This is a method that has attracted much attention latterly and has met with marked favor at the hands of a number of operators. DeKeating-Hart devised the plan of applying fulguration, or effective cauterization, by means of the high frequency electric current to warty and cancerous growths on various parts of the surface of the body. This was found to be very successful in many instances. To Edwin Beer,* of New York, must be given the credit of planning and carrying to successful issue the application of the same principles to the treatment of growths within the bladder through the cystoscopy The outcome has proved most for- tunate. Upward of 200 tumors of the bladder have so far been reported! as having been treated with this method, the several operators being highly enthusiastic in the praise of their results. * Beer, Jour. Am. Med. Assn., May 28, 19 10; N. Y. Med. Jour., Oct. 29, 19 10; N. Y. State Jour, of Med., Sept., 191 1. + Beer, Jour. Am. Med. Assn., Nov. 16. 1912. 138 CYSTOSCOPY AND URETHROSCOPY This is particularly gratifying, in view of the fact that methods of treatment for vesical neoplasms hitherto in vogue have been uncertain and inadequate in a large proportion of cases. This was true of both operative and non-operative measures. The percentage of recurrences was discouragingly high, even in cases that were deemed benign by clinicians and pronounced non- malignant by laboratory findings. Albarran used to be quoted as saying, "All vesical tumors are malignant or Hkely to become so." Beer first made use of a small cable of copper wires held together and covered by insulating material resembling that of a ureteral catheter. It was made in the size and shape of a No. 5 or 6 ureteral catheter, with the wires exposed at each end. This provided for connection at one end with the source of the current, and for contact in the bladder with the tumor. It was found unnecessary to provide two contacts with the body for com- pleting the electric circuit, as with the galvanic or Faradic current, and that mono-polar contact, as with ordinary galvano- cauterization, was sufficient. Later, a single strand of steel wire was substituted for the cable of copper wires. It proved more easily handled than the cable. It may be had in any desired length from the supply houses. FULGURATION APPARATUS A number of high-frequency apparatuses have been placed on the market to meet the requirements of the work. The list includes several so-called portable apparatuses. As a matter of fact, it requires an apparatus of considerable power to effect destruction or decomposition of these aggressive growths, and the strength of the current delivered is therefore of much impor- tance. Of the several that have been subjected to trial by the author the one pictured in Fig. 66 has proved the best by a considerable margin. It delivers a powerful current whose immediate effects are evident in the bubbling that occurs at the OPERATIVE CYSTOSCOPY 139 point of current impact, in the immediate whitening of the tissues there, and also in the odor of burnt flesh that soon be- comes perceptible. More important still is the after-effect of an efficient ap- paratus, as compared with one of inferior strength. The involution of the tumor begins more promptly and is carried on more rapidly than after inefficient fulguration. Presumedly, Fig. 66. — The Bransford Lewis Fulguration apparatus (Kny-Scheerer Co.). the ability to prevent recurrence is also greater with the use of the better apparatus. This apparatus is built on the interrupterless transformer principle, it is simple of adjustment and is easy of application and control. Used in connection with the alternating current it consists of a high-tension transformer, the secondary of which discharges over a multiple arm spark gap and loads a set of 140 CYSTOSCOPY AND URETHROSCOPY high-frequency condensers. These in turn discharge through a large resonator and produce the following varieties of currents: Auto-conduction, Auto-condensation, Thermo-penetration , Fulguration. A d'Arsonval current can be delivered up to any desired amperage; and the Oudin current is such as described above. When a direct current is the source of supply, a motor is added to the apparatus; this converts the current into the re- quired alternating variety. In either case the make and break of the current is controlled by the operator by means of a foot switch. This apparatus is manufactured by the Kny-Scheerer Co., of New York City. Fig. 67. — Mode of applying fulguration to papilloma by direct method. Method of Application.— With the patient in the usual posi- tion for cystoscopy (Fig. 19) and the usual technique of clean- liness, irrigation and anesthesia having been carried out, the cystoscope is introduced and the tumor located, the catheteriz- ing telescope carrying the wire electrode serving for this purpose. When brought within range, the electrode is pushed through its OPERATWE CYSTOSCOPY 141 channel until it comes into view in the bladder. A little further manipulation brings it into contact with the side or pedicle of the tumor, where it is held during the process of cauterization. Sometimes the direct telescope is preferable for controlling the direction and placing of the electrode, sometimes the indi- rect, according to the location of the tumor (Figs. 67 and 68). If attached to the posterior wall or base of the bladder the growth may be reached more readily through the direct telescope; whereas, if attached to the anterior or lateral walls or the apex, the indirect telescope serves much better. On this point Beer* Fig. 68. — Mode of applying fulguration by indirect method. expresses a similar conclusion, and regards an instrument fur- nishing both direct and indirect modes of control as essential. He says: "Of late I have used the Bransford Lewis cystoscope, as it allows of direct and indirect vision applications at one sit- ting without withdrawing the instrument." Water is univer- sally used as a distending medium and interferes not at all with the effectiveness of the fulguration. Having brought the exposed end of the electrode in contact with the growth, as previously described, the operator turns on the current by means of a foot switch conveniently located on * Beer, Annals of Surgery, August, 1911; New York State Jour, of ]Med., Sept., 142 CYSTOSCOPY AND URETHROSCOPY the floor. The duration of the application is timed by an assist- ant. The operator watches the effect of the application through the cystoscope. Formerly short flashes, of ten or fifteen seconds time, were made use of; but latterly operators have prolonged this to forty or fifty or more seconds, at the same time diminish- ing the intensity of the current by shortening the spark in the muffler. Similar applications are successively made to other areas of the tumor, particularly to pedicle or base, and to any other tumors, if more than one are present; after which it is well to complete the seance with a prophylactic irrigation (without catheter) of some mild antiseptic fluid. It is usually advisable for the patient to keep moderately quiet for the remainder of the day after such treatment, especially if there is any tendency to urinary chills or fever; otherwise, he may be about, as usual. The treatment may be repeated at intervals of four or five days, the length of time being determined by the reaction obtained from the instrumentation rather than the direct effect of the fulguration. At each successive seance the marked influence of the previous treatment becomes evident, both in the diminution in size of the growth and in the blanching and necrotic changes apparent on its surface. These have been noted by all observers, and they furnish evidence of the favorable influence being ex- erted on the neoplasm (see Figs. 69 and 70). For the purpose of securing late reports of the results ob- tained in various quarters, Beer wrote, in 19 12, to all surgeons who he thought might be using the treatment. He reports (Jour, of Am. Med. Assn., Nov. 16, 19 12) having received a large number of replies. Almost aU were enthusiastically favor- able to the new method. One or two answers were favorable but not particularly enthusiastic. One answer was far from favorable, but in view of the fact that the surgeon in question had never used the method, his comment was not considered of much moment. These opinions were based on more than two Fig. 69. — Benign papilloma. Appearance Feb. 5, 1913. The continuous stream of blood shown made marked hematuria for more than a month previously. Left ureteral orifice in view. Case of author. Fig. 70. — Same as Fig. 69. March 5, after five fulgurations had been given. Bleeding ceased after second treatment. Fig. 71. — Same as Fig. 70. Appearance April 4, after eight fulgurations had been given. A depression indicated the former location of the tumor. Vesical mucosa normal. Arrow indicates site of healed tumor. OPERATIVE CYSTOSCOPY I43 hundred cases treated by this method in the United States, up to the time of the making of the report. While, in his earHer writings, the author portrayed hopes of obtaining success with the method in early cases of malignant growth, in this later report he expresses his conviction that no malignant growth will be cured by it. In this connection, the result so far obtained by Keyes (Siirgery, Gynecology and Obstetrics, Jan., 19 13) in a case of vesical carcinoma is interesting. In mentioning the weU substantiated fact that carcinomata have proved amenable to treatment by the curette and by arsenic pastes, in certain in- stances, and by radium and X-rays, in others, when in accessible situations, he calls attention to the lately developed fact that the bladder has been made accessible by means of the cystoscope, at least for cauterization methods of treatment; and that it is not outside of the bounds of possibility to obtain success with them (as embodied in the Oudin current, plan of Beer) in early carcinoma. At any rate, he reports the interesting details of a case under his observation from July, 1909, to December, 191 1, and sums up as follows: ''A small papillary growth was removed from the bladder and proved carcinomatous by pathological examination. It recurred, as was to be expected, but was apparently cured by four burns with the d'Arsonval current, and is known not to have relapsed from April 23, 1910, to Oc- tober 26, 1911. "in the meanwhile, four other growths of similar character appeared. These were all burned with the Oudin current. Two of them were cured by a single burn on May 14, 1910, one by two burns, in January, 191 1, and the cures were cystoscopicaUy verified on October 26, 191 1. The fifth tumor was burned four times and the patient was not cystoscoped after the last burn. " Thus we have a known carcinoma apparently cured for eighteen months, two recurrences in other parts of the bladder cured seventeen months, one cured nine months, and one of which the cure was not verified." The author deems this clear 144 CYSTOSCOPY AND URETHROSCOPY evidence, at least, of complete control of a small carcinoma for a considerable number of months. In view of the difficulty of determining . the question dis- cussed between clinician and pathologist, as to whether a given tumor will prove malignant or benign in its clinical course, and its probable amenability to fulguratiqn, the same author submits criteria which he deems more serviceable than the mere report of the pathologist; namely, (a) the hardness of such tumors; (b) their multiplicity and size; (c) sloughing of the surface; (d) intractable cystitis. Hard masses are more resistent to burning than soft ones. A moderate number of tumors should not preclude the applica- tion of the method, but an excessive number, together with extensive involvement, would be factors in favor of the operative rather than the fulguration method. While small hemorrhagic and sloughing spots do not necessarily indicate malignancy, the author has never yet been in the least successful in burning any tumor covered with extensive sloughing areas. Intractable cystitis is likewise considered a condition unfavorable to the success of cauterization. It is therefore proper, in such cases, to give attention to this factor before beginning cauterization. Ureteral Stricture.^ — The ureter is not infrequently the sub- ject of subacute or chronic infection and inflammation, gonor- rheal, tuberculous, etc.; or it may be injured by the passage of a stone or the impaction of a stone; or its outlet may be narrowed (Fig. 72) by pathological processes within the bladder — even- tuating in the production of cicatricial stricture of that organ at some point or points. Ureteral stricture is by no means an uncommon condition. It occurs in both men and women, more frequently in the latter, according to the experience of the authors. Its capacity for injury is not small. By narrowing the passage through the ureter it promotes and perpetuates inflammatory processes above it, either in the ureter, the pelvis or the kidney, w^hich naturally result in the production of mucus and pus. Plugs of muco-pus come down the narrowed channel OPERATIVE CYSTOSCOPY 145 in the urine. Occasionally such accumulations or plugs fail of passage through the strictured portion, become impacted there, and act just as do concretions of other sorts that become impacted in the ureter. They cause ureteral colic, severe pain, even writhing on the floor, in some instances. With the solution Dilated left ureter Narrowing ureter Minute strictured orifice Fig. 72. — Dilated ureter due to stricture near vesical end of ureter. or the passage and escape of the plug there is relief from the suffering, and the patient for a time feels as well as usual, only to experience a recurrence of the attack with the engaging of another plug in the strictured part of the canal. The injurious effects are not limited to the ones mentioned — the sufferings of 146 CYSTOSCOPY AND URETHROSCOPY the patient — but they may be expended on the kidney itself, which may become seriously damaged or finally destroyed in a manner similar to that in which a kidney undergoes destruction from an impacted calculus, large or small, in the ureter. A female patient under our observation had been incapacitated from performing even the ordinary household duties for more than three years by a series of such attacks, but was promptly and permanently restored to health and comfort when a definite stricture was recognized at the lower end of the right ureter and sufficiently dilated to permit the free passage of the urine and its contents. In this case it was difficult at first to gain entrance for even the smallest ureteral bougie into the narrowed opening. But after a number of attempts, with repetitions of the pressure of the bougies against the orifice, a small one did effect entrance and passed up the ureter. Successive sizes were then introduced, until the opening was large enough to permit the introduction of the metal ureteral dilator (3, Fig. 58), after which success was assured. If the narrowing be located immediately at the orifice it may be incised with the ureteral scissors (2, Fig. 58). The alligator forceps may be used also as a dilator when the stricture is at the outlet, but its angle of opening is too abrupt for safe use far within the channel. A styletted silk-web bougie, insulated except at the end, may be provided for applying electrolysis against a stricture higher up in the ureter; but it is questionable whether it would be entirely safe. It is conceivable that the electrolytic action might be against the wall of the ureter instead of the stricture, with the result of making a false passage. Ureteral stenosis or obstruction may be caused by the pres- sure of a tumor or growth in adjacent structures, or by the con- traction of adhesions in neighboring tissues. It is scarcely probable that any lasting benefit can come from intraureteral manipulations under such circumstances. Obstruction of the organ from kinks or bends is also not amenable to relief by OPERATIVE CYSTOSCOPY 147 this means, and resort must be had to repositing the kidney or plastic work on the pelvis, etc. Obstruction due to the crossing of the ureter by an anomalous vessel is best relieved by tying and cutting the vessel. Ureteral Calculus. — Much may be done by cystoscopic means to assist the passage of a stone through the ureter, so that the authors are not in sympathy with and cannot support the unqualified adoption of the measures customarily applied in the Fig. 73. — Stone in orifice of left ureter. presence of calculus in transit or impacted in the ureter; that is^ the placing of one's faith in a strictly expectant plan, in the belief that the ureter will eventually expel the intruder, if aided with hot applications and the use of morphia, as strongly urged by some; or the early or immediate resort to laparotomy and the extraperitoneal incision into the ureter for the direct removal of the stone. Since it is an indisputable fact that ureteral stones have in numerous instances been removed or assisted in their 148 CYSTOSCOPY AND URETHROSCOPY transit and expulsion by various cystoscopic measures and ma- neuvers, it would seem beyond all argument that such measures, innocuous as they are, should have a definite and well-established position in the esteem of the profession, under such circum- stances. But such is not the case. A review of the literature of ureteral calculus of the past few years shows the therapy of the subject to be dominated with but the two ideas, the expectant Fig. 74. — Removing stone from orifice of left ureter by means of alligator forceps used \ through operating cystoscope. plan^'or the major surgical one of abdominal incision. And therein may be found, as well, evidence of the disastrous outcome of both plans: The destruction of kidneys from too prolonged reliance being placed on the efficacy of the former, and the serious complications that have followed, in certain instances, the appli- cation of the latter (dangerous hemorrhage, primary or second- ary, from iliac arteries,* ureteral leakage from fistula, etc.). * Moschowitz: Annals of Surgery, Dec, 1908. OPERATWE CYSTOSCOPY I49 Allusion to the efficacy of cystoscopic measures is practically confined to contributions of reports of cases successfully handled in this way. It cannot be claimed that this is either just or fair to a deserv- ing method of therapy. It is neither fair to the profession nor to the sufferers from such conditions. Whatever possibility of relief it embraces should be made known to both, and patients should at least be given the benefit of the doubt — a trial of cysto- scopic methods — before being subjected to major surgical pro- cedures, the outcome of which can never be assured. The cystoscopic method, if it fail, wiU leave the patient in no worse condition for the adoption of other measures; and if successful, affords the relief without entailing a more or less dangerous cut- ting operation and without the patient's having to remain in bed for any length of time. He is an ambulatory patient, meantime, even if the attempt to remove the stone has to be repeated sev- eral times. (See "Removal of Ureteral Stone by Cystoscopic Methods," by Bransford Lewis, New York ]\Ied. Jour., Nov. 16, 1912.) Not all stones are impacted at the same point in the ureter; not all stones are of equal dimensions; and not all stones are equally accessible or equally amenable to the cystoscopic method of removal. The three points of natural narrowing of the ureter, are the locations at which calculi are prone to hang; that is, within an inch below the kidney pelvis; at the site of the crossing! of the iliac artery; and the lower ureteral orifice (Fig. 73) on part of the ureter that passes obliquely through the vesical wall (intramural portion). j To illustrate the manner in which a stone may hang at the lower orifice for a long period, apparently ready to emerge, yet failing to do so, and then prove readily amenable to cystoscopic removal, the following case may be cited: Dr. W. L. Goddard, practising physician, Saulsbury, Tenn. ; first consultation Oct. 29, 1908. History of repeated attacks of renal colic on the left side, dating from twelve years previously; 150 CYSTOSCOPY AND URETHROSCOPY the passage of a small stone one and one-half years previously; and the existence, during the past nine months, of an unceasing dull pain in the left inguinal region, never absent day or night in the waking moments of the patient. Urine perfectly clear. Cystoscopy easily carried out at the first interview (universal cystoscope); showed the bladder and the right ureteral orifice normal; within the orifice of the left ureter a little dark-looking plug appeared, plainly visible to both direct and right-angle view. The universal was replaced with the operative cysto- scope, with water as a distending medium. The alligator for- ceps was inserted into the affected opening, the plug escaping and passing backward along the channel of the ureter. The forceps was then dilated strongly, opening the orifice widely, and then withdrawn. Immediately the little plug popped out of the ureter, plainly under the observation of the operator, and was followed by a rush of pus and urine, as though it had been pent up in the ureter. Almost immediately afterward Dr. Goddard, the patient, remarked, "That's the first time in nine months that I have been free from that pain in the lower part of the abdomen." And, it may be remarked, he has never felt it since that time. Several physicians were in the office at the time, and observed the plug in the orifice and the maneuvers executed in its removal ; and also saw it as it then lay in the bas fond of the bladder. The patient shortly afterward passed it out by natural urination. If this had not occurred it would have been an easy matter to grasp and remove it with the forceps. The specimen shows a small spicule at one point. This spicule had caught in the lip of the ureteral orifice and had been the means