REVIEW OF 
NITZE’S TEXTBOOK ON 
CYSTOSCOPY. 
WILLY MEYER, M.D., 
OF NEWYORK. 
/05 East j()th Street. 
Reprint from Annals of Surgery, June, 1890. CYSTOSCOPY. 
Text-Book on Cystoscopy—lts Technique and Clinical Impor- 
tance. By Max Nitze, Berlin. Pages, 329. Wiesbaden: J. F. 
Bergmann. 1889. 
A little more than two years have elapsed since cystoscopy, this new 
branch of surgical diagnostics, has been established in its modern 
shape, and a text-book on this subject has already been published, 
written by that author, who has the greatest experience and merits in 
this line. The book will be welcome to the beginner as well as to 
the more experienced one in this interesting and important method of 
examination. The former finds in it a thorough, fascinating introduc- 
tion, the latter many valuable hints and facts which make him under- 
stand better what he has already seen himself; he further gets a great 
number of practical rules how he may best overcome, even in desperate 
cases, such obstacles, which seem to prevent the doctor from making 
a cystoscopic examination. We are instructed how we may succeed 
with perseverance and tact, in the gentlest manner for the patient “to 
view the interior of the bladder,” Very satisfactory is the effect of 
the truthful reproduction in text and cuts of exactly what has been 
seen, without any ornamental addition or any exaggeration. Every- 
body who has practiced cystoscopy will admit this. Of course even 
Nitze is not yet able to give a correct pathological anatomical explana- 
tion of every picture he has seen. But he gives at least the most 
probable one. His text book does not at all claim to treat a perfectly 
developed branch of medical science. It only is the author’s inten- 
tion “to give a structure, the perfect completion of which can only be 
realized by the united work of numerous investigators.” The main 
fact is, that cystoscopy to-day enables us after some experience—and 
this, says Nitze, is absolutely necessary—to obtain a clear view of the 
interior of the morbid bladder and even though it be a very irritable one. 
That such a satisfactory exploration is really possible is, as the reviewer 2 
RE VIE WS OF B 0 OKS. 
knows by personal experience, not yet generally admitted amongst 
surgeons. 
Part I explains in 124 pages the history and technique of cysto- 
scopic examination. 
Nitze divides his book into three parts. 
After having given a short history of the development of endoscopy 
and the changes in the relative size, length and position of bladder and 
urethra produced by the manipulations connected with cystoscopy, the 
author dwells at length on the importance of the two new principles in 
this new method of examination invented by him, viz.: the introduc- 
tion of the light itself into the cavity to be examined and the optic ap- 
paratus which magnifies the spot coming into view. The two devices 
combined effected the immense progress which has been made. There 
is no doubt that also the original cystoscope which was presented by 
Nitze to the Imperial Society of Vienna Physicians in 1879 gave 
splendid pictures, as a small number of cases, reported by different 
authorities, prove. But in using the incandescent platinum wire which 
gave the light, too many expensive and unhandy accessory apparatuses 
were required. The original instrument therefore did not come into 
general use. Edison’s lamp, of a very small caliber, so-called mignon 
lamp, determined a radical change. The cystoscope in its newest 
construction is simple, handy and cheap, not larger than an ordinary 
silver cathether, No. 22-23 French scale. The optic apparatus 
which enlarges the area of the bladder brought into the field 
of vision and at the same time magnifies it, consists of a special 
combination of lenses. This optical apparatus has been called a 
“telescope,” but the term does not adequately describe it. Its proper- 
ties and usefulness are dwelt upon at length in the text. (The 
peculiar combination of the different parts will probably make photog- 
raphy of the pictures possible. Nitze makes a few remarks in this re- 
spect at the conclusion of his book). The three different cystoscopes 
—No. x is mostly used and the most important one; No. 2 is for the 
fundus of the bladder, especially useful in cases of hypertrophy of the 
prostate gland; No. 3, which can still be improved, for the internal 
orifice of the urethra and the surrounding portions of the bladder, and 
the present accessory apparatus (battery and wire with handle) are 
then fully described and a number of important rules in regard to keep- 
ing and preserving the instruments given. The eighth (last) chapter 
of the first part of the book treats the “technique of cystoscopic ex- 
amination.” It would surpass the limits ot this review if we would try 
to give a short report of what is given and worth knowing. For TEXT-BOOK ON CYSTOSCOPY.—NITZE. 
3 
such a purpose the book itself must be studied. Here it must be suf- 
ficient to state that in nearly every case we can fulfill the three main 
requirements for a successful cystoscopic examination, viz.: 
i. We must not dim prism and lamp in introducing the instrument 
into the bladder. 
2. The caliber of the urethra must be large enough to allow of the 
passing of the cystoscope (No. 23 French) and also the capacity of the 
bladder sufficient (five ounces). 
