On Cystoscopy, and the New 
Cystoscope of Nitze and 
Leiter. 
With a Demonstration of the Same. 
BY 
WILLY MEYEE, M. D., 
CLINICAL PROFESSOR OF SURGERY IN THE WOMAN’S MEDI- 
CAL COLLEGE ; ATTENDING SURGEON TO THE GERMAN 
HOSPITAL AND DISPENSARY, NEW YORK. 
REPRINTED FROM 
"Meto York metrical journal 
for April 21, 1888. Reprinted from the New York Medical Journal 
for April 21, 1888. 
OX CYSTOSCOPY, 
AND THE NEW GYSTOSOOPE OF NITZE AND LEITER. 
WITH A DEMONSTRATION OF THE SAME* 
WILLY MEYER, M. D., 
CLINICAL PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE, 
ATTENDING SURGEON TO THE GERMAN HOSPITAL AND DISPENSARY, 
NEW YORK. 
Mr. Chairman and Gentlemen : The two new cysto 
scopes of Dr, Max Nitze and Mr. Josef Leiter are the im- 
proved forms of an instrument known to the medical world 
since the year 1879. It was formerly called the Bruck- 
Nitze-Leiter or Nitze-Leiter cystoscope. 
Brack, a German dentist of Breslau, Silesia, was the 
first who, in 1857, used platinum wire heated to whiteness 
for illumination of parts of the body. He tried to accom- 
plish this by making use of the diaphanic qualities of the 
tissues. To examine the bladder he introduced a strong 
light, the white-hot platinum wire, into the rectum and a 
tube per urethram into the bladder. Through the latter tube 
he then inspected the bladder and its adjacent parts. 
Twenty years later Dr. Max Nitze proposed to introduce 
the white-hot platinum wire directly into the cavity or 
canal to be examined. He designed and constructed va- 
rious instruments with which he intended to inspect more 
* Read before the Section in Surgery of the New York Academy of 
Medicine, April 9, 1888. 2 
OX CYSTOSCOPY, AND THE 
closely the urethra, bladder, stomach, etc,, the two latter 
organs through a telescope situated in a central cavity form- 
ing the axis of the instrument. 
But these instruments were very defective yet. They 
were improved and made available for general use by the 
patience and perseverance of Leiter, a well-known instru- 
ment-maker of Vienna, after many months of expensive and 
troublesome experiments. On the 9th of May, 1879, the 
cysto-urethroscope was presented to the Society of Physi- 
cians of Vienna by Dr. Nitze.* 
There is no doubt that Dr. Nitze is the inventor of the 
urethro-cystoscope, and that the medical profession is in- 
debted to him for his continuous efforts, extending over 
more than twelve years, to improve the instruments. But 
at the same time we must appreciate the ingenious work of 
Mr. Leiter. He also deserves that his name be for ever 
connected with these electric endoscopes. 
Wall of the bladder 
Window! 
Platinum. 
Prism. 
Telescope. 
Fig. l.t 
Water-pipes. 
The cystoscope (Fig. 1), then, consists of a silver tube 
of the shape of a catheter, in the short beak of which a 
* “ Wiener med. Wochenschrift,” 1879, No. 24, and “Wiener med. 
Presse,” 1879, No. 26/ 
f Instead of the wire loop at the end of the instrument there should 
be a straight wire. NEW CYSTOSCOPE OE NITZE AND LEITEJR. 
3 
platinum wire is fastened. The latter is made incandes- 
cent by means of an electric current which passes through 
it, and then darts its rays upon the wall of the bladder 
through an oval window in the concavity of the beak, cov- 
ered with transparent quartz. To convey the current of 
electricity to the platinum an insulated wire runs through 
the whole length of the shank; the metal of the tube forms 
the connection with the opposite pole. The platinum wire 
is surrounded by a combination of pipes through which a 
current of cold water runs, to keep the heated instrument 
perfectly cool. They measure only one millimetre and a 
half in diameter and pass through the whole length of the 
sound, entering at its collar. According to Nitze’s design, 
a telescope is introduced into the shank of the cystoscope, 
a» above mentioned. It enlarges and magnifies the spot 
j O o X 
coming into sight. Without this telescope we should not 
see much more at the time than a spot of about the size of 
a pea; with it we are enabled to inspect a portion as large 
as a silver dollar, and even more. 
