The Results Obtained by Examination of the 
Air-Distended Bladder in Females, 
WITH REMARKS UPON THE TECHNIQUE AND A 
SUMMARIZED REPORT OF CASES. 
BY 
EDWARD REYNOLDS, M. D. 
Reprinted from the Boston Medical and Surgical Journal 
of January 30, i8q6. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1896. THE RESULTS OBTAINED BY EXAMINATION 
OF THE AIIl-DISTENDED BLADDER IN FE- 
MALES, WITH SOME REMARKS UPON THE 
TECHNIQUE AND A SUMMARIZED REPORT 
OF CASES.1 
BY EDWARD REYNOLDS, M.D. 
Cystoscopy of the bladder is no new procedure 
either in men or women. But the loug-established 
method of examination of the bladder, when distended 
with fluid, through a fenestrated cystoscope carrying 
an obliquely placed mirror within its calibre, is so un- 
satisfactory in its results as never to have attained 
popularity, nor to have established any very familiar 
knowledge of the viscus. This method further labors 
under the disadvantage that local treatment is of 
course impossible through such an instrument. 
The direct exploration of the female bladder was 
placed upon a wholly different plane, however, when, 
but little more than two years ago, it occurred to Dr. 
Howard A. Kelly, that if a woman were placed in an 
appropriate position and air allowed to enter the 
bladder, it could be made to dilate under the influence 
of negative abdominal pressure, ju9t as the vagina is 
dilated in the familiar use of the Sims speculum; and 
it is to-day a matter of familiar knowledge that direct 
inspection of the mucous lining of the bladder is by 
this method a procedure sufficiently easy, rapid, and 
painless to be used in the office, and to be applicable 
to ordinary cliuical work. Its value and results are, 
1 Read before the Obstetrical Society of Boston, November 9, 1895. 2 
however, still sufficiently sub judice to render it desir- 
able that we should accumulate as large an amount of 
testimony as possible upon this point. 
Our knowledge of the pathology of the bladder is 
Btill small, and workers in this field still labor under 
great difficulties, many if not most of which are owing 
to the absence of a satisfactory literature, and indeed, 
of the knowledge which produces such a literature. 
This scarcity of literature is to be deplored, but is per- 
haps natural when we remember how very recent 
the introduction of the method is. Not quite two 
years ago, when I personally first began to study the 
subject, there was not even a satisfactory account of its 
technique to be procured, and I was obliged to start 
by a visit to Baltimore, where Dr. Kelly very kindly 
demonstrated his method to me. Even then I was 
obliged to expend the labor of a number of months 
before I was able to make a satisfactory examination 
of the bladder; for at that time even Kelly, whose 
mind was principally occupied with the affections of 
the ureters, had paid but little attention to the bladder 
itself; and I believe that most workers are to-day in 
the same position in which he then was, that is, 
occupied chiefly with the ureters and content to ignore 
the bladder, unless incidentally; and, although there 
is now a considerable volume of periodical literature 
descriptive of the technique of Kelly’s method, yet 
the scantiness of the literature which relates to its re- 
sults is shown by the fact that when I attempted to 
read up whatever had been written, in preparation for 
this paper, an exhaustive search of the “Index Medi- 
cus ” up to the date when its publication ceased, and a 
letter to the office of the Surgeon-General at Washing- 
ton, asking for a list of articles published since that 
date, furnished me, indeed, with a few papers in which 
single cases were detailed, but with no single effort at 3 
any general statement of what should be looked for, or 
of the results of treatment in any series of cases, how* 
ever small. The individual cases reported were, more- 
over, almost without exception, affections of the ureters, 
and there was no single reference to any condition of 
the bladder except tuberculosis. I am, therefore, led 
to hope, that though many others are now working in 
this field, a brief statement of my own experience may 
help other beginners in avoiding the great waste of 
time which attended my own blind efforts to obtain a 
knowledge of the normal bladder, and of the more 
familiar of the pathological appearances which may be 
expected ; or that it may, at least, produce criticisms 
and differences of opinion from others who are now 
familiar with the method. My object to-night is to 
present to you a preliminary numerical statement of 
the lesions which I have so far observed, of the num- 
ber of cases in which each has appeared and of the re- 
sults of treatment in these cases; and, afterwards, to 
speak briefly of certain rules of procedure which I 
have picked up slowly by the disagreeable process of 
studying out the causes of my failures, and which my 
experience now leads me to believe to be essential to 
success in the diagnosis and treatment of affections of 
the female bladder. 