of prevent- ing the expulsion of the intruder. It might have remained indefinitely, unless removed by some surgical measure, cysto- scopic or otherwise, grown larger by accretion, and gradually injured or destroyed the kidney above it, through backward pressure, infection, etc. The patient left for home two days afterward, feeling per- OPERATWE CYSTOSCOPY 15I fectly well, and has had no recurrence of the trouble since (six years) . If the stone be located higher up in the ureteral channel it may not be possible to reach it or remove it immediately, and yet it is not necessarily beyond the sphere of cystoscopic Fig. 75. — Stone lodged in mid-ureter, J.S.F. influence. The ureter below the point of impaction may be stretched or dilated by the passage of sounds or bougies, or by distending it with fluids or oils, injected through a ureteral catheter; all of which tend not only to dislodge the stone but to lubricate the channel and facilitate its passage downward, 152 CYSTOSCOPY AND URETHROSCOPY especially if assisted by the drinking of considerable quantities of "water for the vis a tergo that comes in the elimination. Once it reaches the lower end of the ureter or its immediate neighbor- hood, the metal instruments may be used: The dilator for further stretching the orifice, if necessary; the flexible forceps for efforts at grasping the stone if within an inch or two of the orifice, or the alligator forceps if nearer the outlet. Fig. 76. — Showing cystoscope, X-ray catheter and stone in lower end of ureter, after descent from position shown in Fig. 75. When the stone has been brought into the bladder the re- mainder of the problem is easy of solution: It is picked up with the alligator forceps and removed (Fig. 74). If it be too large to pass through the sheath of the cystoscope it may be either crushed and removed, or it may be grasped and drawn as far as possible into the beak-end of the sheath in which it is OPERATIVE CYSTOSCOPY 153 held while sheath, forceps and stone are drawn out coincidently. A small stone will usually pass from the bladder in voluntary urination, only it is liable to be lost unless arrangements are made for the patient to urinate into a vessel covered by a layer of gauze as a sieve. Patient, J. S. F., age 44, gave history of fourteen months standing; renal colics on right side, frequent, severe and often requiring the h>podermic use of morphine for relief. Was under "solvent" treatment for about a year, without favorable result. On coming under our care, a radiograph catheter was ob- structed at about four inches above the right ureteral orifice, and X-ray showed a stone, together with the catheter, at that Fig. 77. — Ureteral stone removed from J. S. F.; actual size. point (see Fig. 75). The catheter was moved up and down, for its loosening effect; and liquid albolene was injected on two occasions. Another X-ray taken two weeks later showed that the stone had descended to the intra-mural part of the ureter (Fig. 76). It was known by cystoscopy that the orifice of this ureter was contracted tightly, presenting an effective barrier to the escape of the stone, although it had reached this low posi- tion. Indeed, a small-sized catheter was all that could be introduced into the orifice, up to this time. Not even a small metal dilator could be made to enter. Through the operating cystoscope, therefore, one blade of the ureteral scissors was in- serted into the orifice and an incision was made though the dorsal lip for a half inch (Figs, 79 and 80). On the following 154 CYSTOSCOPY AND URETHROSCOPY day the patient voluntarily passed the stone (Fig. 77) and was completely relieved thereafter. He gained about fifteen pounds during the next month; and has had no recurrence of symptoms or signs. Fig. 78. — Diagram showing strictured Fig. 79. — Ureteral scissors cutting stric- right ureteral orifice retaining a stone. tured orifice of ureter. Fig. 80. — Orifice widened by scissors permits escape of calculus. PART II URETHROSCOPY CHAPTER I ANATOMY OF THE MALE URETHRA The urethra is the passage for the exit of urine from the blad- der, and, in the male, for the emission of the contents of the seminal vesicles and prostate gland. While the urethra is thus a canal in fact, in the flaccid state of the penis it is a canal only in theory, for the walls are in com- plete apposition throughout its extent, except when they may be spread apart by the passage of urine or instruments. The urethral walls, lying in apposition, have, upon transverse section, the appearance of a vertical slit in the region of the glans; in the membranous, a stellate appearance; they present a transverse slit in the spongy region and in the prostatic region, the form of an inverted Y. For descriptive purposes the urethra is divided into the prostatic urethra, about one and one-quarter inches in length, which is that part of the canal surrounded by the prostate gland; the membranous urethra, about three-quarters of an inch in length, which extends from the apex of the prostate to the bulb of the corpus spongiosum; and the spongy urethra, which is enclosed in the corpus spongiosum from the bulb to the termina- tion of the canal at the tip of the glans — about six inches. The spongy urethra is still further subdivided into the bulbo- perineal, scrotal, penile and navicular portions, the names of which are sufficiently descriptive. In a state of distention the form of the canal is that of a cylinder of irregular contour and size, the walls having a varying 155 156 CYSTOSCOPY AND URETHROSCOPY degree of distensibility. In the meatus we ordinarily find the lowest distensibility and the smallest caliber, often not more than 24 of the French scale. The fossa navicularis, a small flask-like dilatation, which lies just inside the meatus, quickly contracts again into a neck-like narrowing, often less in caliber than the meatus itself, but more distensible. The spongy urethra gradually widens in the form of an elongated, truncated cone from the narrow inlet at the navicular fossa, to its maximum dimensions at the bulb. At this point the walls of the urethra, especially the lower or posterior wall, are very distensible, and, even in the flaccid state, form a well-marked dilatation just anterior to the cut-off muscle, the bulbar cul-de-sac or the bulb. Then the canal again narrows, at the point where it pierces the external layer of the triangular ligament, and maintains a like diameter throughout the whole membranous portion. Upon passing the deep layer of the triangular ligament and entering the prostatic portion, the urethra takes on a fusiform shape, becom- ing narrowed at the vesical neck, and there enters the bladder. In the foregoing description we have taken, not the course of the flow of the urine, but the one of the passage of instruments through the urethra into the bladder. The urethra, though in a state of tonic closure having the contour as described, is capable of a great and varying amount of distention in its different segments, by virtue of the elasticity of the urethral walls. In general, the deeper parts are the more dilatable. Thus, while the meatus may exhibit a caliber of only 24 French, and with difficulty be dilated to receive a 26 sound, the spongy portion back of the fossa will take a 28 or 30, and the bulbous urethra up to 40 or higher. The canal narrows in the membranous portion, the site of the cut-off muscle, but in this part may be dilated to 30 or higher. In the prostatic region one may, without inconvenience, dilate up to 40 or 45. To repeat, the points of constriction in the male urethra are, first, at the meatus; second, at the neck of the fossa navicularis; third, at the cut-off muscle, and fourth, at the bladder neck. THE ANATOMY OF THE MALE URETHRA 157 There is a great amount of variation in individuals in the caliber and the amount of constriction at these points; but the general ratio is, in the absence of pathological change, practically always preserved, excepting that the meatus is sometimes found to be unduly small, compared to the rest of the urethra. The cause of the difference in distensibiUty of these constrictions may be found in the structure of the peri-urethral tissues at these points: At the meatus, the urethra being imbedded in the glans portion of the corpus spongiosum, which here is relatively compact, restricts the elasticity of the canal wall. This is true also, though to a less extent, at the deeper inlet of the fossa, and all along the spongy portion in lessening degree, to the bulb; as the pars spongiosum, it is recalled, lies between and below the corpora cavernosa. The constriction at the membranous portion and that at the bladder neck are purely muscular in character and are much more accommodating than that at the meatus, once the muscular spasm is overcome. Though, as before stated, there exists a marked sagging of the floor of the urethra at the bulb, the roof of the urethra forms an uninterrupted curve from the fossa navicularis to the bladder (when the penis is erect). The mucous membrane of the roof is more closely adherent than that of the floor, and is less elastic. These facts show the proper wall to follow in the passing of instru- ments to be the anterior or roof. Thus, the curve of the urethra is the curve of the roof with its fixed point between the two layers of the triangular ligament. Behind this point the direc- tion of the prostatic urethra is up and back, and in front of it the bulb takes a direction forward and up by reason of the ten- sion of the suspensory ligament of the penis. This forms the so-called fixed curve of the urethra, though the parts anterior and posterior to the two layers of the triangular ligament are not fixed, absolutely. Though the degree of curve differs in individuals, and even in the same person at different ages, the one which will accord with the greatest number of urethrae is that of a circle 8.125 cm. in 158 CYSTOSCOPY AND URETHROSCOPY diameter ; and the proper length of arc of such a circle to repre- sent the suprapubic curve, is that subtended by a cord 6.875 centimeters long (Keyes). Histologically, the urethra is composed, in its thickness, of some four layers of tissue. Lining the canal is the epithelial layer, which differs somewhat in the morphology of the cells in the several parts of the canal. Just inside the meatus the cells are similar to the other mucous orifices of the body, partak- ing of the nature of the epidermis in their stratified squamous appearance, merging in the fossa navicularis into the stratified cylindric type which prevails until the epithelium again reverts to the squamous type in the upper part of the prostatic urethra, where it merges insensibly into that of the bladder. The urethral epithelium is normally smooth, moist, and shiny — showing by its transparency the color of the mucosa beneath. The second layer constitutes the mucous membrane. Being continuous anteriorly with that of the glans and posteriorly fused into that of the bladder, it extends into Cowper's glands, the ejaculatory ducts, the seminal vesicles, the vasa deferentia, and the epididymis. This layer is very elastic and is intimately adherent to the subjacent layers, particularly on the roof of the spongy portion, and in the prostate. Beneath the mucous membrane is a layer of thick, smooth- fibered musculature, especially thick in the membranous portion. This coat is in two layers, more or less distinct. The inner lies longitudinally, while the outer fibers are disposed circularly. At the point where the urethra reaches the bladder there is a distinct thickening of the circular fibers, forming a sphincter, the internal or vesical sphincter. The external sphincter is formed in the following manner : In all of the neighborhood of the bladder there appears a third layer of muscle fibers above the urethra, forming a sort of arciform muscle, held between the prostatic lobes. These fibers increase in number in passing through the prostate, and, where the urethra pierces the deep layer of the THE ANATOMY OF THE MALE URETHRA 1 59 triangular ligament, they form a sphincter-like ring which is continuous with the muscles of the hgament, this making up the cut-of muscle. Anterior to the superficial layer of the triangular ligament lies the spongy body, the corpus spongiosum, which forms the! fourth or erectile layer of that part of the male urethra. It begins in a bulbous enlargement which is fixed to the lower part and between the corpora cavernosa of the shaft by the hulho cavernosus muscle, and ends in a dilated extremity, the glans penis. The internal surface of the male urethra, excepting when in a state of complete tension, forms a series of longitudinal folds, more or less numerous and of varying size. There are also certain folds disposed transversely to permit of extension during erection. These folds, and the intervening sulci present a large number of orifices of small glands and culs-de-sac, as well as papillcB, these latter being more numerous in the fossa navicularis. The culs-de-sac {Morgagni's lacunce) penetrate obliquely from before back and up, in the mucous membrane of the roof of the spongy region. The largest of these culs-de-sac is the lacuna magna, found on the roof of the fossa navicularis, just inside the meatus. For the most part, Morgagni's lacunae are of a size to hardly admit the head of a pin. There are from six to ten of them and they are found along the median line. Owing to the oblique direction of the sac, backward and up, the upper wall forms a sort of valve, the one at the site of the lacuna magna being known as the valve of Guerin. The importance of the amount of obstruction which these culs-de-sac oppose to instrumentation has been greatly exag- gerated. Using an instrument with a tip the size of that of an ordinary sound, they need not be considered. In largest number are found the glands of Littre. Most abundant upon the roof of the spongy portion, where their orifices form a close dotting, they are also found in large number l6o CYSTOSCOPY AND URETHROSCOPY throughout all portions of the urethra — though in the posterior urethra the gland bodies are rudimentary. The depth at which the bodies of the glands of Littre lie varies. Though for the most part they lie just beneath the epithelium, they may be also found deep in the sub mucosa and even in the erectile tissue. The length of the excretory ducts, therefore, also varies greatly. These ducts, in general, run in an oblique direction from the gland toward the meatus, opening either upon the surface of the mucous membrane, or into the cavities of Morgagni's lacunae. Littre's are mucous- secreting, conglomerate glands. Cowper^s glands are tw^o small, lobulated bodies the size of cherry stones, lying beneath the fore part of the membranous urethra, between the two layers of the triangular ligament. They lie close behind the bulb and are enclosed by the com- pressor urethra muscle. The lobules are composed of a number of acini, lined by columnar epithelium, which open into a com- mon duct. These ducts are about 1.5 centimeters long and pass obliquely forward beneath the mucous membrane, opening upon the floor of the bulbous urethra by two very small orifices, lying side by side. The prostatic follicles lie in the substance of the prostate gland between inner and outer layers of muscle tissue; being particu- larly numerous in that part of the prostate lying posterior to the urethra. These follicles open into elongated canals which join to form from ten to twenty small excretory ducts which open into the floor of the prostatic urethra on either side of the verumontanum. Both follicles and ducts are lined by columnar epithelium. The mucous membrane in the prostatic portion presents a fold or reduplication lying antero-posteriorly in the middle line of the floor, traceable from the external angles of the bladder trigone. This forms a considerable eminence which is variously known as the verumontanum, caput gallinaginis and colliculus seminalis. To the right and left of this eminence are two small THE ANATOMY OF THE MALE URETHRA l6l slits, marking the openings of the ejaculatory ducts. In the center, anteriorly, is a small depression, the prostatic utricle or uterus masculinus, which extends upward and back a distance of 0,5 centimeter into the substance of the prostate gland beneath the middle lobe. CHAPTER II DEVELOPMENT OF THE URETHROSCOPE The development of the urethroscope is so intimately asso- ciated with that of the cystoscope, that a review of its history in detail from the time of its conception by Bozzini, of Frankfort, in 1806, up to the presentation to the profession of his endoscope by Desormeaux, of Paris, in 1853, would be merely a repetition. In this interval it suffices to mention the work of Segalas, of Strasburg, in 1826, of Fisher, of Boston, in 1827, of John Avery, of London, in 1843, of M. Cazenave, of Paris, in 1848 and the contemporary work of Haken, and Bombalgini, in 1853. Desor- meaux following the lines laid down by Fisher produced his endoscope. His was, in reality, the first work along these lines that received any scientific recognition. For his endeavors in this direction he received a portion of the Argenteuil prize in Paris, in 1853. In 1865 Doctor, afterward Sir Francis Richard Cruise, succeeded in improving the illuminating lamp to such a degree as to give a decided impetus to endoscopy, but the great degree of heat generated proved a serious drawback to the instrument. Efforts were made to provide a satisfactory cool- ing apparatus without marked success. In urethroscopy, as in cystoscopy, the advance was slow. It was not until 1874 that Griinfeld, of Vienna, acting on the prin- ciple suggested by Haken in 1862 gave to the profession a urethral endoscope which was practicable. The tubes were made of hard rubber with a bell-shaped proximal end. The light was reflected into the urethroscope from an independent source of illumination by means of a head mirror. Up to this time all attempts at urethroscopy had been isolated and sporadic and the results achieved were not productive of enthusiasm, but 162 DEVELOPMENT OF THE URETHROSCOPE 1 63 following closely Griinf eld's achievement the results were pro- portionately rapid. To Dr. Max Nitze, of Berlin, must be accorded the credit for the distinct advance over the old t>pe of instruments which made modern urethroscopy possible — the placing of the source of light in the instrument near the field to be examined. Work- ing in combination with Leiter, of Vienna, he produced a ureth- roscope in which the source of light was an incandescent loop of platinum wire placed near the distal end of the urethroscope. Oberlander, of Dresden, acting on this principle and with the assistance of Heynemann, an instrument maker of Leipsic, produced the Nitze-Oberlander instrument, a step which proved creative of modern urethroscopy. While this instrument was a great improvement on former urethroscopes, it was, as compared with those of the present day, crude in the extreme. The source of light in the Nitze-Oberlander instrument was an unprotected platinum loop heated to incandescence by an electric current. The great heat generated necessitated the attachment to the instrument of an apparatus by means of which a constant flow of cold water could be kept circulating in the hollow plane upon which the wire rested. This rendered the instrument complex and cumbersome and the unprotected incan- descent loop made it necessary that the current should be turned off each time before the cotton swabs used in mopping up secre- tions and making applications could be used. These objections necessarily detracted much from the value of the instrument. Following closely upon the work of Griinfeld, Nitze, Ober- lander, Antal, Schutze, Casper, Leiter and Otis produced instru- ments for the purpose of examining and treating the urethra and with the interest thus aroused by placing urethroscopy upon the plane of practicability, much work of a definite character resulted. To overcome the objectionable features of the exposed plati- num loop, Loewenhardt, of Breslau, invented a small incandes- cent lamp to take its place, but it, too, proved productive of so much heat that it was impossible to put it to practical use with- 164 CYSTOSCOPY AND URETHROSCOPY out the addition of a cooling apparatus. The final and crowning step in urethroscopy, the advent of the low amperage mignon lamp with a minimum of heat production, must be credited to America. We believe that this achievement is due to the sug- gestions of Valentine, of New York, and carried out by Preston, an electrician of Rochester, though credit has erroneously been given to Dr. Koch, of Rochester, and the instrument produced at that time, 1899, bears his name. In this instrument the light carrier was sheathed in an auxiliary tube placed on the floor of the endoscopic tube. While the urethroscope taken as a whole was a marked improvement over those formerly in use, still the projection formed by the auxiliary tube made it awkward of insertion and productive of discomfort to the patient. A urethra which would readily admit a No. 30 sound, Charriere scale, would hardly permit the introduction of a No. 26 urethroscope on the same scale, while the actual lumen of the urethroscope was considerably less. At the present time the-re are four distinct types of urethro- scopes : those which have the source of illumination in the form of a cold lamp within the tube, those which have the light pro- jected into the tube from without, those to which the air-infla- tion principle has been applied and those having a lens-system similar to that used in the modern type of cystoscope and employing water distention of the urethra. The Chetwood, Valentine, and Guiteras instruments are the best representatives of those having the source of illumination within the tube. The Otis urethroscope is by far the most satisfactory instrument having the source of light outside the tube. The replacing of the petroleum lamp by the incandescent