The Progress of Cystoscopy- 
in the Last Three Years. 
WILLY MEYER, M. D., 
MBimwwiHi.n ■■ 
Attending Surgeon to tne German aDd New York 
Skin and Cancer Hospitals. 
BY 
RKPSHtTKB FROM 
€TJ}e Neto Yorfe ir8eDtcsl journal 
far January 30, 1892. Reprinted, from, the New York Medical Journal 
for January 30, 1892. 
THE PROGRESS OF CYSTOSCOPY 
IN THE LAST THREE YEARS.* 
By WILLY MEYER, M. D., 
ATTENDING TO 
THE GERMAN AND NEW YORK SKIN AND CANCER HOSPITALS. 
Three years ago Dr. Max Nitze, of Berlin, the inventor 
of the cystoscope, in his well-known essay, Contribution to 
Endoscopy of the Male Bladder,f stated that we could now, 
with the help of the cystoscope in its handy and improved 
shape, establish a strict differential diagnosis between the 
diseases of the bladder. He further said : “ Having seen 
with the cystoscope that the bladder is healthy, and that the 
morbid process therefore involves the upper urinary pas- 
sages, most probably the kidneys, it is tempting to put the 
question whether we shall be able to prove with the cysto- 
scope which kidney or which pelvis of the kidney is dis- 
eased. Either we could attempt to push a thin catheter 
under the guide of our eyes into the orifice of the ureters, 
to draw the urine directly from each kidney separately, or 
we might be able to observe with the cystoscope out of 
* Read in part before the Medical Society of the State of New York 
at its eighty-fifth annual meeting, Albany, February 3, 1891. 
f Y. Langenbeck’s Arcliiv f. Min. Chirurgie, vol. xxxvi, p. 661. 
Copyright, 1892, by D. Appleton and Company. 2 
THE PROGRESS OF CYSTOSCOPY 
which ureter the blood escaped in a case of hsematuria,” or, 
I may add, pus or purulent urine in a case of pyelitis or sup- 
purating kidney. 
It was obvious from the beginning that Nitze’s statement 
would he sustained by all who practiced cystoscopy—namely, 
that our knowledge as Avell as the diagnosis of bladder dis- 
eases would just as rapidly widen, clear up, and improve 
with the help of the new cystoscope as our knowledge of 
laryngeal diseases, for instance, did after the invention and 
introduction of the laryngoscope. But would Nitze’s hope 
also be realized, or could it be realized, in regard to kid- 
ney troubles ? Might we hope to be able to use his cysto- 
scope as at least one means of observing the “ character ” 
of the urine in its direct descent from each kidney ? 
Reviewing the literature on cystoscopy which has ap- 
peared since 1887, and the results of my own work in this 
line, covering now (December, 1891) a period of nearly four 
years, we can unhesitatingly answer this question in the af- 
firmative. 
Before treating of the progress in the diagnosis and treat- 
ment of “ kidney ” diseases with the help of the cystoscope 
—the special object of my paper—any further, I will try to 
give a short review of the development of cystoscopy in 
general, with reference to the construction of additional in- 
struments, made in accordance with the principles laid down 
by Nitze, and to its influence upon the diagnosis, prognosis, 
and treatment of diseases of the bladder. 
I. Instruments. 
After three years’ careful trial and comparison of the 
two chief cystoscopes which have been in the market—viz., 
that of Dr. Max Nitze, manufactured by Paul Hartwig, of 
Berlin (Markgrafenstrasse, 79), and that of Mr. Joseph 
Leiter, the well-known instrument-maker of Vienna, manu- IN THE LAST THREE YEARS. 
3 
factured by himself (Mciriannengasse, 11)—I must slightly 
alter my remark, made a few years ago,* that I “ prefer ” 
Nitze’s instrument. It is true, I still mostly use it, because 
I have become accustomed to it, and because it seems to me 
that the picture, as seen through its prism and lenses, is 
more stereoscopic.f I also believe that, in order to avoid 
diagnostic errors, it is better to train one’s eyes exclusively 
on one instrument. After experience has been acquired, it 
is immaterial which instrument is used. And since Leiter 
has slightly altered the pattern of his instrument in ac- 
cordance with the suggestion of Hurry Fenwick, of London, 
he has secured the essential advantages of Nitze’s cystoscope 
and eliminated the former disadvantages of his own. j( Lei- 
ter’s instrument is now most highly finished and perfectly 
reliable. £ “ The length of the beak is reduced to less than 
an inch.£ The elbow is well rounded; the length of the 
shaft is seven inches and a half. The ocular end is fitted 
with a rotatory plate, carrying the binding screws, while, 
instead of the Nitze slot-key, a small screw upon the face 
of the plate forms a more convenient switch.,? In the 
* Author. A Contribution to the Surgery of the Bladder. New York 
Med. Jour., Feb. 23, 1889. 
f That others are of the same opinion is shown by the following 
passage in a recent treatise by Cecil-Kent Austin, entitled Bur le diag- 
nostic precoce des neoplasmes de la vessie et du rein au moyen du cysto- 
scope, Paris, 1890: “ Je ferai remarquer en passant que les images 
per<;ues au moyen de l’instrument de Berlin m’ont paru plus nettes, 
plus satisfaisantes que celles que donne l’instrument viennois.” 
X In the new one, which is in my possession, the beak still measures 
an inch. 
# This alteration, as it appears, was first employed by Leiter in the 
old Nitze-Leiter instrument. Neue Beleuchtungsapparate mit Zu 
hilfenahme des elektrischcn Liehtes. Nachtrag zu den von Josef Leiter 
verfassten Catalogen, 1890, p. 1. 
| I should say here that Nitze demands that Leiter’s cystoscope 
which is practically the same as Nitze's, be called the Nitze cystoscope 
manufactured by^Leiter. 4 
THE PROGRESS OF CYSTOSCOPY 
Leiter instrument of 1887 the beak was nearly half an inch 
longer, the elbow presented an angle, the shaft was too 
short, and the battery wires had to be fastened in the binding- 
screws, which were immovable upon the instrument, and 
thus would twist around it, if the latter was turned around 
its longitudinal axis in the bladder. The only difference, 
then, which still exists between the two German instruments, 
apart from the arrangement of the mignon lamp, is in 
the telescope. That of Nitze slightly magnifies; that of 
Leiter slightly diminishes. The lenses in Nitze’s instru- 
ment also give a more perspective picture, to my eyes at 
least, and cover a larger field—i. e., the observer’s eye will 
perceive with one glance a larger area.* 
The drawbacks alleged against Nitze’s cystoscope are: f 
1. A somewhat less brilliant light. 
It is true, that of Leiter is brighter, because the still 
longer beak carries a larger, less delicate, and more power- 
ful incandescent lamp. Still, the light as thrown from the 
Nitze mignon-lamp, if tested as to its strength previous to 
the introduction of the instrument (what always should be 
done), will be found entirely satisfactory in every case. 
Where we can not see with it for special reasons, we shall 
most probably also not succeed with the other. 
2. The silver tip, the carbon filament of which has given 
out or has been destroyed, has to he sent to Berlin for put- 
* Take Nitze’s instrument in one hand, turn its prism to the win- 
dow, and hold the palmar side of the slightly flexed fingers of the other 
hand at a distance of about two inches from it; then look through the 
telescope: you will see at once the fifth to second fingers and a part of 
the ulnar side of the thumb. Do the same with Leiter’s cystoscope: 
you will see only two fingers and a half. 
f Cf. E. Hurry Fenwick. The Electric Illumination of the Bladder and 
Urethra, second edition. London: J. and A. Churchill, 1889, pp. 36 
and 43. IN THE LAST THREE YEARS. 
5 
ting in a new incandescent lamp, whereas Leiter has made 
the cystoscopist independent. 
This is now easier arranged for cystoscopists on this 
side of the ocean, who work with Nitze’s cystoscope, as I 
have induced the W. F. Ford Surgical Instrument Company, 
315 Fifth Aveuue, New York city, to carry a number of 
silver tips in stock. Useless tips will there be exchanged 
for new ones, which fit upon the instrument. (Difference 
of price here and in Berlin, 50 cents.) I should add, al- 
though it is self-understood, that it will he necessary to 
have a number of these tips, all armed with the carbon fila- 
ment, constantly on hand, just as the order sent to Leiter 
should include six reserve lamps. The price of the latter is, 
however, one fifth of that of the silver tip of Nitze’s cysto- 
scope. The difference of the two instruments in this respect 
is therefore merely a pecuniary one. To replace a burned-out 
incandescent lamp by a new one does not require a mo- 
ment longer in Nitze’s cystoscope—nay (if such a simple, 
though important, manipulation is to be compared at all), 
is even still simpler than in Leiter’s. But there is— 
3. Another disadvantage, which became manifest to me 
in the course of the last year, since I have been in possession 
of three different Nitze cystoscopes. It is that the screw of 
the different tips in stock will sometimes be found not to 
fit exactly on the thread at the lower end of the shaft. Thus 
the screw of the tips now and then overruns the limit of 
screwing or does not reach it at all. The surface of the 
lamp then points to another direction than the prism, and 
the tip is simply useless. It will, however, be seen at once 
that this is no drawback to the instrument proper, but a 
mistake which can be remedied at once by a greater accu- 
racy of the instrument-maker. It is to be hoped that Mr. 
Ilartwig will yield to the cystoscopists’ urgent requests and 
pay better attention in the future to this slight but impor- 6 
THE PROGRESS OF CYSTOSCOPY 
tant defect, explained to him at length. The screw-thread 
of each cystoscope ought to be manufactured accurately 
alike, and the tips, before being sent away, carefully fitted 
on a standard instrument at Berlin. The arrangement as 
now made here in New York also dispenses with this an- 
noyance. In cities where a similar arrangement is not or 
can not be made, the cystoscopist will soon have his small 
stock of fitting tips, and must insist upon having put new 
incandescent lamps into these very same tips. I should not 
omit to state here that, after some experience and with 
proper care and a good battery, the same tip can be used 
for nearly a year and perhaps still longer.* 
In his first essay, and later also in his Text-book on Cys- 
* Still I have to mention— 
1. To constantly have Nitze’s instrument in good working order, it 
is absolutely necessary to keep clean and dry the two circular grooves 
at the upper end of the instrument, as well as the concave surface of 
the rotatory handle, which, when attached to these grooves, conveys the 
current from the battery to the instrument. This refers especially to 
the irrigating cystoscope. 
2. The slot key, which, under management of the thumb, serves 
for opening and breaking the circuit, may work rather easily after 
some time. The light then will be less brilliant. A simple turn of the 
screw which holds the key in place will correct this difficulty. 
3. If the cystoscope turns too easily in the handle, it will be found 
useful to leave the left hand at the upper end of the cystoscope, the 
so-called “ funnel,” during the examination, while pressing the handle 
with the other hand tightly against it. 
4. If the lamp of a new tip does not burn at once when the current 
passes its filament, a slight straightening of the little cork-screw-like 
silver wire at the basis of the tip, before the latter is screwed on, will 
often be found sufficient to get a bright light. 
5. The small bubbles of air which often arise with a peculiar noise 
from the junction of shaft and tip in Nitze's instrument are caused by 
the decomposition of the water by the electric current. If a bit of wax 
is smeared upon the lower groove of the screw at the tip, previous to 
its being adjusted, this can always be avoided. IN THE LAST THREE YEARS. 
7 
toscopy * Nitze recommended three different cystoscopes 
for a thorough inspection of the entire inner surface of the 
bladder. 
Cystoscope No. 1, which carries the lamp and prism 
at its concave side (the latter at the junction of beak 
and shaft), represents the main instrument, “ the ” cysto- 
scope. 
Cystoscope No. 2, for the inspection of the fundus : The 
lamp on the concave side; the window at the end of the 
shaft, through which the observer looks with the telescope; 
of course, no prism. 
Cystoscope No. 3, for illumination of the internal orifice 
of the urethra and its immediate neighborhood: The lamp 
and prism on the concave side of the beak, which latter is 
about half an inch longer than in the others, and bent in 
nearly a right angle to the shaft. A small mirror, situated at 
the convexity of the curve inside the tube, reflects the picture 
which is thrown into the telescope from the reflecting plane 
of the prism. I have tried this instrument in a number of 
cases, and can state that the picture seen with it is utterly 
indistinct. It is to be hoped that it will soon be improved. 
Although we are able to diagnosticate the hypertrophy of 
the prostate “in the picture” with No. 1, yet a thorough 
inspection of the internal urethral orifice and its surround- 
ings under electric illumination would be very valuable in a 
number of cases. 
In regard to cystoscope No. 2 I can only repeat what I 
said two years ago : j that it is unnecessary to buy it. I have 
always succeeded in inspecting the fundus and trigonum, to- 
gether with the mouth of the ureters, by simply turning No. 
1 180° and depressing the handle, even in cases with hyper- 
trophy of the prostate. The inconvenience to the patient 
* Wiesbaden, 1889. Yerlag von J. F. Bergmann. 
\ Loc. cit., p. 203. 8 
THE PROGRESS OF CYSTOSCOPY 
is slight. Nitze himself advised me, when I saw him at the 
International Congress at Berlin, to exchange my%No. 2 for 
a longer No. 1, which would prove very useful in cases of 
hypertrophy of the prostate, where the urethra is materially 
lengthened. I did so, and can say that I am very thankful 
to Dr. Nitze for this kind advice. The long shaft will he 
found of advantage in many instances. 