In reporting my cases I feel obliged to limit myself 
to those which I have seen since December 1, 1894, 
the date on which my last year’s service at the City 
Hospital began, as my records of those which I had 
seen before that time are rendered valueless by many 
omissions and errors of observation, which were due, I 
hope, to my lack of experience. Those of these cases 
which are of interest I hope to write up in detail at 
some future time, and shall therefore content myself 
to-night with a simple summary of the lesions which I 
saw during a five mouths’ service at the hospital last 4 
winter and spring, together with a few which have 
occurred in my private practice during the year 1895. 
My hospital work during this period was based upon 
the plan of examining the urethra and bladder in 
every case in which frequent, or frequent and painful 
micturition was constantly present in sufficient degree 
to make the patient ready to submit to treatment, aud 
in which there was no contraindication in her general 
condition. As a result of this policy, I cystoscoped at 
the hospital twelve patients, to which I may add four 
cases taken from my private practice, with the follow- 
ing results : 
Negative Results. — Three cases. Nothiug was 
found in the bladder in three cases. In one of these 
the examination was satisfactory, aud the patient re- 
ported at her next visit, a few days later, that she was 
entirely well. I take it that there was some irritable 
condition of the urethra which was relieved by the di- 
latation. In the second case the examination was un- 
satisfactory, but was followed by chilly sensations 
alternating with hot flashes in the next twenty-four 
hours; and as the urinary symptoms were not im- 
portant, the patient was not re-examined and was en- 
couraged to endure her discomforts. In the third 
case, one seen in private practice, a fairly satisfactory 
examination failed to show auything except that the 
posterior wall of the bladder was pressed inward by 
the fundus of what was known to be a sharply ante- 
flexed uterus. The mucous membrane covering this 
mound — so to speak — in the bladder was redder 
than the remainder of the vesical surface; but this, as 
I hope will appear later in my paper, was probably 
not pathological, but due to the existence of imperfect 
dilatation, that is, of less tension over this portion of the 
bladder wall. The results of the treatment were, I 
regret to say, extremely unsatisfactory and the patient 5 
is at present unrelieved of her urinary difficulties. 
[Since this paper was written the patient has been re- 
examined, after an interval of many months, and a 
ureteritis with vesical erosions found. She is now im- 
proving with fair rapidity.] 
Tuberculosis. — Four cases. There were four cases 
which I have classed together under this heading. 
One patient was examined for trifling urinary symp- 
toms in what proved to be the initial stage of a local- 
ized tuberculosis, the diagnosis being sustained by the 
presence of tubercle bacilli in the urine. After some 
weeks of treatment, the bladder was restored to a 
wholly normal condition and the symptoms dis- 
appeared. I have seen this patient recently and she 
is still wholly well, after an interval of eight months. 
[Has since returned with a recurrence, but is agaiu 
well.] A second case was examined first in a reason- 
ably early stage of the disease. She was treated for 
some weeks, and was so greatly relieved that she un- 
fortunately ceased coming to the hospital and took a 
place as a domestic. She returned about a year later in 
an advanced stage of the disease and with well-marked 
renal tuberculosis. She was again somewhat relieved 
by treatment; but there was, of course, no prospect 
of a cure, and she eventually gravitated to Tewksbury, 
in a third case the clinical appearances were precisely 
those which were seen in the first, but two attempts to 
detect the presence of bacilli in the urine yielded 
negative results, and as the bladder was shortly 
brought under treatment into a normal condition, the 
diagnosis is likely to remain open to doubt. In the 
fourth case the patient was seen but once, and the 
diagnosis was made from the clinical appearance only. 