At the junction of beak and shank corresponding to the 
concave side a rectangular prism is cemented in, the hy- 
potenuse-plane of which acts as a mirror on account of the 
total reflection of the rays. Thus a diminished, inverted 
real picture arises in the shank of that wall of the bladder 
which is situated at a right angle to the longitudinal axis of 
the instrument and opposite the prism. It is again in- 
verted by means of the lenses of the telescope and thrown 
to the outer end of it, whefe the examining person looks at 
the now upright picture through the magnifying oci-Ugf of the 
telescope. At the middle of the upper circumference of 
the funnel-shaped handle a small knob is soldered. It en- 
ables us to he permanently informed to which side the beak 
points. 
If the fundus of the bladder is to be inspected with this 4 
ON CYSTOSCOPY, AND THE 
instrument it must be turned 180° and its handle deeply 
depressed between the thighs of the patient, the latter being 
.Wire. 
•Window. 
Window. 
Telescope. 
Wall of the bladder. 
Water-pipes. 
Pig. 2. 
in the recumbent (lithotomy) position, the best for exami- 
nation with the cystoscope. This manipulation may some- 
times be very painful. To avoid this, a second instrument 
(Fig. 2) is made with the window for the incandescent 
platinum on the convex side of the beak. There is another 
window at the end of the straight tube through which the 
observer looks with the telescope. Of course there is no 
prism. 
In using the original cystoscope there were needed, be- 
sides a Bunsen’s battery with a special fluid, a rheostat, to 
give the current with the greatest subtileness of the neces- 
sary strength in each case, and a reservoir containing about 
two or three gallons of cold water. These accessory appa- 
ratuses complicated the instrument very much and made it 
very expensive, in consequence of which cystoscopy was 
very rarely resorted to. The new instrument was only 
bought by some larger clinical institutions and hospitals and 
used by a few specialists and surgeons who take interest in 
investigation of diseases of the bladder, such as Nitze, v. 
Dittel, Nicoladoni, Ultzmann, Sir Henry Thompson, and 
the late Dr. Maas, professor of surgery in the university of NEW CYSTOSCOPE OF NITZE AND LEITER. 
5 
Wurzburg, Bavaria. They all unanimously and repeatedly 
praised the excellent results of inspecting the bladder. 
The enormous advance in electro-technique made in the 
last few years also improved the cystoscope. Edison’s lamps 
of a very small caliber, so-called mignon-larnps, well known 
to you all, took the place of the platinum wire and did away 
with the many accessory apparatuses, especially with the 
water-pipes. The new cystoscope is very handy and not ex- 
pensive. 
That the two men who invented and constructed the 
original instrument are at variance in regard to the priority 
of the improvements may be immaterial to us. We derive 
from the controversy—that even found its way into Dr. 
Nitze’s newest and lucid essay, “ Beitrage zur Endoskopie 
der raannlichen Harnblase ” *—two cystoscopes, made in 
accordance with the same principle and varying only in some 
trifles. It seems that both are equally good and useful and 
of the same price (|lB without duty). Letter’s cystoscope 
shows the old pattern with the improvements mentioned. 
Fig. 3. 
A key near the handle can be made to break or make the 
current by turning it to the right or left upon or from an 
* Langenbeck’s “ Archiv fur klinische Chirurgie,” vol, xxxvi, 3, p. 
661. 6 
ON CYSTOSCOPY, AND THE 
ivory plate. The shank of the instrument is somewhat short; 
its telescope diminishes the part in view a trifle’. Why it 
does not show it in its normal size Ido not know. Nitze 
puts the mignon-lamp into the end of the beak and does not 
protect it with transparent quartz. lie says that it is not 
necessary, and he is thus enabled to use lamps of a larger 
Fig. 4. 
size and therefore a brighter light. His telescope magnifies. 
The shank is an inch longer than that of Leiter’s instrument, 
the beak a trifle shorter. (The wires of the battery are 
connected with the so-called “ tongs ” that are attached to 
two isolated metal rings at the collar of the instrument. A 
slide makes and breaks the current.) Nltze constructed 
two more cystoscopes for the thorough and easy inspection 
of the fundus of the bladder and of the internal orifice of 
the urethra with the surrounding portions of the bladder, 
and especially of a part of the prostate. In these the prism 
is situated in the beak of the sound close to the mignon- 
lamp. In the first (the cystoscope for the fundus), the lamp 
and prism face the convex side of the beak; in the second 
(for the internal orifice of the urethra), the concave side. 