The experienced doctor has means at his disposal (of original) to 
overcome any obstacles which may be in the way. There are 5 exact 
motions of the cystoscope in the bladder, demonstrated by cuts which 
will bring into sight every spot of the interior of the bladder with 
mathematical exactness. With the help of cocain-ansesthesia we can 
make cystoscopy painless, even in very irritable bladders or patients. 
Rarely a preliminary hypodermatic injection of morphia is required, 
still more rarely narcosis. 
3. We must be able to have a transparent fluid in the bladder. 
Part II of the book (100 pages) deals with the cystoscopic appear- 
ance of the healthy and of the morbid bladder. Whoever has already 
had the satisfaction of inspecting the interior of the healthy bladder 
will find that the pictures in Nitze’s book admirably reproduce and 
confirm his own experience. The novice who has not yet had this 
satisfaction will by the inspection of these pictures and the perusal of 
the book learn many facts of which he had been previously ignorant. 
He will read of the coloring (pale, yellowish red, rarely pink) and sur- 
face of the mucous membrane of the bladder; of the fine ramifications 
of small blood vessels similar to those that we see on the retina with 
the ophthalmoscope; of the peculiar picture of the fold of mucous 
membrane around the internal orifice of the urethra; of the glistening 
bubble of air at the vertex, intentionally injected into the bladder for 
easier localization. But the reader’s greatest interest will certainly be 
aroused by Nitze’s clear description of the endoscopic picture of the 
fundus of the bladder, the mouths of the ureters and their fold of mu- 
cous membrane. Many will certainly feel eager to observe once them- 
selves how the urine, descending from the kidneys, enters the bladder 
with a rush at intervals of from 30 to 60 seconds—sometimes as long 
as five minutes—producing whirls in the water that had been injected 
into the bladder; how at the same time the mouth of the ureters first 
slowly contracts to the size of a very small groove and then again 
gradually enlarges to its former size, at this moment suddenly giving 
exit to the urine; how the mouth of the ureter remains in this middle 4 
REVIEWS OF BOOKS. 
position for a short while until the recurrence of the movement deter- 
mines a repetition of the phenomena;1 how the displacement of the 
intra-abdominal organs during respiration reflects upon the vertex of 
the bladder (downward and upward rolling of the injected bubble of 
air); how the same spot of the wall of the bladder, especially on either 
side, shows rythmic pulsation (transmission of the pulse of the external 
iliac artery). Among pathological processes the author treats first the 
cystoscopic picture of catarrh of the bladder. As in other organs 
catarrh of the bladder manifests itself by redness and cedematous 
swelling of the mucous membrane and in the production of a catarrhal 
secretion. The pictures show a great variety and are not distinctly 
differing from each other in accordance with the various degrees of 
catarrh. In a few rare cases a circumscribed portion of the inner sur 
face of the bladder presented the symptoms of a very marked catarrh, 
the other part of the viscus being perfectly healthy. Nitze further 
states at length what he has seen in tuberculosis of the bladder and 
cases suspicious in that respect. One has not yet succeeded in estab- 
lishing a characteristic picture for the tuberculous affection.2 It is 
evident that we can plainly see stones and foreign bodies in the viscus. 
T am of the opinion, according to my own observations, that this phenomenon 
takes place in exactly the opposite way. When the urine begins to enter the blad- 
der the mouth of the ureters with its elevation of mucous membrane keeps its position 
or is sometimes pressed a little forward. Only at the end of each conveyance of 
urine into the bladder, the orifice is drawn inward and assumes with its nearest ad- 
jacent part the shape of a funnel. As soon as the last drop of urine has been passed 
into the bladder the mouth of the ureters returns to its former place. In regard to 
probable explanation, see my article “On Cystoscopy, etc.,’’ N. Y. Medical Journal, 
1888, p. 430.—W. M. 
2Only a few days ago I had occasion of performing cystoscopy in a patient of Dr. 
Le G. N. Denslow, of St. Paul, whose symptoms excited suspicion of tuberculosis. 
I saw a beautifully clear and instructive picture. Immediately above the somewhat 
swollen mouth of the right ureter and iis elevation of mucous membrane, there was 
an ulcerated spot of about the size of two silver dollars. Purplish-red, broad eleva- 
tions (evidently the inflamed fibres of the detrusor muscle) crossed each other in 
different directions. Small particles of snowy shining mucus, adherent to their 
surface, floated in the fluid. The depressions between these elevations were, of a 
ligliter hue, also covered with mucous flakes. In between them numerous very 
small and larger sessile growths of grayish coloring were plainly visible, a few about 
as large as a pin’s head, undoubtedly miliary-tubercles. On one spot a small 
rhomboid-sbaped dark-red spot couldbe seen. The entire other inner surface of 
the bladder was perfectly normal, of grayish-white color, rather anaemic, correspond- 
ing with the condition of the patient. As the microscopic examination showed an 
abundance of tubercle-bacilli in every specimen of urine prepared, the diagnosis 
“tuberculosis of the bladder” is the correct one beyond any doubt,—W. M. TEXT-BOOK ON C YSI OS COT Y.—NITZE. 