Ureteritis. — Eight cases. In eight cases, or fifty 
per cent, of the cases examined, it was possible to es- 
tablish an undoubted diagnosis of ureteritis. In 6 
one case there was an acute cj’stitis, complicated 
by an involvement of the ureters. The patient 
was discharged well. In one, ureteritis was com- 
plicated by a small ulcer near the internal orifice 
of the urethra. This patient was discharged well. In 
two cases the ureteritis was accompanied by granular 
inflammatory patches separated from the mouth of the 
ureter by a small space of normal mucous membrane. 
One of these cases was discharged well. The other 
was treated but twice, and although she was improv- 
ing when last seen, I feel bound to enter the result as 
not treated rather than relieved. In one case there 
was ureteritis and a probable inflammatory patch of 
roughened mucous membrane; but the examination 
was somewhat unsatisfactory and the patieut never 
returned. Discharged, not treated. One case was 
uncomplicated ureteritis, discharged well. To these 
six should be added two cases of acute ureteritis seen 
in private practice, but not cystoscoped ; in one case 
because the diagnosis was clear without cystoscopy 
and the patient was extremely sensitive to pain; in 
the other, on account of the youth and virginity of 
the patieut. Two other cases, seen in private prac- 
tice, are not included in this list because the cysto- 
scope was not used and the diagnosis, though probable, 
could not be regarded as established. 
Ulceration and Sacculation of the Bladder. — One 
case. There was one case, seen in private practice, in 
which the cystoscope demonstrated the presence of 
several deep ulcerations and a large number of cica- 
tricial bands in the bladder of a woman who had been 
the subject of considerable, but not extreme, urinary 
discomfort for many years. In two places the cica- 
trices were annular and the portions of the bladder be- 
yond them communicated with the rest of the viscus 
only by narrow openings. This patient could be ex- 7 
amiued only under anesthesia,, and the treatment was 
necessarily limited to a single sitting. As a result, 
however, of a single local treatment her urinary trouble 
is—six mouths after operation—limited to very 
slight frequency of micturition when she is over-fa- 
tigued. I prefer to report this case as relieved rather 
than well, because I believe the condition likely to 
recur. 
There were in all sixteen cases, of whom three 
were discharged not treated ; nine, well; two relieved 
(one of them the case last reported) ; and two, uure- 
lieved. 
The list includes every case in which the examina- 
tion was made during the period named, and seems to 
me to warrant a belief in the frequency of localized 
lesions in a very large proportion of cases in which 
there is frequent, or frequent and painful, micturition. 
These are, then, my cases of the last eleven months 
and are the only ones which I think worth reporting 
statistically, but in respect to what they have taught 
me, the comparatively ill-observed cases of my first 
year were perhaps more valuable. 
In summing up my whole experience, the first point 
that I notice is that although some of my early cases 
showed what was then, to me, an unexpectedly close 
localization of the lesions; yet in the great majority 
of them i was able to make no very sure diagnosis, 
and iu few or none did I obtain any very marked ben- 
efit from treatment ; but that as I grew more expe- 
rienced, the proportion of cases iu which the diagnosis 
was clear grew greatly larger; until iu the last year, 
as iustanced by the list just read, there were but few 
cases in which I failed to find a definite lesion, and iu 
by far the greater proportion the results of treatment 
were exceedingly gratifying. My resulting position is, 
that though 1 certainly believe that there will always 8 
be cases in which the uriuary difficulty is distinctly a 
reflex from pelvic or general non-urinary disease, I 
have been brought to what was, to me, the very unex- 
pected conclusion, that in the majority of cases in 
which I have been in the habit of believing that 
urinary symptoms were the results of a reflex influence 
from other pelvic diseases, there is, in fact, some local- 
ized vesical lesion which is susceptible of independent 
treatment, writh the result of a relief or cure of the 
urinary troubles, independently of the condition of the 
other pelvic organs; and, believing as I do, that our 
knowledge of the bladder is as yet by no means per- 
fect, and that our knowledge of treatment is very ele- 
mentary, I am led to hope that the proportion of cases 
which we must, as yet, still class as reflex, will be in 
the future somewhat further diminished. 