lamp for the purpose of illumination in the reflecting light instrument is due to the efforts of Schall. The use of air-inflation in connection with urethroscopy must be credited to Dr. Geza Von Antal, of Buda-Pesth, in 1887. He applied the air-inflation principle to an instrument of the Griinfeld type. DEVELOPMENT OF THE URETHROSCOPE 165 In 1890, Dr. Frank Hewell, Jr., of New York, being appar- ently without any knowledge of the work of Antal, suggested the use of air-inflation in urethroscopy. Later, Mr. E. Hurry Fen- wick, of London, modified Leiter's instrument for the purpose of making use of the air-inflation principle. The Fenwick instru- ment, which has in the past had its supporters among those who preferred the air-inflation t^'pe of urethroscope, has failed of greater acceptance by reason of the fact that the source of light was outside the tube and the instrument, as a whole, was cumbersome. On December 19, 1903, we presented in the Journal of the American Medical Association a new type of air-inflation ure- throscope. This instrument, slightly modified, was later pre- sented at the meeting of the American Urological Association held in Atlantic City in June, 1904. We have since made a number of changes in the instrument and, as it stands to-day, we believe that we have obviated the objectionable features of the Fenwick instrument and still retain its advantages. The endo- scopic tube conforms to the general lines of the Guiteras tube and is fitted at its proximal end with a pin projection to which the light carrier is readily attached. The universal head, which is attachable to any size tube by threads, contains the valve for the attachment of the inflating bulbs and in its handle contains a spring contact for connection with the light carrier. An ocular window fits the universal head by a bevel joint, thus making it readily attachable to and detachable from the instrument. The instrument permits of ease in assembling, is thoroughly air- tight and is devoid of cumbersome and complex features. Following the ideas of Kollmann, we have had certain instru- ments constructed for intraurethral work. These instruments comprise knives, forceps, canulae, probes, scissors and cautery. These instruments may be used through the operating window which is fitted with a metal adjustable gland, to which is attached a rubber nipple assuring an air-tight contact and yet allowing perfect mobility on the part of the operating instrument. i66 CYSTOSCOPY AND URETHROSCOPY In the early part of 1907, Dr. George Walker, of Baltimore, devised a lens-system urethroscope having a lateral opening for use with water distention of the urethra. This instrument was Fig. 81. — The Ernest G. Mark Aero-urethroscope. A, Swinburne type of posterior tube with obturator in place; B, obturator; C, long tube for antero-posterior urethro- scopy; D, window; E, short anterior tube completely asssembled; F, catheter carrier for catheterizing the ureter in the female, G, H, knives for intraurethral operations; I, gold canula for injecting the ejaculatory and prostatic ducts or infected glandular openings in the anterior urethra; /, galvanocautery; K, probe; L, syringe for attach- ment to canula. ^ presented to the profession May 18, 1907, in the Journal of the American Medical Association. The instrument was for diag- nostic purposes only. In June, 1907, Dr. Hans Goldschmidt, DEVELOPMENT OF THE URETHROSCOPE 167 Utilizing the principle of the Nitze cystoscope, devised a water distention urethroscope somewhat on the principle of the Walker urethroscope but employing in addition a curved tube for obser- vation of the posterior urethra. This instrument is also fitted with an irrigating attachment. In 19 10, Dr. Leo Buerger, of New York, devised and pre- sented to the profession a urethroscope employing water disten- tion which is exceedingly ingenious. Within the past year McCarthy, of New York, has developed a close- vision lens urethroscope which gives a superior view of the posterior part of the urethra and neck of the bladder. The extension of the beak of other such instruments has been removed, leaving this instrument a straight one, with only the suggestion of a beak in the shape of a pointed upturned tip. This gives the advantages of a straight instrument for turning, and of ease of introduction. For the purposes of treatment we consider urethroscopes employing water distention as having less practical value than those used with air. The operator's preference for any particular type of urethro- scope must be the result of his urethroscopic work with various instruments. Whatever his preference, the instru- ment must fulfill certain requirements. It must not be intricate or cumbersome. It must be readily sterilizable. It must give for its outside caliber the best possible urethroscopic view. It must permit of ease in manipulation on the part of the operator with the least possible discomfort to the patient. These points are essential. For satisfactory urethroscopic examinations, the following tubes are necessary: Nos. 22, 24, 26, 28 and 30, French, in both the short anterior and long posterior tubes. In a series of three hundred measurements made by Kollmann and Ober- lander, it was found that about 2 per cent, would not admit of the use of a No. 23. In 10 per cent., it was necessary to use a No. 23 while 25 per cent, required a No. 25. In the remaining l68 CYSTOSCOPY AND URETHROSCOPY 63 per cent, Nos. 27 and 29 were available. On one patient alone could a No. 31 be used. As a result of these studies, Oberlander pointed out to the profession the fallacy in the use of the tubes of small size which were then employed. The advantages in the employment of the tubes of larger caliber are obvious. The source of electric current used for lighting the small incandescent lamps is in most instances a matter of personal preference. There are at present obtainable many excellent rheostats for attachment to the lamp-sockets of the dynamo- generated current, and for office and hospital uses this method is unquestionably superior to the current obtained from a dry- or wet-cell battery on account of the gradual loss of power in the latter. There is, however, one precaution in the use of the dynamo-generated current whose observance is essential. If the floor of the operating room be of concrete, stone or tile, the current is liable to become grounded through the operator or patient if the floor be damp. Where the direct current is used this grounding is unaccompanied by danger but with the alter- nating current, the shock may be fairly severe. Even the slight- est shock to a patient who is, as a rule, laboring under a certain amount of mental stress, is hardly conducive to a satisfactory examination. We obviate the possibility of such grounding of the circuit by using a rubber castered table and by wearing either rubber gloves or rubber overshoes. The use of the in- duced current rheostat as described on page 135, will obviate all danger of grounding of the current. Care and Sterilization of Instruments. — After each urethro- scopic examination the tube and obturator should be sterilized by boiling — the most dependable method. They should be dried out of boiling water to prevent rusting. The light carrier cannot be boiled and must be washed off thoroughly with liquid soap and dried out of alcohol. This method is efficacious, though the late Dr. Wm. K. Otis insisted upon the necessity of using nothing in or through the tube DEVELOPMENT OF THE URETHROSCOPE 1 69 which could not be boiled, and for that reason advocated the use of the urethroscopes in which the source of light was outside the tube. The light carrier is replaced in the tube and the obturator inserted, effectually plugging both ends of the tube. Subsequently the urethroscope may be hung in a glass jar in the bottom of which is placed formalin pastiles. To prevent the deposit of moisture on the instruments, which tends to rust them, a few crystals of calcium chloride may be suspended in the jar wrapped in gauze. Personally, we do not see the necessity of placing the '.instru- ments in formalin vapor after the tube has been boiled and the light carrier thoroughly cleansed. If the urethroscope, so cleansed and put away in the boxes used for such outfits, is, previous to further urethroscopy, washed thoroughly in liquid soap, we consider our technique sufficient to obviate any accidental infection of the urethra, and in our own urethroscopic examina- tions and others which we have observed we have never seen the slightest evidence of infection following such technique. In the use of the urethroscopic tubes, whose walls are neces- sarily thin, care must be exercised not to dent them, as any denting causes an obstruction in the lumen of the tube, prevent- ing the easy insertion or withdrawal of the obturator. This renders the tube unfit for use. The room used for urethroscopic examinations should be so arranged that it m.ay be made fairly dark in order that all sources of extraneous light, which may confuse the operator, may be obviated as nearly as possible. A dark room is a source of much comfort and satisfaction to the urethroscopist. CHAPTER III URETHROSCOPY OF THE NORMAL URETHRA The indications for the employment of the urethroscope in the anterior urethra may be put down as any chronic lesion of that part of the urethra. There is absolutely no means other than urethroscopy by which we can obtain a comprehensive working basis in such conditions and it should be considered a sine qua non in the diagnosis — a rule to which we believe there can be no exceptions. When urethroscopy of the urethra anterior to the compressor has been decided upon, we proceed to the selection of the tube. The caliber of the meatus should be determined. If this caliber be smaller than 22, French, meatotomy must be done as urethros- copy with a tube smaller than this is impractical. The tube selected should be as large a one as will pass com- fortably into the urethra. We do not agree with the older teachings that, whatever the size of the urethra, the tube used in the first examination must be of the smallest practical caliber. This arbitrary rule which has been much insisted upon in the past by such recognized authorities as Oberlander, Kollmann, and Wossidlo is without sound reasoning basis. The position the patient should assume during an examina- tion should be that which is comfortable for the patient and which will permit of ease in manipulation on the part of the operator. Personally, for anterior urethroscopy we prefer the recumbent posture. Occasionally, preliminary cocainization of the urethra may be necessary but this should be avoided if possible on account of the changes produced in the mucosa by its use, i.e., the con- traction of the peripheral vessels and the mechanical washing 170 URETHROSCOPY OF THE NORMAL URETHRA 171 off of the products of secretion which might prove of diagnostic value. When cocainization is necessary, we have found a i per cent, solution of sufficient strength to produce analgesia. Fig. 82 — Patient in position for urethcoscopy. The glans and prepuce should be thoroughly cleansed by washing with soap spirits and water and the penis isolated from 172 CYSTOSCOPY AND URETHROSCOPY its surrounding parts by means of a sterile towel with a central hole. These towels we have especially made for this purpose. The urethroscopic lamp is tested to see that it is working satis- factorily and the rheostat is turned to the point where the neces- FiG. 83. — Introduction of urethroscope. sary brilliancy of illumination is obtained. The obturator is inserted and the tube, which has been sterilized according to the technique explained in the preceding chapter, is well lubri- cated. As a lubricant we prefer a sterile preparation of Irish URETHROSCOPY OF THE NORMAL URETHRA 173 moss. There are several excellent lubricants having chondrus as a base to be had in convenient collapsible tubes. The penis is grasped in the left hand and the prepuce re- tracted. The lips of the meatus are held apart by retracting Fig. 84. — Urelhroscope introduced and obturator withdrawn. Excess secretion is being mopped up with cotton-tipped applicator. the glans on each side with the thumb and forefinger of the left hand and the urethroscope is gently inserted until the resistance met with at the anterior layer of the triangular ligament is encountered. Should any obstruction to the insertion of the 174 CYSTOSCOPY AND URETHROSCOPY tube be met with prior to reaching this point, the urethroscope must not be forced past it. Even a shght amount of force directed against such an obstruction may result in minute tears or fissures in the mucosa. We have seen a case in which the Fig. 85. — Attaching the observation window preliminary to making forced air-inflation. obstruction w^as due to papillomata and in which the operator used undue force, causing a bleeding which rendered all attempts at urethroscopy unavailing and postponing a diagnosis which should have been readily made. The obturator is withdrawn URETHROSCOPY OF THE NORMAL URETHRA 175 and excess secretion is gently mopped up with small pledgets of sterile cotton attached to applicators. These applicators are made of wood or metal. The wooden ones are in every way preferable. Before each examination a number are freshly Fig. 86. — Window attached and observation being carried on under forced air- inflation, assistant making air-pressure with dilating bulbs. prepared — from twenty to thirty — and each applicator so tipped with its cotton pledget is used but once. This facilitates the examination greatly as it is unnecessary to prepare fresh appli- cators during the seance. Again, should the applicator be not 176 CYSTOSCOPY AND URETHROSCOPY thoroughly tipped with the cotton, danger of injury to the mucosa from the point of the wooden ones is much less than from those made from metal. Occasionally, in mopping up the excess Fig. 87.— Introduction of urethroscope into posterior urethra, the penis being depressed to facihtate passing through the triangular hgament. secretion, the moist applicator comes in contact with the mignon lamp and from this moisture on the lamp there sometimes arises a slight vapor. The result is a haziness at the distal end of the tube which may confuse the operator. A dry applicator or the URETHROSCOPY OF THE NORMAL URETHRA 177 inflation of the urethra with air readily does away with this slight annoyance. The urethroscope is slowly withdrawn, each successive field being slowly studied. The points to be observed as being of Fig. 88. — Urethroscope introduced for intra-urethral operative procedure, duction of operating instrument attached to operating window. Intro- diagnostic value are: (i) The central-figure (Griinf eld's central- figur) and the manner in which the urethra falls into folds, which varies in different parts of the canal. (2) The vascularity of the mucosa. (3) The appearance of the mucosa as to luster. 178 CYSTOSCOPY AND URETHROSCOPY (4) The appearance of the orifices of the lacunae of Morgagni and the glands of Littre. The Elasticity. — Beginning at the bulb there is a longitudinal folding of the urethra as it collapses at the distal end of the ure- FiG. 89. — Intraurethral operative procedure being carried on under forced air-inflation and direct ocular observation. throscope. In the region of the bulb, these longitudinal folds are quite voluminous, being more marked on the inferior wall. This asymmetrical folding is accounted for by the bulbar cul-de- sac. As we withdraw the urethroscope, the folds become less URETHROSCOPY OF THE NORMAL URETHRA 1 79 voluminous and the punctiform central-figure lengthens out into a vertical slit. In the anterior portion of the scrotal urethra, this central-figure becomes punctiform and the endoscopic figure has a stellate appearance, reaching its greatest symmetry in the mid-pendulous portion. At the isthmus just posterior to the navicular fossa, the central-figure changes rather abruptly to a vertical slit and on entering the navicular fossa, the radiat- ing folds disappear. The readiness with which the urethra falls into folds depends upon its elasticity and the size of the urethroscopic tube used, it being readily understood that the larger the tube the less pronounced the folds. The elasticity is greatly impaired in the infiltrations which are an accompaniment of chronic gonorrheal urethritis, and, therefore, this folding is of diagnostic importance in determining the extent of disease and the progress of such lesions under treatment. So great may be the infiltration that the folds may be almost obliterated and we have, instead of the normal infundibuliform picture, a large central opening with stiffened walls standing out from the end of the urethroscopic tube. With air-inflation it is possible to demonstrate this elas- ticity beautifully and with extreme accuracy. By releasing the pressure on the valved, or feeding bulb of the inflation apparatus the air flows back into the retaining bulb allowing the urethra to collapse at the end of the tube. This manipulation may be repeated at will and even the slightest stiffness in the urethra is made readily perceptible. The Vascularity. — Normally, this differs in degree in differ- ent individuals, being more pronounced in the well nourished and those having well-developed organs, and, conversely, being poorly marked in anemic conditions and where the genitals are small and flaccid. The region of the glans is poor in blood vessels and the urethra in this neighborhocd has an anemic appearance. Begin- ning at the navicular fossa, the urethra back as far as the bulb is traversed by minute reddish striae of vessels running longitu- l8o CYSTOSCOPY AND URETHROSCOPY dinally and having numerous ramifications on a background of paler mucosa, which has a slight yellow tinge. Pathological infiltrations markedly modify this vascularity and to the trained observer such changes are readily detected. Luster. — In a normal condition the smooth epithelial sur- face combined with the natural vascularity and lubrication of the urethra impart to the urethroscopic picture a characteristic luster. Any pathological change in these three elements mate- rially alters this normal brilliancy and such alterations are of diagnostic importance. The Appearance of the Lacunae of Morgagni and the Glands of Littre. — Just within the bulbar cul-de-sac, the urethroscopist encounters the two openings of the glands of Cowper, lying about four millimeters apart. On account of the large number and size of the folds in this region, it is difficult to locate these open- ings with the ordinary urethroscope but this becomes a com- paratively easy matter under air-inflation. These openings vary greatly in different urethrae sometimes appearing as easily observable slit-like orifices and again as hardly appreciable reddish punctae. Occasionally a curious congenital malforma- tion is encountered. The orifices of the ducts appear as V- shaped openings, the point of the V being placed toward the triangular ligament. Englisch accounts for this anomaly on the ground of lack of development of the superior wall of the duct. This lack of development, which we have encountered in a number of cases, is always bilateral and is not readily recog- nized except under air-inflation. As the urethroscope is withdrawn, there appear on the supe- rior wall a number of punctiform or slit-like openings — varying from four to twelve — the mouths of Morgagni' s lacunae. Ordi- narily it is possible to pass the tip of a urethral probe into these openings. The valve of Guerin, located in about three centi- meters from the meatus, is the largest of these lacunae. Their mouths are of the same color as the surrounding mucosa and are not raised above the surface. Fig. 90. Fig. 91. Fig. 92. Fig. 90. — Normal urethra with vascular mucous membrane. Fig. 91, — Normal urethra with anemic mucous membrane. Fig. 92. — Soft infiltration (acute urethritis; beginning of the chronic form). de Keersmaecker and Verhoogen.) (After URETHROSCOPY OF THE NORMAL URETHRA l8l Normally, the openings of the glands of Littre are not visi- ble through the urethroscope though, in a diseased condition, they become distinctly perceptible and this change is, as a rule, permanent. Posterior Urethroscopy. — Urethroscopy of the posterior urethra is essentially different from that of the anterior and demands a greater degree of skill in manipulation for reasons which readily suggest themselves. The normal curvature of the urethra makes access to that part posterior to the anterior layer of the ritangular ligament difficult. The prostatic mucosa is extremely delicate and ex- hibits a pronounced tendency to bleeding which obscures the field, while the greater degree of dilatability of this region requires considerable manipulation for the obliteration of the numerous folds. It is practically impossible to avoid traumatism, though this is reduced to a minimum in skilled hands, and for this reason it is inadvisable to urethroscope the posterior urethra unless such a procedure is deemed absolutely essential. To avoid the difficulties detailed above a number of instru- ments have been devised. The jointed obturator of Oberlander, so constructed as to approximate the normal urethral curvature, has not been received with much favor, w^hile the posterior tube of Swinburne (see Fig. 8i), resembling in general a short curved sound, has found much wider acceptance, though it is open to two valid objections — the fact that with this instrument it is possible to observe only a limited area confined to the floor of the urethra, and that manipulation for the purpose of minute observation of the urethroscopic field is too restricted. For the purpose of inspection and diagnosis the instruments of Buerger, or of McCarthy, mentioned in the preceding chapter, give excel- lent service. Our personal preference is for the straight posterior tubes with the air-inflation attachment. It requires no great skill for their