5 
make out their mobility, estimate their size after some experience and 
observe their shadow on the wall of the bladder. Sometimes the larger 
size of the bodies or their position in the groove behind the swollen 
prostate gland for instance, as also the morbid condition of the blad- 
der produced by their presence, causes difficulty in regard to a correct 
diagnosis. By closely following a few practical rules we can overcome 
such difficulties in nearly every instance. 
But cystoscopy celebrates its greatest triumph in establishing the 
diagnosis of tumor of the bladder. If the urine is clear, no prepara- 
tory treatment (washing the bladder) is required. The cystoscope is 
immediately introduced at a time when the bladder probably holds a 
sufficient quantity of urine for examination (about 5 ounces). Thus a 
haemorrhage, which might arise in consequence of the washing, will 
best be avoided. If haematuria is just present at the time of consul- 
tation. the doctor should not yield to the patient’s demands and try to 
get the bleeding under control by irrigation, but rather wait until it 
has stopped. This usually will occur soon. Immediate success in 
the first attempt at cystoscopy will be the probable reward. If an in- 
fectious catarrh of the bladder has already set up, a condition which is 
mostly found in these cases, grave obstacles will be sometimes en- 
countered. Frequently they will be overcome by patience and careful 
handling, now and then they will prevent the examination. As this 
accompanying catarrh of the bladder, which so terribly torments and 
weakens the patients, is in all cases carried into the bladder by the 
doctor with the sound or catheter, Nitze postulates to absolutely 
avoid the introduction of an instrument into the bladder of patients, 
where a tumor of the bladder is suspected. The cystoscope must be 
the first instrument in future which is resorted to in these cases. It 
is selfunderstood that we will always apply strict antisepsis in prepar- 
ing the patient and in performing the cystoscopic examination. At 
the conclusion of this interesting chapter a short report of twenty cases 
of tumor of the bladder will be found, being diagnosed by Nitze with 
his cystoscope. All their characteristics were verified by epicystotomy 
or post-mortem as previously diagnosed.1 
xThree weeks ago I was called in by a colleague to see a man, set. 53 years, who 
had constantly passed bloody urine since about six months, without ever consulting 
a doctor. He only suffered from frequent forcible micturition and nowand then pain 
in the glans, otherwise he felt comfortably. Repeated careful chemical and micro- 
scopical examination only showed blood and mucous cells, never a panicle of a new 
growth. Bimanual palpation was very difficult and also promised no result on ac- 
count of the patient’s corpulence and marked hypertrophy of the prostate. I there- 6 
REVIEWS OF BOOKS. 
In the following chapter, “Hypertrophy of the Prostate,” Nitze puts 
special stress upon the appearance of the fold of mucous membrane 
surrounding the internal orifice of the urethra, which can be perfectly 
viewed with the cystoscope, Nitze believes that he will be able, in 
course of time, to diagnosticate the species of hypertrophy in the pic- 
ture by seeing the changes of this fold. In many cases it will be de- 
sirable to corroborate the result of the examination with the cysto- 
scope No. i, also with the cystoscope No. 3. 
Part 111 of the book, closely resembling Nitze’s former treatise (v. 
LangenbecEs Archiv., Yol, 36, III), speaks of the importance of cys- 
toscopy in regard to the diagnosis and treatment of urinary and blad- 
der diseases. An objective comparison of the former methods of ex- 
amination of the male bladder (as chemical and microscopical analy- 
sis of the urine, examination with sounds, combined rectal palpation, 
as proposed by v. Volkmann, digital exploration of the bladder after 
median section, epicystotomy, etc.) with cystoscopy shows that the lat- 
ter is the most perfect one, that it is greatly superior to all of them, 
because it promises the most reliable result. It is at the same time 
the gentlest method in regard to the patient. It is safe to say that 
cystoscopy has the same importance for the diagnosis of bladder dis- 
eases as laryngoscopy has for those of the larynx. It should, there- 
fore, not be applied as a “last resort.” as one frequently hears said, but 
it should rather be the very first, before the bladder has been infected 
by intra-vesical useless manipulations and before obstacles have arisen 
to render orular-inspection impossible. Once more the medical col- 
leagues, therefore, are'earnestly requested to stop introducing a sound 
fore immediately resorted to cystoscopy. As a hypodermic of morphia with local 
cocaine-anaesthesia did not quiet the irritable bladder, the patient was narcotized. 