As a third instrument I procured the new irrigating cys- 
toscope of Nitze, which permits of changing the fluid in the 
bladder without being removed itself.* It contains two 
small tubes in its shaft, which is thus increased in size to 
25 gauge, French. (The size of the beak is 22, as in 
the others.) The one tube ends just in front of the prism 
with three small holes side by side. It carries fresh water 
into the bladder. The water, thrown in with the help 
of a hand syringe, passes with considerable force over the 
surface of the prism, thus washing it and removing blood 
coagula or pus shreds which so frequently settle there and 
render a successful cystoscopy impossible. This is a very 
clever arrangement. The other tube ends, or rather begins, 
with a single oval-shaped opening at one side of the lower 
end of the shaft; through it the water passes out of the 
bladder. Both tubes are carried to either side of the 
upper end of the instrument, and their current can there 
be shut off by a small stop-cock. Both these stop-cocks 
are attached below the funnel to a metal ring, which 
also carries the handle with the slot-key. They thus 
remain steady in the hand of the observer while the shaft 
can be turned around its longitudinal axis. The irriga- 
* Centralblatt f. Chirurgie, 1889, p. 949. Nitze had two irrigating 
cvstoscopes made—a “ simple ” and a “ more complicated ” one. The 
former, oval in shape, only permits of throwing more water into the 
bladder; the latter, which is round, enables us to really change the 
water. Only the latter is to be recommended. IN TIIE LAST THREE YEARS. 
9 
tion can be effected without regard to the turning of the 
shaft. To put the whole into working order, rubber tubes 
are attached and tied on the end of the two tubes. It will 
be found of advantage to have the one which carries the 
water out of the bladder cut so long as to hang into a basin 
under the table. If the water is changed and the examina- 
tion continued—which will frequently be of great impor- 
tance—an assistant or the patient must pump the water in. 
This latter manipulation is best done intermittently by sud- 
den brief pressures on the handle of the syringe. A fount- 
ain syringe can also be used. Of course, this arrangement 
does not enable us to flush the viscus or wash it out in the 
ordinary sense. Still, I have found this irrigation sufficient 
and of the greatest value in clearing up an obscure bladder 
trouble as well as in the diagnosis of renal disease, pyuria, 
and haematuria. In examining the bladder of patients who 
suffer from such troubles, the originally transparent medium 
becomes rapidly and suddenly turbid and the outlook is at 
once clouded by a dense fog ; nothing can be distinguished. 
I succeeded, in one of these cases where I had to perform 
nephrectomy for pyonephrosis and cystic degeneration, and 
therefore wanted to determine the condition and excretory 
power of the remaining kidney, in establishing the fact, just 
after fresh water had been thrown into the bladder, that the 
urine descending from the other kidney was clear (cf. Case 
III, nephrectomy). In another troublesome case also I could 
make out only with the help of the irrigating cystoscope 
that the large amount of pus which always turned the in- 
jected water murky in a few seconds was ejected from one 
ureteral orifice only (cf. Case I, nephrotomy). In fact, I 
should prefer to use the irrigating cystoscope mostly were 
it not that, on account of the increased size of the shaft, its 
use is only practicable when the urethra is of a certain di- 
mension. 10 
THE PROGRESS OF CYSTOSCOPY 
In vesical hsematuria, where the blood more easily co- 
agulates, the irrigating cystoscope of the present size will 
often he of little or no use, as the blood-clots generally block 
at once the canal which carries the water out of the bladder. 
Fresh water is then pushed into the vesical cavity, hut the 
turbid fluid can not get out.* If a tumor is to be examined 
and it does not bleed during the examination, the instru- 
ment will also prove valuable in determining the insertion 
of the growth. The jet of water propelled across the prism 
and beak will make a pedunculated growth swing, while it 
leaves the sessile growth undisturbed. (The same result 
can he obtained in using cystoscope No. 1, by pressing with 
one hand in sudden short shocks on the epicystic region.) 
The irrigating cystoscope will be also found of advan- 
tage in cases where papillomatous growths, inserted around 
the internal urethral orifice, cover lamp and prism of the 
instrument as soon as it has entered the bladder, and thus 
render an examination impossible. The field of vision then 
appears dark. These growths can he easily pushed aside 
by the forcibly injected fluid, and will then be suddenly 
seen in bright illumination, swaying in the fluid. Concre- 
ments and foreign bodies lying in the pouch behind an hy- 
pertrophied prostate gland, and not to be detected there by 
the examining eye, may sometimes be thrown by the water 
out of the recessus, and thus diagnosticated. Lastly, it is 
worth mentioning that the irrigating cystoscope enables us 
to view the bladder in different degrees of distention. In 
a certain number of cases the ureteral openings can be seen 
only by this means. (Nitze, loc. cit.) 
Having thus carefully compared and tried the cysto- 
* The instrument could be made more useful by increasing the cali- 
ber of the tubes and thus, of course, also, of the cystoscope up to No. 30 
and more. A female urethra will always, and the male urethra in a few 
instances or after meatotomy, admit that number. IN THE LAST THREE YEARS. 
11 
scopes of Nitze and Leiter, I am ready to say that it is dif- 
ficult to give proper advice as to which of the two had 
best he bought by the beginner, as both instruments are 
equally worthy of being in the hands of everybody who 
practices electric illumination of the bladder. But, whereas 
Nitze has given us three useful cystoscopes (according to 
pattern No. 1), and whereas I deem it of pre-eminent impor- 
tance, in order to avoid mistakes, to stick to one pattern in the 
beginning, I prefer to advise the beginner to buy the Berlin 
instruments. T, personally, have so far gladly incurred the 
slight annoyance of sending my few burned-out reserve tips 
to Berlin for repair once in a year. The pleasure of being- 
enabled to work with the three cystoscopes has amply re- 
warded me. Still, I also often find advantage in using 
Leiter’s elegant instrument in its new shape. 
The very newest instrument of this class, which has just 
been made known to the profession in a preliminary com- 
munication, is the operating cystoscope, invented by Nitze, 
and constructed by P. Ilartwig, of Berlin (Ctrlbl. /. 
Chirurgie, No. 51, 1891, p. 993). A cutting forceps is at- 
tached, by a peculiar mechanism, to the lower circumfer- 
ence of a cylindrical tube. Its two blades carry at their 
end a small, sharp scoop. They are opened and closed by 
a lever, which moves in a longitudinal slit at the upper end 
of the same tube. The whole is slipped on the shaft of the 
ordinary cystoscope No. 1, and can be moved on it, down- 
ward and upward (see Fig. 1 and Fig. 2). 
A few more mechanisms of a similar pattern have been 
designed for intravesical topical treatment. 
To enable one to disinfect these different instruments, 
and also to make the armamentarium which is needed for 
intravesical surgery as simple and comparatively cheap as 
possible, the funnel of the cystoscope has been made mova- 
ble. It can he screwed on or off the shaft. Thus we can 12 
THE PROGRESS OF CYSTOSCOPY 
use the same cystoscope for alJ the manipulations, and only 
need a number of the cylindrical tubes, which carry the 
Fig. 1. IN THE LAST THREE YEARS. 
13 
proper mechanism. The cystoscope for this kind of work 
has, besides the movable funnel, a smaller caliber and a 
longer shaft than the ordinary No. 1. The instrument 
armed with the forceps has the size of an evacuator as used 
in litholapaxy; if armed with the other mechanisms, it 
corresponds to about Nos. 21 to 23 of the French gauge. 
Before introducing the operating cystoscope the cylin- 
drical tube, Fig. 2, a, is shifted down toward the prism and 
the forceps, for instance, closed by pressing the lever, 6, 
upward. The two blades then surround the beak in such a 
manner as to form one solid body with it. (The arrange- 
ment of the other mechanisms is similar to this.) The in- 
strument will now easily pass a urethra which is not too 
narrow. As soon as it has entered the bladder the tube is 
slipped back toward the funnel of the cystoscope (Fig. 1), 
the light is turned on, the forceps, etc., opened, and every- 
thing is ready for work. In looking through the telescope, 
the motion of the two blades of the forceps or of the cold 
or red-hot wire of the snare-ecraseur can be thoroughly 
observed and controlled by our eyes. 
Thus, an immense progress has again been made. The 
cystoscope, which hitherto could only he used for diagnostic 
purposes, is now ready for local intravesical treatment. 
With the same, if not with more, precision than, for in- 
stance, in laryngoscopy, we can make topical application 
with certain drugs in the bladder without bringing them in 
contact with other spots of the vesical mucous membrane; 
we can cauterize (with the galvano-cautery) ulcers and flat 
tumors,* can tear off pedunculated growths with the for- 
* Of courge this can not be done if the bladder is filled with water. 
For such purposes it has to be expanded by air. As Nitze’s lamp is 
situated in the extreme end of the beak, it can burn in the open air for 
about two to three minutes without spoiling the prism. I presume 
Nitze intends to proceed in this manner. He promises, in his prelimi- 
nary article, to give soon full particulars in a more elaborate essay. 14 
THE PROGRESS OF CYSTOSCOPY 
ceps, can seize and extract foreign bodies, small stones, or 
the fragments of larger ones, which have been previously 
crushed. And all this under the direct guidance of our eyes. 
Indeed, the medical profession, as well as a great portion of 
suffering mankind, owe thanks to Dr. Nitze for the many 
brilliant gifts he has bestowed upon them. 
In the last three years a few more varieties of the same 
mechanical principle have been advanced. I will mention 
these for the sake of completeness: 
1. Hurry Fenwick's Modification of the Leiter Instru- 
ment.*■—Part of it has been mentioned above. A further 
modification is the perforation of the silver cap by three small 
holes on the side opposite the pane of rock-crystal which 
covers the oval window. This is done “to allow of a free 
current of water to surround the lamp, whereby the hood 
is kept perfectly cold.” In haematuria the non-perfo- 
rated hood has to be slipped on. Fenwick adds in a 
foot-note: “ I break more lamps in the long run, but 
incur less risk of burning the mucous membrane.” In 
buying a Leiter cystoscope it will be certainly advisable to 
also order a perforated cap, which is, no doubt, a pretty 
and sensible improvement, as the larger mignon lamp, situ- 
ated in the middle of the beak and covered by the rock- 
crystal pane, heats the entire cap. When in use, the urine 
or water in the bladder carries off this heat as fast as it is 
formed, its temperature not being perceptibly raised, even 
if the lamp is burned for an hour in the bladder. But as 
soon as it comes in contact with the sensitive mucous mem- 
brane of the bladder wall, the patient invariably has a burn- 
ing sensation. It will be readily understood that a longer 
unintentional contact, for instance, during narcosis, may 
really burn the mucous membrane. 
The short-beaked Nitze cystoscope carries the incandes- 
* Fenwick,'Joe. cit., p. 43. IN THE LAST THREE YEARS. 
15 
cent lamp in the tip uncovered in direct contact with the 
surrounding medium. It presents the perforated hood in a 
peculiar original form. Its lamp does not heat by far as 
much. In a large number of cystoscopies, with or without 
anaesthesia, I have so far never had a mishap. The touch 
of the bladder-wall with Nitze’s eystoscope also creates a 
slight burning sensation. 
2. The Irrigating Cystoscope of Berkeley Hill.—Hill pro- 
posed * to add two small tubes to the lower aspect of the 
instrument through which irrigation is easily made. The 
tubes do not greatly increase the caliber.f Nitze’s irrigat- 
ing cystoscope, which carries the tubes inside, seems to 
offer better advantages. 
3. The “ Improved ” Incandescent-lamp Cystoscope of 
Whitehead, Manchester.J—The Leiter pattern of 40 French 
gauge (instead of the usual 22 French); the window of ob- 
servation and incandescent lamp present double the size, 
thus increasing the field of vision as well as the brilliancy 
of light. It is introduced through a median incision in 
the membranous urethra. 
Such an application of the instrument directly annuls 
the special advantage of cystoscopy—namely, “ that it af- 
fords a visual diagnosis without a cutting operation.” It 
* Irrigation of the Bladder in Cystoscopy. Lancet, London, 1889, 
i, 169. 
f In a valuable essay of Alexander Stein, New York—Some Points 
in the Differential Diagnosis of Bladder and Kidney Affections—which 
appeared in the Journal of Cutaneous and Genito-urinary Diseases, 
1888, p. 370,1 find this passage: “ In hsematuria the injected fluid soon 
loses its transparency, so that we can see but indistinctly or not at all. 
I think this latter can be remedied by soldering an oval tube to the bot- 
tom of the eystoscope, which would reach to the curve, so that the blad- 
der could be irrigated and refilled without removing the instrument.” 
\ British Medical Journal, April 7, 1888, p. 768. 16 
THE PROGRESS OF CYSTOSCOPY 
may, however, be useful and valuable in the female, where 
the urethra can be easily dilated to No. 40 French.* 
4. Brunner's Modification of the Leiter Pattern for 
sounding the Bladder and Catheterism of the Ureters 
under the Guidance of the Eye.\—Cystoscope No. 2, of No. 
28 French, which carries a separate small channel on the 
convex side of the shaft. This channel terminates just 
below the window and can also be used for changing the 
water in the bladder. It is occluded by a mandrel, when 
the instrument is introduced. The mandrel later is ex- 
tracted and replaced by a minute English catheter or an 
elastic metal sound. Brunner thus succeeded in pushing 
the catheter into each ureter of a female patient exposed 
by the light, hut failed to do the same in the male. He has 
had no opportunity to continue his trials in this direction. 
When the catheter or sound is in the ureter, the instrument 
itself may be slipped back over it. Perhaps also topical 
treatment of the bladder could be instituted with this help. 