introduction with the minimum of trauma and the air- inflation feature obviates the necessity for painful manipulation. l82 CYSTOSCOPY AND URETHROSCOPY It is in this region that the remarkable advantages of air-inflation present themselves so prominently. Previous to the introduction of the urethroscope, the pos- terior urethra is cocainized either by means of the tablet depositor described in the technique of cystoscopy (page 25) or by the instillation of thirty minims of a 5 per cent, solution of cocaine, the bladder having been emptied prior to cocainiza- tion and the patient urinating again immediately before the urethroscopy. The cocaine is allowed to remain for about five minutes, the length of time usually required for thoroughly obtunding the sensibility of the urethra. The position of the patient for posterior urethroscopy is a point of importance and should conform to the rule laid down on page 170 for anterior urethroscopy, i.e., it must be that which is comfortable for the patient and which will permit of ease in manipulation on the part of the operator. The position which best jftlls these requirements is a half-sitting one, and is fully explained by Fig. 82. The urethroscopic tube is inserted as in anterior urethroscopy until the resistance met with at the anterior layer of the triangu- lar ligament is encountered. The proximal end of the instru- ment is then depressed with the right hand while the fingers of the left, by pressure over the perineal urethra, elevate the point of the tube from the bulbar cul-de-sac into the membranous urethra. The instrument is then slowly pushed in until it enters the bladder. The obturator is removed and the excess secretion mopped up. The urethroscope is withdrawn until it enters the prostatic urethra which is readily recognized. If bleeding obscures the field, as it may do even with the most careful manipulation, it is advisable to swab the surface with a solution of suprarenal extract. The resultant blanching of the mucosa must be taken into consideration. The points of particular importance to be observed in this region are the general aspect of the mucosa, the verumontanum, URETHROSCOPY OF THE NORMAL URETHRA 1 83 the prostatic utricle, and the orifices of the prostatic and ejacu- latory ducts. It will be noted that the mucosa has a much red- der appearance than that of the anterior urethra and has not the peculiar luster or vascular striations. The verumontanum varies greatly in different individuals and is also much modified by sexual excesses and disease. In anemic persons and in those whose vita sexualis is slight, the verumontanum will be correspondingly poorly developed and, conversely, in sexually vigorous individuals, the verumontanum will be prominent. Norm.ally it has an extent of from one to two centimeters in the direction of the canal and, in its most prominent part, is of about the size of a small pea, though under the influence of disease or excesses it may assume much larger proportions and become extremely turgescent. In about the center of the anterior, or most prominent part of the verumontanum will be found the sinus pocularis, which has as great variations as the caput gallinaginis. It may be noted as a small depression or a relatively deep excava- tion. Its depth has apparently no relation to the size of the veru montanum. Ordinarily, in a condition of health, it is impossible to recog- nize the openings of the prostatic ducts through the urethroscope though in disease they often become distinctly visible, taking on much the same appearance as the orifices of the glands of Littre under similar conditions. The orifices of the prostatic ducts are scattered along the sides of the caput gallinaginis and are from twelve to twenty in number. The orifices of the ejaculatory ducts are situated forward of the verumontanum on the edges of the prostatic utricle, some- times being found just within its margins. They are easily seen and are larger than is usually taught, readily admitting the tip of the urethral probe. In ordinary urethroscopy, the central-figure in the prostatic urethra appears as an inverted U, the upward projection being 184 CYSTOSCOPY AND URETHROSCOPY formed by the verumontanum while the superior wall falls around it closely in folds more delicate and numerous than those of the penile urethra. In this collapsed condition, a great deal of dexterous manipulation is necessary to examine this region in detail and the recognition of lesions and their extent is rendered extremely difficult. Under air- or water-inflation the numerous folds are obliterated, the essential manipulation is reduced to a minimum and the different landmarks and lesions are readily identified. There can be no question of its decided advantages in this portion of the canal. As the instrument is withdrawn, the projection formed by the verumontanum grows abruptly less and disappears entirely before the extreme forward portion of the prostatic urethra is reached. Leaving the prostatic urethra, the instrument passes through the posterior reflection of the triangular ligament and enters the membranous urethra. The urethroscopic characteristics in this portion of the canal are the great vascularity and the punctiform central-figure with numerous delicate radiating folds. Occasionally, a prominence is noticed upon the inferior wall extending into the bulbar portion which suggests to a slight degree the verumontanum. This similarity has led some observers into incorrectly interpreting it as a prolongation of the verumontanum. According to Oberlander it corresponds to the location of the ducts of Cowper's glands. The Female Urethra.— On account of its shortness and its almost entire lack of glandular structure, the female urethra presents but few points of interest to the urethroscopist. For the purposes of urethroscopy the short tubes used for anterior urethroscopy in the male are sufficient. The large caliber and extreme degree of dilatability of the canal in the female permit of the use of tubes of large caliber. The external meatus is the narrowest part of the urethra and preliminary meatotomy is sometimes required. The gynecologic position with pelvis elevated is by far the best posture for both operator and patient. URETHROSCOPY OF THE NORMAL URETHRA 1 85 The vulva and vaginal vestibule are thoroughly cleansed and the labia are held apart by the thumb and forefinger of the left hand. The bladder is catheterized. The urethroscope, well lubricated, is inserted through the urethra into the bladder and the excess moisture mopped up with the cotton- tipped applica- tors. It is now withdrawn until it enters the grasp of the com- pressor urethrae. This point is readily recognized by the pecul- iar symmetrical folding of the canal as opposed to the picture presented while the urethroscope is still within the bladder. The urethroscopic appearance is almost identical with that of the membranous urethra in the male. The folds are numerous and delicate. The central-figure is punctate. Farther for- ward the central-figure becomes a vertical slit and the folds less numerous and more voluminous. Near the meatus the same vascular striations noticed in the anterior urethra in the male are observable but near the bladder the vascular striations become so merged as to be noticeable only under extreme dilatation. Just within the meatus on the floor are found the two open- ings of Skene's ducts. As they are observable without resorting to urethroscopy, they hold but little interest for the urethro- scopist. Occasionally, as the urethroscope is withdrawn from the bladder a projection is noticed springing from the floor of the urethra. This projection is due to the extension of the angle of the vesical trigone and is analogous to the verumontanum in the male. CHAPTER IV URETHROSCOPY OF THE DISEASED URETHRA THe correct interpretation of the pathological changes found in the urethra via urethroscopy necessarily presupposes a thorough knowledge of the normal urethroscopic pictures. This knowledge can come only with practical observation through the urethroscope and requires a wide clinical experience. Opportunity for urethro scoping the normal urethra very seldom presents itself and in the preceding chapter we have endeavored to supply this deficiency in text. In this chapter, the pathological urethra will be considered in detail and this consideration embodies, primarily, the elemental changes produced by chronic urethritis. These changes are so multiform in character that we find it expedient to classify them under the same general headings that we have applied to the normal urethroscopic picture, viz: (i) The changes in the elasticity. (2) The modifications in the vascularity. (3) The changes in the luster. (4) The appearance of the pathological lacunae of Morgagni and glands of Littre. The Changes in the Elasticity. — Neelsen and Finger have conclusively shown that the essential lesion of chronic urethritis / is a connective- tissue change. This connective-tissue prolifera- tion begins in the acute form of the disease as a round-cell infiltration and is seen in a progressive degree in the chronic form. Based on the researches of Neelsen and Finger, Ober- lander has classified these changes as: (i) Soft infiltration, (2) hard infiltration. Oberlander's soft infiltration has prac- tically the same characteristics as the circumscribed hyperemia first described by Furstenheim. To the latter form he ascribes three grades or degrees. Of this subdivision we shall speak later, in considering the glandular modifications. URETHROSCOPY OF THE DISEASED URETHRA 187 The characteristic folding of the urethra with the resultant central-figure is dependent upon the elasticity. As a result of the infiltration which takes place in chronic urethritis, there is a consequent stiffening of the urethral wall. This stiffening varies in degree from a slight loss of elasticity to the absolute rigidity of the most pronounced form, Oberlander's third degree of hard infiltration, or stricture. All degrees of loss of elasticity may be found in the same urethra, the lesser degrees shading off from the extreme form as a center. Soft infiltration in reality belongs to acute urethritis and therefore hardly belongs in the realm of urethroscopy. In the transitional form from soft infiltration to the first degree of hard infiltration it is, however, often observable. In this transitional form the central figure is only slightly modified. The funnel formed by the collapsed urethra is larger than under normal conditions and as the urethroscope is withdrawn, the tendency to the longitudinal folding of the mucosa is not as decided as in the normal urethra. The elasticity is apparently retarded, not destroyed, and to the trained observer, this sluggishness in the folding is characteristic. The tendency, if we may call it such, toward lack of elas- ticity observed in soft infiltration becomes decidedly more marked when the stage of hard infiltration is entered upon. The funnel at the end of the urethroscope becomes much elongated and the urethra, which normally collapsed in fairly regular folds, is seen to collapse irregularly, the area of infiltra- tion being marked by a decided stiffness and an almost entire lack of folds. As this infiltration progresses the folds decrease proportionately until, in the most extreme degree, these folds disappear entirely and the central figure becomes an irregular opening, the sides of which have a crinkled appearance and are not in contact. We may have, then, an area of extreme hard infiltration, at both the proximal and distal periphery of which may be found this infiltration in varying degrees. Occasionally, this transi- 156 CYSTOSCOPY AND URETHROSCOPY tional form is not present at the proximal end but is practically always observable on the distal side of hard infiltration of the pronounced type. Modifications in the Vascularity. — In the vascularization of the urethra, infiltration produces decided changes. In soft infiltration and in the transitional form, there is a passive hy- peremia. The vascular striations are not as delicately marked and the normally pinkish-yellow mucosa which forms their background is turgescent and of a purplish-red. As the infiltra- tion advances this turgescence gradually fades from the center toward the periphery. The strangulation of the vessels by the forming fibrous tissue produces an obliteration of the longitud- inal striations and their ramifications with a resultant anemia. The mucosa becomes pale yellow and finally takes on an eschar- otic appearance in the advanced grades of infiltration. Occasionally, in an anemic urethra, the careless observer may be misled by the apparently abnormal lack of blood supply. Closer observation will disclose the vascular striae and even should these be not observed, the normal elasticity will dispel the possibility of the anemia being due to infiltration. The Changes in the Luster. — In its normal condition, the epithelial layer of the urethra is smooth and in combination with the natural moisture and vascularity gives a characteristic brilliancy to the urethroscopic picture. In the superficial forms of soft infiltration this luster is enhanced. But with the pro- gression of the infiltration and the consequent nutritive changes there ensues a desquamation. This desquamative process pro- vokes irregularities in the epithelium and it loses its smooth transparency. It is roughened and, on close observation, has a tufted appearance due to epithelial proliferation. These tufts vary in dimension, occasionally extending over an area of several millimeters. In the advanced grades of infiltration, the lack-luster appear- ance of the epithelium is characteristic. It is dull and grayish- yellow. Through this layer of infiltration, the redder mucosa Fig. 93. Fig. 94. Fig. 95. Fig. 93. — Glandular urethritis. Hard infiltration of the first degree. Fig. 94. — Same form as Fig. i, under treatment. Fig. 95. — Same form as Figs, i and 2, nearly cured. (After de Keersmaecker and Verhoogen.) URETHROSCOPY OF THE DISEASED URETHRA 1 89 beneath may sometimes be observed as though obscured by a veil. * The Appearance of the Pathologic Lacunae of Morgagni and the Glands of Littre. — In Oberlander's most excellent classifica- tion of chronic urethritides, into soft and hard infiltration, he recognizes three degrees of the latter, the first and second degrees being marked by glandular changes. These glandular modifica- tions are of much interest to the urethroscopist and upon their recognition depends much of the intelligent treatment of chronic urethritis. Broadly considered, Oberlander recognizes a glandular form in ' which the excretory duct is patent and a dry form which is charac- terized by an obstruction of the excretory duct. As a result of this , obstruction, the gland may become C3^stic or entirely obliterated. ' In Oberlander's first degree of hard infiltration, the first noticeable changes in the glands are found. They are usually found in small scattering groups. In the glandular form they ^ appear slightly swollen and red. The infiltration surrounding them is superficial and has the appearance of the transitional form from soft into hard infiltration. This transitional infiltra- tion, if we may so designate it, is hardly ever seen surrounding the excretory ducts. In the dry form of this degree the excretory ducts are - obstructed and the glands become rapidly cystic. If these glands are superficially placed they appear as small translucent vesicles of about the dimensions of a canary seed. The excre- tory ducts are not visible, but their location may be marked by small radiating cicatrices. In the glandular form of the second degree of hard infiltration the process indicated in the first glandular changes is found in an accentuated form. The grouping of the glands is more marked and takes on a compactness, in contradistinction to the scattering tendency noticeable in the earlier stages. This grouping is met with especially at the peno-scrotal juncture. * Chronic Urethritis of Gonococcic Origin, J. DeKeersmaecker and J. Verhoogen. igo CYSTOSCOPY AND URETHROSCOPY The location of the excretory duct is well marked and sur- rounded by a pronounced inflammatory zone. These glandular changes are made readily perceptible upon the inferior wall, on account of the more superficial situation of the glands. For this same reason, the glandular changes on the inferior wall disappear more rapidly under treatment. In the dry form of the second degree of hard infiltration, the obstruction of the excretory duct is more chronic in character and decidedly more cicatricial. For this reason the glands themselves show a decided tendency toward obliteration by rupture into the surrounding tissue or by fibrous encapsulation. The glands show as small nodular masses and at no time are the small canary-seed vesicles found. The tendency toward group- ing is entirely lost, and the noticeable changes are isolated. The Lacunae of Morgagni. — The Lacunae of Morgagni par- ticipate in the glandular changes of chronic urethritis in a manner analogous to those changes which take place in the glands of Littre. The pathologic process is much more easily observed in the lacunae on account of their larger size. In the earlier stages of chronic urethritis, the opening of the lacuna which, in a normal state, is of the same color as the sur- rounding mucosa and is not raised above the surface, shows a pronounced change. The mouth is turgescent and red and the epithelial luster is greatly modified. At the same time a muco- purulent secretion may be seen issuing from the mouth of the lacuna. The different degrees of infiltration may attack the lacunae with varied results. The orifices may become widely dilated by the contracting infiltration. The urethroscopic picture is typ- ical. The edges of the orifice are everted and reddened and sur- rounding this everted orifice is a zone of paler infiltration. Instead of an enlarged pouting orifice, the lacuna may present an obstructed condition with a resultant cyst of the lacuna. The cyst has not the translucent vesicular appearance of similar cysts of Littre' s glands, but appears as a red nodule, the contents Fig. q6. Fig. 97. Fig. 98. Fig. 99. Fig. 100. Fig. 96. — Mixed urethritis, hard infiltration of the second degree. Fig. 97. — Dry urethritis, infdlration of the second degree. Fig. 98. — Dry urethritis, hard infiltration of first degree, vesicles are present. Fig. 99. — Dry urethritis showing large submucous nodosities. Fig. 100. — Dry urethritis, infiltration of second degree. (After de Keersmaecker and Vcrhoogen.) Fig. ioi. Fig. I02. Fig. 103. Fig. ioi. — Membranous urethra in normal state. Fig. 102. — Normal prostatic urethra. Fig. 103. — Urethritis of the prostatic portion. (After de Keersmaecker and Verhoogen.) URETHROSCCPY OF THE DISEASED URETHRA 19I of which may rupture into the surrounding tissues. In this cystic type of lacunar involvement, it is extremely difficult to make out the orifices of the lacunae. The lacuna may rupture into the canal and become transformed into a longitudinal slit at the bottom of which may be observed the orifices of infected glands of Littre. Occasionally, granulation tissue is observed — the urethritis granulosa of Oberlander. These granulations resemble to a great degree the peculiar granular points of trachoma. The Posterior Urethra.- — As indicated in the chapter on nor- mal urethroscopy, the posterior urethra should not be thus invaded until the lesions therein are decidedly chronic. Soft infiltration and the transitional form are not to be observed as pure clinical entities, though they may be found in a condition of retrograde metamorphosis or at the periphery of the areas of hard infiltration. In the prostatic urethra, we find areas, or plaques, of sclerotic appearing mucosa. These areas of infiltration never attain the degree of stricture formation, properly speaking, that is found in the anterior urethra. The characteristic folding of the urethra is not markedly modified. On account of the small number of Littre' s glands found in this region, their pathology is unimportant. The most notice- able changes are found in the verumontanum, the prostatic utricle, the ejaculatory ducts and the prostatic ducts. The verumontanum in a state of soft infiltration is turgescent and has a peculiar dull, cyanotic aspect. It bleeds more readily than in health and its surface may appear creased or wrinkled. The utricle is gaping and of a deeper red color. The mucosa may have a "plushed" appearance. In the hard infiltration the verumontanum seems to flatten out and has a sclerotic appearance. This pachydermic appear- ance may be limited to small areas in the midst of a turges- cent periphery. In this form of chronic posterior urethritis, the prostatic 192 CYSTOSCOPY AND URETHROSCOPY utricle may take on changes analogous to those observable in Morgagni's lacunae. Its edges may become everted and red- dened. If it is of small dimensions normally, the infiltration may close the orifice sufficiently to form a distinct cyst. In the earlier forms of infiltration the orifices of the ejaculatory ducts, normally slit-like and of the same color as the surrounding mucosa, assume a more rounded shape, are slightly raised above the contiguous surrounding surface and have a surrounding reddish zone. As the infiltration progresses, two changes may take place. The orifices may become dilated with slightly everted edges, giving rise to a pouting appearance or the infiltra- tion may cause a stenosis at the orifice. The former is most usual, but it must not be forgotten that even with a dilated, pouting orifice, a deeper infiltration may cause a stenosis back of the orifice. The orifices of the prostatic ducts, barely observable in health, take on changes analogous to those observed in the glands of Littre in the anterior urethra and the analogy is so close that the changes taking place in them under the influence of chronic urethritis require no especial description. The Membranous Urethra.