EXAMINATION OF THE BLADDER WITH THE 
ELECTRIC-LIGHT CYSTOSCOPE. 
BY 
JOHN B. DEAYER, M.D. 
REPRINTED FROM THE 
TRANSACTIONS OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, 
NOVEMBER, 1891. [Reprinted from the Transactions of the Philadelphia County Medical Society. 
EXAMINATION OF THE BLADDER WITH THE 
ELECTRIC-LIGHT CYSTOSCOPE. 
By JOHN B. DEAVER, M.D., 
[Read November 11,1891.] 
My remarks on cystoscopy will embrace first, exhibition and 
description of the instrument I use and believe to be best, namely 
“The Leiter Incandescent-light Cystoscope.’’ 
Second, the battery I regard the simplest, the least expensive, and 
which fulfils every purpose. In my office I use a stationary storage 
battery. 
Third. How to use the instrument, and the most favorable position 
in which to have the patient. 
Fourth. Normal appearance of the healthy bladder. 
Fifth. The pathological conditions where such an examination is of 
special value. 
The Leiter incandescent-lamp cystoscope consists of three portions, 
the beak, the shaft, and the ocular end. The beak is a hollow hood 
fastened to the body or shaft by a screw and has on its upper surface 
an oval aperture covered in by a rock-crystal plate. The hood, wThen 
in position, protects the lamp. 
The shaft or body is inches in length and 22 millimeters in cir- 
cumference ; a tube rests within the body or shaft containing a system 
of lenses which extends from the window of the prism to the ocular 
end, and can be lengthened like the tube of a microscope, increasing 
the size of the image presented to the prism. 
The elbow is furnished with a prism to reflect entering rays of light 
directed along the central tube to the observer’s eye. 
These instruments have the window and lamp on the concavity. 
There is another form where the window and the lamp are placed on 
the convexity; still this instrument answers all practical purposes as 
it can be rotated. 2 
DE A VER, 
To the distal end of the shaft a small incandescent lamp is attached 
by means of the terminals which fit into two sockets; these are in 
direct communication with the battery by means of insulated surfaces. 
The manner by which the lamp is placed in position makes it easy 
to remove when the carbon is burned out. The hood is unscrewed, 
the lamp lifted out of the sockets by a pair of forceps or the fingers, 
the new lamp fitted in position in the same manner, and the hood re- 
placed. 
At the junction of the shaft and ocular portions there is a holder 
containing the two binding posts to connect the cords with the battery, 
Fig. 1. 
y*' WINDOW. 
ELECTRIC 
LAMP. 
PRISM 
TELESCOPE 
WIRES 
EVE-P/ECE. 
a, Rubber insulators; m, metal plates ; w, connecting wires; s, screw closing circuit. 
also a small knob upon the ocular end to show the position held by 
the cystoscope in the bladder. 
The improved cystocope is essentially the same as the original with 
the exception of the holder. This contains the binding posts to con- 
nect it with the battery and the cut-off key, which is manipulated by 
means of a screw instead of a kick-over, which is used in the original 
instrument. The holder allows rotation of the instrument without 
changing the position of the hand. It also permits the current from 
travelling behind it by meaus of an ebonite or rubber insulation. EXAMINATION OF THE BLADDER. 
3 
This is not present in the original instrument, therefore disagreeable 
electric shocks are sometimes received by the observer. 
The objections to the use of the cystoscope are: first, the danger 
of burning the mucous membrane, as the lamp becomes hot quickly 
if it is allowed to burn in air instead of immersed in water; it becomes 
warm in four seconds, unbearable in ten seconds, and scorching the 
skin often in fifteen seconds. This can be avoided, however, by 
immersing the beak in water, when it can be touched with impunity, 
the heat being rapidly absorbed. This occurs in the bladder, the heat 
being carried off by the medium contained therein, either urine or water. 
It is the rule in electric cystoscopy that the bladder must contain 
from four to six ounces of urine or water, the greater the distention 
of the bladder the more satisfactory will be the examination, the com- 
fort of the patient being considered. Even though the bladder con- 
tain a sufficient quantity of the fluid medium and the beak of the 
instrument is brought in contact with the bladder-wall for any length 
of time, scorching of the mucous membrane will take place. 
The second objection that may be raised against the use of the 
instrument is the danger of the lamp breaking upon contact of the 
heated hood with the medium. Should this accident occur the bladder 
would not be exposed as the lamp would still be enclosed in the metal 
hood, the opening of which is covered by an unbreakable plate of rock 
crystal. 