5. Messrs. F. A. Reichardt & Co., surgical instrument 
makers, New York city, have tried to manufacture a cysto- 
scope according to a modified Berlin pattern, which latter 
bears no international patent. They have, however, not yet 
succeeded in accomplishing the difficult and expensive task. 
The instrument which I have inspected at their store was 
very unsatisfactory in many respects. 
6. The French Cystoscope of Boisseau Du Rocher, of 
Paris, £ is manufactured by Collin, Maison Charriere, of 
# At Hurry Fenwick’s suggestion, Leiter has made a larger cysto- 
scope of 40 French, to be used exclusively for the female bladder. Its 
shaft is three inches shorter than in the ordinary cystoscope. 
f Leiter. New Beleuclitungsapparate mil Zuhilfenahme des elek- 
trisclien Lichtes. Wien, 1889, p. 9. 
| Presented by me with the following remarks to the Surgical Sec- 
tion of the New York Academy of Medicine, March 9, 1891. IN THE LAST THREE YEARS. 
17 
Paris. In July, 1885, the first report was made about it to 
the Academie des sciences. But the instrument was not 
used by others until last year, when Boisseau du Rocher de- 
scribed it at length in an article which appeared in the An- 
nalesdes maladies des organes genito-urinaires, fevrier, 1890.* 
He called his instrument “ megaloscope,” and the method 
of examination for which it was to be resorted to, “ megalo- 
scopie vesicate." The doctor maintains that his “ megalo- 
scope ” is an entirely new design; that its pattern originated 
with him independently from those which are already in 
the market. 
To settle this question from the start, it must he said 
that Boisseau Du Rocher’s cystoscope is in its principle 
nothing else than an elongated ordinary cystoscope of the 
Leiter pattern No. 2, which is used for an easy inspection 
of the fundus of the bladder. 
In comparison with the latter, the specially striking 
new features of the Paris instrument are: 
A longer beak; a longer telescope, which causes the 
length of the instrument and in its peculiarities greatly en- 
larges the spot coming into view; an additional combina- 
tion of pipes for irrigating the bladder and also for passing 
the telescope, or passing instruments for catheterism of the 
ureters. 
But the principles in accordance with which the megalo- 
scope has been constructed are, of course, and had neces- 
sarily to be, the same as those brought out in the Nitze- 
Leiter original cystoscope—viz., the introduction of the light 
itself into the cavity which is to be examined, and an optic 
apparatus which magnifies and enlarges the object. The 
priority of these two devices, which, combined, effected the 
immense recorded progress in cystoscopy, is due to Nitze 
* See also W. v. Yragassy. Das “ Megaloskop ” des Dr. Boisseau 
du Rocher in Paris. Wiener med. Presse, 1888, pp. 51 and 90. 18 
THE PROGRESS OF CYSTOSCOPY 
beyond a doubt. Any new cystoscopes or endoscopes can 
only be variations of this original idea. 
Further, the medical profession should not accept a new 
name for Boisseau Du Rocher’s instrument and for that 
which can be done with it. We talk of a laryngoscope and 
laryngoscopy, of an ophthalmoscope and ophthalmoscopy. 
We should only have different patterns of a “ cystoscope,” 
and one name for the practice created by it—“ cystoscopy.” 
The probable advantages of the Paris instrument, in 
comparison to the Berlin or Vienna one, as far as I have 
been able to see them, are the following: 
1. That, on account of the length of its telescope, it is 
six to seven inches longer, and the face of the observer is 
therefore farther removed from the genitals than is possible 
in using the other cystoscopes. (But, on account of the 
great length, a slight motion of the handle will result in a 
by far greater one of the beak, which thus will often touch 
the wall of the bladder.) 
2. That we can perceive with one glance a larger area 
and see everything in the same upright position as our eyes 
would see it without the telescope. (The latter is also ex- 
perienced in using the Nitze or Leiter pattern No. 2.) 
3. That the pipes which run alongside and inside of the 
lower aspect of the shaft enable us to wash out the bladder 
before, and apply permanent irrigation during, the cysto- 
scopic examination. There is a wider canal in the center 
of the instrument for passing the telescope. It is filled out 
by a steel mandrel while the instrument is introduced into 
the bladder. If we make use of this canal for irrigation, 
the viscus can be very thoroughly flushed. 
4. That the larger one of the small pipes can be utilized 
for passing instruments of minute caliber for catheterism 
of the ureters.* 
* Cf. the Brunner modification IN THE LAST THREE YEARS. 
19 
5. That the telescope is introduced after the whole in- 
strument has passed the urethral canal—i. e., is in the blad- 
der. The objective lens can thus never be dimmed by an 
adherent mucous or pus shred or a small blood-coagulum.* 
6. That the instrument can he sterilized by boiling wa- 
ter, the cement which is used for fastening the rock-crystal 
pane in the window of the beak, etc., being such as to 
stand a great heat. The other cystoscopes can not be 
boiled. They are disinfected by wiping them very carefully 
and thoroughly with gauze dipped in a three- to five-per-cent, 
solution of carbolic acid. 
Now, has the French cystoscope also drawbacks as an 
offset to these advantages ? Yes, and very serious ones. 
1. We can not inspect the whole inner surface of the 
bladder with this cystoscope, which, besides, is quite 
clumsy and not at all as easy to handle as that of Xitze or 
Leiter. 
Boisseau Du Rocher finds an objection to Nitze’s in- 
strument on account of the latter’s advice f to make five 
exact motions with the cystoscope in the bladder in order 
to bring into sight every spot of its interior with mathe- 
matical exactness. With his own, when introduced into 
the bladder, the whole fundus, the posterior wall, and a 
portion of the upper and the two lateral walls come at once 
into view, without turning or moving the instrument. (In 
trying to obtain this result we shall, however, get a kind of 
bird’s-eye view.) But to examine the anterior portion of 
* Cf. Nitze’a irrigating cystoscope. If we make it a rule always 
to inject some glycerin into the posterior portion of the urethra with 
the help of a Nelaton catheter right after a careful irrigation of the 
anterior portion of the urethra, of the neck of the bladder, and of the 
latter organ itself, and right before introducing the cystoscope, we 
certainly shall quite rarely meet with this annoying occurrence when 
using the ordinary cystoscope. 
f Cf. Nitze’s Text-book on Cystoscopy, pp. 93-99. 20 
THE PROGRESS OF CYSTOSCOPY 
the vertex with the Paris cystoscope, the examining person 
would nearly have to sit on the floor, and even then the re- 
sult might not be satisfactory. Therefore two instruments 
become necessary. 
2. The caliber of the shaft is No. 27 of the French 
scale, that of the beak No. 23. The increase of the size of 
the shaft is caused by the pipes for irrigation. It is to be 
mentioned, though, that they are situated at the lower as- 
pect of the shaft, and thus give the tube a conical shape 
(cf. Brunner’s modification). The top of this cone corre- 
sponds with the lower circumference of the urethra, which 
can be stretched. (The size of Nitze’s and Leiter’s cysto- 
scope is No. 22, that of Nitze’s irrigating cystoscope, the 
shape of which is round, No. 25.) 
3. The beak is very long—half an inch longer than that 
of Leiter’s, and twice as long as that of Nitze’s cystoscope. 
4. The angle at the junction of the beak and shaft is 
130° and abrupt; in the other two instruments only 145° 
and well rounded. 
5. The lumen of the two pipes used for irrigation and 
passing catheters for catheterizing the ureters is extremely 
small. There is at present no catheter in the market, in this 
city at least, small enough for this purpose. 
6. There is no key or screw to make and break the elec 
trie circuit. We always have to put in or unscrew one of 
the conducting wires for this purpose. 
7. It is difficult to thoroughly cleanse the inner surface 
of the objective lens of the telescope. This lens can not 
be detached from the tube, but has to be reached by a long- 
conductor which holds at its end a piece of maple-marrow. 
I have not, so far, succeeded in removing some particles 
of dust from the inner surface of this lens. A compliance 
with this need by the manufacturer would mean an im- 
provement of the telescope. IN THE LAST THREE YEARS. 
21 
8. The spherical aberration of the lenses of the tele- 
scope. 
9. A constant dripping of 'water out of the tipper end 
of the instrument during examination. The intravesical 
pressure constantly forces the water alongside the telescope, 
which does not snugly occlude the lumen of the central 
canal. 
So far I have got the impression that the French eysto- 
scope will not as easily come into general use as that of 
Nitze and Leiter. It decidedly has a few important new 
features, which will make it desirable for the cystoscopist 
to he in possession of it. But until the defects mentioned 
above shall have been remedied,* we certainly shall always 
need the additional use of one of the two other cystoscopes 
in the market if we want to he ready to thoroughly perform 
a cystoscopic examination in cases where this method can 
be applied. 
In closing this section, a tabulated comparison of the 
size of the different parts of the three cystoscopes which 
attract special interest may perhaps be welcome. (See next 
page.) 
In regard to the batteries, a great variety is now at 
our disposal. Hartwig <fc Leiter sell a battery with the 
cystoscope which fully answers the purpose.f The fluid is 
a mixture of pure chromic acid (to be ordered of Messrs. 
Churchman & Co., Philadelphia), sulphuric acid, and water. 
(Formula for Hartwig’s battery: Chromic acid, 375; sul- 
phuric acid, 300; water, 3,000. For Leiter’s: Chromic 
* According to a remark of Dr. W. K. Otis, of this city, in the dis- 
cussion on Dr. L. B. Bangs’s paper—Cases illustrating some Difficulties 
in the Use of the Cvstoscope (Section in General Surgery of the New 
York Academy of Medicine, meeting of November 9, 1891)—this gentle- 
man is at present engaged in improving Rocher’s instrument. 
f For description, see Nitze’s Text-book, p. 62; Leiter, Catalogue, 
1889, pp. 13-1'7.  
Length of that part of the 
Length of entire in- 
Length of shaft, 
instrument which alone 
Size, 
French gan e. 
struihent, measured 
measured from 
comes into consideration 
Size of angle 
Cystoscope. 
from outer brim of 
outer brim of funnel 
with reference to length 
Length of beak. 
between shaft 
funnel to tip of beak. 
to junction with 
of urethra—namely, from 
and beak. 
in a straight line. 
beak. 
inner brim of funnel to 
lower border of prism. 
Inches. 
Centim. 
Inches. 
Centim. 
Inches. 
Centim. 
Inches. 
Centim. 
fNo. 1 
22 
10J 
25* 
H 
24 
8* 
21 
3 
2 
145° 
\itze. -j Q j ]0I)g 
(Rounded.) 
22 
11* 
281 
10* 
26* 
9* 
23| 
3. 
4 
2 
U 
[ Irrigating cystoscope 
25 
n* 
281- 
10* 
26* 
84 
22* 
3 
4 
2 
“ 
Leiter, No. 1 
22 
n 
16f 
25 
9 
23 
7* 
18§ 
22* 
1 
u 
j Shaft = 2V 
42-i- 
16 
41 
8f 
1* 
8f 
130° 
(Abrupt.) 
1 Beal: = 23 
(vv ltn telescope, j 
ltn telescope.) 
[r rom entrance or tuoes 
for irrigation to ver- 
tex of angle between 
shaft and beak, at its 
concave side.) THE PROGRESS OF CYSTOSCOPY. 
23 
acid, 500; sulphuric acid, 375; water, 3,000.) The two 
original Leiter batteries, with hard-rubber cells, are not 
to be recommended, as they will'surely crack and leak after a 
short while. The repair of such a crack is troublesome and 
always unreliable. Since last year the cells have been made 
of glass. Thus a very annoying disadvantage is at last elimi- 
nated. Fenwick uses a battery supplied by Schall (Lon- 
don),* and is pleased with it. He wants a rheostat. For 
cystoscopists on this side of the ocean I would recommend 
the cheap and easily manageable, portable, small six-celled 
battery of the Galvano-Faradic Manufacturing Co., New 
York city. Not to destroy with it the incandescent lamp at 
once, the elements must be screwed very slowly and care- 
fully into the fluid until the light is bright. In all these 
batteries there is no rheostat attached. I so far have 
never seemed to he in actual need of the latter. In a nearly 
four years’ practice in cystoscopy the number of lamps de- 
stroyed by me is a very small one. Still, its presence in a 
battery will he welcome. A very fine storage battery, Gib- 
son’s (three different sizes),f is sold by the W. F\ Ford 
Surgical Instrument Co. It contains four large cells and 
has a rheostat. Its lighting power is ample.J It can he 
arranged to permit of endoscopic and galvano-caustic work 
* Loc. cit., pp. 46, 47. 
f Size I weighs about fifty pounds, and has a capacity of fifty amp. 
hours ; size II, about forty pounds, capacity thirty amp. hours; size III, 
about thirty pounds, capacity fifteen amp. hours. 
\ TheNitze mignon-lamp requires more electro-motive force (9 to 10 
volts) than that of Leiter’s cystoscope and urethroscope (6 volts), be- 
cause its filament is finer, and consequently offers more resistance to 
the current. The maximum force of the Gibson four-cell storage battery 
is eight volts and a fifth. The Ford Co. is now constructing a six- 
cell storage battery which lights the Nitze lamp also to brilliancy. Its 
price and weight are of course slightly higher. The manufacturer of the 
Nitze lamp should build it eight volts or less. This can easily be done. 24 
THE PROGRESS OF CYSTOSCOPY 
at the same time, which will be found especially convenient 
in urethroscopy. Recharging once in two to six months ; * 
in spite of its price, I should advise its purchase by a cystos- 
copist who lives in a great city. 