The picture arising, after having passed a system of two 
strong convex lenses in the beak, is reflected from a mirror NEW CYSTOSCOPE OF NITZE AND LEITER. 
7 
fastened at the curvature of the instrument. Another lens 
in the middle of the shank throws the picture to the outer 
Fig. 5. 
end, where the examining person again looks at it through 
the magnifying ocular. Both certainly are very important 
instruments. 
Fig. 6. 
On account of the difference's named, Nitze alleges supe- 
riority for his cystoscope. Nevertheless, I first sent for Lei- 8 
ON CYSTOSCOPY, AND THE 
ter’s, because he makes use of the mignon-lamps also for ure- 
throscopy in a very practical manner. To be sure, a kero- 
sene-lamp with one or a few burners or a gas-lamp gives 
sufficient light to illuminate the urethra by means of a head- 
mirror through Griinfeld’s or Klotz’s urethral endoscopes; 
but it is undoubtedly an advantage to have an even brighter 
light in a handle that is easily attached to the endoscope 
after it has been introduced, and can readily follow the mo- 
tions of the patient. It also seems that it is just as handy 
as the former patterns after some practice. 
On account of the possibility of using the same electro- 
scope, only with different head-pieces, for rhinoscopy, la- 
ryngoscopy, oesophagoscopy, otoscopy, etc., v. Dittel called 
it “pan-electroscope.” I shall also demonstrate it here- 
after. A thorough description of these instruments—also 
of the new gastroscope, which illuminates portions of the 
wall of the stomach as large as the palm of the hand—can 
be found in J. Leiter’s separate edition of his catalogue of 
surgical instruments, Vienna, 1887. 
For the generation of the electric current I ordered the 
battery designed by Leiter, too, Nevertheless, any electric 
battery used for galvano-caustic purposes will light the bow 
of carbonized vegetable fiber. But with Leiter’s battery we 
are able to regulate the strength of the current with great 
ease by millimetres. He slowly dips the elements into the 
fluid of pure chromic acid, sulphuric acid, and water by 
means of a screw and winch, thus taking care to reach ex- 
actly the strength of the current that is needed to light 
the bow sufficiently without destroying it. Should this 
happen, however, the mignon-lamp is very easily replaced 
by a new one. 1 have been using the same and first lamp 
for the last ten weeks. It is worth mentioning that the six 
small elements can be converted without trouble into one 
very powerful, and then be used for galvano-caustic pur- NEW CYSTOSCOPE OF NITZE AND LETTER. 
9 
poses. P. Hartwig, an instrument-maker of Berlin, who 
makes Nitze’s cystoscope, sells an electric battery con- 
structed exactly after the same principle. 
I received Nitze’s cystoscope and the battery only this 
afternoon, and so can not say much more about the battery 
at present. But, according to information 1 got from Dr. 
Nitze a few days ago, it seems to work well likewise. 
In using the cystoscope we put its beak into a glass or 
bowl under water (the above-mentioned key touching the 
metal of course), and then slowly turn the winch until the 
lamp gives a constant and bright light. Then we break the 
current by bringing the key in contact with the ivory plate, 
dip the instrument into glycerin (vaseline would dim the win- 
dow and prism), and introduce it into the bladder. This 
manipulation is just as easily performed as the introduction 
of a simple catheter. Before we apply the instrument, the 
bladder must be washed, provided the urine is bloody or 
cloudy with mucus, and then be partially distended with 
from five to six ounces of clear water. If the urine is quite 
clear, no preliminary washing is necessary. The water 
cools the heated beak without getting warmer itself. As 
soon as we feel, after the introduction, that the beak moves 
freely in the bladder, we light the lamp again by simply 
turning the key to the left, and are now able to inspect the 
bladder in perfect daylight. 
The advance, Mr. Chairman, that will result from this 
simpler and more convenient cystoscope for the diagnosis 
and treatment of diseases of the bladder is groat and easy to 
see. There is no doubt that cystoscopy, tins new method 
of ocular inspection of the interior surface of the bladder, 
“ has as great importance for the diagnosis of diseases of the 
bladder as laryngoscopy has for those of the larynx ” (Nitze). 