- — In this part of the canal we find changes similar to those taking place in the anterior urethra. Littre' s glands are few in number in the membranous portion and are even less developed than they are in the prostatic por- tion. For this reason, glandular changes are seldom capable of demonstration here. We find the different degrees of infiltra- tion and this infiltration practically always extends from the bulbous region. With the exception of the glandular form, which is never encountered in the membranous region, the modifica- tions in the endoscopic picture are of the same character as those which are found in the anterior urethra. The characteristic changes in the luster and the folds are easily identified and require no especial description. Stricture. — In Oberlander's classification of the different degrees of infiltration already referred to in the study of chronic URETHROSCOPY OF THE DISEASED URETHRA 193 I A i Fig. 104. Fig. 105. Fig. 106. Fig. 107. Fig. 108. Fig. 109. Fig. 1 10. Fig. hi. Fig. 112. Fig. 104. — Floor of Ihe proximal portion of the supramontani region when this forms a valley surmounted by prominent side walls. Fig. 105. — Normal colliculus with prominent posterior frenula. Fig. 106. — Normal colliculus viewed from in front (distally). Presenting summit and acclive. Fig. 107. — Atypical colliculus with peculiar utricle. Fig. 108. — Small cysts in roof of the pars supramontana Fig. 109. — Fossula prostatica and declive. Fig. 1 10. — Inflammatory excrescences on the colliculus. Fig. III. — Small papilloma lying against colliculus and arising by a slender pedicle from the foot of that body. Fig. 1X2. — Enlarged prostatic duct in depressed scar tissue in the right sulcus lateralis; displaced and distorted colliculus. (After Leo Buerger.) 13 194 CYSTOSCOPY AND URETHROSCOPY urethritis, he classifies stricture in the third degree of hard infil- tration, i.e., that infiltration that has progressed to such a degree that it precludes the passage of an instrument as large as num- ber 23, Charriere scale. This classification is arbitrary and must be abandoned in the endoscopic study of stricture, as it will be readily understood that infiltration to the degree of stricture formation is encountered at a larger caliber than number 23, French. Finger has shown that the connective-tissue proliferation which eventually ends in gonorrheal stricture practically always has its beginning in the glandular recesses. This process begins in the mucosa, later extends to the submucosa and over into the erectile tissue of the corpora cavernosa unless checked. As a result of this connective-tissue proliferation there is produced a strangulation of the vessels with a resultant anemia. To the urethroscopist, stricture appears as an encroachment on the lumen of the urethra, having the characteristic appearance of extreme hard infiltration. Its appearance is sclerotic — a cadaverous yellowish white — and the epithelial luster has dis- appeared. There is a complete absence of the longitudinal folds in the infiltrated area. This infiltration may present at any part of the urethral lumen. The first noticeable encroachment on the lumen anterior to the bulbous portion is usually observed on the superior half of the urethral wall, preferably to one side of the center. An encroachment beginning on the inferior wall is extremely unusual in gonorrheal stricture, except in the bulbous portion of the canal, where the beginning sclerosis is usually on the floor. From its point of inception the infiltration extends, showing the characteristic transitional forms toward the periphery. This extension is more marked in an antero-posterior direction, though frequently the lateral growth is proportionately rapid. While the diagnosis of an obstruction in the urethral lumen is readily made by means of flexible bougies a boule, the urethro- scope holds an invaluable place in the diagnosis. By its use we URETHROSCOPY OF THE DISEASED URETHRA 1 95 are able to determine the clinical variety of the stricture, the point of extreme infiltration, the presence or absence of compli- cating papillomata, the presence or absence of false passages and the relative location of the stricture to the urethral lumen. The latter point is of extreme importance in the accurate treatment of stricture. In stricture of filiform caliber where there is great distortion of the tissues, the location of the lumen of the stricture is readily determined by air-inflation urethroscopy. In such cases its value is beyond question. The different clinical varieties of stricture are easity recog- nized by the urethroscopist. Their nomenclature suggests their urethroscopic appearance and a detailed description of each is superfluous. False passages are by no means an infrequent accompaniment of small cahbered stricture and their recognition is not always easy, i.e., their dift'erentiation from the actual lumen of the stricture. In false passage of comparatively recent origin, the diagnosis is easily made. The use of air-inflation is of great value in these cases. By its means a wider field anterior to the obstruction is obtained and a comparison of the false and true openings is readily made. Where false passages are present we find in the sclerosed tissue forming the stricture, two or more openings, one of which is the true strictural lumen. The orifice of the latter is characterized by the extreme degree of infiltra- tion. The edges of the opening are rounded, not ragged or clear-cut. The gentle introduction of a urethral probe into the opening does not provoke bleeding. The opening of the false passage presents a different appear- ance. It is situated away from the area of greatest infiltration. Its edges are ragged. If recent its orifice is usually closed by a clot of blood. The introduction of a urethral probe even with great gentleness produces bleeding. Even in false passage of long duration, its appearance is characterized by more recent infiltration than the true lumen and careful comparison of the 196 CYSTOSCOPY AND URETHROSCOPY two openings can hardly result in a mistaken differentiation. Fenwick, who is an ardent supporter of air-inflation urethroscopy, relates the following case which is of interest as it presents an "accident" occurring under the use of air-inflation, the possi- bility of which must not be ignored in similar cases. "I examined with inflation a patient who had had profuse bleeding from attempts at catheterism some few hours before applying to me for relief. I was able to find the opening of the false passage with ease. It lay just below the pin-point orifice of the strictured part of the urethra, and it appeared as a bloody- edged ragged slit. But the patient called out almost immedi- ately that something was running down the insides of his thighs, and I then became aware that air was passing freely through the opening of the "false passage" and escaping into the tissues of the perineum. There was no doubt that the false passage was very extensive. No ill results ensued, but it is easily conceivable that damage of a grave description can be inflicted by unfiltered air passing over an inflamed surface and opening up extensive cellular planes in the thighs, perineum and pelvis."* The accurate localization of stricture in its relative position to the urethral lumen is extremely important. The reasons for this position will be fully explained in the consideration of the operative treatment of stricture via the urethroscope. We wish here to call attention to the salient points in the use of air-inflation in the urethroscopic diagnosis of stricture. We believe that it can be asserted without fear of contradiction that the urethroscopic picture of stricture presented under air- inflation is much clearer and the essential detafls much more readily recognized than under ordinary urethroscopy. With the distal end of the urethroscope close to but not against the ante- rior face of the stricture, the air-inflation brings the stricture out in detail. The urethra anterior and posterior to the stric- *The Urethroscope: Its Development and Its Use. William R. Fox, Austral- asian Medical Gazette, October 20, 1906. URETHROSCOPY OF THE DISEASED URETHRA 1 97 ture is dilated and the irregular lumen of the urethra at the point of encroachment of the infiltration contrasts markedly with the normal lumen. The relative position of the stricture to the lumen, its extent and its classification from a clinical standpoint and the presence or absence of other strictures in its neighbor- hood and posterior to it, are points which are clearly demon- strable under air-inflation. Of these last points, the first is practically the only one which can be definitely determined by ordinary urethroscopy. The presence, relative location, clin- ical character and extent of other strictures posterior to the one immediately under observation can be positively diagnosed by no other means than air-inflation urethroscopy. Valves and Diverticula. A. Valves. — The occurrence of valves in the urethra has usually been attributed to the presence of greatly enlarged Morgagni's lacunae or lacunae which, during the process of dilatation for chronic urethritis, have become split. This view is not supported by clinical evidence for in many cases these valves are located on the inferior wall. They may be found in any portion of the urethra, though the region just behind the navicular fossa, the bulbous portion and the prostatic portion seem to be the locations in which they are most generally found. Both Segall and Schlagenhaufer have reported cases of fatally obstructive valvular formation in the prostatic portion of the canal. The position which these valves occupy and their direction varies. Valves w^hich are formed by dilated or split Morgagni's I lacunae always occupy the superior half of the canal and have their openings directed anteriorly. They cause trouble only by reason of a possible obstruction to the passage of instruments, or by becoming the seat of a retained infection. Other valves of unknown origin are occasionally found in the urethra. These valves may occupy any part of the circum- ference of the canal. Their openings may be directed either toward the meatus or the bladder. In the former case, in the absence of infection, they rarely, if ever give rise to symptoms. iqS cystoscopy and urethroscopy If of the latter form the symptoms are usually obstructive in character. Personally, we have observed two cases of valvular formation on the floor of the urethra, one of which was located just back of the glans with its opening directed toward the meatus while the other was in the bulbous cul-de-sac with its opening toward the bladder. The former, which was in a man fifty-five years of age, gave rise to no symptoms and was discovered accidentally by means of the urethroscope. The latter case was in a young man of twenty-one years and was accompanied by slight dribbling. Seen through the urethroscope the valves formed from the lacunae of Morgagni usually present simply as dilated lacunar orifices. The opening appears as a slit either in the direction of the canal or placed transversely to it. The orifice is ordinarily V-shaped, the point of the V being placed distally. In non- infected valves the edges of the orifice appear slightly paler than the surrounding mucosa and fall closely together. In cases of infection the edges become decidedly more prominent and red- dened, taking on practically the same modifications which char- acterize infections of lacunae of normal size. Those valves which do not originate in Morgagni' s lacunae appear as transverse or V-shaped slits. These valves are formed by a thin covering of mucosa, paler than that surrounding them. Their dimensions vary greatly. The over-lying thin edge is closely in contact with the subjacent mucosa. The orifice in uninfected cases appears as a thin line placed transversely to the urethra. On the mucosa where the opening is V-shaped the edges may simulate the normal folds, especially in the bulbar portion, giving rise to an error in diagnosis. The diagnosis is not difficult in those valves having their orifices directed toward the meatus. A urethral probe may be placed under the overlying edge affording a ready diagnosis. Better still, under air-inflation, the air is forced under the valve URETHROSCOPY OF THE DISEASED URETHRA 1 99 causing it to become raised and its presence and extent can thus be diagnosed with certainty, with a minimum of trauma. In the valves having their orifices directed toward the bladder and which are giving rise to but little obstructive symp- toms, the diagnosis may prove more difficult. In the case which came under our observation, the valve was in the bulbar cul- de-sac and its identity could not be established by ordinary urethroscopy. Under air-inflation, the air was refluxed back from the obstruction presented by the compressor and lifted up the valve, bringing it plainly into view and establishing the diag- nosis beyond doubt. We should strongly suggest the use of air- inflation in the diagnosis of this variety of valvular formation, believing that it affords a more certain method of diagnosis. B. Diverticula. — Diverticula of the urethra are of two t>^es — those due to a congenital absence of erectile tissue and those due to a gradual dilatation behind acquired stricture. Both forms are practically always found upon the floor of the urethra. It is extremely exceptional to be able to observe the congeni- tal form through the urethroscope as it usually becomes thor- oughly recognizable at an age too early for urethroscopy. The latter form is often observed in strictured urethrae and, as it always forms back of fairly small-calibered strictures, its detection by means of urethroscopy necessitates the use of air- inflation. With the end of the urethroscope against the anterior face of the stricture the air balloons the urethra back of it. The urethra is seen to be pouched and of larger than normal caliber. This pouching practically always takes place on the inferior wall back of annular stricture. The diverticulum is much redder than the infiltrated tissue around it, and the pouching, or dip- ping in, of the urethral wall is characteristic. Tumors. — New-growths of the urethra with the possible exception of the vascular poh'pi, or caruncles, found in the female urethra, are comparatively rare. Papillomata, both sessile and pedunculated, fibrous, fibro-myomatous, fibro-myxomatous and 200 CYSTOSCOPY AND URETHROSCOPY vascular polypi, cysts of Cowper's glands and of the prostatic utricle, carcinomata and sarcomata occur in frequency in about the order mentioned. (A) Papillomata. — The site of predilection of the most com- mon form of urethral new-growth is at, or in the neighborhood of, the external meatus, though papillomata have been found throughout the entire extent of the urethra and may even invade the bladder. Oberlander, Desgueir (Soc. beige de chir., Decem- ber 28, 1890) and Reboul (Assoc, franc, d'urologie, 1896) report cases of this character. For the first description of papillomata of the deeper portions of the urethra we are indebted to Vajda (Wiener medic. Wochenschrift, 1882). Similar cases are cited by him, the reports emanating from Morgagni, Rokitansky, Hunter, Tarnowsky, Dittel and others. Since that time there have been numerous cases reported by various observers, not- ably Rosenthal, Kollmann and Oberlander, in Germany, and Klotz, in this country. While recognizing the fact that urethral papillomata are not invariably preceded by a chronic urethritis, Oberlander (Sa- jous's Annual, 1888, II, 212, from Vierteljahresschrift fiir Derm, und Syph.) has described a form of papillary over- growth — "urethritis papillomatosa " — which takes place upon the areas of infiltration found in chronic urethritis. Bruggs (Gaz. hebd. de Montpelier, 1890, No. 5, p. 58) reports a charac- teristic case of this form of urethritis. It may be stated as practically axiomatic that those papillomata which originate back of the navicular, fossa arise from, but two causes — chronic gonorrhea and syphilis. Legeueu's investigations (Traite de Chirurgie, tome IX) bear out this contention, and Halle and Wassermann have given a most excellent description of those papillomata which arise from the extreme degree of hard infil- tration, while papillomata originating in the lesser degrees of infiltration have been thoroughly studied by Griinfeld (Die Endoscopic der Harnrohre und Blase). Cases of a similar character have been reported by numerous observers, notably URETHROSCOPY OF THE DISEASED URETHRA 20I Bryant (Med. Chir. Trans., Vol. LXXVI, p. 191), Klotz (N. Y. Med. Jour., Jan. 26, 1895), Goldenberg (N. Y. Med. Jour., Nov., 1898, p. 600), Eversole (St. Louis Polyclinic, Aug. 5, 1889) and Briggs (Boston Med. and Surg. Jour., Oct. 24, 1889). Endoscopically considered, papillomata present themselves either singly or in groups, or "nests" (Rosenthal, Berliner klin. Wochenschrift, 1884, No. 23). Single papillomata, unassociated with multiple growths in other parts of the urethra, are of extreme rarity. They are almost invariably found in that portion of the urethra lying between the peno-scrotal junction and the anterior layer of the triangular ligament, apparently springing from iso- lated papillae. According to Henle (Handbuch der Systemat. Anatomic, Vol. II, p. 433), papillae in the male urethra are par- ticularly abundant in the region covered with stratified pavement epithelium, an extent of from one to four centimeters from the meatus. Back of this, single, isolated papillae are found and it is from these scattered papillae that the single papillomata arise. Multiple papillomata practically always originate at, or in the neighborhood of, the external meatus and are usually asso- ciated wdth similar papillary exuberances on the glans and prepuce in the male and vulva in the female. They have a tendency to extend along the inferior wall, though no part of the urethral circumference is exempt, and the entire extent of the urethra may be invaded. Through the urethroscope papillomata have the appearance of roughened warty excrescences of a glistening pale pink color. They resemble closely the verrucae acuminata, exhibiting the same differences in shape and extent. In the grouped, or nested, papillomata the base of the growth is broader than in the single isolated growth. The latter occasionally appear as thin delicate fibrillae. Both forms are usually found when the growths invade the urethra to any extent. The urethroscopic appearance of these growths is so typical that it is hardly possible for a mistake in diagnosis to occur. The 202 CYSTOSCOPY AND UEETHROSCOPY fact that they are readily rubbed off their site of attachment leaving a freely bleeding base makes the diagnosis certain. In the urethroscopic examination of papillomata, the readi- ness with which they may be separated from their site of attach- ment and the tendency of any laceration of these growths to produce hemorrhage which will make the diagnosis difficult must be kept in mind. In the accurate diagnosis of the presence and extent of urethral papillomata, air-inflation urethroscopy is absolutely essential. By means of air-inflation the tendency to tearing the growths is reduced to a minimum and their charac- ter and extent may be easily determined. (B) Polypi. — The term polyp as applied to certain new- growths in the urethra has been so varied in its application as to cause much confusion in the classification of tumors of the urethra. Legeueu (loc. cit.) , Janet (Cinq cas de pol}^es uretraux, Assoc, franc, d' urologie, 2nd session, Comptes rendus, Paris, 1898, p. 402) and others have included papillomata in their classification of polypi, serving further to confuse the literature. Janet divides polypi into two classes: (i) Worm-like, single growths found in the region of the bulb and (2) papillomatous, sessile growths disseminated throughout the urethra. The inclusion of the latter under the head of polypi seems to us to be manifestly incorrect. In order to obviate this confusion in classification we consider it more logical to include under the clinical term of polypi those growths which resemble clinically the tumors found elsewhere which have been consistently classified as polyps. Under this heading come fibromata, fibro-myxomata, fibro-myomata and vascular polypi, the caruncles of the female urethra. ' Fibromata are rare and true myxomata are never found. We do not include under the heading of polypi those glandular hypertrophies occurring as an accompaniment of chronic gonorrheal urethritis. They have been classified as polypi by several authors, notably Legeueu, who considers them to be the purest type of polyp, and insists upon their constant pedunculation. URETHROSCOPY OF THE DISEASED URETHRA 203 (A) Vascular Polypi. — Vascular pol}^i, to which the terms urethral caruncles and angiomata have been applied, are found with great constancy in the female urethra but are exceptionally rare in the male, only a few instances being recorded. According to Pozzi, this form of urethral new-growth in the female results from the retention of erectile tissue which normally belongs to the male, and their growth is dependent upon some local irritation. The growth is composed of dilated capillaries intermixed with connective tissue and has a covering of stratified epithelium. It has a plentiful nerve supply. The vascular pohpi must not be confounded with the varices occurring in the female urethra, from which they difi'er both histologically and clinically. They are found most commonly at the middle period of life, though Giraldes observed a case in an infant of three years and Trelat has operated for this condition on a woman of seventy- five years. In the female they present themselves, as a rule, at the meatus externus or just within the urethra on the floor. In the cases recorded as occurring in the male, the polypi were found just within the meatus