In cases where the prostate gland is irregularly enlarged it may be 
difficult if not impossible to make a satisfactory cystoscopic examina- 
tion, as the instrument cannot be made to engage properly in the 
bladder. Where the urethra is the seat of stricture, the calibre of 
which is less than twenty-two millimetres, it goes without saying, that 
the cystoscope cannot be introduced until the calibre of the urethra 
at this point is raised to that of the size of the instrument; where the 
meatus is contracted it will call for enlargement. 
Where the urine contains pus or blood, the walls of the bladder 
cannot be clearly made out. This can generally be overcome, how- 
ever, by washing out the bladder thoroughly and injecting boric-acid 
solution. 
Where the bladder is contracted it is difficult to manipulate the 
cystoscope satisfactorily. Some cases of irritable bladder will not 
tolerate a sufficient amount of urine or water to permit of an exami- 
nation. Here an injection of cocaine can be used to overcome the 
difficulty. The other conditions for the successful manipulation of the 
cystoscope are : 4 
DE A VER, 
Before arranging the patient for the examination, it should he the 
rule to see that the lamp and the battery are in working order. Con- 
nect the cystoscope with the battery, turn on the current with the 
rheostat at 0. Now gradually increase or diminish the resistance by 
means of the rheostat until the lamp burns with a bright white light. 
The lamp not working satisfactorily it will be necessary to change it 
before the examination can take place. 
As the carbon filaments in the lamp vary, it will be necessary to 
guage the resistance offered by the carbon by means of the rheostat. 
In those lamps where the resistance offered by the carbon is slight 
the lamp will burn only when the rheostat is at the maximum, and in 
those where the carbon offers greater resistance the lamp will only 
burn when the rheostat stands at the minimum. 
The Grenet or plunge battery, which I prefer to use outside of my 
office, is made by Mr. Flemming, of Philadelphia, and consists of a 
box containing two equal compartments ; the first of which is occupied 
by a series of rubber cells, one-half filled with the following solution : 
Potassium bichromate, 6 ounces ; sulphuric acid, 5 fluidounces ; water, 
3 pints. This solution must be renewed every two or four Aveeks, 
according to usage. The second compartment contains one large cell, 
the object of which is to catch the drip from the plates after their re- 
moval from the bichromate bath, and also to protect them. 
The two compartments are covered by a bed, the under surface of 
which is divided into two equal parts, onedialf being covered by a 
sheet of rubber, to close the cells when not in use, and the other half 
occupied by a number of sets of plates. Each set is composed of 
two carbon and one zinc plate, which are fastened to the bed in the 
usual manner, and so connected as to have independent action, the 
number of cells being thrown into circuit as required. After using 
the battery and wishing to discontinue the current it is merely neces- 
sary to lift out the plates, change sides, and deposit them in the one 
large compartment. 
Upon the upper surface of the bed are a number of binding posts 
corresponding to the number of cells employed, and by attaching the 
cords in a proper manner the number of cells desired can be brought 
into circuit. On this surface there is also a rheostat consisting of a 
rubber plate wrapped with silver wire, connected with the cells and 
having a swinging arm which can be moved to any part of the plate; 
the object of the rheostat I will speak of later. 
For office use a storage battery is probably the best, as it has in its 
favor cleanliness, all the cells being placed in the cellar, and these EXAMINATION OF THE BLADDER. 
5 
requiring but little attention. The cost is the only objection which 
which can be raised against it. The battery plant I use in my office 
consists of five Gibson storage cells connected with the switch-board, so 
that the cells may be added one at a time; also sixteen gravity cells, 
which are connected with the switch-board and are connected through 
a separate switch. 
Fig. 2. 
Rheostat 
Charc/e 
Storage Cells 
Switch 
2 
Bind my Posts 
Switch 
3 
Switch 
l 
The switch-board was designed by Dr. Brinkmann, a diagram of 
which will be seen on the blackboard. 
When using the storage battery for cystoscopic work the switch No. 
1 is carried to point 3, which represents six volts; switch No. 2—the 
rheostat—is then carried over until the lamp burns with a white light. 
During the time that this battery is not in use the storage cells 
should be charging. This is accomplished by moving switch No. 3 to 
point 2, thus bringing the terminals of the constant cells in contact 
with those of the storage cells. 
Two binding-posts are placed at the lower corner for the cords to 
transmit the current to the cystoscope. 
The rheostat consists of a number of independent coils of wire, so 
that as the current is made to pass through them it increases the 
resistance. 
The examination may be performed with or without a local or 
general anaesthetic. I think the latter is preferable, for reasons 
stated further on. The best position for examination is that used in 
lateral or median perineal lithotomy. If the bladder has been recently 
examined, or if pus or blood be present in the urine, it must be 6 
DEAVER, 
withdrawn, and the bladder washed out thoroughly through an ordi- 
nary catheter with a boric-acid solution until the fluid runs clear. The 
bladder being now thoroughly clean, from four to six ounces of boric- 
acid solution are thrown in, and, if necessary, a drachm or more of a 
four per cent, solution of cocaine also injected into the bladder. The 
catheter is then withdrawn and the cystoscope introduced, previously 
smeared with a few drops of glycerin. Care should be taken not to 
turn the switch until the beak has fully entered the bladder, to avoid 
scorching the prostatic urethra. 