In searching for the causes of my failures in my 
early work, I notice first an imperfect appreciation of 
the importance of obtaining complete dilatation of the 
bladder. It would seem at first sight as if a moder- 
ately complete dilatation would, in the end, yield as good 
results as a wholly complete expansion, even though 
the resulting examination were less comfortable and 
more tedious; and such was at first my own belief. 
In point of fact, it has been demonstrated to me in 
case after case that no diagnosis can be considered 
satisfactory unless it is made by the inspection of a 
fully dilated bladder. 
It is more especially, and most emphatically true 
that a negative result derived from anything but com- 
plete dilatation is absolutely worthless. 
Three factors enter into the difference of results. 
First, and least important, in the partially dilated 
bladder the speculum is necessarily so near to the wall 
which is under examination that but a small field can 
be 6een at any one time, and a systematic inspection 9 
of every part of the bladder is almost impossible from 
the loss of time involved; whereas, when the bladder 
is dilated to its full capacity, by holding the inner end 
of the speculum but little inside the internal orifice of 
the urethra, the bladder wall is at a considerable dis- 
tance from the end of the speculum, and a large field 
can be covered by very slight motions of the speculum 
and in a short space of time. 
Secondly, and more important, in the partially di- 
lated bladder there are necessarily numerous folds in 
which small lesions may be concealed ; and, moreover, 
our inspection of the all-important trigonal region is 
always rendered difficult, and sometimes impossible, by 
the presence of even a small quantity of urine ; and 
it must be remembered that even if the bladder be 
wholly emptied at the start, the urine rapidly re-accu- 
mulates during the examination. 
Thirdly, and most essential, the appearance of the 
mucous membrane during partial dilatation is utterly 
and wholly different from its appearance when the 
bladder is in complete expansion. While the bladder 
wall is lax, as must always be the case with partial 
dilatation, the mucous membrane has a soft, velvety- 
looking surface, which is rendered rough by the pres- 
ence of innumerable minute, one might almost say 
microscopic, wrinkles; that is, the surface looks 
granular; it is uniformly pink in color, granular 
inflammatory patches are almost indistinguishable from 
the surrounding healthy mucous membrane, and even 
shallow ulcerations are distinguished with the greatest 
difficulty. In contrast to this, in the presence of full 
dilatation, that is, when the bladder walls are rendered 
tense by their intrinsic resistance to the expansile 
force of a fully developed negative intra-abdominal 
pressure, the normal mucous membrane shows a white 
and glistening field, over which branching blood-vessels 10 
throw a coarse network of brilliant red, and against 
which the smallest ulcer or inflammatory spot exhibits 
itself with almost startling distinctness. The appear- 
ance of the vesical mucous membrane in this condition 
may be not inaptly compared with the base of the eye as 
seen with the ophthalmoscope. All folds are obliterated, 
the all-important trigonal Tegion is easily found, and it 
can be readily appreciated that only in this condition 
can a sure diagnosis be reached; or, at least, that it is 
only when the bladder has been inspected iu this con- 
dition that we can be safe in assuming the absence of 
abnormalities. Iu the presence of full dilatation we 
can inspect with ease every part of the bladder wall 
except the anterior portion, and this is, so far as we 
now know, unlikely to be the seat of disease. The at- 
tainment of complete dilatation is then the first point 
which I now insist upon. 