or in the navicular fossa and resembled, in all clinical peculiarities, the caruncles found in the female. They appear as bright-red, succulent looking growths, having a distinct pedicle and are exquisitely sensitive. While ordinarily single they are very often multiple. The urethroscope is seldom called upon in the diagnosis of vascular polypi on account of their location. Their extreme sensitiveness combined with their bright red appearance serves to differentiate them from the other forms of urethral polypi. (B) Fibromata, Fibro-m3rxomata and Fibro-myomata. — These three varieties of urethral new-growth resemble each other so closely clinically that it is practically impossible to make a differential diagnosis until the tumors are examined histologic- ally. On account of the lack of clinical individuality we shall consider them collectively. True fibromata are extremely rare, 204 CYSTOSCOPY AND URETHROSCOPY the mixed types, fibro-myxomata and fibro-myomata, being most commonly found. They present themselves, as a rule, in the adult female, Legeueu absolutely excluding their presence in the male, though this stand is refuted by numerous observers. The fibro-myxomata develop in areas of infiltration, usually the result of chronic urethritis. Fibro-myomata develop at the expense of the fibro-muscular elements and, in their incipiency, are not intraurethral growths, but in the course of their develop- ment project into the urethral lumen. (Dubar, Notes sur un volumineux polype de I'uretre chez la femme. Bull. med. du Nord, t. XXVIII, p. 4SI-) In the male, the mixed forms have been reported by various observers as occurring in the different anatomical divisions of the canal, the bulbous portion seeming to be the most common site. The predilection of these polypi for this location is borne out by the observations of Janet, Klotz and others and is in accord with our own clinical experience. Klotz reports one case as springing from the membranous urethra, a most unusual location. Well-authenticated observations of true fibromata occur- ring in the male urethra are exceptionally rare, and in all of the reported instances the growths were located in the pros- tatic urethra and had their site of attachment in the immediate neighborhood of the ejaculatory ducts. They were almost invariably single. We have observed postmortem a case of multiple fibromata in the prostatic portion of the canal. In this case there were six distinct polypi scattered over the inferior wall and sides of the prostatic urethra. In the female, as in the male, the growths may spring from any point in the urethra and on account of their pedunculation, which is sometimes extreme, may present at the external meatus though their site of attachment may be a considerable distance within the urethra. Their point of origin is usually at the level of the posterior wall in the urethro- vaginal partition. Endoscopically, these growths appear as smooth, rounded URETHROSCOPY OF THE DISEASED URETHRA 205 polypi having a distinct pedicle or stem, the pedunculation being more pronounced in the fibro-myxomata and fibromata. The growth has a tendency to stand out fairly prominently exhibit-i ing a stiffness, as it were, of the pedicle. Normally, the color varies. In the fibro-myomata it is practically the same as that of the surrounding healthy mucosa. In the fibromata and fibro-myxomata, the coloring is paler, almost sclerotic in the latter. In the diagnosis of these growths their possible malignancy must be taken into consideration. Both sarcomata and carcinomata may present as pedicled growths and the possibility of malignant transformation of essentially benign growths must not be overlooked. Toupet, in examining Schwartz's case (Sem. Med., 1889), found in the center of the polyp a transitional change toward malignancy. In his work (Die Endoskopie der Harnrohre und Blase) Griinfeld has noted a difficulty in recognizing the larger worm- like polypi on account of the growths falling closely against the walls on the withdrawal of the urethroscope and simulating the natural folds. To prevent this, he has suggested that the urethra be inspected while inserting the urethroscope, thus unrolling the growth into the lumen of the tube. We cannot conceive the possibility of such an error in diagnosis at the hands of a skilled and careful urethroscopist, and even admitting the possibility under ordinary urethroscopy, such an error could not arise under the use of air-inflation. We cannot commend the procedure recommended by Griinfeld on account of its being so productive of trauma. Varices. — The occurrence of varices in the female urethra is not uncommon but their existence in the male urethra is of exceptional rarity, their being but two cases whose authenticity seems established, those of Klotz (N. Y. Med. Journ., Jan. 26, 1895) and Young reported by Fowler (The Johns Hopkins Hospital Reports, Vol. XIII, p. 91). The urethroscopic descrip- tions of these cases are so interesting that we give them in extenso. 206 CYSTOSCOPY AND URETHROSCOPY Klotz's Case. — "The protruding portion of the mucous membrane was found to be of a smooth surface and a dark bluish color, of the shape and size of a coffee bean, sharply defined at the base from the dark pink surrounding portions. The tumor was soft and easily yielded to the pressure of the tube, although on introduction it seemed to offer a slight resistance. On close inspection within the tumor a number of separate cords, separated by yellowish white lines resembling the rings of a coil, could be distinguished, apparently representing dilated blood vessels, and imparting to the whole mass the character of a cavernous angioma." Young's Case. — " Urethroscopic examination by Dr. Young. No. 26 Otis tube was passed into the prostatic urethra, but it was impossible to introduce it as far as the verumontanum. The anterior portion of the prostatic urethra which was examined showed nothing particularly abnormal. The membranous ure- thra was also about normal. As soon as the bulbous urethra was reached, in drawing the urethroscope outward, the picture was at once remarkably abnormal. Several large, deep-red, irregular masses projected into the lumen, and between them were depressions of a dull gray color which suggested ulceration or old scars, but were probably not. This condition was present in the entire anterior urethra. As the instrument was drawn slowly out, a succession of irregular, rounded, deep red masses projected over the end of the endoscope; these were apparently covered by healthy mucous membrane, and between them were irregular depressions of grayish color, supposed at first to be ulcers, but no exudation could be obtained from them, and prob- ing did not cause any hemorrhage, so that it was evident that they were not ulcers. The rounded deep masses which were scattered over the mucous membrane were evidently dilated blood vessels. There were no ulcerations to be seen, and no ruptured vessels or definite points of active hemorrhage, though blood constantly appeared in the endoscopic field." Varices of the female urethra usually present at or im- UEETHROSCOPY OF THE DISEASED URETHRA 207 mediately behind the meatus externus. They may attain a rela- tively large size. On account of the accessibility and their hemor- rhoidal appearance, their urethroscopic description is unnecessary. Carcinoma. — Primary carcinoma of the urethra is an ex- tremely rare affection, especially so in the male. At different/ intervals various observers have collected the literature bearing' on the subject so that we may say that carcinoma, while of extreme rarity, is probably the most thoroughly studied of all of the new-growths of the urethra. The combined investigations of latter-day observers, notably Basil, Hall (Ann. of Surgery, March, 1904) and M. Hartmann (Travaux de Chirurgie, 1906) show but twenty-seven proved cases of carcinoma of the male urethra, and thirty-six in the female. To these cases we wish to add two observations, one by Dr. Frank J. Hall, a squamous- cell cancer of the female urethra and the other by Dr. J. Block and ourselves, a carcinoma of the bulbous urethra. The first case reported is that of Thiaudiere, in 1834. This case is rejected by both Kaufmann and Hall though in all probability the growth was a carcinoma. The first authentic case is that reported by Hutchinson (Trans. Path. Soc, London, Vol. XIH, p. 167, in 1861). Since that time there have been a number of theses on the subject by Thiersch, Billroth, Poncet, Guyon and Guiard, Salzer and Griinfeld, Griffith, Czerny and Witzenhausen, Carey, Beck, Oberlander, Albarran, Hall, Hartmann and others. A full review of the literature, which is fairly voluminous, would be out of place in a work of this character. , Practically all of the reported cases were squamous-cell I carcinoma. Kocher's case (Deutsche Chirurgie, 1884) was partly a t>pical glandular carcinoma and partly a cylindroma. The case of W. Knoll (Deutsche Zeitschriftfiir Chirurgie, 1906) was an adeno-carcinoma. The site of predilection of carcinoma in the male urethra is in the bulbar portion. In the cases of Thiaudiere, Hutchinson, and Buday, the growth was located just posterior to the glans. 2o8 CYSTOSCOPY AND URETHROSCOPY In Billroth's case, the cancer began in the mid-pendulous portion, while in Griinfeld's case, the prostatic urethra was the point of origin. Hartmann is of the opinion that the tumor in Griin- feld's case originated in the prostate and that the urethra became involved secondarily. In the majority of cases in the male, the growth was preceded and accompanied by gonorrheal stricture, though some cases presented no history of gonorrhea. Hartmann thinks, however, that gonorrheal stricture occurs with sufficient frequency to be considered as a factor in the etiology. Urethrorrhagia is considered by Beck to be a fairly common symptom though in quite a considerable proportion of the cases there was no hemorrhage from the urethra. In the cases of Beck, Guyon and Guiard and of Griinfeld, hemorrhage was a prominent symptom. In the case observed by Dr. Block and ourselves, hemorrhage from the meatus, occurring independently of micturition, was one of the earliest symptoms. Carcinoma of the urethra has been observed but three times via the urethroscope — by Griinfeld, 1885, Oberlander, 1893, and Beck, 1890. In Oberlander's case the diagnosis was made by means of urethroscopy and later confirmed. The observations of these three authors are of such interest as to justify a detailed description. Griinfeld's Case. — Urethroscopy with a straight tube. On inserting the tube to a depth of twelve centimeters, a small polypoid growth was encountered, implanted with a short pedicle. Four centimeters further back, a second growth flattened in shape was found. Their color was whitish yellow. The urethral mucosa of the entire posterior urethra had an abnormal appearance. On inserting the tube to the verumon- tanum a narrow, horseshoe-shaped band of congested mucosa was encountered having its convexity at the right. The re- mainder of the urethroscopic field was filled by a tumor lying transversely. One-half of this growth was of a pale rose color; the other half was grayish. URETHROSCOPY OF THE DISEASED URETHRA 209 The surface of the growth, which bulged into the lumen of the tube, exhibited a furrowed appearance with small red excavations. Dilated blood vessels were also noted. On slight withdrawal of the tube a thin septum, running horizontally, was noticed. The mucosa above this septum was deeply livid and bled on the slightest touch. Below, the mucosa was ulcerated. By manipulation the tumor could be raised, disclosing the ulcer- ated mucosa. On the inferior surface of the tumor, two faceted appearing spots were observed. The growth was carcinomatous. Oberlander's Case. — Urethroscopic tube No. 27 inserted to the extremity of the bulb. In the inferior half of the field was seen a semilunar pale cicatrix. The surrounding mucosa was grayish and sclerotic looking. The entire extent of the mucosa, almost to the region of the navicular fossa, presented a similar sclerotic appearance, with several cicatrices. At some points a plicated appearance of the mucosa was noted. There was a glandular urethritis. Behind and above the semilunar cicatrix a growth was ob- served. By drawing the penis forward and pushing in the tube the growth could be made to present in the lumen of the tube. The growth was distinctly raspberry-like, being irregularly mammillated and presenting a bright red appearance. The tumor was a squamous-cell carcinoma. In Beck's case the growth was found in the neighborhood of a stricture. The tumor presented as a papillary prominence on the superior wall and toward the right side of the urethra. The growth was a freely bleeding one. It was a squamous-cell carcinoma. The value of the urethroscope in the early diagnosis of ure- thral cancer cannot be overestimated. A review of the litera- ture relative to carcinoma of the urethra discloses the fact that in the vast majority of the cases the growth had advanced to the point of urinary extravasation and fistula before the diagno- sis was made. It will be noted in the record of the twenty-one microscopically confirmed cases, recorded by Basil Hall, that the case of Oberlander's is the only one in which the growth 14 2IO CYSTOSCOPY AND URETHROSCOPY had not recurred within one year from the first operation. In Oberlander's case there was no recurrence twenty-one months after an operation which was fairly conservative — a resection of the urethra. Beck's case was lost sight of. In Carey's case, in which total emasculation was done, there was no recurrence in ten months and in one of Montgomery's cases, there was no recurrence four months subsequent to an amputation of the penis. In all of the other cases, recurrence was noted within six months. While from the standpoint of urethroscopy we have but meager data at our command on which to base a diagnosis, we may safely consider any easily bleeding, fungating or raspberry- like growth in the urethra of a man who has attained the age of forty years to be under suspicion. A small piece removed via the urethroscope is sufficient for the purpose of an exact micro- scopic diagnosis. Under such diagnosis, early operation is possible with a proportionately favorable prognosis. Sarcoma of the Urethra. — Of all new-growths found in the urethra, sarcoma is most uncommon, there being but few reported instances. To Hoening (Berlin klin. Wochenschrift, 1869, p. 55) belongs the credit for the first reported case. Rizzoli (Jour, de med. de Bruxelles, 1875), Tillaux (Annales de gynecolo- gic, 1889), Buttner (Zeitschrift fiir Geb. und Gynaek., Bd. XVIII, p. 122), Ehrendorfer (Centralblatt fiir Gynaek., 1892), Lejars (Lecons de chirurgie), and Albarran have all reported well authenticated cases of fibro-sarcoma. Hall and Frick (Jour. A. M. A., June 23, 1906) record a case of melanotic sarcoma which they assume from the postmortem findings must have originated in the urethra. The case is unique but the clinical evidence is well supported. In the Annals of Surgery for March 191 2, page 416, one of us (Mark) reports a case of primary sar- coma of the male urethra which is of sufficient interest to merit a detailed report. The patient was 24 years of age. The urethroscopic examination follows: No. 24 F. tube met obstruction just posterior to the corona. Under air-inflation URETHROSCOPY OF THE DISEASED URETHRA 211 very pale pol}poid masses, irregular in outline were observed, springing from the entire urethral circumference. Using the urethroscopic tube as a curette these masses were removed with great difficulty as far back as the scrotal urethra. On account of the bleeding and the duration of the operative procedure it was deemed advisable to postpone any further measures. The masses thus removed were left at the hospital for pathological examination which was somehow neglected. Six days later the work was taken up where it had been left off and utilizing the same procedure as at the former operation, the remaining growths, or portion of the growth, were removed back to the anterior layer of the triangular ligament, A cystoscope was now introduced without difficulty and examination revealed a high-grade cystitis but no e\ddence of new growth. The bladder capacity was much diminished. The specimens removed were submitted to Dr. Frank J. Hall whose report follows : " Gross specimen consists of a number of whitish soft fragments. Section shows sarcoma poor in blood vessels with small amount of stroma. The cells are of the large round type, with a suggestion of polymorphus cells with vesicular nuclei and pinkish staining cytoplasm. (Frozen section, H. & E. Stain)." Legueu makes the statement, based on his investigations, that sarcoma occurs exclusively in the adult female. In the case reported by Hall and Frick, the patient was a male, thirty- three years of age. Fibro-sarcomata of the urethra pursue the same indolent course that characterizes their growth in other parts of the body. Their appearance is in no way tjqDical and their clinical differ- ential diagnosis from fibromata is almost impossible. On account of their appearing almost exclusively in the female, their large size and the ready diagnosis of their presence by ordinary methods of clinical investigation the use of the ure- throscope is never demanded. We ha\e included mention of them in this section merely for the sake of completeness. 212 CYSTOSCOPY AND URETHROSCOPY Urethral Tuberculosis. — Tuberculosis of the urethra is prac- tically always secondary to lesions of the upper urinary tract or adnexa, there being absolutely no convincing evidence in support of the few reported cases of so-called primary urethral tuberculosis. Thisstatementis supported by the investigations of Hogge (Ann. des malad des Organes Genito-urinaires, 1901, Vol. XIX, p. 1 491) who makes the statement that there is abso- lutely no recorded case of primary urethral tuberculosis. Kraske believes that it does occur and Baumgarten, cited by Ahrens (Beitrage zur Klin. Chirurgie, 1891-92, Vol. VIII, p. 312) has produced experimentally typical tuberculous lesions in the urethra of a buck rabbit by direct inoculation, thus demon- strating the possibility of the occurrence of primary urethral tuberculosis, though similar experiments by Blandini (Annales des mal. des Org. Genito-urinaires, 1901, Vol. XIX, p. 1491) failed signally in this respect. , There have been a few cases reported in which the tuberculous lesions of the urethra v/ere secondary to a tuberculosis of the glans penis. In the cases of Kraske (Centralbl. fur Chirurgie, 1888, Vol. XV, p. 889), Poncet (Abstract Central, fiir. Krank. der Harn. und Sex. -Org., 1893, Vol. IV, 512) and Hartmann (H. Hartmann, Travaux de Chi- rurgie Anatomo-Clinique, p. 278), the extension was by perfora- tion, while in Ehrmann's case the disease extended to the urethra via the meatus. In the case reported by Hartmann, the growth simulated closely a neoplasm. The conclusions of different investigators as to the relative frequency of urethral tuberculosis are greatly at variance. From the combined investigations of Steinthal, Krzywicki and Pavel in 433 cases of urogenital tuberculosis (Ahrens, loc. cit.) there wxre noted but eighteen instances of urethral involvement — slightly over 40 per cent. In the investigations of Halle and Motz (Annales des mal. des Organes Genito-urinaires, Dec. i and 15, 1902) which covered a series of over 160 cases of genito- urinary tuberculosis observed in the Hopital Necker, urethral involvement was noted in twelve instances. URETHROSCOPY OF THE DISEASED URETHRA 213 Urethral tuberculosis is found with much greater frequency in men, Ahrens being able to find but four recorded instances of its occurrence in women. ("Die Tuberculose der Harnrohre," Beitrage zur klinischen Chirurgie, Vol. VIII, p. 312). It appears most commonly during the time of greatest sexual activity, i.e., between the ages of twenty and thirty. In the vast majority of instances of tuberculosis of the ure- thra, the disease is confined to that part of the canal lying posterior to the triangular ligament and is so intimately asso- ciated with lesions in the bladder and adnexa that it requires no\ consideration as a clinical entity. From the standpoint of the urethroscopist, it becomes of interest only when it attacks the anterior urethra and we shall confine ourselves to the considera- tion of anterior involvement. We shall exclude peri-urethral tuberculosis and that form of the disease attacking Cowper's glands, minutely studied by Englisch (Allg. Wien. med. Zeit- schrift, 1891, p. 2). The lesions of the mucosa present as two clinical forms, tuber- cles and ulcers, most commonly the latter . Ulceration is simply the advanced stage of the tubercle and its more frequent obser- vaiton is dependent upon the lack of symptoms which accompany the earlier manifestation of the disease, i.e., the tubercle. The urethroscopic picture is rather characteristic. The tubercle appears as a yellowish or grayish spot in the midst of a zone of bright red infiltration. In the very early stages of the lesion, it is often impossible to recognize the presence of the tubercle through the urethroscope on account of its minute size. It may attain the dimensions of a pea, as in the case observed by Michaut (Bull. Soc. Anat., 1887, p. 103). The reddish periphery is fairly regular while the tubercle, which is raised above the sur- rounding zone of infiltration, is distinctly so. Later, in the ulcerative stage, the zone of surrounding red loses its regularity of outline. The tubercle, which in the early stages of disintegration, closely resembles a chancre, becomes punched out and ragged 214 CYSTOSCOPY AND URETHROSCOPY looking and evinces a tendency toward phagedena. This latter tendency is more marked in, and in fact, may be almost wholly dependent upon, a diffuse preulcerative infiltration, to which, in greatly marked cases, the term "diffuse caseous infiltration" has been applied. The lesions are practically always observed to begin in the bulbar portion and to extend in the direction of the meatus. In the case reported by Kidd (Trans. Path. Soc, London, Vol. XXXIX, p. 185) the lesions became markedly modified as they approached the meatus. Apparent calcification of tuberculous deposits in urethral tuberculosis has been observed by Berard and Trillat (Le Bull. Medicale, Vol. XV, p. 737). The patient was a child and no satisfactory examination was made, though, in all probability, there was calcification of a periurethral tuberculosis. Chute (Boston Med. and Surg. Jour., Oct. i, 1903, p. 361) has reported a case of calcification taking place in the urethral glands, sub- sequent to urethral tuberculosis. The diagnosis in this case lacks both clinical and pathological confirmation and must be questioned. The urethroscopic diagnosis of tuberculous lesions should offer no difficulty. In the preulcerative stage of minute tuberculous deposits, the associated lesions should suggest the diagnosis. In the early ulcerative stage, the location of the lesion and the lack of pronounced induration together with the entire clinical picture makes the differential diagnosis from urethral chancre easy. In the advanced stage of ulceration, especially the diffuse type, the direction of the extension from behind forward and the asso- ciated lesions, serve to obviate the possibility of confounding it with urethral chancroid. The age of the patient combined with the entire clinical and urethroscopic picture serves to differen- tiate distinctly between tubercle and epithelioma. Herpetic Eruptions of the Urethra. — The occurrence of herpes within the urethra, while comparatively rare, has been reported by a number of competent observers. The herpetic eruption URETHROSCOPY OF THE DISEASED URETHRA 215 within the urethra has in practically every instance been asso- ciated with a similar eruption on the glans or prepuce and the inception and subsidence of the two involvements were synchro- nous. In all of the studied cases the eruption within the urethra was confined to the first inch and a half of the canal. Endoscopically, intraurethral eruptions have practically the same appearance as that of herpes of the glans or prepuce. They arise as small painful vesicles, exhibiting a tendency to grouping. These vesicles rapidly break, leaving superficial, irregular, markedly red erosions of the mucosa. There is no peripheral infiltration. The extremely painful character of these lesions, their loca- tion, their bright red base and their lack of surrounding infiltra- tion serve to make the diagnosis clear. Chancroid. — Chancroid of the urethra practically never oc- curs as a purely intraurethral lesion, and it is with extreme rarity that the urethra is involved back of the navicular fossa. The disease extends by continuity from the meatus. As in chancre, the attendant infiltration is so great as to make the introduction of the urethroscope both difficult and painful and with the exception of those rare cases in which there is a marked tendency to phagedena or where the chancroidal in^'olve- ment has extended to the deeper parts of the urethra through previous instrumentation, urethroscopy is distinctly contrain- dicated. Through the urethroscope, chancroid appears as a grayish, ragged ulceration irregular in shape within definite borders. There is a well-marked periphery of dark-red infiltration. If the lesion is very extensive, there appear irregular patches of non-ulcerated mucosa, dark-red or bluish-red. In other words, as far back as the lesion extends, the ulceration is practically continuous. No differential diagnosis is required, though study of the case reported by Ricord of extensive chancroidal ulceration extending into the bladder, has convinced some observers that 2l6 CYSTOSCOPY AND URETHROSCOPY the case was one of tuberculosis rather than chancroid. Such a mistake is very unhkely to occur and we consider a detailed study of possibly confusing conditions unnecessary. Syphilis of the Urethra. — Syphilis of the urethra presents in two forms of interest to the urethroscopist, the primary lesion and the mucous patch. The chancre is most commonly observed on account of the lack of subjective symptoms to which the latter gives rise, though it is exceedingly probable that the mucous patch is in reality the more common lesion. Chancres involving the lips of the meatus or situated just within the meatus are of no interest urethroscopically. Their observation and diagnosis via the urethroscope are required only when they are located within the navicular fossa or back of this point. They are rarely located posterior to the fossa though the primary lesion has been found as far back as two inches from the meatus (Keyes). The introduction of the urethroscope in urethral chancre is usually attended with considerable pain on account of the extreme stiffness of the urethral wall in the neighborhood of the lesion. There is a marked tendency toward bleeding. The uretliroscopic appearance of the unmixed form of chancre is fairly typical. The chancrous erosion may be located at any point in the urethral lumen or it may occupy the entire lumen. The ulcerated surface is raw and bleeding with quite a marked periphery of deep red infiltration. The edges of the ulcer are clear cut. The appearance of the mixed form is practically that of urethral chancroid. It must not be forgotten that purely chancrous lesions of the urethra give rise to a pronounced degree of infiltration. '' In the unmixed form of urethral chancre, it is possible, though hardly probable, that a differential diagnosis may be required from tuberculosis and carcinoma. In tuberculosis we find the lesions to be multiple, relatively smaller and advancing from the deeper portions of the urinary tract. While in its early stage of ulceration, the tubercle may bear some resemblance to URETHROSCOPY OF THE DISEASED URETHRA 21 7 chancre, the rapid excavation of the tuberculous lesion destroys this possible ( ?) source of error. In carcinoma we find the growth almost always arising back of the peno-scrotal junction, usually in the bulbous urethra. The hemorrhagic tendency is thoroughly pronounced — far more so than in chancre. The growth bears practically no resemblance to chancre and we cannot conceive of the possibility of confound- ing the two lesions. The Mucous Patch. — While we believe that the occurrence of the mucous patch within the urethra is by no means an un- usual accompaniment of syphilis, the resultant urethritis is usually of such a mild degree as to rarely attract the attention of the medical attendant. Bassereau and Bumstead have, however, reported cases in which a profuse urethritis developed from the presence of mucous patches within the urethra. In the cases which we have observed, the urethritis was mild and the subjective symptoms slight — presenting practically the same clinical characteristics as an old gleet. The endoscopic diagnosis offers no difficulties as the lesion presents the same clinical peculiarities that characterize it on other mucous membranes. It is irregular. It is superficial and accompanied by but slight infiltration. The ulceration is yellowish and the edges are well defined. The lesion may be single, though when the disturbance caused by the presence of mucous patches within the urethra is sufficient to call for inves- tigation, it is rare that but one lesion is found. The presence of secondaries elsewhere should suggest the diagnosis and, in fact, there is but one condition which it in any way resembles — the chancroid. The fact that chancroidal ulcerations invariably extend by continuity from the meatus, coupled with the greater degree of infiltration and the tendency to great destruction of tissue which accompanies the chancroid, should make the differ- ential diagnosis easy. Leukokeratosis (Psoriasis Mucosa). — The occurrence of whitish plaques on the urethral mucosa was first pointed out by 2l8 CYSTOSCOPY AND URETHROSCOPY Kollmann and Oberlander who applied to this condition the term ''psoriasis mucosa" — a term which is, unfortunately, too broad in its application to be definite. On account of its analogy to leukoplakia lingualis, to which Butlin has given the patho- logically correct term of leukokeratosis, we deem it advisable to apply the term leukokeratosis urethralis to the condition de- scribed by Kollmann and Oberlander under the more vague name of psoriasis mucosa. The formation of these plaques on the urethral mucosa is dependent upon local nutritional disturbances resulting in great epithelial proliferation. These disturbances are of an extremely chronic character and practically always arise on the areas of infiltration of chronic urethritis. Leukokeratosis urethralis may present as a single isolated plaque or as scattered patches distributed over a considerable area. It is found in patients over middle age and, as in leukokeratosis lingualis, may be considered a pre-epitheliomatous condition, Endoscopically considered, these plaques appear as flat or slightly raised lusterless white patches. They exhibit no tendency to a regularity of outHne. In color, they vary accord- ing as the epithelial proliferation has advanced, from a grayish- white to a dead-white. They are with difficulty scraped from their bases to which they are firmly adherent. They give rise to no subjective symptoms and are associated with a gleety discharge. Their urethroscopic diagnosis presents no diffi- culties, as their appearance is typical. They are unaccompanied by a general psoriasis. Urethral Calculi. — Calculi of the urethra are either primary and originating in the urethra or secondary, having their origin higher up in the urinary tract or in the prostate. They occur with extreme infrequency in women, Finsterer being able to find but fourteen recorded instances (Deutsche Zeitschrift fiir Chirurgie, Last index, XL VI, 1404). Primary calculi of the urethra are comparatively rare. They practically always have their origin in valves or diverticula, URETHROSCOPY OF THE DISEASED URETHRA 219 fistulous tracts or behind some point of extreme pathological narrowing of the urethra. The nucleus may be made up of inspissated pus and epithelium or be formed around a sym- pexion. We have observed a case originating from Robin's sympexions and which is, as far as our investigations have been pursued, unique. For this reason we report it in detail. The patient, Mr. S., aged forty-four years, had on different occasions passed small gelatinous-like bodies ovoid in shape, which on minute examination, corresponded to the vesicular formations described by Robin under the name of sympexions. He had a resilient stricture just anterior to the bulbar cul-de-sac for which I urged urethrotomy. He was, however, compelled to go East on some matters of business before operation and dur- ing a prolonged stay, neglected treatment. On his return to Kansas City, we passed a urethroscope down to the face of the stricture which had become greatly contracted. Under air- inflation it was possible to observe just back of the stricture and lying within the cul-de-sac of the bulb, a white body. A ure- thral probe demonstrated that this body was a calculus and was freely movable. The stricture was incised through our operating urethroscope and the tube pushed down into the cul-de-sac. The calculus entered the lumen of the tube and was removed by means of an applicator loosely tipped with cotton. It was ovoid in shape and undoubtedly phosphatic. It was crushed accident- ally and found to be merely a shell containing a much smaller dried nucleus of what had apparently been a sympexion. The sympexion had apparently passed into the cul-de-sac of the bulb and been held in this location by means of the obstruction offered by the stricture. A deposit of urinary salts had taken place and the sympexion had gradually disintegrated leaving the egg-shell calculus. So-called primary calculi having for their nucleus some re- tained foreign body are not true calculi but merely incrustations. The deposit of phosphatic plaques on the urethral mucosa is an anomaly, but such a case has been reported by Chute. 2 20 CYSTOSCOPY AND URETHROSCOPY Secondary calculi may present as (a) urethral calculi, lying entirely in the urethra; (b) vesico-urethral, the so-called "pipe" stones, lying partly in the bladder and partly in the urethra; (c) prostato-urethral, originating as prostatic calculi and pro- jecting into the urethra. The first forms pass into the urethra from the upper urinary tract and are arrested at the points of physiological narrowing or behind a stricture. The occurrence of prostato-urethral calculi, while denied by some authorities, is con- firmed with certainty by the observations of Casper and others. In both the diagnosis and treatment of calculi of the urethra, the urethroscope is indispensable. The urethroscopic appear- ance of calculi requires no especial description as no differential diagnosis is required. Cyst of the Prostatic Utricle. — The occurrence of utricular cyst in the adult is extremely rare. Englisch, in seventy autopsies on new-born infants, found this condition five times and Cabot (Trans. Amer. Assn. G.-U. Surgeons, Twentieth Annual Meet., Vol. I, p. loi, 1906) concludes from his investi- gations that it is practically never found in the adult. A few instances have, however, been reported in which the cyst has been observed urethroscopically. Klotz's case (" Endo- scopic Studies," N. Y. Med. Jour., Jan. 26, 1895) appears to be well authenticated by its clinical description though the author hesitates to report it unequivocally as a utricular cyst. In the few reported cases observed through the urethroscope the existence of the cyst has in every instance been traceable to the infiltration of chronic lu-ethritis occluding what was pre- sumably originally a prostatic utricle of very small dimensions. Urethroscopically, such a cyst has the peculiar bluish-white, translucent appearance of similar cysts of Littre's glands but attains a size proportionately larger. Its diagnosis is dependent upon its location and the existence of a surrounding zone of infiltration. Argyria. — Discoloration of the urethral mucosa from the topical use of silver salts, usually the nitrate, has been occa- URETHROSCOPY OF THE DISEASED URETHRA 221 sionally observed. It results from the oxidation of the silver and the resultant staining is black or brownish-black. This staining presents as isolated areas of discoloration, sometimes being limited to the orifices of the glands and lacunae. It may disappear within a short time or remain indelinitel}-. The endoscopic picture is tj-pical. The irregular areas of black or brownish-black discoloration exhibit a loss of luster and the vascularity is obscured. These spots are painless and unac- companied by symptoms. CHAPTER V OPERATIVE URETHROSCOPY The practicability of the use of the urethroscope for the performance of certain intraurethral operative maneuvers has long been demonstrated and Kollman and others have devised numerous ingenious instruments to be used through the urethro- scope. To attempt to describe all of these instruments and their application is unnecessary as the use of the various instru- ments is suggested by the instruments themselves. To certain procedures to which we have had recourse and which have appealed to us as being especially valuable, we shall accord special mention. In intraurethral work we have found air-in- flation urethroscopy to be practically indispensable and we have made use of the Ernest G. Mark Aero-Urethroscope in all work of this character. The Treatment of Cystic Follicles and Suppvirating Glands of Littre. — The end to be attained in these conditions is the thorough destruction of the infected follicle or gland. Simple drainage has, in our experience, been insufiicient. This obliteration of the infected sac may best be secured by opening up the sac through the operating urethroscope and then destroying the infected area by galvano- or acid-cauterization. The procedure we have adopted is as follows : The urethro- scope is introduced and the infected follicle or gland brought into the urethroscopic field. A solution of adrenal extract, i to 1000, is applied with a small pledget of cotton to the area to be operated upon. This is allowed to remain a few minutes. The cotton is then removed and a 4 per cent, solution of cocaine, similarly applied, is kept in contact with the infected gland or follicle for about five minutes. The cotton is now OPERAXrVE URETHROSCOPY 223 removed and the operating window, through which the knife is passed and attached to the handle, is introduced, care being taken that when the window is firmly attached the blade of the knife shall not protrude beyond the distal end of the urethro- scopic tube. Under air-inflation the point of the knife is plunged into the infected area and a free opening made. The blood and purulent material are mopped up with cotton-tipped applicators and the cavity thus exposed is seared over with the urethral cautery. The subsequent treatment consists of the injection twice daily of a 15 per cent, solution of argyrol. On the fifth day topical applications of 12 per cent, silver nitrate or of a solu- tion containing equal parts of iodine and carbolic acid may be made via the urethroscope. It seems unnecessary to state that the above procedure is applicable only in chronic infections. Stricture. — The employment of certain maneuvers via the operating urethroscope in the treatment of stricture has already been indicated in the chapter dealing with the urethroscopy of stricture. In the application of the urethroscope to the opera- tive treatment of stricture, there is no intent to supplant other operative measures of known value. The field of urethroscopy in urethral stricture is, of necessity, limited and we shall consider the operating urethroscope rather in the light of a valuable adjunct. In so-called impermeable stricture, where it is found ex- ceedingly difficult or impossible to introduce even a filiform bougie we have found the following procedure of great service. The urethroscope is introduced down to the face of the obstruction. Often this is impossible on account of coexisting strictures of lesser degree anterior to the point of apparent impermeability. When the instrument is introduced as far as possible, the observation window is attached and air-inflation employed. Even though the urethroscope may not have been passed to the main point of obstruction, the ballooning of the 2 24 CYSTOSCOPY AND URETHROSCOPY urethra will bring this point into view. If false passages coexist, then differentiation from the contracted urethral lumen is readily made {vide page 195). If there is accompanying bleeding the application of adrenal extract, i to 1000, is of service, both in stopping the bleeding and in lessening the congestion. The observation window is replaced by the operating window and a whalebone filiform passed through it. The urethra is inflated and with the narrowed lumen in view the bougie is passed into and through it. With the filiform in place, further procedures may be left to the discretion of the surgeon. In the cases in which we have employed this procedure, we have found it easy of accomplishment and thoroughly practi- cable. In most of these cases there have been persistent un- successful attempts to pass filiforms and in the majority of such cases there have been accompanying false passages. In the time-honored performance of internal urethrotomy, the procedure has been stereotyped and especial insistence has been made that the incision be made in the median line of the roof of the canal. This has been considered an absolute es- sential of the operation. In the urethroscopic study of stricture it will be found that the obstruction in the majority of instances does not present at the upper middle portion of the urethral lumen. It will be found usually to one side of the median line, occasionally on the floor. Under such circumstances, and they are the usual ones, severing the relatively normal mucosa in the upper median line and leaving the infiltrated portion untouched, does not appeal to us as a logical procedure. The application of the urethroscope to the performance of accurate internal urethrotomy is in our judgment almost indispensable. We employ it as follows: (i) To locate ac- curately the relation of the infiltration to the urethral circumfer- ence. (2) If the stricture is of a filiform caliber, it is quite possible by means of the intraurethral knives used via the operating window, to so incise the infiltration that the passage OPEEATIVE URETHROSCOPY 225 and further use of the urethrotome becomes possible, the best line of cleavage having been ascertained by means of the urethro- scope. (3) In fairly extensive cicatricial formations, it has been found impracticable to perform internal urethrotomy \da the 'urethroscope on account of the essential feature of dilatation which is afforded by the ordinary urethrotome. In such cases the urethroscope is used merely for the purpose of accurately locating the relative position of the infiltrated area. The ure- throtome is then introduced and the incision made according to the information gained, absolutely no attention being paid to the old rule of cutting directly in the median line of the roof. Papillomata. — Various procedures for the removal of papil- lomata situated in the urethra have been de\dsed. Several years ago Oberlander suggested the following method which was fairly successful and met with general approval. Oberlander's Method. — Pass the urethroscope beyond the point of involvement. Pass through the tube two cotton- bearing applicators. Remove the tube leaving the applicators in situ. Extend the canal by pulling on the penis and by alternately pushing and pulling on the applicators, lacerate the growths. The preceding operation is crude and must be considered obsolete. Schwartz