I still have to call attention to the various attempts 
which have been made in regard to fixing the picture as 
seen with the cystoscope by clay or wax modeling, colored 
drawings, and. photography. 
Fenwick, the originator of the first-mentioned method,f 
has proved, by the very pretty pictures in his work, how 
nicely and thoroughly the various pathological conditions of 
the interior of the living bladder, especially of tumors, if 
modeled in some plastic material, wax or clay, and then 
photographed, may be recorded and demonstrated to others 
who could not attend the examination. 
E. Burckhardt very lately gave us a fine collection of 
colored drawings of bladder images in health and disease ; \ 
every one of them was observed by himself and drawn at 
once with the cystoscope in position. The Atlas will espe- 
cially he useful to the beginner, and explain to him many a 
picture which was seen but could not be at once identified. 
Instantaneous photography, “ the ne plus ultra of cysto- 
scopic delineation (Fenwick),” is still in its infancy. Nitze 
has theoretically laid out an interesting method of best 
getting a small negative, and then magnifying it. Want of 
* This is, of course, a disadvantage, as it makes us dependent upon 
the electrician. In houses that are connected with the street electric, 
light system, charging can be done at home. 
f Clay and Wax Modeling of the Living Urinary Bladder under 
Electric Light, British Medical Journal, January 5, 1889 ; and The 
Electric Illumination, etc., loc. cit., p. 88. 
\ Atlas der Cystoskopie, mit 2J+ Tafeln in Farbendruck: Basel, 1891. 
See, also, the few excellent colored drawings at the end of Nitze’s hand- 
book. IN THE LAST THREE YEARS. 
25 
time has not permitted him to make practical experiments.* 
Geza von Antal, f by his assistant, B. Hermann, published 
the photographic picture of the cystoscopic appearance of 
a black hair-pin in a female bladder. It is, however, utterly 
indistinct. 
Fenwick (in connection with Mr. Pearson-Cooper, of 
the London Camera Club) has succeeded in obtaining good 
negatives of artificial growths both in the dummy and the 
dead bladder. But the negatives of the living bladder 
were too indistinct. A number of certain mechanical ob- 
stacles have so far formed an almost insuperable harrier to 
such a method being successful and practical. 
In view of the rapid strides of modern technique, it is 
to be hoped that these obstacles will soon be overcome 
and that we shall then be enabled to “ graphically record the 
many new and interesting clinical facts which the electric 
cystoscope is constantly revealing.” 
As it seems, this hope has meanwhile already been ful- 
filled. (See TJeber Photographie innerer Korperhohlen, 
inshesondere der Ilarnblase und des Magens, by Ilr. Robert 
Kutner. Deutsche med. Wochenschrift, Berlin, No. 48, No- 
vember 26, 1891, p. 1311. Kutner is a former assistant 
of Nitze.) 
II. Cystoscopy with Reference to Diseases of the 
Bladder. 
To give an accurate account of everything of interest 
that has so far been seen in the bladder and published is a 
difficult task and one of no intrinsic value. The literature 
on cystoscopy, which has appeared mostly within the last 
three years, is already very large. Nitze’s so often men- 
* Text-book, p. 325. 
f Internationales Ctrlbl. fur Physiologie u. Pathologie der Ham- u. 
Sexualorgane, Bd. i, Heft i, p. 18. 26 
THE PROGRESS OF CYSTOSCOPY 
tioned fundamental and instructive Text-book on Cystoscopy, 
Hurry Fenwick’s valuable, lucid, and extremely interesting 
work, The Electric Illumination of the Bladder and Urethra, 
as well as also many other articles bearing on the same 
subject, written by different men, fully cover the ground. 
The appearance of these writings within the very last 
years renders an attempt in this direction at my hands a 
work of supererogation. The manifold brilliant results as 
enumerated in this part of medical literature demonstrate 
how often and sometimes easily an exact diagnosis of a pre- 
viously obscure urinary disease can be and has been estab- 
lished with electric illumination of the bladder. These re- 
sults fully sustain Nitze’s original statements and predic- 
tions in every particular—namely, that the present electric 
illumination of the bladder gives us the means of establish- 
ing a strict differential diagnosis between the various forms 
of catarrh of the bladder—acute,* chronic, haemorrhagic, 
diphtheritic; that it is easy to see with it ulcerations, to 
demonstrate diverticula, to find and localize foreign bodies ; 
that it seems almost unnecessary to mention how plainly 
we can now see stones, make out their number, size, shape, 
and mobility, and percuss them with the beak of the instru- 
ment ; how encysted stones, too, will not escape the exam- 
ining eye; that especially the diagnosis of tumors of the 
bladder is now easy and can be made early. 
It is obvious how strongly this exact diagnosis at once 
reflects upon prognosis,! indication, and treatment. Not 
infrequently an unnecessary operation can thus be avoided. 
* In cases of acute catarrh the use of the cystoscope is, of course 
just as much to be prohibited as that of a catheter or sound. 
f Fenwick believes he has seen and found a peculiar condition of 
the vesical mucous membrane which he calls “ precancerous.” The 
Elect. Ilium,., etc., p. 153; also Brit. Med. Journal, September 22, and 
October 13, 1888. IN THE LAST THREE YEARS. 
27 
Certainly it has been sufficiently established that if any 
doubt exists of the diagnosis in a case of vesical disease 
and the three cardinal conditions which enable a cystoscopic 
examination to he made * are fulfilled, it is the duty of the 
attending physician to submit his patient as early as possible 
to this ocular inspection. This on the same ground as he 
would look with the help of a mirror at the interior of the 
larynx, eye, nose, or ear in their respective disorders. 
A few cases of my own, each representing a different 
chapter of vesical disease, selected from a large number of 
interesting cystoscopies, perhaps deserve to be briefly re- 
ported in this place. In every one of them (the one sub a 
alone excepted) the cystoscopic diagnosis was verified in 
the subsequent operative interference. I shall omit cases 
illustrating the various forms of catarrh (localized and 
general) and the hypertrophy of the lateral lobes of the 
prostate, although they were frequently met with. 
a. Tuberculous Ulceration.—Mr. FT. 0. E., aged forty-five 
years, married, came to me for examination through the court- 
esy of Dr. L. G. N. Denslow, of St. Paul, in April, 1890.t 
Twelve years ago first pain in glans penis, which in the follow- 
ing ten years often gave rise to trouble. Two years and a half 
ago first appearance of blood and mucus in urine, with increased 
pains in glans. November, 1889, a large, painful swelling in the 
right lumbar region, which had formed under considerable rise 
of temperature, nearly disappeared after the passage of a large 
* 1. The caliber and shape of the urethra must permit of passing 
the cystoscope into the bladder. 2. There must be sufficient capacity 
of the bladder (average = 5 ounces). 3. The fluid in the bladder must 
be transparent, at least during the time of examination (cf. irrigating 
cystoscope). See author on Cystoscopy and the New Cystoscope of 
Nitze and Leiter, with a Demonstration of the Same, N. Y. Med. Jour- 
nal, April 21, 1888, p. 429. 
f Cf. the author’s review of Nitze’s Text-book on Cystoscopy, Annals 
of Surgery, June, 1890. 28 
THE PROGRESS OF CYSTOSCOPY 
quantity of pus with the urine. One month later last haematu- 
ria at the end of micturition. Present condition: Greatly re- 
duced man ; pains in glans penis if bladder is full. Urinates 
every two hours day and night. No tenesmus, no stoppage. 
Eight kidney palpable, slightly painful on pressure. Urine 
only slightly turbid; contains a large amount of tubercle bacilli 
in every microscopical specimen. Cystoscopy (Nitze’s cysto- 
scope, No. 1): Immediately above the swollen mouth of the 
right ureter and its elevation of mucous membrane an ulcerated 
spot of about the size of twro silver dollars appears. Purplish- 
red, broad elevations (evidently the inflamed fibers of the detru- 
sor muscle) cross each other in different directions. Small 
particles of snowy, shining mucus, adherent to their surface, 
float in the fluid. The depressions between these elevations are 
of a lighter hue, also covered with mucous flakes. In between 
them numerous very small and larger sessile growths of grayish 
coloring are plainly visible, a few about as large as a pin’s head, 
undoubtedly miliary tubercles. On one spot a small rhomboid- 
shaped, dark-red (haemorrhagic) spot can be seen. The entire 
other inner surface of the bladder is perfectly normal, of gray- 
ish-white color, rather anaemic, corresponding with the condi- 
tion of the patient * As I was informed' by Dr. D. some 
time ago, the right kidney was lately removed, with great 
* It has to be stated that the cystoscopic picture of a tuberculous 
infiltration has not yet been established. A failure in making the 
diagnosis of tuberculous non-ulcerative cystitis with the cystoscope 
before the suprapubic incision is resorted to for clearing up the ob- 
scure trouble is no reproach to this mode of examination. If tubercle 
bacilli have been found in the urine before cystoscopy is tried—and 
they will be by far easier found, even in a relatively clear urine and if 
present in a very minute quantity, by the centrifugal method of 
Stenbeck, modified by v. Frisch (Zur Diagnose der tuberkulosen Er- 
krankungen der Urogenitalsystems, Internat. klin. Rundschau, 1891, 
Nos. 28-30)—a localized hypersemic spot of the vesical mucous mem- 
brane seen through the cystoscope has to be diagnosticated as being 
most probably one of tuberculous character (tuberculous infiltration). 
It is to be hoped that such cases, if made out in this manner, wil 1 
henceforth be published in detail. IN THE LAST THREE YEARS. 
29 
benefit in regard to the patient’s general condition. It had 
been converted into a large pus-sac. 
b. Diverticulum.—Mr. J. P:, aged sixty-four, had come under 
my care in the summer of 1888 on account of an intense catarrh 
of the bladder, due to hypertrophy of the prostate of long stand- 
ing. Urine of foetid smell, voided every few minutes. Cystos- 
copy (Leiter, No. 1). Mucous membrane of dark-grayish ap- 
pearance, nearly black. Shreds of mucus and necrotic tissue 
adherent to the wall, floating in the injected water. No diag- 
nosis made. Subsequent examination of urine showed a far ad- 
vanced diabetes which so far had not been diagnosticated. Strict 
antidiabetic regimen brought comparatively quick relief. Cys- 
toscopic (probable) diagnosis then advanced: diabetic superficial 
gangrene of the mucous membrane of the bladder.* About one 
year later cystoscopy (Nitze, No. 1) was again performed : All 
symptoms of chronic catarrh, vessie d colonnes; a little out- 
ward of the mouth of the left ureter a large, dark spot of about 
a five-cent piece is seen. Its lining mucous membrane is wrink- 
led. The light of the cystoscope is then turned off and the tip, 
posted right in front of this spot, gently pushed forward. It 
evidently enters a cavity but touches no concrement. Diagno- 
sis : diverticulum. Operative interference for the hypertrophy 
of the prostate is not proposed, as patient is satisfied with the 
use of the catheter. Strict antidiabetic regimen. Two years 
later patient has to catheterize himself every fifteen to twenty 
minutes; constant pain, fever, seven per cent, sugar. Epicys- 
totomy becomes imperative and shows a large diverticulum at 
the diagnosticated spot filled with phosphatic debris. 
c. Foreign Bodies.—B. v. P., aged forty-one, was admitted 
to the German Hospital on May 22, 1888.t lie had always 
been a healthy man up to three years ago, when left renal colic 
with hsematuria had first appeared. The latter had been inter- 
mittent since then. Frequently the first drops were mixed with 
blood during micturition ; then the urine was clear. Now and 
then he passed pure blood. According to the advice of one of 
* Author, jV. Y. Med. Journal, February 23, 1889, p. 203. 
f N. Y. Med. Journal, 1889, p. 198. 30 
THE PROGRESS OF CYSTOSCOPY 
the gentlemen whom he had consulted abroad, he had for a long 
time had his bladder Hushed daily with a mild solution of per- 
manganate of potassium. Two months before entering the hos- 
pital a severe catarrh of the bladder had set in. With gnat 
strain small' particles of a semi-solid substance bad now and then 
been voided through the urethra Frequent stoppage of flow of 
urine; great pains; morphine habit. On examination, the 
searcher did not strike stone. Urine, muddy and of alkaline re- 
action, contains three per cent, albumin. Under the micro- 
scope : red blood-corpuscles, pus and mucus, no casts. A tumor 
of about two fists’ size with a smooth surface, evidently belong- 
ing to the left kidney (tumor or pyonephrotic stone-kidney ?), 
can be palpated in the left hypochondrium of the anaesthetized 
patient. Cystoscopy under chloroform (Nitze, No. 1) : As soon 
as the instrument had entered the bladder and the light had been 
turned on, I saw a few (six to eight) curiously shaped more or 
less flat curved bodies of black color, covered with whitish de- 
posits of phosphates. Stirred up by the outflowing streams of 
urine from the ureters, they constantly tumbled over each other 
and were thrown against the beak. No click, however, was no- 
ticed ; their consistence was soft. Besides these bodies there 
was no stone, no tumor, only evidence of catarrh. 
To establish a diagnosis with reference to the nature of these 
bodies from this cystoscopic picture was entirely impossible. 
None of those present had ever seen anything like them. The 
most probable supposition seemed to be that of coagulated blood, 
which had descended from the left kidney. Still the semi-solid 
condition and peculiar shape of the bodies remained unexplained. 
Nevertheless the result of cystoscopy was highly satisfactory. 