I should here like to say that I had studied this chapter 
carefully and with great interest for many months, when 10 
ON CYSTOSCOPY, AND THE 
Nitze’s treatise, mentioned above, the best and most com- 
plete we have on cystoscopy in literature, was published. It 
is rather difficult now to bring out anything new on this 
subject. Nitze leaves hardly anything unsaid that could be 
thought of only in regard to the future progress in diag- 
nosis and treatment with the help of the cystoscope. I fol- 
low him in some of my further explanations. 
Before giving you a summary of this advance, I must 
mention the conditions that have to be fulfilled if the endo- 
scopical examination of the bladder is to be successfully 
tnade. I just said “ advance.” I should better say “future 
advance ” that will be surely made in the diagnosis of ob- 
scure diseases of the bladder with the help of the cysto- 
scope, and that not only by the specialist, but by the gen- 
eral practitioner also. 
There are three conditions : 
1. The caliber of the urethra must be sufficiently large 
to allow of the passing of the cystoscope (No. 23 French). 
2, There must be sufficient capacity of the bladder. 
Nitze usually injects five ounces, a quantity that can be re- 
tained in nearly every instance. To get an easier view of 
the upper region he adds some air. The bubbles can be 
seen very distinctly with the cystoscope. 
3. We must be able to have a transparent fluid in the 
bladder, at least during the time of examination. It is 
important to know, however, that the water does not need 
to be perfectly clear. The view we get when the water is 
a little muddy is still quite satisfactory. In cases of hsema- 
turia originating in the bladder, it will be advisable to 
postpone the examination until the flow of blood has 
ceased. 
Then, also, I should like to tell you, Mr. Chairman and 
gentlemen, what is to be seen in the healthy bladder before 
we inspect the morbid one. Of course, the picture is more NEW CYSTOSCOFE OF NITZE AND LEITER. 
11 
monotonous than, for instance, that of the larynx, but it is 
very interesting nevertheless. 
The normal mucous membrane of the bladder mostly 
has a pale, yellowish-red coloring in bright illumination, 
more rarely a pink one. If the prism is brought near 
enough, we perceive in it fine ramifications of small blood- 
vessels, similar to those that we see on the retina with the 
ophthalmoscope. Furthermore, there come into view irregu- 
lar projections (the innermost layer of the detrusor muscles) 
between flat, but sometimes very deep, holes. The latter 
ones are “acquired diverticula,” which are found, accord- 
ing to Nitze, much oftener than is usually believed. The 
other class of diverticula—the congenital ones—will be seen 
when the mucous membrane has its normal smoothness and 
only shows slight elevations. At last the orifices of the 
ureters are conspicuous. In most cases they can be seen 
with great ease. I myself have been able to see them 
very plainly in all the cases I have thus far examined. 
They appear as long, slit-formed notches in the middle 
of an oblong protuberance, or as small, round holes. In 
watching more closely the orifice of either of the ureters 
for some time, I have easily been able to see how the 
urine entered the bladder at intervals of from thirty to 
sixty seconds. I have been enabled to do so by the 
whirls which the urine—viz., a solution of salts—produced 
in the water that had been injected into the bladder. We 
can see the same arise at any time when we pour urine into 
a test-tube filled with water. On the same occasion I ob- 
served quite an interesting physiological phenomenon, which 
is not mentioned, as far as I have seen, in any one of our 
hand-books on physiology. You all know that the urine en- 
ters the bladder at intervals with a rush, and so much so that 
it forms a real little fountain when the bladder is filled with 
air, or opened by incision. The urine is pressed forward, 12 
ON CYSTOSCOPY, AND THE 
first, by the vis a tergo ; second, by the difference in pressure 
between the pelvis of the kidney and the cavity of the 
bladder; and, third, by the peristaltic contractions of the 
ureteric muscles. Now, as there are in the wall of the ure- 
ter more muscular fibers running longitudinally than trans- 
versely,* the orifice of the ureter, and with it the elevation 
of the mucous membrane in which it ends, is drawn in- 
ward at the end of each conveyance of urine into the blad- 
der, the orifice and its nearest adjacent parts then taking 
the shape of a funnel. After a few seconds it returns to its 
former position. That this occurs each time and is a physi- 
ological phenomenon I have 'fully convinced myself in two 
cases. 
Now, what is the advance in the knowledge of the dif- 
ferent diseases of the bladder which cystoscopy has accom- 
plished, in addition to what we learn by the examination of 
the urine and of the interior of the bladder by means of 
sounds and the combined rectal palpation ? 
First, we are able to decide with absolute certainty 
whether the bladder is healthy or morbid. 