The following rules should be observed in cystoscopy : 
Why I prefer to conduct the examination without an anaesthetic is, 
that there is less danger of burning the mucous membrane of either 
o o 
the bladder or prostatic urethra, when we have the sensations of the 
patient to guide us. There are cases, however, where a successful 
examination depends upon having the patient anaesthetized. 
When the examination is completed, before withdrawing the instru- 
ment the current is to be shut off and the hood allowed to cool before 
removal. 
In conducting the examination the part of the bladder first exam- 
ined should be the base, more pathological conditions being met with 
here than elsewhere. The examination of the interior of the bladder 
is never complete until the ureteral orifices have been seen. 
The mucous membrane of a healthy bladder presents a reddish- 
yellow or light-straw color with a glistening surface. A few vessels 
will also be seen. 
The object of having the bladder well distended is to be able to see 
the orifices of the ureters, otherwise they may be concealed by folds 
of the mucous membrane. 
With the orifices of the ureters in the field of vision, the escape of 
the urine which takes place in the jets can be readily seen. The 
escape of blood or pus from the ureter can also be seen. 
I wrnuld not advise the use of the instrument in all bladder cases by 
any means; on the contrary, I regard it as playful to examine cases 
where the diagnosis can certainly be made by other means. 
I believe the greatest field for the examination of the bladder with 
the electric-light cystoscope is, in obscure cases of lnematuria, where, 
without this instrument, it is absolutely impossible to differentiate 
between renal and vesical hsematuria by an examination of the urine 
of the bladder with the searcher and by the finger in the rectum, 
coupled with any additional light that may be thrown upon the case 
by a familiarity with its history. EXAMINATION OF THE BLADDER. 
7 
I will relate the history of a case in point: 
W. R. was admitted to the medical wards of the German Hospital suffer- 
ing from haematuria. It was thought that his trouble was a surgical affection, 
and he was therefore referred to me for a cystoscopic examination. 
The patient complained of pain referred to the right loin, which at times 
radiated down to the line of the ureter. He had lost flesh progressively for 
the past two months. The urine had contained blood for some little time. 
Examination of the loin revealed nothing abnormal. The bladder was 
washed out and injected with six ounces of boric-acid solution; this quantiiy 
exciting tenesmus, he was allowed to empty the bladder, when but four 
ounces of the same solution was thrown in and retained comfortably. 
The instrument, lubricated with a few drops of glycerin, was gently passed 
into the bladder. 
The medium was thoroughly clear, and there was no difficulty to map out 
the relations. 
On observing the ureters, it was observed that a gush of blood made its 
exit from the right side, to which all the pain had been referred. The diag- 
nosis of sarcoma of the kidney was made. 
He presented himself some three or four months later, when there was a 
large mass which could be both seen and felt in the region of the kidney. 
The patient died several days later, and a post-mortem examination revealed 
a large sarcoma of the kidney. 
To distinguish between the different forms of vesical hsematuria 
cystoscopic examination is required in only a few instances. The 
most common cause for vesical haematuria is one or other form of 
malignant growth; here the diagnosis can usually be made by the 
means already well known to us. There is a variety of hsematuria 
always associated with cystitis, which, if it does not yield readily to 
treatment, suggests something more serious. I will direct special 
attention to this form, as well as to the value of a cystoscopic exami- 
nation in the diagnosis of it. Some authorities describe it under the 
name of hemorrhagic cystitis. One of its causes is the complete 
evacuation, by means of a catheter, of a greatly distended bladder the 
seat of cystitis. Under these circumstances, the pressure being 
removed from the bloodvessel walls suddenly, hemorrhage is a con- 
sequence. It may also result from the presence of a foreign body 
which has excited ulceration, from an enlarged prostate, etc. 
We meet with cases of vesical haematuria when a cystoscopic exami- 
nation shows nothing more than a cystitis, yet it will not yield to 
treatment. This is, to say the least, suggestive. I recall one such 
case, the history of which I will relate : 
The patient, a man, forty-two years of age, had suffered from cystitis for 
some months previously to coming under my care. The urine was never free 8 
DEAVER, 
from blood, and at times contained a considerable amount. Examination 
showed nothing other than a subacute inflammation of the mucous membrane. 