The cause of all the vesical trouble had been found. No searcher, 
no bimanual palpation could ever have accomplished anything 
like it. When the bladder was incised—above the pubes—about 
eight bodies of various size could be easily extracted. They 
were of a semi-solid, black substance, flexible, and covered with 
phosphatic deposits, just as they were made out through the 
cystoscope. Chemical analysis showed that they consisted of 
sixty per cent, fibrin and forty per cent, permanganate of po- 
tassium. IN THE LAST THREE YEARS. 
31 
d. Stones.—Case I.—Mr. D., fifty-three years old,* merchant, 
for several years troubled with chronic gastritis, was seized with 
pain in the glans penis and in his left lumbar region in the fall of 
1886. After three days the pain left him and did not return 
until a year later, September, 1887, when he developed symp- 
toms of stone in the bladder. Neither hsematuria nor stoppage 
of the flow of urine had ever been present. A thorough exami- 
nation with the searcher repeatedly performed at that time by 
a very able surgeon failed to detect stone, and the patient was 
therefore put on suitable internal medication. But as his con- 
dition got steadily worse, his family physician courteously sent 
him to me for cystoscopy June 11, 1888. The patient’s bladder 
being extremely irritable, and examination with the searcher 
having been accompanied and followed before by great agony, I 
yielded to the patient’s urgent request and immediately intro- 
duced the cvstoscope (Leiter, No. 1). Having turned the instru- 
ment 180°, thus directing the prism toward the fundus of the 
bladder, I saw at the first glance in brightest illumination an 
oval-shaped, brownish body covered with white spots (evidently 
phosphatic deposits) of the size of an almond, lying in the pouch 
behind the enlarged prostate. It threw a distinct shadow upon 
the opposite wall of the bladder. I then turned off the light and 
touched the body with the tip of the instrument. I got an un- 
mistakable click. The bladder otherwise presented symptoms 
of catarrh. The ureteral openings emitted a clear and trans- 
parent fluid. No further special attention was paid to the char- 
acter of the jets of urine coming from the ureters at that time, 
as no symptoms indicated a diseased kidney. 
Suprapubic lithotomy was performed and the stone easily 
removed. It presented the characteristics as seen with the cys- 
toscope. 
Case II.—Mr. X., always healthy, is suddenly unable to uri- 
nate. A doctor tries to introduce a soft-rubber catheter, but 
does not succeed. When I saw the patient in consultation my 
perforated sound struck a hard substance just at the neck of the 
bladder, which slipped back into the viscus. Nearly two quarts 
of urine were voided. The patient then was all right. Three 
* N. Y. Med. Journal, 1889, p. 199. 32 
THE PROGRESS OF CYSTOSCOPY 
days later retention for a second time set in, and was again re- 
lieved by catheterization. I was convinced that there was a 
small stone in the bladder, but was unsuccessful in striking it 
with the searcher. The cystoscope (Nitze, 'N'o. 1), of course, 
gave at once evidence of a small, uneven concrement, about half 
an inch long, not unlike a small dried bean. . I proposed to try 
and aspirate it with Otis’s evacuator. Meanwhile the stone 
again blocked the urethral canal, but, with the help of a sudden 
forcible strain, was expelled, to the greatest delight of the pa- 
tient. Its characteristics were found as stated in my letter to 
the colleague. ■ * 
e. Hypertrophy of the Median Lobe of the Prostate.—-X., 
aged seventy, relies entirely upon catheter, which has frequent- 
ly to be passed. Passage attended by difficulty and pain. Two 
strictures—one in the anterior, the other in the posterior portion 
of the urethra—had been divulsed about a year before, and then 
the bladder carefully washed for some time. - Urine was clear— 
no blood, no pus, no albumin, no casts;' great local distress. 
Cystoscopy (Nitze, No. 1, long) : In introducing the instrument 
its handle had to be pressed far down before the beak enters the 
bladder. A slightly hypertrophied third lobe, of about half to 
three quarters the size of the third phalanx of the middle 
finger, is easily diagnosticated”; the bladder presents a vessie 
d colonnes in a most beautiffll manner. Soon afterward su- 
prapubic cystotomy was performed by another surgeon. The 
third lobe was found as diagnosticated, and pinched off with 
the rongeur. 
f. Tumors.—Out of a greater number of these cases I 
cite the following two, which may serve as paradigms: 
Case I.—Mr. X., aged fifty-three years,* was seen by me in 
consultation on March 20, 1890. For six months lie had nearly 
continuously passed bloody urine without submitting to a close 
examination. He had suffered from frequent forcible micturition 
and intermittent pain in the glans ; otherwise he had felt comfort- 
ably. Repeated careful chemical and microscopical examination 
* Cf. Annals of Surgery, l. c. IN THE LAST THREE YEARS. 
33 
only showed red blood-corpuscles and mucous cells, never a par- 
ticle of a new growth. Bimanual palpation was very difficult, 
and also promised no result on account of the patient’s great 
corpulence and marked hypertrophy of the prostate. I there- 
fore immediately resorted to cystoscopy. As a hypodermic of 
morphine, with local cocaine anaesthesia, did not quiet the irri- 
table bladder, the patient was narcotized. Now I saw in 
brightest illumination a round sessile growth with an uneven 
surface, not unlike a large round strawberry, on the left wall of 
the bladder, about an inch above the mouth of the left ureter. 
I very plainly observed that blood was oozing out of its surface. 
The other portion of the interior of the bladder appeared to be 
healthy; there were symptoms of a slight catarrh. 
Diagnosis.—Cancerous sessile tumor of the bladder. 
Suprapubic cystotomy, March 25, 1890 (performed as usual 
in Trendelenburg’s posture). Growth, on the spot localized be- 
fore, presented all the characteristics as formerly diagnosticated 
with the cystoscope. It was, with the adjacent parts of the 
wall of the bladder, cut out with the knife by an ellipsoid in- 
cision. The base was then carefully burned with Paquelin’s 
thermo-cautery. Uninterrupted recovery. No recurrence till 
date. 
Case II.—Mr. J. B., aged forty-eight years, had been in per- 
fect health up to May, 1889. At that time he had a sudden and 
causeless attack of haematuria, which ceased as suddenly after 
forty-eight hours, but only to return after a few weeks. The 
bleeding then became intermittent, appearing first about every 
one, two, or four months, later in as many weeks. Pain in 
glans and frequency of micturition also were experienced. 
January, 1890, retention caused by clots. The catheter brought 
relief, but started catarrh. The patient had consulted different 
doctors, but only irrigation had been advised. One colleague 
proposed suprapubic incision without having strictly diagnosti- 
cated the case. Cystoscopy on May 12, 1890 (Nitze, No. 1); 
five ounces thrown in. On turning the beak to the left side and 
slightly directing the prism toward the floor, a large, cock’s- 
comb-like, pinkish-red tumor is at once detected. Deep, ir- 
regular furrows divide the surface into larger and smaller, un- 34 
THE PROGRESS OF CYSTOSCOPY 
even, and tabulated areas, which bleed when touched with the 
beak of the instrument. The growth is planted on a thick and 
succulent base, a little outside of the left ureteral orifice, and 
embraces an area of at least a silver dollar. Illuminated by the 
electric light—the peaks and plateaus in brightest sunshine, the 
many irregular wounded valleys, out of which a few trickling 
streams of blood slowly find their way, in dark shade—the ap- 
pearance of the whole succulent, erect, and pulsating growth 
was picturesque in the extreme. Nearer to tbe fundus and the 
median line a second smaller tumor is seen about as large as a 
cherry. The interposed portion, as well as the whole of the in- 
terior of the bladder, appears healthy. 
Diagnosis.—Cancer of the bladder, still extirpable. 
When the bladder had been opened above the pubes, the 
condition corresponded exactly to my cystoscopic diagnosis, 
which I had before explained to the gentlemen who kindly as- 
sisted me during the operation. The large tumor was shelled 
out in healthy tissue with Paquelin’s thermo-cautery knife. Two 
large spurting arteries which entered the base of the growth 
and fed it were ligated with medium-sized silk, as catgut seemed 
unreliable and the bladder was to be drained. They could be 
easily tied, as they had been torn about an inch above the in- 
ner bladder surface. The smaller cancer was cut out with the 
knife and its insertion carefully burned. Tamponade with iodo- 
form gauze ; drainage for twelve days. Quick recovery. Seven 
months later I had to extract a longitudinal small stone from 
the patient’s urethra. Nucleus: a silk ligature! Seven weeks 
later the patient again called on me on account of great distress 
and heematuria. On introducing the cystoscope I saw in the 
fundus a stone, of at least almond-size, covered with mucus and 
phosphates, and in the upper inner angle of the fiat, whitish, 
shining scar (the result of the former operation) a small, stalked 
recurrent growth, of cauliflower shape, overhanging tbe mouth 
of the ureter and swaying at every eddying rush of the ureteral 
streams. 
In view of this complication, I proposed and performed su- 
prapubic cystotomy for a second time. The stone was easily 
removed (its nucleus was the other silk ligature), and the bleed- IN THE LAST THREE YEARS. 
35 
ing spot, where the recurring tumor had been inserted, thor- 
oughly burned. To-day patient is doing well. (This case will 
soon be published in extenso.) , 
Before closing this section I ought to say that the cys- 
toscopic diagnosis in bladder diseases is not at all always so 
easily made. First of all, it must be borne in mind that this 
ocular inspection can not he applied in every case, and that, 
if it can be resorted to, it requires in praxi a great deal of 
patience and, to avoid mistakes, also experience. The three 
cardinal conditions which alone guarantee a successful ex- 
amination should be carefully investigated before the instru- 
ment is introduced. If one of them can not be fulfilled, a fail- 
ure may be expected. Although I am well aware that we may 
be able to make a correct diagnosis, after some experience 
at least, with only from three to four ounces of water in the 
bladder, still I have made it a point—and I would especially 
give this advice to the beginner—always to try and have five 
ounces thrown in. We know, from Nitze’s investigations, 
that this amount just expands all the folds and grooves of 
the intravesical surface. The only exception from this rule 
I make is in cases of supposed tumor of the bladder with 
obstinate hsematuria, but without a marked vesical catarrh. 
Here the cystoscope is introduced as soon as the bleeding 
has ceased, and probably a sutficient amount of urine is in 
the bladder. Washing will frequently start the haemorrhage 
again. (If we wish to increase the capacity of the bladder, 
we must inject the fluid forcibly with the syringe, and not 
use the irrigator; and even then we may sometimes be un- 
successful.) Only in this way, by training our eyes to in- 
spect the surface of the properly and more or less always 
equally expanded viscus, can we hope to learn by and by 
how to avoid the many pitfalls which await the cystos- 
copist. If the surface of the prostate begins to bleed at 
the slightest touch of a solid instrument, I at once try to 36 
THE PROGRESS OF CYSTOSCOPY 
examine with the irrigating cystoscope and have the nurse 
throw water in while the beak passes the posterior urethra 
and neck of the bladder. 
We also have to pay attention to the magnifying power 
of the Nitze telescope as well as to the fact that the nearer 
the prism the larger the object. If after a careful examina- 
tion and deliberation there is still doubt with reference to 
explaining and identifying the image observed, a second 
cystoscopy should he insisted upon. 
Lastly, the cystoscopist should accustom himself, espe- 
cially in cases which he sees in consultation, first to obtain 
a thorough history, then to make a general examination, 
especially with reference to tuberculosis, to carefully analyze 
the urine, to palpate the lumbar region of each side, the 
testicles, and the prostate, and test the caliber of the urethra. 
The operator should always start with the'case as if he did 
not yet possess the cystoscope to enable him to view the 
interior of the bladder. He should push his means of diag- 
nosis as far as possible by rational signs and examination 
of the urine. But the first instrument he then takes in 
hand should be not the sound, but the cystoscope. Only 
when a stone in the bladder is strongly suspected should 
the sound be used first. 
Here are a few examples, for the beginner as well as for 
him who uses the cystoscope without a previous general 
examination, as just explained, and also possibly fails to 
read the literature beforehand and thus benefit by the ex- 
perience of others: 
He will easily take the taggy shreds of necrotic tissue, 
hanging at the edge of a tuberculous ulcer and floating in 
the fluid, for a polypus, without at all noting the ulcer, 
especially if the prism is brought close to it (the experi- 
enced and careful examiner has probably found before tu- 
berculosis of the testicles, or an enlarged kidney, or tubercle IN THE LAST THREE YEARS. 
37 
bacilli in the urine, or such a detritus under the microscope 
which will lead him to suspect the existence of an ulcer and 
thus make him look out for it); he will take the prolapse 
of the ureter for a sessile growth (but if the prism is car- 
ried near by, this growth is entirely transparent, and on 
careful inspection it will be seen that out of one spot of its 
perfectly round and smooth surface a whirl of urine will 
suddenly be expelled). 
He will take an incrusted growth for a stone (a touch 
with the beak will quickly dispel any doubt); a deposit of 
coagulated blood around one of the ureteral cones will per- 
haps puzzle him (the experienced will take it as a hint at 
haunaturia of renal origin, most probably on the same side), 
as will also the picture of the enlarged median lobe of the 
prostate. 
Success will not be with him if the just injected 
clear fluid turns murky at once after a long-continued 
irrigation, or is found to be so as soon as the cysto- 
scope has entered the bladder. (The experienced man 
at once suspects kidney trouble, will exchange the ordi- 
nary for the irrigating cystoscope, and watch, after a 
quick glance at the interior of the bladder, the ureteral 
orifices. Most probably pains or the already palpated 
swelling in one lumbar region will guide him on which side 
to look first.) 