Every one of you, gentlemen, who has been unable to 
make out in a certain case of urinary trouble the location of 
the disease, after a very careful chemical and microscopical 
analysis of the urine, and exhausting all the older methods 
of examination, will appreciate the great value of such a 
surety. 
“ The negative result is here fully equivalent to the posi- 
tive one.” For, if it is proved that the seat of the disease 
is not in the bladder, then it must be looked for somewhere 
else, especially in the upper urinary passages, most probably 
in the kidneys. 
The importance of this fact—namely, to be able to de- 
cide whether the bladder is healthy or morbid—for a diag- 
* Ranke, “Grundzuge d. Physiol,,” 1875, p. 496, NEW CYSTOSCOPE OF NiTZE AND LEITER. 
13 
nosis per exclusionem is evident. Only a few days ago I 
had an interesting experience in that respect. A young 
man, twenty-five years of age, was sent to me by a colleague 
for cystoscopy on account of an obscure trouble of bis 
urinary system. The patient bad bad gonorrhoea twice, 
the last time fifteen months ago. It was complicated with 
catarrh of the neck of the bladder. Lately he had been 
treated with local applications, made with the help of the 
endoscope ; but he never was relieved. For about seven 
months there had been a constant painful feeling of pressure 
in the region of the bladder, sometimes retention for a 
whole day, sudden stop in the flow of urine, and no relief 
when the bladder was emptied. Now and then the last 
few drops were mixed with blood. No symptoms of catarrh, 
no tenesmus. The urine contained a trace of albumin. 
Specific gravity, POl6. The patient was a good deal ema- 
ciated, unable to work, and depressed. The early history 
revealed that he had masturbated more or less for many 
years when he was a boy. 
On inspecting the cavity of the bladder with the cysto- 
scope, I could only detect a very dense network of enlarged 
small blood-vessels, “a marked hyperannia ” of the trigonum 
Lieutaudii; everything else was in a perfectly normal con- 
dition. 
Whether this hypenemia, undoubtedly a continuation of 
the catarrh of the neck of the bladder, is the cause of all 
trouble, I don’t venture to decide. Perhaps it is. If so, one 
or more instillations of a few drops of a five- or ten-per cent, 
solution of nitrate of silver into the trigonum and neck of 
the bladder should bring some change for the better. 
Should this not happen, the symptoms must be looked at 
as dependent upon a nervous origin, either reflex spasm 
of the sphincter or paresis of the detrusor muscle. Cer- 
tainly the formerly obscure disease, and the way of its treat- ON CYSTOSCOPY, AND THE 
raent, has thus been materially cleared up by the cystoscopic 
examination. 
Can we prove now with the cystoscope which kidney is 
diseased? It seems that we may perhaps be able to do this 
in future, when we have sufficiently learned to see and to 
manipulate inside of the bladder after the cystoscope has 
been introduced. Either we could attempt, according to 
Nitze, to push a very thin catheter (introduced alongside the 
cystoscope into the bladder), under the guide of our eyes, 
into one of the orifices of the ureters—provided they have 
been found at all—and draw the urine directly from the 
kidney, or we might be able to observe out of which ureter 
the blood escaped, for instance, in a case of hsematuria. 
Many atimethe blood has been seen flowing from an injured 
papilla of a tumor of the bladder that was examined with 
the cystoscope. 
Looking over the well-known diseases of the bladder, we 
shall be able, first of all in catarrh, to make a strict differ- 
ential diagnosis between the different forms—acute, chronic, 
haemorrhagic, diphtheritic—and probably learn to diagnos- 
ticate in the picture those differing in respects, 
especially the tuberculous one. It will be very easy to see 
ulcerations. Diverticula are very exactly demonstrated. 
Even in 1883 Sir Henry Thompson maintained that their 
presence could not be proved in vivo in the majority of cases 
Foreign bodies not to be detected by the sound, even 
in the hands of a well-experienced surgeon, may not only 
be seen, but localized. 
A very interesting case of this kind was published by 
Nicoladoni * two years ago. Most of you have read it 
in the journals. In a lad eighteen years of age, who had 
introduced a medium-sized pin, head forward, into his ure- 
thra nine days before, he saw, by means of the old-shaped 
* “Wiener med. Wochenschr.,” 1886, 7, 8, NEW CYSTOSCOPE OF NITZE AND LEITER. 