The second source of error which I note is that I 
was at first unacquainted with the comparative im- 
portance of the different regions of the bladder; and 
that when, as is often unfortunately the case, the com- 
.plete dilatation is inconstant, and the diagnosis must 
be made by quick glances during the short periods 
when it is present, a hap-hazard search may fail to re- 
veal lesions which would be promptly discovered by a 
more systematic inspection. As a matter of fact, it 
seems to be a rule that if the region of the trigonum 
and its neighborhoods on the posterior and lateral 
walls, are free from disease, there is every probability 
that the bladder as a whole is normal. In every vis- 
cus with which we are familiar it is known that dis- 
ease is apt to localize itself at a certain point or 
points; and when we consider the physiology of the 
bladder, and that any irritating substance, whether in- 
troduced from above or below, will first come in 
contact with the trigonum; also that the contained 11 
fluids will constantly gravitate to tins point in all the 
ordinary positions of the patient, it is easy to under- 
stand why this should be the most frequent seat of 
disease. In the event, moreover, of our being obliged 
to suspend the inspection after having seen these 
regions only, we may feel fairly confident that the ap- 
pearance of the remainder of the bladder will be but 
slightly modified from those seen here. The importance 
of this region is further emphasized by a fact iu treat- 
ment, of which I feel reasonably confident, that if the 
region of the trigonum has once been rendered nor- 
mal, there is, in the majority of cases, a tendency to 
the resolution of the usually less marked lesions in 
other portions of the bladder; hut upon this point I 
must be content with a passing reference, since to 
enter upon a discussion of treatment would he to ex- 
tend au already long paper to an unconscionable 
length. I may, however, he pardoned if, after empha- 
sizing the absolute importance of complete dilatation, 
I permit myself to add a few words upon the compara- 
tive value of the different postures and methods of ob- 
taining dilatation and a consequent easy opportunity 
of examining the all-important region of the trigonum. 
Dilatation of the bladder depends upon relaxation of 
the abdominal muscles, and as every gynecologist 
knows, this can be attained only by obtaining the full 
confidence of the patient, by persuading her that she is 
not liable to unexpected pain, and in many cases only 
by the training which comes from several examina- 
tions ; some points iu the avoidance of pain are, how- 
ever, peculiar to this special examination, and must be 
referred to here. The meatus uriuarius is the only 
organically narrow portion of the urethra, and is 
usually lacerated by the passage of a No. 12 Kelly 
dilator. I believe it to be well worth while to make 
it a rule to devote the first sitting to this process of 12 
dilating the meatus, and to make no attempt to pass 
the eystoscope at this visit. 
I am in the habit of beginning each sitting by the 
insertion of a small pledget of absorbent cotton, 
wrapped upon an applicaror, and saturated with a 20- 
per-cent. solution of cocaine. At the first visit the in- 
troduction of the cotton usually causes considerable 
pain, but when it is once in position, one is justified in 
assuring the patient that she has passed through the 
only very painful stage of the ordeal. After allowing 
the cocaine five minutes in which to attain its effect, I 
dilate the meatus, as a rule, to the size of a No. 13 or 
14 cvstoscope. This dilatation is always attended by 
bleeding, but the bleeding has never been known to be 
of moment. The patient is then assured that the 
subsequent sittings will be far less painful, and dis- 
missed for the day. At her next appearance the co- 
caine is again inserted, this time with little or no pain, 
and the meatus is then dilated to about No. 13. The 
dilatation is much less painful than on the preceding 
occasion. She is assured that the rest of the opera- 
tion will be practically painless, and after resting for 
a few moments is turned over into position for the use 
of the eystoscope. The passage of the No. 12 cysto- 
scope is then almost painless, and at this or the next 
sitting most patients are able to relax completely. I 
believe that a gradual training of this kind is in most 
cases far preferable to making the first examination 
under general anesthesia. 
For obtaining dilatation of the bladder, we have the 
choice of three positions: first, the Kelly position, that 
is, with the patient upon her back, her hips elevated 
by a pillow, the thighs flexed to the sides of the ab- 
domen, and the knees extended across the chest; 
second, the knee-chest position ; and, third, the famil- 
iar Sims. Each position has its advantages and its dis- 13 
advantages. Kelly’s position is rather uncomfort- 
able for the patient, but is far more comfortable than 
the knee-chest. It renders the region of the trigonum 
more easily accessible than any other. It is conse- 
quently more convenient for both diagnosis and treat- 
ment, and more especially for the use of the ureteral 
catheter. Its disadvantages are that complete dilata- 
tion is less easily attained in this position than in 
either of the others, that the urine is less completely 
out of the way, and that a small amount makes more 
trouble. Kelly himself says that it is better to use the 
knee-chest position until the patient has become well 
trained, and always in unfavorable cases. In my expe- 
rience Kelly’s position has been unsuccessful in stout 
patients, in patients with rigid abdominal walls, and in 
the great majority of all patients in their early sittings. 