Of course an infiltrated spot in the wall of a blad- 
der which can not be properly distended, or greatly 
hypertrophied and easily bleeding rugae in a case of 
localized chronic catarrh, will also easily mislead the well- 
trained eye and induce one to diagnosticate a tumor 
where the suprapubic incision will merely show infiltra- 
tion. Also many other mistakes may occur. But they 
will become rarer with increasing experience; and if, 
nevertheless, they still occur, the physician may console 38 
THE PROGRESS OF CYSTOSCOPY 
himself with the reflection that mistakes occur just as 
often and as easily in the other and older branches of 
surgical diagnosis. 
III. Cystoscopy with Reference to Diseases of the 
Kidney. 
Nitze, Fenwick, Goldschmidt, Poirier, Tuffier, Janet, 
and many others have published interesting cases where 
negative vesical evidence gave a positive diagnosis of renal 
disease and where cystoscopy not only proved the formerly 
obscure trouble to be of renal origin, but gave the means for 
exactly locating the lesion and distinguishing which kidney 
is diseased or whether both are affected. 
Under ordinary circumstances it is not difficult to de- 
termine whether the urine propelled from the ureteral cones 
is clear, murky (purulent), or bloody. We simply have to 
place our prism just opposite and comparatively close to the 
mouth of the ureter, and then carefully watch. Some ex- 
perience and patience, a quiet hand, and close attention are 
all that is needed. But, as mentioned above, this task at 
once grows more difficult if the injected clear water rapidly 
becomes turbid. The inspection can then only be effected 
by means of the irrigating cystoscope. 
Case I. Pyv/ria ; Cystoscopy; Nephrotomy ; Nephrectomy ; 
Recovery.—Mrs. X., aged forty-five years, had noticed since 
several years that her urine was now and then cloudy; had also 
occasionally experienced some pain in her left side. The latter 
was attributed to a fall the patient had received while out sleigh- 
riding in the country twenty years ago. Otherwise she had 
always been in apparently good health. At the middle of June 
this year she was suddenly taken very sick with high, continu- 
ous fever, enlarged spleen, and general symptoms, which were 
suspicious of typhoid. But a tumor was palpated in the left 
lumbar region, and the urine contained pus. The gentleman IN THE LAST THREE YEARS. 
39 
who had been consulted proposed cystoscopy, and I was called 
in to perforin it. After a short irrigation the water returned 
clear. Quickly the elements of the battery were screwed down 
into the acid, the full strength of the current allowable for get- 
ting a bright light determined, and the circuit broken. The 
catheter, corked, had been left in the bladder meanwhile. In 
extracting it then a few drops of water escaped, perfectly tur- 
bid. Of course only renal trouble could have done that. Again 
the fluid in the bladder was changed and the irrigating cysto- 
scope introduced. One glance in bright illumination, showing 
a healthy bladder; and a dense fog suddenly came up and threw 
a heavy veil over the whole landscape. Now the irrigating 
cystoscope was put at work. The prism was turned to the left 
and the murky fluid allowed to run off, while the hand-syringe 
threw in short jets of clear water. The fog lifted, and I clearly 
perceived the left ureteral opening, and out of it nearly at the 
same moment a forcible eruption of a snowy-white, milky fluid. 
Spurting forward into the medium, which was contained in the 
bladder, in the shape of a fire-sheaf, the first rather thick mass 
at once dispersed and was dissolved into myriads of minutest 
snow-flakes, which slowly came down and at once put a stop to 
all further examination. The manoeuvre was now repeated on 
the same side and the diagnosis of suppurating kidney clearly 
established. The very frequently descending jets, which always 
are pathognomonic of an irritative process in the pelvis of the 
respective kidney, could be attributed to the coexisting pyelitis 
or the presence of a stone in the pelvis. Of course the urine of 
the right kidney was now analyzed in the same manner. It was 
clear.* A few days later I performed nephrotomy and found a 
pyoneplirotic kidney with a large stone in the greatly enlarged 
* I want to state here that even with the able help of the irrigat- 
ing cystoscope it is extremely difficult, if not in many cases impossible, 
to make out a urine which is only very slightly turbid or which is clear 
and contains long shreds of tissue, as I have seen it in one case. Gen- 
erally a certain amount of turbidity is required before it becomes visu- 
ally apparent and perceptible. Bimanual palpation of the suspected 
diseased organ or pressing it will frequently help in making the cysto- 
scopic diagnosis of renal pyuria. 40 
THE PROGRESS OF CYSTOSCOPY 
pelvis. Only the debilitated condition of the patient prevented 
me from removing the diseased organ at once. Primary ne- 
phrectomy seemed to me to be fully justified in view of the 
cystoscopic result, and would have spared the patient a second 
operation. The kidney was, however, left in and drained, with 
the intention of extirpating it as soon as the lady’s health would 
permit it. Nephrectomy was done by me four months later, on 
account of an annoyingly running renal fistula. To-day the pa- 
tient is cured. 
A number of patients with intermittent abundant hsema- 
turia have been under my care in whom the cystoscope 
demonstrated a perfectly healthy bladder. In only one of 
them have I been so lucky as to make the examination just 
at the time of the bleeding, and I then saw a red, rapidly 
propelled whirl crossing the prism, and slowly mix with the 
transparent water, slightly coloring the same. None of the 
patients, who just happened to be examined at the bloodless 
period, reappeared at the time of the next hsematuria as 
ordered. Perhaps they were unable to come. The one in 
whom I had diagnosticated unilateral renal hsematuria— 
which, according to the symptoms, was evidently caused by 
a new growth—declined the proposed operation. She died 
after an abundant haemorrhage not long afterward. A few 
cases of this kind are published by Nitze, Fenwick, and 
others. 
But the transparency, color, and frequency of the de- 
scending jets of urine are not the only points which have to 
be observed and noted in exploring the bladder with the 
electric light. We are able to still further analyze and 
specify the character of the whirls as they can be seen jet- 
ting from the ureters. 
The history of a few more cases of renal disease, which 
lately occurred in my own practice, will well illustrate 
this. IN THE Last three years. 
41 
Case II.—Cystoscopy ; Suprapubic Lithotomy ; Cystoscopy ; 
Nephrolithotomy; Recovery (the continuation of a case previ- 
ously mentioned in this paper).* On the 10th of March, 1891, 
Mr. D., of whom I had lost sight since the summer of 1888, 
again called upon me, a sick man. His stomach was entirely 
out of order. Every few days he vomited great masses of 
sticky mucus, and was only able to do so by first drinking a 
tumbler of very strong salt water. Cathartics were freely 
used. Entire loss of appetite. He had been for this trouble 
under a physician’s care, who was, however, unable to im- 
prove his condition in spite of constant careful attendance. The 
doctor diagnosticated “ nephrolithiasis on the left side ” and sent 
the patient to me for operation. The history further revealed 
that not long after the suprapubic wound had definitely closed 
an attack of epididymitis on the right side had twice set in. The 
urine had never entirely cleared up. Last summer (1890) the 
left testicle became suddenly inflamed. At the same time, the 
former dull and constant pain in his left lumbar region, which 
had now and then troubled him during the entire last year, be- 
came more marked. For three days the urine was mixed with 
blood. A similar attack occurred in January, 1891. At present 
he had a constant pain and he was obliged to get up twice dur- 
ing the night to pass water. In the daytime he urinated about 
every four to five hours. 
Cystoscopy (cocaine): Mucous membrane of the bladder com- 
paratively healthy. Ho scar as a result of the operation visible. 
Prostate large, easily bleeding. Right ureter is pumping at regu- 
lar, though rather short, intervals; ejects clear fluid. The whirl- 
ings propelled from the left ureteral opening are by far less fre- 
quent and last nearly as long as three of the opposite side com- 
bined. This phenomenon can be noticed with so much greater 
precision as the urine of the corresponding kidney is slightly 
turbid. Ho renal haematuria at present. 
Considering all these facts, I diagnosticated “a stone in the 
* Read before the Section in Genito-urinary Surgery of the New 
York Academy of Medicine, November 12, 1891, the patient being 
present. 42 
THE PROGRESS OF CYSTOSCOPY 
pelvis of the left kidney large enough to partially block the upper 
ureteral opening.” Taking this conclusion as correct, it was 
evident that the urine had to gather in greater quantity and had 
to distend the pelvis of the kidney more than ordinary before 
finding or rather making its outlet on one or more spots along- 
side the necessarily irregular surface of the stone. And this 
again explained best the curious character of the jets as observed 
at the left ureteral cone. Taking further into account that the 
patient had noticed his very first pain in the left lumbar region 
as early as 1886, and that I had to remove a stone from the blad- 
der two years later, my diagnosis was well founded that nephro- 
lithiasis had been the primary and constantly persistent trouble 
in this case. No doubt a small piece of the renal calculus 
had been broken off as early as 1886 and carried down to the 
bladder, and had there formed the nucleus of the stone which 
was removed by me in 1888. Was the other kidney healthy ? 
I did not venture to answer this question on the ground of 
the cystoscopic result. Certainly the abnormal rapidity of the 
jets was suspicious and pointed to an irritation in the pelvis 
of the right kidney. But the answer to this question was less 
important, as only nephrotomy on the left side seemed to be 
indicated. 
I told the patient my diagnosis, and also my hope of being 
able to help him by operative interference. But, to confirm what 
I had just seen, I asked for a second cystoscopic examination. 
The patient at once agreed. When he returned for this purpose, 
he reported that in walking home from my office the other day 
he had felt a sharp pain in his right side. This had at first fright- 
ened him very much. But, as the pain had not reappeared, he 
felt easier now. The second cystoscopic examination fully cor- 
roborated the result of the first one. 
Nephrotomy was proposed and accepted. On May 5th, this 
year, I made the lumbar incision. A large stone, entering the 
ureter for some distance, was felt as soon as I was down on the 
kidney. The pelvis was transfixed with two silk threads which 
afterward served as holders, and then incised between them in 
the length of fully an inch and a half. To extract the stoue in 
one mass proved to be impossible. I broke it with my fingers IN THE LAST THREE YEARS. 
43 
by pressing npon the upper portion of the ureter from outside. 
Then I was able to pull the two pieces out with an ordinary dress- 
ing forceps, the larger upper portion from 
the pelvis of the kidney and the more 
slender lower one from the ureter. The 
whole stone presented a perfect cast of the 
enlarged pelvis of the kidney and the up- 
per part of the ureter. Its lower pole 
was flattened, in a shape not unlike the 
mouthpiece of a flute. It is in all two 
inches long (see Fig. 3). Now I pushed a 
long thin rubber bougie down the ureter, 
and then a small-sized soft-rubber cathe- 
ter cut otf at its end, through which I 
flushed a syringeful of warm boric water 
into the bladder. The ureteral canal evi- 
dently was free. Still I carefully pal- 
pated with a curved steel sound the in- 
terior of the kidney from the pelvis up- 
ward. No other concrement was found. 
Meanwhile great care had been taken not to tear the cut 
surfaces of the pelvis of the kidney by pulling too hard on 
the silk threads which held it apart, as such a tear generally 
produces urinary fistula. Now the wound of the pelvis was 
closed with six catgut stitches, which did not include the mucous 
membrane, and the wound loosely packed with iodoform gauze. 
A small-sized short drainage-tube led down to the sewn-up 
wound in the pelvis of the kidney. The outer wound was closed 
with silkworm-gut threads which were only loosely tied. 
The patient made an uninterrupted recovery. He never was 
feverish. Gauze and drainage-tube were removed after forty- 
eight hours. Leakage never set in. The wounds healed by pri- 
mary union throughout. The patient left the hospital with the 
wound firmly closed on May 21st, sixteen days after the opera- 
tion. 
When I saw him again he reported that, four days after hav- 
ing returned to his home in Brooklyn, he was suddenly seized 
with a very intense renal colic on the right side—that is, the 
Fig. 3. 44 
THE PROGRESS OF CYSTOSCOPY 
side opposite to the diseased kidney—which lasted six hours. 
The pain was so severe that the attending physician had to ad- 
minister chloroform for a full hour. When the pain began to 
subside, he passed about ten ounces of urine at two times inside 
of an hour. Since that accident he was free from pain. Only 
the stomach was still troublesome. He soon left for the coun- 
try, where he spent the summer. Lately a throat specialist has 
burned his nose and throat, which, according to the patient’s 
statement, has greatly improved the still slightly rebellious 
stomach. A fortnight ago he passed, after some pain in his left 
lumbar region, two round, semi-solid masses, each of a bean’s 
size. This was from the side operated on. To-day he appears 
hale and hearty, fully able to attend to his business. lie is en- 
tirely free from pain and trouble. His urine at present is clear. 
He, of course, has to remain under observation on account of 
the probable nephrolithiasis on the right side. 
Case HI. Suppurating Floating Kidney ; Nephrotomy ; sub- 
sequent Cystoscopy ; Nephrectomy ; Recovery.—Mrs. X., forty- 
tive years old, came under my care in July, 1887. Two months 
previous she had been operated upon for an inflammation which 
had set up in the left (floating) kidney. The lumbar incision 
had revealed a cystic degeneration of the organ, the cysts being 
filled with clear, transparent fluid or pus, or a mixture of both. 
A number of cysts were opened, and communication established 
between as many as could be reached with Paquelin’s thermo- 
cautery. The pelvis of the kidney was not opened. The wound 
had healed well up to two small sinuses, which remained in the 
scar and gave a continuous exit to a small or larger amount of 
sero-pus. The patient was greatly benefited by the operation. 
For more than two years she felt comfortable and enjoyed life; 
only at the time of menstruation she suffered from more or less 
intense bladder tenesmus. But after a while this symptom ceased 
to be limited to the menstrual periods and became nearly constant. 