15 
cystoscope, the pin fixed in the right part of the anterior 
wall close to the vertex after he had tried in vain to de- 
tect it with the probe. The pin cast a shadow on the oppo- 
site wall of the bladder. In the same year v. Dittel * saw a 
piece of sealing-wax, covered with salts, in the bladder. 
In 1884 Fillenbaum f found in the bladder of a fifty- 
four year-old tabetic patient, who catheterized himself, the 
broken piece of a Nelaton catheter with the cystoscope. 
Griinfeld’s endoscope, that was tried first, gave a negative 
result. 
Last year Nitze J diagnosticated in the wall of the blad- 
der of a woman a silk ligature, and removed it with the 
help of his cystoscope. Martin, of Berlin, had performed 
ovariotomy on her a short time before, and ligated the 
pedicle and vessels with silk. Some of the ligatures caused 
an intraperitoneal abscess that perforated into the bladder. 
It seems almost unnecessary to mention that we can 
plainly see stones in the bladder, make out their size, shape, 
and mobility, and percuss them with the beak of the cysto- 
scope by the guidance of our eyes. (Those gentlemen who 
take interest in the matter may try this afterward on the 
phantom.) Cystoscopy is of special importance for the 
diagnosis of encysted stones. 
Allow me, Mr. Chairman, to give here the short history 
of a case of stone in the bladder that recently occurred in 
my private practice, and had passed through the hands of 
a number of doctors of this city. It shows the predominant 
place we must accord to cystoscopy in the diagnosis of ob- 
scure diseases of the urinary system : L. T., aged twenty three 
years. First gonorrhoeic infection two years ago ; second, last 
year. Complications with prostatitis, catarrh of the neck, 
* “ Wiener med. Wochenschrift,” 1886, p. 793. 
f ‘‘ Deutsche Zeitschr. f. Chirurgie,” vol. xx, p. 453. 
I Langenbeck’s “ Archiv,” vol. xxxvi, 3, p. 680, 16 
ON CYSTOSCOPY, AND THE 
afterward of the whole bladder; symptoms of stricture. The 
necessary treatment was ordered and the bladder washed 
for eight months. No material benefit. In the course of 
treatment, about seven months ago, a marked chill of ten 
minutes’ duration set in, with pains in the right lumbar re- 
gion, Since that day there has been a large amount of pus 
in the urine, sometimes the sixth of the whole quantity. 
Soon a good deal of albumin was found, and, the diagnosis 
being made as pyelonephritis ascendens, the prognosis, of 
course, was very doubtful. In the beginning of February 
the patient came to my office. I found stricture of the 
pendulous and membranous portion of the urethra, large 
prostate, painful on pressure, and urine with a large amount 
of pus and mucus, very few cells, resembling those of the 
pelvis of the kidney, prostate corpuscles. No pain in urin- 
ating, no blood, no sudden stop in the flow of urine. The 
patient being opposed to any direct surgical interference, I 
had to content myself with widening his strictures by the 
introduction of steel sounds and with internal treatment, 
keeping in view internal urethrotomy and drainage of the 
bladder, or, as soon as it could be diagnosticated whether 
both kidneys were affected or only one, nephrotomy. A 
careful examination of the bladder revealed nothing at all, 
the same result the other colleagues had had before me. 
At that time I received Leiter’s cystoscope, and at once re- 
solved to look into this bladder. Without any difficulty I 
saw there two dark-brown, even stones, of the size of a hazel- 
nut, lying in the groove behind the swollen prostate. With 
the beak of the instrument I succeeded in throwing them 
out into the fundus, where I could easily percuss them, find- 
ing them very hard. A large, snow-white piece of coagu- 
lated mucus was lying at their side, its slender, dentritic 
ramifications floating in the fluid. The mucous membrane 
of the bladder was more or less healthy. Only here and NEW CYSTOSCOPE OF NITZE AND LEITER. 
there I saw a purple-colored spot with an adherent flake of 
mucus. I further discovered the mouth of the ureters 
without any difficulty, and could plainly perceive how 
whirls originated there that permanently set in motion the 
whole injected fluid. I was not yet able to make out whether 
the urine in entering the bladder was clear or muddy. But 
as the injected water, at first perfectly transparent, became 
opaque in a few minutes, I could conclude that the pus most 
probably descended from one kidney or both. Thus far the 
patient, who feels otherwise very well, has not consented 
to the proposed removal of the stones. Meanwhile I have 
had the pleasure of demonstrating them to Dr. A. G. Gerster, 
who also saw them very distinctly. 