Treatment, which was prolonged, was of no avail. Finally I advised, and 
subsequently performed, a median perineal cystotomy, to determine first it 
there was any obscure pathological condition sufficiently far advanced to 
account for the trouble; and, secondly, with the hope that a cure might be 
thus brought about. The only additional light thrown on the case by the 
operation was the presence of questionable nodular points here and there. 
This patient has gone from bad to worse, until I now believe the trouble to 
be carcinoma. 
Foreign Bodies in the Bladder.—A cystoscopic examination 
should be made in those cases of foreign bodies introduced from with- 
out into the bladder where the history is unreliable, granting of course 
a diagnosis cannot be made by other means. Again we meet with 
cases where the patient, who is the subject of a catheter life, believes, 
yet is not positive, that a piece of the instrument is in his bladder 
from some mishap occurring either in its passage or upon its with- 
drawal. Ordinarily I admit that such an examination is not only not 
necessary but meddlesome interference. Here the question arises, 
IIowr are we to obtain our experience to make us cystoscopists ? In 
Such cases when the examination is not called for to make the diag- 
nosis, and wrhere we operate for its removal, in the event it cannot be 
extricated through the natural outlet, after the patient has been ether- 
ized, look into the bladder and locate the body. Observing the pre- 
cautions mentioned in the early part of my remarks, trouble cannot 
arise, nor do we complicate the operative procedure by such an ex- 
amination. 
In foreign bodies formed as a result of a pathological process, in- 
cluding growths, stones, etc., the instrument has a limited field, but 
its use here will be discussed under their respective heads. 
Stone in the Bladder.—There are a few cases of vesical calculi 
where a cystoscopic examination is required to reveal their presence, 
yet it has a limited field here. One class of cases is where we have 
examined the bladder for stone and believe we have found one and at 
a second examination fail. It is the practice of surgeons, having 
found a stone in the bladder at a previous examination, and now 
being prepared to operate, when under ether to explore again, and if 
the stone cannot be found not to operate. In such cases the cysto- 
scope should be used. Another class is where litholapaxy has been 
done and in the course of a few days the symptoms make both patient 
and surgeon doubtful as to whether there has been a fragment left 
which the sound has not been able to detect. EXAMINATION OF THE BLADDER. 
9 
Encysted stone, particularly if small and cannot be detected by 
other means, the cystoscope will aid us in clearing up the diagnosis. 
I will relate the history of a case of stone in the bladder occurring 
in a patient of my friend, Dr. James Anders, of this city, where a 
careful cystoscopic examination after either of the first two operations, 
three in all having been performed for recurring stones, would have 
revealed that which subsequently proved to be the nucleus of each of 
these stones. The patient, a female, had sometime previous to the 
first operation for stone an ovarian tumor removed. The ligature, or 
at any rate one of the ligatures employed in treating the ovarian 
pedicle, had ulcerated through the bladder-wall to the mucous coat, 
where it not only became imbedded, but projected as well, thus ex- 
citing acute cystitis which resulted in the deposition of calcareous 
material to the extent of producing a considerable sized stone. The 
operation performed each time was that of litholapaxy. At the end of 
the second operation digital exploration of the bladder showed a pro- 
jection from the right lateral aspect of the posterior wall, when gentle 
attempts to remove it failed. 
At the end of the third operation, feeling it imperative to get rid 
of this foreign body if still present to insure the patient against the 
formation of another stone, the bladder was again explored digitally, 
and a foreign body detected and removed after considerable difficulty : 
it proved to be a ligature. Since the last operation, now over three 
years, the patient has remained well. The interval between the 
formation of the stones was but six months, therefore, it is fair to infer 
that the trouble will not recur. 
Ulceration.—In cases of vesical haematuria where the cystoscope 
shows the presence of one or more ulcers not associated with a growth 
or foreign body, the testicles, spermatic cords, and prostate being free 
from nodular masses, the most probable cause for such is either tuber- 
culosis or scrofula. The history of the case, a careful examination ot 
the chest, the appearance of the patient, the presence of glandulai 
enlargement, etc., may assist materially in forming an opinion. 
Growths.—In growths of the bladder the instrument is of inesti- 
mable value. No longer will we, as was formerly the practice, advise 
a cutting operation where we are in doubt as to the presence of such, 
but will settle this definitely by making a cystoscopic examination. 
Here too, I grant, we meet with cases of malignant growth where it 
is not necessary to make such an examination, the diagnosis being 
readily made without it. In papilloma, which by no means has 
hmmaturia associated with it in all instances, the instrument serves 10 
EXAMINATION OF THE BLADDER. 
first to determine the nature of the growth, if it is not already known, 
and second its situation and extent of attachment, thus guiding the 
surgeon in the selection of the operation to be done for its removal. 
With the bladder as with other organs it should not be cut into for 
obscure trouble for the purpose of making a diagnosis until all other 
justifiable measures have been exhausted with negative results.