It increased in such a degree of severity and frequency, in spite of 
manifold and persevering trials to fight it, that life was a misery, 
and the question came up, Could the patient still he improved 
by operative interference? Of course, this question had been 
frequently considered at length before, but it was always re- IN THE LAST THREE YEARS. 
45 
jected in view of the clinical fact that cystic degeneration of the 
kidney very rarely is a unilateral disease. Usually both organs 
are involved.* Cystic degeneration is therefore rather a con- 
tra-indication to nephrectomy. And indeed in this case the 
lower pole of the right kidney was palpable in the right hypo- 
chondrium. But could this enlargement of the organ not be 
just as well due to compensatory hypertrophy, in view of the 
constantly diminishing size of the left one, which had always 
been easily palpable in the slim patient ? If we could know 
that the right kidney had already assumed the work of the other, 
or that the secretion of urine from the left diseased organ was 
insignificant in comparison with that of its fellow, the patient 
could only be benefited by the removal of this nearly useless 
cystic mass, provided that she stood the operation. That the 
greatest amount of pain and trouble was dependent upon the 
presence of the left kidney could he proved by vaginal palpa- 
tion of the ureters. The left ureter presented a cord as thick 
as a thumb, the slightest compression of which created at once 
an urgent and painful desire to urinate; the right one was per- 
ceptible merely to the normal degree. Pressure upon it did 
not irritate the bladder. 
Active treatment, however, became imperative when in No 
vember, 1890, chills, followed by high though short-lasting 
fever, repeatedly set in, apparently due to progressive ureteritis. 
To determine the exact condition of the right kidney it was, of 
course, very tempting to compress the left ureter, or even drain 
it for some time from the vagina. Either of the procedures, 
however, would have required narcosis, which, if possible, had 
to be avoided. 
* Cf. 0. Riegner. Exstirpation einer wandernden Cystenniere. 
Deutsche med. Wochenschr., 1888, No. 3.—Clark. Case of Cystic Kid- 
ney in which Nephrectomy was performed. Glasgow Medical Journal, 
1889, p. 177.—Newman. A Case of Cystic Disease of the Kidney diag- 
nosed during Life. Ihicl., 1889. p. 265.—C. A. Ewald. Ein Fall von 
totaler cystoser Degeneration beider Nieren beim Erwachsenen nebst 
Bemerkungen zur Klinik dieser Erkrankung. Berlin. Min. Wo eh., 1892, 
No. 1. 46 
THE PROGRESS OF CYSTOSCOPY 
T now resorted to cystoscopy and saw the following condi 
tion: Catarrh of the bladder, minutest and larger blood-vessels 
injected. The place where the orifice of the left ureter should 
he seen presented a succulent and curiously folded growth— 
viz., the swollen and inflamed fold of mucous membrane be- 
longing to and surrounding the ureteral opening, the whole 
mass resembling a large lump-shade. Still looking at the pict- 
ure with interest and trying to find the mouth of the ureter, T 
suddenly noticed a jet of fluid, mixed with smaller and larger 
yellow flakes and shreds, which came from a somewhat re- 
tracted spot, a little to the left from the top of the mass. This 
exactly recalled the appearance of an eruption of a volcano, as 
drawn by the pencil of the artist. A few minutes later a long 
thread of thick, yellow pus was slowly making its way out of 
the same opening into the bladder. It took some time before I 
found the other, rather rounded, ureteral opening, a portion of 
normal though deeply injected mucous membrane, about three 
quarters of an inch in length, being interposed between it and 
the swelling just described. At this moment I had to stop the 
examination, which was made under local cocaine anaesthesia, 
as the weak 'patient felt rather tired. A short time later the 
bladder was again illuminated, this time with the intention to 
determine, if possible, the character of the jets descending 
from the right kidney. The ureteral orifice was quickly found 
and carefully watched. This orifice was pushed forward and 
retracted alternately, as we see it normally with each jet of 
urine thrown into the bladder. The regularity and frequency 
of this intermittent movement markedly contrasted with the 
slow and irregular working done on the other side. It struck 
me whether this symptom might not he used in finding out the 
exact amount of work done by each kidney. So I asked the 
assisting nurse to look at the watch and carefully count the 
time between my saying “Now,” which marked each jet. I 
noted a passage of every twelve, fifteen, twenty, twenty five 
seconds on the right side, while on the other only every four, 
six, eight minutes, the period of the emission of the jet besides 
covering a somewhat longer time on the right than on the left 
side. Meanwhile the water had become muddy. It was easily IN THE LAST THREE YEARS. 
47 
changed, as I performed the examination with the irrigating 
cystoscope, and now I also perceived that the urine of the right 
kidney was clear. 
What conclusion could I draw from these facts? I believed 
this: that the right kidney was doing from twelve to sixteen 
times as much work as the left one.* Was I therefore justified 
in pronouncing the right kidney healthy ? I did not venture to 
make such a definite diagnosis, especially in view of the frequent 
bilateral affection in cystic degeneration of the kidneys. The 
urine might be at times transparent, while at others turbid. 
Only often-repeated cystoscopy might possibly have cleared up 
this part of the diagnosis. 
But to diagnosticate health or disease of the right kidney 
was not the main question. The question really was: “ Would 
the work of the right kidney be sufficient if the left had been 
removed? ’’ That it would be so seemed to be amply proved by 
the cystoscopic examination, and if it did, the diseased organ, 
which caused the repeated weakening attacks of ureteritis and 
septic fever, was a burden to the organism and could and 
should be removed. 
On these grounds a favorable prognosis was made in regard 
to nephrectomy in its future results, provided the immediate 
effects of the operation were well borne. 
I therefore performed the operation, and the specimen thus 
obtained showed that only the lower third of the organ con- 
tained secreting tissue and that the upper two thirds consisted 
of cysts, smaller and larger in size, more or less communicating. 
In one of them there was a very small round stone. The whole 
organ was greatly diminished in size. 
In the first twenty-four hours after the operation urine was 
scarce on account of the loss of blood. Fx-om the second day 
on the daily average quantity was thirty to forty ounces. The 
former chills and fever ceased at once. The patient made an 
uninterrupted recovei-y, and is so far greatly benefited by the 
operation. 
* I think this is the first time that this kind of observation has ever 
been used for determining the work done by each kidney, and that its 
correctness was afterward proved by the specimen obtained. 48 
THE PROGRESS OF CYSTOSCOPY 
Case IV. Left Suppurating Kidney ; Cystoscopy ; Nephrec- 
tomy; Recovery.—Mrs. P. M., aged forty-eight years, was sent 
to me from Collinsville, Conn. Her father had died of phthisis. 
She had had eleven children, of whom seven were still living. 
For fourteen years the urine had been muddy and of offensive 
smell. Tenesmus changing in severity toward and after the 
end of micturition. Two years ago pains in the left lumbar 
and hypochondriac region appeared ; the urine became of a 
milky color, and had lately contained small particles of coagu- 
lated blood. It was voided ten to twelve times in the day-time 
and at least four times during the night. The patient had con- 
tinuously lost flesh and felt very weak. December 18, 1890, 
examination : On deep pressure below the border of the left 
false ribs, a hard, not very large, mass can be palpated, which 
is rather immovable, painful to the touch, and of apparently 
smooth surface. Vaginal exploration reveals a thickened left 
ureter, which, if compressed, is quite painful and creates the 
desire to urinate. On the left side of Douglas’s cul-de-sac an 
enlarged, painful, immovable swelling (probably the ovary); 
urine of neutral reaction; smells very offensively; two thirds 
of volume sediment; show's pus and mucous cells, a few red 
blood-corpuscles, micro-organisms of great variety, crystals of 
oxalic acid and ammonium phosphates; detritus; one-per-cent, 
albumin in the filtered specimen. 
Could this evidently suppurating left kidney still be re- 
moved? Did it still partake in the secretion of urine? Were 
both kidneys diseased ? 
Cystoscopy under cocaine: Mucous membrane of the blad- 
der hypersemic, and around the left ureteral orifice papilloma- 
tous in appearance. Out of the latter a very long, worm-like, 
under the electric illumination snow-white, shining thread of 
thick pus of the size of a thin pencil is very languidly making 
its way at short intervals. No jet whatever. The pus evi- 
dently was very viscid, as the long strings settle and curl in the 
bladder fundus—a very characteristic picture, which was also 
plainly noticed by a number of gentlemen present. It took 
some time before the medium became muddy. The right ure- 
teral orifice was occupied by a round red growth of the size of IN THE LAST THREE YEARS. 
49 
a cherry. On putting the prism quite close to it, it appeared 
transparent. It consisted of mucous membrane (prolapse of the 
ureter). Out of its left (median) side jets of seemingly clear 
urine were thrown at short intervals. 
Cystoscopic diagnosis: “ Left suppurating kidney. Its secret- 
ing tissue entirely gone. Eight kidney already does double 
duty for its destroyed fellow. Borne irritation in the pelvis of 
the right kidney.” 
On account of this cystoscopic diagnosis I proposed nephrec- 
tomy. The operation was done by me at the German Hospital, 
December 29, 1890. It was found that the whole greatly en- 
larged left kidney was sclerosed and did not present a bit of 
normal secreting tissue. It contained many cavities communi- 
cating with its pelvis. A large ramified stone entered a number 
of them. After the operation the amount of urine never varied 
except in the first twenty-four hours. The patient made an un- 
interrupted recovery up to the thirty-ninth day, when she was 
suddenly seized with intense right renal colic and abundant 
hsematuria. After five days of serious, nearly hopeless, illness 
she passed a stone (an excellent demomtratio ad oculos of the 
pathognomonic correctness of prolapse of the ureter). From 
that moment on she was again well and remained well. To-day 
she is perfectly healthy ; her urine absolutely clear. 
These cases present the most interesting ones in which 
I have resorted to endoscopic examination of the bladder 
for the purpose of diagnosticating disease of the kidneys. 
The last two cases especially are, I believe, of so much 
more value as not only did cystoscopy enable me to estab- 
lish the indication for nephrectomy and to make the prog- 
nosis that this operation would most probably not interfere 
with the patient’s general condition, apart from its possible 
immediate consequence's, but the specimen proved in each 
case the correctness of the different important points thus 
made out. 
The catheterism of the ureters, with the help of still 
improved cystoscopic instruments, will, I trust, soon be an 50 
THE PROGRESS OF CYSTOSCOPY 
extremely important and never-to-be-omitted factor in cys- 
toscopy for renal disease. Its results will greatly reflect 
upon and vastly increase the value, correctness, and ex- 
haustiveness of such a cystoscopic diagnosis. The cathe- 
terism of the ureters in this way will easily, simply, and 
happily solve the problem on which many an ingenious 
mind worked in vain, or at least without general and recog- 
nized success—namely, the bloodless, separate collection 
and analyzation of the secretion of each kidney. 
The only non-operative method which formerly could 
be applied to localize and diagnosticate a kidney trouble in 
the male,* where a large swelling or growth in one of the 
hypochondriac regions did not at once show where to 
search for it, was by compression of the ureter. The at- 
tempts at solving this task have been very ingenious, but 
have not been generally adopted in practice, f Axel Iver- 
sen, J therefore, proposed to open the bladder above the 
pubes and then to catheterize each ureter separately. Fully 
appreciating the great value of this mode of procedure, and 
not looking at suprapubic cystotomy as being a dangerous 
* In the female our non-operative diagnostic means in this respect 
have been more ample, however difficult to practice, for a number of 
years. Cf. G. Simon. Ueber die Methoden, die weibliche Urinblase 
zugangig zu machen u. iiber die Sondirung der Harnleiter beim Weibe. 
Volkmann’s Klin. Vortrdge, No. 88.—Lewers, Lancet, 1886, November 
13th.—K. Pawlik. Ueber Harnleitersoudirung beim Weibe u. ihre prak- 
tische Verwendung. Wiener med. Dr esse, 1886, Nos. 44-61. 
f Tuchmann, Ueber ein neues Mittel zur Diagnose der Blasen- u. 
Nierenkrankbeiten, Wiener med. Wochenschr., 18*74, Nos. 31 and 32.— 
Ueber den kiinstlichen Verschluss u. iiber die Sondirung des Harnleiters, 
Deutsche Zeitsc.hr. f. Chirurgie, Bd. vi, p. 660.—0. Silbermann, Ueber 
eine neue Methode der temporaren Harnleiterverschliessung u. ihre diag- 
nostische Yerwerthung fur die Krankheiten des uropoetischen Systems, 
Deri. klin. Wochenschr., 1883, No. 34. 
\ Beitrag zur Katheterisation der Ureteren bei dem Manne. Central- 
hlatt f. Chirurgie, 1888, No. 16, p. 281. IN THE LAST THREE YEARS. 
51 
operation, I am perfectly convinced that cystoscopy will 
ere long make it just as superfluous and unnecessary, in the 
majority of cases at least, as it has already made Sir 
Henry Thompson’s digital exploration of the bladder in 
most instances. 
Of course, I do not want to be understood as if I 
thought that all exploratory operations would now become 
obsolete. It is obvious that there will still be a number of 
cases where obstacles will render the ocular inspection of 
the bladder and of the descending jets of urine im- 
practicable ; where an insufficient capacity of the bladder, 
purulent or bloody urine will make the electric illumination 
of the bladder resultless ; where, I may add, the ureters 
can not be catheterized, because their orifices can not he 
found or approached. In such cases we, of course, have to 
operate for diagnostic purposes. But these cases will hence- 
forth be exceptions and their number will still lessen with 
the advance of this endoscopic branch, with the increased 
dexterity and experience of the cystoscopist, and with the 
additional construction of a really useful cystoscope for 
catheterism of the ureters. 