Returning to our subject, lastly, let us see in which way 
the treatment of tumors of the bladder—this favorite child 
of modern surgery of the bladder—has been benefited by 
cystoscopy. One word will say how we did and shall advance 
here, too, “ early diagnosis.” If the cystoscope had brought 
nothing else than this, it would be enough. What prevents 
our patients on whom we have operated for tumor of the 
bladder from enjoying the benefit of the removal of the 
new growth for many years still, to-day, where technique 
and after-treatment have been so greatly improved, is not 
the operation itself, epicystotomy or median section. It is 
pyelonephritis, produced by the long-continued disease of 
the bladder. As long as we drain the bladder after the opera- 
tion (by Trendelenburg’s T-tube in open-wound treatment, 
or a permanent catheter after having closed the wound of the 
bladder by suture), we also drain the pelvis of the kidney. 
Every drop of urine that enters the bladder from above will 
leave it immediately by way of the tubes. Reflux is im- 
possible. Of course, the uncomplicated pyelitis will get 
better under this treatment, as well as the chronic catarrh 
of the bladder; both even may get cured by prolonged 18 
ON CYSTOSCOPY, AND THE 
drainage. But, unfortunately, nephritis is so often combined 
with pyelitis. Pyelonephritis can only improve. A “ resti- 
tutio ad integrum ” by draining the bladder would be an ex- 
ceptional case. To cure it we should have to add nephroto- 
my, and even that sometimes without permanent success, 
or, if the diagnosis of a unilateral affection has been made, 
nephrectomy. 
T, too, had to have this experience in the case of a patient, 
fifty-three years of age, in whom I extirpated a villous growth 
(papilloma) by epicystotomy in October, 1886. It had the 
size of an apple, and had troubled the patient for several 
years. He was entirely relieved of all his troubles, was 
well last summer and able to work, and enjoyed his life. 
He could easily retain the urine for three hours and more, 
and passed the water in a strong spurt. But by and by 
the quantity of albumin in the urine, that had never fully 
disappeared, increased, the old nephritis that had slumbered 
for several months made progress, without a recurrence of 
the chills that had frequently set in before the operation, 
caused by the cystic pyelitis. A few weeks ago the urine con- 
tained about one third of its volume of albumin. The pa- 
tient is m>w unable to work, and will certainly die in a short 
time. If he could have been examined with the cystoscope 
two years ago, at the time of the first spontaneous hsematu- 
ria, before he came under my attendance, and if with the 
cystoscope the diagnosis had then been made and the small 
new growth removed, the patient would probably now be 
cured. 
That c3Tstoscopy will enable us to diagnosticate tumors 
of the bladder early is certainly a progress that can not be 
overestimated. It will now become the duty of the attend- 
ing physician to take care that the cystoscope is introduced 
into the bladder of a patient who is attacked with hsema- 
turia of short duration without any warning. He will no NEW CYSTOSCOPE OF NITZE AND LEITEK. 
19 
longer satisfy himself and the patient with the diagnosis so 
much in favor—“haemorrhoids of the bladder.” 
Of course, we shall try to find out the size, location, and 
manner of insertion, whether the tumor has a pedicle or a 
broad base. Y. Bergmann was enabled, in performing epi- 
cystotomy for tumor, not to incise the site of insertion, 
and consequently to avoid a serious haemorrhage, having, 
with Dr. Nitze, localized the growth before by endoscopical 
examination. Nitze reports in his essay sixteen cases of tu- 
mor of the bladder (Nitze 8, Schustler 7, Nicoladoni 1) in 
which the diagnosis had been made or confirmed with the 
cystoscope. As Dr. Nitze writes me last week, he has diag- 
nosticated seven more of them with his instrument since his 
last publication. Six of them were operated on. The diag- 
nosis in regard to size, localization, etc., was sustained by 
the operations in every particular. 
But the cystoscope will often have to reveal the secret 
hidden in the bladder, not only in recent cases, but also in 
an advanced stage, of tumor, when the other diagnostic 
means have failed. It is well known that often in a case of 
tumor of the bladder nothing can be found in the urine ex- 
cept blood and the evidences of catarrh, that examination 
with sounds and the combined rectal palpation give no 
positive result, and that we do not always succeed in tear- 
ing off small pieces for microscopical examination. Besides, 
such particles have caused grave errors when examined. 