devised a method for the removal of various urethral growths which is fairly practicable and efficacious. Schwartz's Method. — The instrument is made up of an ordinary urethroscopic tube having near its distal end an open window placed laterally and a second tube made to closely fit the lumen of the first. The edges of the distal opening in the second tube are sharp. The first tube is introduced with obturator in place. The obturator is withdrawn and by manipulation the growth is made to project into the lumen of the tube through the laterally placed window. The second tube is now introduced, the cutting edges of which shave off the projecting growth. This instrument 15 226 CYSTOSCOPY AND URETHROSCOPY with various modifications has been presented quite frequently, the last presentation being that of Young, of Baltimore, before the American Urological Association in 1909 (Trans. Amer. Urolog. Assn., 1909). Both the hot and cold snare have been suggested and utilized by various writers, much being claimed for the former method. Authors' Method. — The urethra is anesthetized by the use of alypin or cocaine. Adrenalin is applied freely to the growths by means of cotton swabs passed through the urethroscope and left in situ for a few moments. The urethroscope is now passed beyond the point of further- most involvement, the secretions mopped up and the observation window attached. The urethra is now inflated with air and slowly withdrawn. When papillomatous masses present in the field, the urethroscope is inclined at a slight angle toward the growth, and the urethra being inflated beyond the growth, the urethroscope is pushed quickly against the tumor at its base, the sharp edges of the distal extremity of the tube shaving the growth from the urethral wall. This procedure is accompanied by practically no bleeding. The instrument is still further withdrawn and as other masses come into view, the same procedure is made use of. After all growths have been removed, the urethra is stripped to empty it of the detached papillomatous masses and adrenalin is instilled into the canal. In a few minutes the urethroscope is reintroduced and the points of former attachment of the papil- lomata are slightly touched with a fine galvano-cautery point. Subsequent treatment is made at the discretion of the operator. Other Tumors. — In the removal of other growths of the urethra, the urethroscope plays but little part unless the growth be pedunculated and non-malignant. In tumors of this char- acter, the galvano-cautery snare may be used with success. Enlarged Turgescent Verumontanum. — Where this condition is persistent and resists the topical applications of silver salts, the partial removal of the enlarged veru is indicated. For this OPERATR'E URETHROSCOPY 227 purpose the galvano-cautery knife or snare is of much service. Hawkins, of Pittsburg, has made use of the same procedure for the removal of the veru as that advocated by the authors for the removal of urethral papillomata, i.e., shaving off the growth with the urethroscopic tube. Vesiculitis and Strictures of the Ejaculatory Duct. — In 1904 one of us (Mark) presented to the American Urological Association the fallaciousness of the view formerly held as as to the extremely small size of the ejaculatory duct. It was found possible to pass into the ejaculatory ducts of prostates remo^'ed from the cadaver probes of ordinary size. Reasoning from this knowledge the possibility of medication to the vesicles and ampullae of the vasa by means of injections through long canulae passed via the urethroscope was suggested and has been carried out in a number of instances. We do not, however, consider the procedure to be practicable in most instances on account of the distortion of the structures in the prosta- tic urethra by accompanying disease of this portion of the urethra. In stricture of the ejaculatory duct it is advisable to attempt dilatation of the duct by means of whalebone filiforms passed via the urethroscope. The passage of small probes and canulae into the orifices of the ducts is sometimes surprisingly easy of accomplishment and in all cases of chronic vesiculitis, is worthy of a trial. Valves and Diverticula. — Vah^ular folds and diverticula whose openings are toward the meatus are readily obliterated by splitting up the folds via the urethroscopic tube with urethral scissors or a curved knife. The small tags left by this splitting quickly contract and practically disappear. Operative work on those valves whose openings are toward the bladder is more difficult. In the one case of this character observed by us we made use of the following procedure which seems to us to be readily applicable and indicated in all cases of this character. 2 28 CYSTOSCOPY AND URETHROSCOPY Author's Method. — The author's air-inflation urethroscope was introduced to a point just beyond the valve and withdrawn until the edge of the valvular fold came into view. The opera- tive window with the curved knife attached was now afi&xed to the urethroscope and with the stop-cock to the urethroscope turned off, the dilating bulbs were inflated. The stop-cock w^as now opened and the urethra inflated with a sudden inrush of air. The air striking the interference opposed by the com- pressor at the anterior layer of the triangular ligament was thrown back, lifting up the valvular fold into the urethral lumen. With steady pressure of air the fold was kept in its extended position and the knife passed through the center of its apex and the fold completely split, thus obliterating it. Com- plete and immediate relief from symptoms followed. Foreign Bodies. — The long list of foreign bodies found in the urethra precludes individual mention. It suffices to say that the removal of the majority of these is rendered easy by the use of the urethroscope. In work of this character it is best to use a tube of fairly large caliber. Air-inflation is distinctly advantageous, if not essential. The endoscopic tube is introduced down to the foreign body which can usually be palpated through the urethra. If the foreign body is in the penile urethra it is well to compress the urethra proximally to the body so as to prevent its being pushed further into the urethra. The usual urethroscopic technique is observed and the foreign body having been once brought into view, its removal is dependent upon the ingenuity of the operator. In the removal of sharp substances such as spiculated stones, pins, pieces of glass, etc., great care must be taken to prevent undue laceration of the urethral mucosa. The ordinary types of alligator- jawed urethral forceps are the only accessories needed. Warning. — Within the past three years we have observed cer- tain phenomena occuring in operative work under air-inflation OPERATIVE URETHROSCOPY 229 which have led us to believe that there are certain dangers against which a warning must be issued. In the Journal of the A. M. A., February ii, 191 1, we reported a case of air embolus which occurred during operation under air-inflation urethroscopy. While this case did not come to a fatal issue, the possibility of such an issue must not be denied. We have observed cases in which localized emphysema occurred during intraurethral operative work and we believe that all of these cases have been caused by an undue amount of air-inflation. Therefore, in all cutting operations in the urethra under air- inflation the bulbs should be released at the moment of the incision so that air cannot be forced into the tissues thus opened up. We believe that if this rule is followed no untoward symptoms will arise in work of this character. INDEX Adenoma of the bladder, 109 Accessories, cystoscopic, 17 Acute cystitis, 95 Afterword on tumors and changes in bladder, 121 Air-inflation of bladder by Rutenberg, 6 cystoscopy, technique, 28 heated air preferred in, 30 position of patient for, 29 Albarran's lever device, 10 Anatomy of bladder, i Anatomy of male urethra, 155 Cowper's glands, 160 Littre's glands, 159 prostatic follicles, 160 the trigone, 2 Analgesia required in cystoscopy, 23 method of securing, 23 Appearance of normal bladder, 31 of normal ureteral orifice, 33 Armamentarium, cystoscopic, 15 Bladder, tuberculosis of, 109 tumors of, loi adenoma, 109 carcinoma, 105 contraindication to cystoscopy in, 102 sessile growth, 105 villous-covered growth, 105 divisions of, loi fibroma, 109 myoma, 109 myxoma, 109 papilloma, 103 color of, 104 treatment of, 104 types of, 103 villi in, 104 sarcoma, 105 ulcer of, simple, 115 tuberculous, 1 1 1 Box phantom, Valentine's, 35 Bransford Lewis' first cystoscope, 10 fulguration apparatus, 139 B Beer's treatment of vesical tumors, Bierhoflf's modification of Nitze's toscope, 1 1 Bilharzia disease, 107 Bladder, anatomy of, i bullous edema of, 117 coloring of normal, 31 congestion of, 94 cysts of, dermoid, 107 echinococcus, 108 follicular, 107 diverticula of, 117 leukoplakia of, 118 lymphoid tubercle of, 112 trabeculation of, 117 tabetic, 118 138 Calculi of bladder, 97 cys- encysted, 98 of ureter, 90, 119, 147 removal of, 147 of urethra, 218 Catheters for ureteral catheterization, 18 selection of, 43 sterilization and care of, 34 Carcinoma of bladder, 105 of urethra, 207 Catheterization of bladder before using cystoscope, 29 of male ureter, 9 ureteral, in America, 9 ureteral, 37 choice of methods in, 41 231 232 INDEX Catheterization, ureteral, dangers of, 63 diagnosis by, 39 difficulties in, 60 direct method, preference for, 42 technique of, 45 history of, 37 indirect method, technique of, 52 Pawlik-Kelly method, 58 technique of, 45 purposes of, 39 treatment by, 40 under forced air-inflation, 57 X-ray work in, 45 Cauterization through cystoscope, 135 Chancroid of urethra, 215 Chromocystoscopy, 63 Classification of bladder tumors, 100 Congenital malformations of kidney and ureter, 85 Congestion of bladder, 94 Cowper's glands, 160 Cryoscopy, 66 Cystic kidney, 82 distention of lower end of ureter, 120 follicles, 221 Cystitis, acute, 95 subacute and chronic, 95 Cystoscopes, historical review, 4 Bierhoff's modification of Nitze's, II Boisseau du Rocher's, 8 Bozzini's, 4 Bransford Lewis', 10, 11, 130 Brenner's, 9 Brown-Buerger's, 14 composite, first, 8 Leiter's, 7 Nitze's, 6 requirements in, 16 Tilden-Brown's, 10, 11 Operative, 125 air-inflation instruments, 127 Bransford Lewis', 130 Casper's, 128 Cathelin's, 125 Luys', 125 Nitze's, 127 Cystoscopic accessories, 17 armamentarium, 15 Cystoscopy, i air-inflation in, 28 technique of, 28 analgesia in, 23 divisions of bladder for, 2 fallacies in findings, 33 free irrigation in, 16 indications for, 22 interpretation of picture, 34 of normal bladder, 31 of pathologic bladder, 94 of stone in bladder, 97 in ureter, 119 of vesical new growths, loi of tuberculosis of bladder, 109 of tumors of bladder, 100 Pawlik-Kelly's method of, 30 preparation of patient for, 22 Valentine's phantom in, 35 Operative, 122 cauterization in, 135 cystoscopes used in, 125 fulguration by, 137 in ureteral calculi, 147 in ureteral stricture, 146 purposes of, 124 Cysts, dermoid, 107 echinococcus, 108 follicular, 107 of Littre's glands, 189 of prostatic utricle, 220 of urethra, 190 D Dangers of ureteral catheterization, 63 Dermoid cysts of bladder, 107 Desormeaux's endoscope, 5 Diagnosis of adenoma, 109 Bilharzia disease, 107 bullous edema, 117 carcinoma of bladder, 105 urethra, 207 chancroid of urethra, 215 congestion of bladder, 94 congenital malformations of kidney and ureter, 85 cystic distention of lower end of the ureter, 120 INDEX 233 Diagnosis of cystic kidney, 82 cystitis, 95 cysts of bladder, 107 Littre's glands, 189 prostatic utricle, 220 urethra, 190 dilatation, ureteral, 205 diverticula of bladder, 117 acquired, 117 congenital, 117 urethra, 199 acquired, 199 congenital, 199 eversion of ureteral orifice, 119 fibroma of bladder, 109 urethra, 203 fibroma-myoma of bladder, 109 urethra, 202 fibro-myxoma of bladder, 109 urethra, 202 fibro-sarcoma of urethra, 211 functionating capacity of kidney, 63 herpes of urethra, 21 hydronephrosis, 40 inflammatory dilatation of renal pelvis, 77 lacunae of Morgagni, diseased, 189 leukoplakia of bladder, 118 urethra, 217 lymphoid tubercle, 112 papilloma of bladder, 103 urethra, 200 polypi of urethra, 202 pyelitis, 40, 77 pyonephrosis, 40 sarcoma of bladder, 106 urethra, 210 solitary kidney, 90 stricture of ureter, 40, 44- urethra, 194 stone in bladder, 97 ureter, 90 urethra, 218 syphilis of urethra, 216 trabeculation of bladder, 1 1 8 tabetic, 117 tuberculosis of bladder, 109 kidney, 85, 112 Diagnosis of tuberculosis of urethra, 212 ulcer, simple, of bladder, 115 tubercular, 11 1 valves of urethra, 197 varices of bladder, 108 urethra, 205 Ducts, ejaculatory, 183 orifices of, 183 size of, 183 stricture of, 227 E Echinococcus disease, 108 Edema buUosum, 117 Ejaculatory ducts, 183 orifices of, 183 size of, 183 stricture of, 183 Endoscope, Desormeaux's, 5 Fisher's, 5 Grunfeld's, 5 Haken's modification of, 5 Endoscopy, historical review, 4 Eversion of ureteral orifice, 119 Examination of bladder, 27 Excretion of phenolsulphonephthalein, 69 in normal cases, 69 (see phenolsulphonephthalein test) 67 Extrarenal shadows, identification of. Fallacies in cystoscopic findings, 33 Fibroma of bladder, 109 urethra, 203 Fibro-myoma of bladder, 109 urethra, 203 Fibro-myxoma of bladder, 109 urethra, 203 Fisher's endoscope, 5 Follicular cysts, 107 Follicles, prostatic, 160 Foreign bodies in urethra, 228 removal of, 228 Free irrigation through cystoscope, 16 234 INDEX Fulguration, apparatus, 138 Beer's report, 1909-1911, 140 Beer's report, 1912, 142 cauterization by means of, 137 Keyes' report, 1913, 143 technique, 139 Functionation of kidney, 63 Glands, Cowper's, 160 Littre's, 159 appearance of, 180 H Haken's modification of endoscope, 5 Hemoglobinometer, Hellige, 69 Hemorrhage in bladder tumors, loi control of, loi of urethra, 208 Herpetic eruptions of urethra, 214 Hydronephrosis, 75 diagnosis, 77 Incandescent lamp, first use of, 7 Identification of extrarenal shadows, 84 intrarenal shadows, 84 Inflammatory dilatation of the kidney pelvis, 77 Inflation of bladder by air, 28 Pawlik-Kelly method, 30 urethra, 164 Instruments, care and sterilization of, 18, 168 Interpretation of cystoscopic picture, 34 Irrigation through cystoscope, 17 Lacunae of Morgagni, 180 appearance of, 180 Lamp, first use of incandescent, 7 general use of, 7 low amperage (cold), 10 Leukokeratosis of urethra, 217 Leukoplakia of bladder, 118 Litholapaxy, cystoscopic, 128 Littre's glands, 159 appearance of, 180 Localization of renal shadows, 82 stones in renal pelvis, 83 Luster of normal bladder, 32 urethra, 180 Lymphoid tubercle, 1 1 2 appearance of, 115 Kretschmer's studies of, 113 location, 115 M Male urethra anatomy of, 156 Cowper's glands in, 160 Littre's glands in, 159 natural constrictions in, 156 prostatic follicles, 160 Male ureter, catheterization of, 9 congenital malformations of, 85 Malignant sessile growth of bladder, 105 villous covered, 105 Mark's aero-urethroscope, 165 Meatoscopy, ureteric, 119 Methods of ureteral catheterization, choice of, 41 Mode of use of Lewis' cystoscope, 133 Morgagni, lacunae of, 180 Myxoma of bladder, 109 Janet's syringe, 18 use of, in cystoscopy, 18 K Kidney, cystic, 82 functionation, 63 tests for, 63, 64, 66, 67 and 70 N New growths, cystoscopy of, loi progress of (Fenwick), loi Normal bladder, examination of, 27 appearance of, 31 coloring of, 31 luster of, 32 vascularity of, 31 INDEX 235 Normal pelvis of kidney, 75 pyelography of, 75 Normal urethra, 170 urethroscopy of, 170 O Operative cystoscopy, 122 air-inflation cystoscopes, 125 Bransford Lewis' instrument in, 125 accessories for, 125 technique of, 130 cauterization by, 135 fulguration by, 137 apparatus, 138 Kelly's method, 125 Litholapaxy in, 128 Luys' instrument in, 125 purposes of, 124 technique of, in Nitze's instru- ment, 127 urethroscopy, 222 possibilities of accident in, 228 removal of foreign bodies by, 228 of verumontanum, 226 treatment of diverticula, 226 stricture, 223 strictures of the ejaculator>' ducts, 227 valves, 227 author's method, 228 vesiculitis, 227 Papilloma of bladder, 103 urethra, 200 Pawlik-Kelly method of inflation of bladder, 30 Pedersen's divisions of bladder for cystoscopy, 2 Pelvis, renal, inflammatory dilatation of, 77 normal, 75 Phenolsulphonephthalein test, 67 Phloridzin test, 64 Platinum loop period of endoscopy, 5 Polypi of urethra, 202 Posterior urethroscopy, 181 Preparation of patient for cystoscopy, 22 urethroscopy, 172 Preston's cold lamp urethroscope, 164 Prolapse of ureteral orifice, 119 Prostatic utricle, 161 cysts of, 220 Psoriasis mucosa, 217 Pyelitis, indications of, 77 treatment through ureteral cathe- terization, 65 Pyelography, 71 R Radiography, contraindications to, 92 failure of, 74 identification of extrarenal shadows by, 84 intrarenal shadows by, 84 in congenital malformations of kidney and ureter, 85 cystic kidney, 82 deformity due to renal tumors, 79 differentiation of tumors of the upper abdomen, 81 hydronephrosis, 75 inflammatory pelvic dilatation, 71 localization of renal shadows, 82 media used in, 71 amount necessary, 72 of normal renal pelvis, 75 renal tuberculosis, 85 solitary kidney, 90 technique of, 71 ureteral dilatation, 90 used in kidney pelvis and ureter, 71 Requirements in cystoscopes, 16 Rheostats, 135 Bransford Lewis', 135 Rutenberg's female vesical speculum, 6 Sarcoma of bladder, 106 urethra, 210 Schlagintweit's cystoscope, 1 1 Segalas' urethro-cystic speculum, 4 236 INDEX Segregators, arguments against use of, 39 varieties of, 39 Sessile growths in bladder, 105 Simple ulcer of bladder, 115 Sinus pocularis, 183 Solitary kidney, 90 Sterilization of instruments, 20, 168 Stomatoscope of Bruck, 5 Stone in bladder, 97 appearance of, 97 diagnosis of, 97 in ureter, 147 cystoscopic method of removal, 149 in urethra, 218 removal by urethroscope, 219 Stricture, ureteral, 144 treatment of, 144 urethral, 192 air-inflation urethroscopy in, 195 appearance of, 194 classification of, 194 diagnosis of, 194 false passages in, 195 pathology of, 194 relative location of, 197 treatment through urethroscope, 223 Suppurative glands of urethra, 190 treatment of, 222 Syphilis of urethra, 216 Syringe, Janet's, 18 Tabes, diagnosis of cystoscope, 118 Technique of cystoscopy, 22 fulguration, 140 functional kidney tests, 63 operative cystoscopy, 122 urethroscopy, 222 uretero-pyelography, 71 urethroscopy, 171 Tests for functional capacity of kidney, 63 by chromocystoscopy, 63 hemo-cryoscopy, 66 indigo-carmine, 63 iodide of potassium, 64 Tests by methylene-blue, 63 phenolsulphonephthalein, 67 phloridzin, 64 urino-cryoscopy, 66 Three-ureter cases, 10 Tilden Brown's cystoscope, 118 Trabeculation, true, 118 apparent, 34, 118 tabetic, 118 Trigone, anatomy of, 2 variations in, 32 Tuberculosis of bladder, 109 kidney, 85 urethra, 212 Tumors of bladder, 100 classification of, 100 contraindications to cystoscopy in, 102 control of hemorrhage in, loi cystoscopy of, 100 care in, 102 Keyes' criteria for fulguration in, 1 44 location of, 103 progress of, loi urethra, 199 U Ulcer of bladder, simple, 115 tuberculous, 11 1 traumatic, 116 Ureters, supernumerary, 86 Ureteral calculi, 147 catheterization, 37 by direct method, 45 by indirect method, 52 catheters used in, 18, 43 care and sterilization of, 21 choice of method, 41 cystoscopes used in, 4 dangers of, 63 difficulties in, 60 Pawlik-Kelly method in, 58 purposes of, 39 under forced air-inflation, 57 dilatation, 90 orifices, eversion or prolapse of, 119 location of, 33 variation of appearance in, 33 stenosis or obstruction, 146 INDEX 237 Ureteral stricture, 144 Ureteric meatoscopy, 119 Uretero-pyelography, 7 1 Urethra, anatomy of normal, 155 argyria of, 220 calculi of, 218 chancroid of, 215 cyst of prostatic utricle, 220 diverticula of, 199 elasticity of, 178 herpes of, 214 histology, 158 leukokeratosis of, 217 luster of, 180 pathologic conditions of, 186 chronic urethritis, 186 appearance of glands in, 189 changes in elasticity in, 186 in luster in, 188 glandular form of, 189 modifications in vascularity in, 188 Oberlander's classification of, 186 of membranous urethra, 192 posterior urethra, 191 sphincters of, 158 stricture of, 192 syphilis of, 216 tuberculosis of, 212 tumors of, 199 carcinoma, 207 fibromata, 203 fibro-myomata, 203 fibro-myxomata, 203 papillomata, 200 polypi, 202 sarcomata, 210 vascular polypi, 203 valves in, 205 varices of, 205 vascularity of, 179 Urethroscope, development of the, 162 air- inflation, 164 Antal's, 164 Buerger's, 181 care and sterilization of, 168 Goldschmidt's, 166 Kollmann's operative, 165 Urethroscope, Mark's, 165 McCarthy's, 181 methods of illumination of, 164 Oberlander's, 181 requirements of, 167 types of, 164 Valentine's, 164 Walker's, 166 Urethroscopy, analgesia in, 170 applicators used in, 175 fallacy in use of small tube, 170 indications for, 1 70 lubricants used in, 172 of male urethra, 170 female urethra, 184 points observed in, 177 position of patient for, 170 posterior, 181 straight tubes in, 181 technique of, 182 operative, 222 in cystic follicles and, 222 enlarged verumontanum, 226 foreign bodies, 228 papillomata, 225 Mark's method of removal, 226 Oberlander's method, 225 Schwartz' method, 225 stricture, 223 suppurating glands of Littre, 222 tumors, 226 valves and diverticula, 227 Mark's method, 228 vesiculitis and strictures of ejaculatory duct, 227 water-inflation in, 167 practical value of, 167 Urethro-cystic speculum, 4 Valentine's box phantom, 35 Valves, urethral, 197 urethroscopic treatment of, 227 Mark's method, 228 Varices of bladder, 108 cystoscopic appearance of, 108 238 INDEX Varices of urethra, 205 Klotz' case, 206 Young's case, 206 Vascularity of normal bladder, 227 Vascular polypi of urethra, 227 Vesiculitis, 227 Verumontanum, 160, 181 removal of enlarged, 226 variations in, 183 W Walker's urethroscope, 166 Water distention of bladder for cysto- scopy, 5 advantages of, 28 cystoscopes, 5, 6 Janet's syringe in, 18 Politzer's bag in, 18 urethroscopes, 166 Date Due "~" L. B. Cat ] fJo. 1137