The knee-chest position is perhaps the most gen- 
erally useful. Its great advantage is its creation of a 
more powerful negative abdominal pressure than can 
be obtained in any other, and therefore in the attain- 
ment, as a rule, of better dilatation than by any other 
position. The urine gravitates to the fundus and is 
wholly out of the way, so that a comparatively large 
amount makes no trouble. Its disadvantages are that 
any long maintenance of it is uncomfortable to the pa- 
tient, and that the trigonal region is rather difficult of 
access for the surgeon, more especially so when we 
come to consider the question of treatment or of 
ureteral catheterization. It is, nevertheless, the posi- 
tion which must be used in a large majority of cases. 
The Sims position is only occasionally useful. It is the 
most comfortable for the patient. Distention is more 
easily obtained than in the Kelly position, but less 
easily than by the knee-chest. So, too, in the amount 
of trouble caused bv the urine, it occupies an inter- 
mediate position. It produces, however, a lateral dis- 14 
location of the bladder which is confusing to the 
surgeon and makes the lower side of the trigonum and 
the lower lateral wall somewhat inaccessible; but this 
can, of course, be obviated by placing the patient upon 
one or the other side in accordance with the region 
which we wish to inspect, and the position is therefore 
occasionally useful for the treatment of cases in which 
the location of the lesion is already known. 
In conclusion, I may say of the value of Kelly’s 
method of examination of the air-distended bladder 
that it has already changed our ideas of vesical disease, 
and has certainly transferred the affections of the 
lower urinary tract of women from the region of diag- 
nosis from obscure symptomatology, to that of a clear 
and definite physical examination, that is, from med- 
icine to surgery. As our knowledge of the subject in- 
creases, this change is likely to become even more 
pronounced. The method has already established it- 
self as not only the best, but as, so far, the only satis- 
factory method for diagnosing and treating the more 
serious affections of the bladder. Its practice is likely 
to lead us to pay an increasing attention to the lesser 
degrees of vesical disease, both because it has already 
been established that a very slight degree of irritabil- 
ity may be due to the initial stages of important 
disease, and because it offers a prospect of cure in 
many cases in which we have been in the habit of en- 
couraging patients to endure slight urinary distress, 
simply because we knew of no way of relieving it, or 
because we believed it to be of reflex origin, and there- 
fore not susceptible of improvement by direct local 
treatment. Many such cases can, moreover, be shown to 
be susceptible of cure by but a few local applications, 
and it is to be hoped that this number will in the 
future prove to be greater than we can believe it to be 
to-day. I am unwilling to trench upon the domain of 15 
treatment in this paper, but must here permit myself 
the reminder that when we use the word cure in this 
connection we must add the corollary that in many of 
these cases, the local lesions will be sure to recur un- 
less the brief local treatment is backed up by the ap- 
propriate and often long-continued course of general 
medicinal and hygienic care, which is alone able to 
control the underlying vicious diathesis. 
It is, moreover, important tt> remember that the 
process of direct treatment of the bladder is yet in its 
infancy, that its development requires much patience 
and prolonged work, and that it is yet too soon to 
speak with confidence even of its immediate, and far 
less of its ultimate results. It may yet be found that 
the examination is not per se the harmless thing w hich 
we now believe it, though so far no evil results have 
been reported. Moreover, to avoid an over-enthusi- 
asm, it is important for us to remember that the fe- 
male bladder is comparatively seldom the seat of even 
slight affections, and still less frequently of serious 
disease, so that even the most ideal methods of ex- 
ploration are never likely to develop a field for exten- 
sive work, but I thiuk that we are justified in saying 
that in so far as the comparative unimportance of the 
field permits, the method of examination which 
we have been discussing has inaugurated a great ad- 
vance in our knowledge. 
It may be noted that I have said little or nothing of 
the exploration of the ureters, but this omission is 
compelled by lack of space. I felt it impossible to 
discuss both questions, even cursorily, within the 
limits of a single article, and chose the bladder, 
because, fascinating as the ureteral work is, I believe 
that it offers far less promise of valuable results than 
are to be attained in the treatment of the bladder. S. J, PARKHILL A. CO., BOSTON, U.S.A. 
PRINTERS