Cases of Czerny’s, Krister’s, and Tuchmann’s demonstrate 
this possibility. 
It need not be mentioned that we shall not depend upon 
the result of cystoscopy alone. In some instances it will 
undoubtedly be very difficult to make with its help the dif- 
ferential diagnosis between a new growth that covers a 
large spot and chronic circumscribed catarrh of the blad- 
der. We rather ought to compare the result gained by 20 
ON CYSTOSCOPY, AND THE 
ocular inspection of the vesical cavity with those achieved 
by other methods, judge by all, and then only operate. 
Let us see finally, Mr. Chairman and gentlemen, how 
much the treatment of diseases of the bladder has profited 
by the more exact diagnoses made with the cystoscope. A 
very great deal! The catarrh in its variations will undergo 
different treatment; ulcerations of the wall of the bladder 
will be attacked with the knife, those of tubercular charac- 
ter, according to Schatz, radically extirpated, the wall of 
the bladder included. Diverticula could be washed with 
catheters of a special curvature, as Nitze proposes, but has 
not yet tried. Their presence would require a very care- 
ful distension of the bladder for the suprapubic incision. 
We know that rupture of the bladder especially takes 
place at a diverticulum with thin walls. Foreign bodies 
can not only be diagnosticated, as mentioned above, but 
plainly localized, and therefore removed with absolute cer- 
tainty by one of the methods. In regard to lithiasis, cysto- 
scopy will again intensify the international discussion, go- 
ing on for about five years, on “ which is the best method 
of operating”—whether by epicystotomy or median sec- 
tion, or by lithotripsy or litholapaxy. The main reproach 
to litholapaxy, the frequent and early recurrence of the old 
trouble, has lost its foundation, as we are now enabled to 
inspect the interior of the bladder and to crush and evacu- 
ate as long as there are fragments to be seen. When this 
is accomplished the patient will be cured in the simplest 
and quickest manner. On account of this possibility, Nitze 
predicts for the crushing method a due and firm place among 
the different operations for stone in the bladder. How far 
this will he realized we must wait to see. It has been men- 
tioned above that encysted stones will be seen. The possi- 
bility of their removal is thereby materially increased. 
The vital statistics of tumor of the bladder will be NEW CYSTOSCOPE OF NITZE AND LEITER. 
21 
greatly improved by the early diagnosis. To remove small 
benign polypi, Nitze proposes not to incise the bladder, but 
to crush the growths, when localized, with a long forceps, 
introduced ptr urethram, and then to evacuate them. We 
can only agree with him when he says that a strong and 
healthy patient who passes blood, pure or mixed with urine, 
for a few days will more readily submit to cystoscopy and 
tearing or crushing of the tumor than to a more serious op- 
eration. Whether that will be realized, we again must wait 
to see. At all events, it seems to be easier to destroy a poly- 
pus floating in the fluid and having an insertion known to 
us than to perform median section and grasp the growth 
within the empty organ by the aid of digital exploration, as 
recommended by Thompson. Large and infiltrating neo- 
plasmata will belong, as formerly, to the suprapubic in- 
cision. 
It is evident, Mr. Chairman, that the advance in the diag- 
nosis and treatment of diseases of the bladder, as described 
by me, is not so easily, and especially not so quickly, made. 
No, cystoscopy not only wants to be thoroughly studied in 
regard to technique, but has to be investigated yet in many 
respects. “ Now, being enabled to inspect the morbid blad- 
der with the help of brilliant illumination in the living sub- 
ject, the characteristic pictures of different pathological 
alterations will have to be studied in the same manner as 
it was necessary to do and was done in regard to the larynx 
and the eye when the laryngoscope and the ophthalmoscope 
were invented.” “ When the cystoscopy of to-day,” says 
Nitze, “ is of the same age as, for instance, laryngoscopy, 
that has been diligently and enthusiastically cultivated and 
improved by generations, then it will have, beyond any 
doubt, an equal, perhaps even a greater, surety in the diag- 
nosis of pathological conditions of the bladder.” 
Although I am not able to-day, Mr. Chairman and gentle- 22 
ON CYSTOSCOPY. 
men. to let yon inspect the diseased bladder of a living 
subject, I sincerely hope that the instrument that allows us 
to do this in such a simple and handy way is sufficiently 
interesting to justify me in its demonstration and a short 
discussion of the new branch of surgical diagnostics created 
by it—cystoscopy.