In closing my remarks I offer the following conclusions: 
1. In all obscure reno-bladder diseases cystoscopy has 
to he practiced, if necessary repeatedly, before operative 
interference for diagnostic purposes is resorted to. 
2. There are a number of causes which make cystoscopy 
impracticable. 
3. Cystoscopy is an easy and harmless examination; hut 
its successful employment requires experience. 
4. It should be performed as a dernier ressort after all 
other well-known means for making a diagnosis have been 
exhausted. 
5. If properly applied, cystoscopy will generally clear up 
an obscure disease of the bladder. 52 
THE PROGRESS OF CYSTOSCOPY 
6. In most cases we can determine, with the help of elec- 
tric illumination of the bladder, whether we have to deal 
with a disease of the bladder or of the kidneys. 
I. We can thus find out whether there are two working 
kidneys, also whether only one of the two kidneys is dis- 
eased or both. 
8. We shall most probably soon be able, perhaps, in the 
greatest majority of cases, after sufficient personal practical 
experience and with the help of proper cystoscopic instru- 
ments designed for this purpose, to catheterize the ureters 
and thus gather in a bloodless manner the urine from each 
kidney separately. 
9. We can make out in certain cases by observing the 
character of the jets of urine, especially by timing their fre- 
quency and duration at the ureteral orifices, whether the 
other kidney is doing the work for the one which is diseased. 
10. These facts will tend to make superfluous, in the 
majority of cases at least, a preliminary suprapubic or peri- 
neal incision for diagnostic purposes, as well as a nephroto- 
my performed for determining the action of the other (not 
diseased) kidney. They greatly widen and strengthen our 
means for making the indication and prognosis of nephrec- 
tomy*. 
II. With the aid of Nitze’s newest instrument, the op- 
erating cystoscope, we may look forward to being able to 
carry on intravesical treatment under the direct guidance of 
our eyes. 
The following is a partial list of the literature of the 
subject since 188V : * 
Antal, G6za von. Spezielle chirurgische Pathologic und 
Therapie der Harnrohre und Earnblase. Stuttgart, 1888.—Diag- 
* Cf. E. Hurry Fenwick, l. c., and Cecil Kent Austin, l. c., Literature 
Index. IN THE LAST THREE YEARS. 
53 
nostik der Harnblasenaffektionen. Cystoskop. Bilder. Wien, 
med. Pr., xxviii, 49, p. 1688. 
Bangs, L. B. Oases illustrating Some Difficulties in the Use 
of the Oystoscope. Report, New York Ned. Journal, January 
9, 1892, p. 51; Med. Record, January 2, 1892, p. 24. 
Barling, G-. The Electric Oystoscope and the Method of 
using it. With Notes of Oases. Birmingham Med. Review, 
1889, pp. 257-270. 
Boisseau du Rocher. De la m6galoscopie. Gomptes-rendus 
de VAcademie des sciences, vol. ci, 1885, p. 329.—Megaloscopie 
vesicale. Annales des maladies des organes genitaux-urinaires, 
1890, p. 65. 
Broca, A. De la cystoscopie ou endoscopie v6sicale. Gaz. 
hebd., 15 mars, 1889.—De l’endoscopie v6sicale ou cystoscopie 
Annales des maladies des org. gen.-ur., 1889, p. 166. 
Brokaw, A. V. L. Cystoscopie Explorations. Interna- 
tional Journal of Surgery, New York, 1889, ii, pp. 5-7. 
Burckhardt, E. Endoskopische Befunde und endoskopische. 
Therapie bei den Krankheiten der Harnrohre und der Blase. 
Beitrdge zur klinischen Chirurgie, Band v, pp. 1 and 261.— 
Ueber Endoskopie. Korrespondenzblatt fur schweizer Aerzte, 
xix, p. 755.—Atlas der Cystoskopie. Basel, 1891. 
Clarke, W. B. Obscure Affections of the Bladder and Diag- 
nosis by Means of the Oystoscope. Brit. Med. Journal, 1890, 
No. 1,555, p. 893. 
Cruise. On Irrigation of the Bladder in Cystoscopy. Lancet, 
London, 1889, p. 372. 
Davis. Epicystic Surgical Fistula for Cystoscopie Explora- 
tion, Intra-vesical Treatment, and Drainage. Jour, of the Am. 
Med. Assoc., 1889, p. 685-688. 
Desnos, E. Traite elementaire des maladies des voies uri- 
naires. Paris, 1890, p. 445. 
Dittel, von. Ueber Fremdkorper in der Ilarnblase. Wiener 
Tdinische Wochenschrift, 1891, No. 12. 
Fenwick, E. Hurry. Electric Illumination of the Male Blad- 
der by Means of the New Incandescent Lamp-cystoscope. 
Brit. Med. Journal, February 4, 1888.—The Value of Electric 
Illumination of the Urinary Bladder (the Nitze Method) in the 54 
THE PROGRESS OF CYSTOSCOPY 
Diagnosis of Obscure Yesical Disease. Brit. Med. Jour., April 
14, 1888.—The Value of Inspecting the Orifices of the Ureters 
by Electric Light in the Diagnosis of Symptomless Haematuria 
and Pyuria. Brit. Med. Jour., June 16, 1888.—The Bloodless 
Method of removing Vesical Growths controlled by Electric 
Illumination. Brit. Med. Jour., September 22, 1888.—The 
Prognostic Power of the Electric Oystoscope. Brit. Med. Jour., 
October 13, 1888.—Olay and Wax Modeling of the Living Uri- 
nary Bladder under Electric Light. Brit. Med. Jour., 1889, i, 
13.—Fifteen Months’ Experience of Electric Illumination ot 
the Bladder in the Diagnosis of Obscure Vesical Disease. Brit. 
Med. Jour., 1889, i, 989, 1053.—Precancerous Conditions of the 
Mucous Membrane of the Bladder Recognizable by Electric 
Light. Brit. Med. Jour., July 6, 1889, ii, p. 13.—Electric Illu- 
mination of the Bladder and Urethra. Second edition. London, 
1889: J. & A. Churchill.—The Influence of Electric Illumina- 
tion of the Bladder upon our Knowledge and Treatment of 
Urinary Disease (abstract). Brit. Med. Jour., 1890, p. 894, No. 
1,555. 
Goldschmidt, H. Ueber den praktischen Wert der Nitze- 
schen Cystoskopie. Therap. Monatshefte, iii, 10, p. 442, und 
Allgem. med. Centralzeitung, 1889, p. 2303. 
Gruenfeld, J. Eine vereinfachte Methode zur Demonstration 
endoskopischer Bilder. Allgem. Wiener med. Zeitung, 1888, p. 
375.—Cystoscopy in General. Medical Press, 1889, p. 670.— 
Ueber Cystoskopie im Allgemeinen und Blasentuinoren im Be- 
sonderen. Wiener Min. Woch., Band ii, 21, p. 423.—Endo- 
skopische Untersuchung der Blase. Wiener med. Blatter, 1889, 
xii, 328. 
Guyon, J. C. Felix. Legons cliniques sur les affections chi- 
rurgicales de la vessie et de la prostate. Paris, 1888.— Verhand- 
lungen des 3. franzosischen Ghirurgenkongresses. Paris, 12-17. 
Marz 1888.—Endoscopie pour tumeur vesicale. Gaz. held., 26 
avril, 1889.—Diagnostic des tumeurs de la vessie. Gaz. med., 
27 juillet, 1889.—N6oplasmes de la vessie, diagnostic et indica- 
tions op6ratoires. Annales des maladies des org. gen.-ur., 1889, 
p. 449.—Diagnostic pr6coce des tumeurs malignes du rein. An- 
nales des mal. des org. gen.-ur., 1890, p. 329.—Diagnostic des IN THE LAST THREE YEARS. 
55 
tumeurs v6sicales, h6raaturie et endoscopie, Bull, med., Apr. 
22; Ann. des mal. des org. gen.-urin., 1891, p. 481. 
Harrison, R. Remarks on Endoscopy with the Electric 
Light. Lancet, May 26, 1888. 
Helferich. Ueber die praktische Bedeutung der modernen 
Cystoskopie. Munch, med. Woch., 1890, p. 1. 
Hermann, B. Eine Haarnadel in der Harnblase. Interna- 
tionales CentraTblatt fur Physiologie und Pathologie der Harn- 
und Sexualorgane. Band i, Heft 1, p. 18. 
Hill, B. Irrigation of the Bladder in Cystoscopy. Lancet, 
1889, vol. i, p. 169.—Some Affections of the Genito-urinary Or- 
gans. Brit. Med. Jour., June 22 to July 6, 1889. 
Kaufmann, C. Cystoskopischer Nachweis eines Katheter- 
stucks in der mannlichen Harnblase. Korrespondenzblatt fur 
schweizer Aerzte, 1889, p. 375. 
Kntner, Rob. Ueber Photographie innerer Korperhohlen, 
insbesondere der Harnblase und des Magens. Deutsche med. 
Woch., Ho. 48, Nov. 26, 1891. p. 1311. 
Leiter, J. Neue Beleuchtungsapparate. Wien, 1889. 
Linhart. Zur Endoskopie. Archiv fur Derm, und Syphilis, 
Band xxi, p. 519. 
Malherbe. De la cystoscopie. Progr. med., 1891, Nos. 
1, 2. 
Meyer, Willy. On Cystoscopy and the New Cystoscope ot 
Nitze and Leiter, with a Demonstration of the Same. New Yorlc 
Med. Journal, April 21, 1888.—A Contribution to the Surgery 
of the Bladder. New Yorlc Med. Jour., Feb. 23, 1889.—Review 
of Nitze’s Text-book on Cystoscopy (with Remarks). Annals of 
Surgery, June, 1890. 
Newell, 0. K. Diagnosis of Tumors of the Bladder and 
Stone with the Cystoscope. Boston Med. and Surg. Journal, 
1889, p. 381.—The Diagnosis of Vesical Tumor by the Oysto- 
scope. Med. Record, vol. xxxiii, p. 596.—The Endoscopic In- 
struments of Leiter, of Vienna, and the Present Development 
of Endoscopy. Boston Med. and Surg. Journal, cxvii, 528- 
530. 
Newman. Lectures on Surgical Diseases of the Kidney. 
1888, p. 415. 56 
THE PROGRESS OF CYSTOSCOPY 
Nitze, M. Beitrage zur Endoskopie der mannlichen Harn- 
blase. 1887. Langenbeck’s Archiv, xxxvi, Heft 3, p. 661.— 
Lehrbuch der Cystoskopie. Wiesbaden: J. F. Bergman, 1889.— 
Das Irrigations-Cystoskop. Centralblatt fur Chirurgie, 1889, 
p. 945.—Das Operationscvstoskop. Vorlaufige Mitteilung. Cen- 
tralblatt fur Chirurgie, No. 51, December 19, 1891.—Sur le 
chirurgie intra-vesicale. Ann. des mal. des org. genit.-urin., 
Dec., 1891. 
Otis, F. N. Papillomatous Tumor of the Bladder demon- 
strated by Means of Leiter’s Electro-Oystoscope. Med. Record, 
May 18, 1888. 
Otis, W. K. Recent Improvement in Endoscopic Apparatus. 
Med. Record, xxxiv, p. 658. 
Poirier. Cath6t6risme des ureteres. Annales des mal. des 
org. gen.-ur., 1889, p. 625. 
Raymond, P. L’Endoscopie a Vienne. Annales des mal. des 
org. gen.-ur., 1888, p. 776. 
Riviere. L’Endoscopie a Vienne et a Paris. Progres medi- 
cal, 1888, 12 mai. 
A Oystoscope. The Sei-I-Kwai Medical Journal, T6ky6, 
vol. viii, No. 1, 1889. 
Southam. On Endoscopy in Tumors of the Bladder. Lancet, 
1885, p. 729. 
Stein, Alexander W. Some Points in the Differential Diag- 
nosis of Bladder and Kidney Affections. Journal of Cutaneous 
and Genito-urinary Diseases, 1888, p. 370. 
Stelzner. Mitteilung eines durch Operation geheilten Falles 
von grossem Blasentumor und Demonstration des neuesten Bla- 
senbeleuchtungsapparats. Jahresberichte der Gesellschaft fur 
Chirurgie und UeilTcunde in Dresden, 1889, p. 58. 
Tuffier et Janet. Endoscopie v6sicale appliqu6e & l’extrac- 
tion des corps Strangers. Annales des mal. des org. gen.-ur., 
1889, p. 126. 
Ultztnann und Schustler. Die Krankheiten der Harnblase. 
Deutsche Chirurgie. Billroth und Llicke, Wien, 1890. 
Verhoogen, J. De l’endoscopie de l’ur&thre et de la cysto- 
scopie. Journ. de med., chir. et pharmacol. Bruxelles, 1889, p. 
161. IN THE LAST THREE YEARS. 
57 
Vragassy, W. von. Das Megaloskop des Dr. Boisseau du 
Rocher in Paris. Wiener med. Presse, 1888, Nos. 8, 4. 
Wallace, D. Electric Cystoscopy. Edin. Med. Journal, 
February, 1890.—Cystoscopy, etc. Edinb. Med. Jour., Oct., 
1891, p. 324. 
Whitehead, W. A New Incandescent-lamp Cystoscope. 
Brit. Med. Journal, April 7, 1888. REASONS WHY 
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