Now we saw in brightest illumination a round, sessile growth with an uneven sur- 
face of about the size of a cherry on the left wall of the bladder, about one inch 
above the mouth of the left ureter. I very plainly saw that blood was oozing out of 
its surface. The other portion of the bladder appeared to be healthy; there were 
symptoms of a slight catarrh. The diagnosis of tumor thus having been made, 
epicystotomy was proposed to the patient. The operation was performed in the 
posture and with the help of the cross incision, as proposed by Trendelenburg. 
The bladder having been incised the growth was found on the spot localized before; 
it presented all the characteristics as formerly diagnosed with the cystoscope. The 
tumor was grasped with along Muzeun’s forceps, pulled forward and cut with tre 
adjacent parts of the wall of the bladder with the knife by an elipsoid incision. The 
base was burned with Paquelin’s thermo-cautery. Drainage of the bladder with the 
T-tube in latero-abdominal position; the lower two-thirds of the wound in the 
bladder were closed by catgut sutures. Patient made an uninterrupted recovery. He 
is already out of bed.—W. M. TEXT-BOOK ON CYSTOSCOPY.—NITZE. 
7 
or catheter into the bladder in cases of obscure urinary trouble in fu- 
ture, but to let these patients primarily be examined with the cysto- 
scope, before any other local examination has been tried. Only if 
there is ample reason for suspecting stone in the bladder, sounding 
should be resorted to at once. 
The advance in the diagnosis of the various urinary and bladder 
diseases, made by the use of the cystoscope up to date is immense. 
The one very important fact deserves to be mentioned first: That we 
are able to decide with absolute certainty whether the bladder be 
healthy or morbid, and thus definitely localize the trouble For if it 
be 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. Furthermore, we can learn 
to see out of which ureter purulent or bloody urine escapes, whether 
in a case of disease of one kidney the other continues to perform its 
functions. 
The more thorough knowledge of the various forms of catarrh of 
the bladder will demand a modified treatment. The diagnosis of ul- 
cerations of the wall of the bladder, especially those of a tuberculous 
nature, will force the knife into the surgeon’s hands to perform supra- 
pubic cystotomy, to scrape the ulcers under the guidance of the eyes, 
and burn their base, or to make a radical extirpation which includes 
the wall of the bladder, according to Schatz. Foreign bodies can not 
only be diagnosticated, but plainly localized, and therefore removed 
with absolute certainty by a proper method. If after litholopaxy any 
detritus remains in the bladder, the cystoscope will find and localize 
it, and therewith greatly facilitate its removal. The only one, but most 
important reproach to litholapaxy has thus lost its foundation. Litho- 
lapaxy, with the help of cystoscopy, will forever rank highly amongst 
the operations for stone. It is well known that now and then even a 
very experienced hand will fail to detect a stone with the sound. By 
using the cystoscope such cases will not occur any more. Diverticula 
are very easily demonstrated. If a catheter, with a curvature adapted 
to their locality, is introduced into their cavity, they may be washed 
out, and the catarrh of the bladder, created by them, improved. Their 
presence would require a very careful distension of the bladder for the 
suprapubic incision. 
But before all, the treatment of tumors of the bladder has been ben- 
efited by cystoscopy. Their soft structure makes it impossible 
nearly in all cases, to diagnose them with the sound or bimanual pal- 
pation. The cystoscope enables us to view them in the brightest il- 8 
RE VIE WS OF BOOKS. 
lumination. To remove benign, pedunculated growths, Nitze pro- 
poses, not to incise the bladder, but to crush the growth, when local- 
ized, with a long forceps, introduced per urethram. The curvature of 
the forceps must correspond with the insertion of the growth1; the ope- 
ration may be performed in one sitting or more. The result will be 
easily controlled by repeating cystoscopy after some time. If the 
technique of epicystotomy continues to be improved, and if this ope- 
ration is not looked upon any more as a dangerous one whatsoever. 
Nitze would prefer it in all cases to the procedure just described. Re- 
cently von Antal diagnosticated a polypus of the bladder with the cys- 
toscope and removed it with a long forceps by way of the urethra. He 
has published the case in his new treatise (Pathology and Treatment 
of Urethra and Bladder, Stuttgart, 1888, p. 401) without giving 
credit to Nitze, who first recommended this method. (A second case 
of this kind is published by E. H. Fenwick, of London, Brit. Med. 
Jour., Sept. 22, 1888.— W. M.) Such cases will multiply “if the gen- 
eral practitioner begins to realize the eminent pathognomonic im- 
portance of a spontaneous hsematuria.” 
Willy Meyer. 
JA very good instrument which has recently been constructed by Dr. G. G. Hop- 
kins, of Brooklyn, can, as it seems, be well used for this purpose. A new curette 
for the male bladder. Brooklyn Medical Journal, January, 1890.—-W.M.