REPRINTED FROM Z\)t 2So£ton Stoical anti Surgical journal APRIL 18. i88g. DIAGNOSIS OF TUMORS OF THE BLADDER AND STONE WITH THE CYSTOSCOPE. BY L— OTIS K. NEWELL, M.D., Surgeon to Out-Patients, Massachusetts General Hospital, Assistant Demonstrator of Anatomy, Harvard Medical School. Cupple£ % l)ur&, $ubli£f)cr£, €1)t 3tlgonciuin 23o£ton. DIAGNOSIS OF TUMORS OF THE BLADDER AND STONE WITH THE CYSTOSCOPE.1 Surgeon to Out-Patients, Massachusetts General Hospital, Assistant Demonstrator of Anatomy, Harvard Medical School. BY OTIS K. NEWELL, M.I)., In no less comprehensive and recent a work than the sixth volume of the International Encyclopaedia of Surgery, published in 1886, less than one page is devoted to the direct consideration of the diagnosis of tumors of the bladder, and this subject has, until recently, been only investigated by what have been more or less indirect methods. The great advance made by the introduction of cystoscopic examina- tion of the bladder cavity may be somewhat appre- ciated by the fact that within the last year I have been able to collect twenty-nine cases of tumors thus diagnosed. As these include three cases of my own, and as I had, as far as I know, the good for- tune to be the first in this country to thus diagnose a bladder tumor, I wish to call your attention, not to the subject in general, with which you are all familiar, but to some of the facts concerning the details of examination. In the first place, as to the possibility of always getting a clear view of the bladder cavity. In my early experience Avith the cystoscope I must con- fess that I felt somewhat as though the process was still a quite complicated one, and that too often I should find a bloody or cloudy urine an obstacle in the way of getting a clear view of the bladder wall 1 Read before the Surgical Section Suffolk Distinct, Massachusetts Medical Society, Feb. 6, J889. 2 but I ran now say, without hesitation, that always, whether in the course of a day or a week, the bladder can l>e pot into such condition that it is no exas- peration to say with Nit./e. it may lx* examined “as with the lipht of day.” We all know how at times a bladder with haemorrhagic tendencies will seem for a time to bleed at the least touch or after the sliphtest locomotion, while again this condition passes off and no ordinary instrumentation or move- ments seem to incite luemorrhape. In chronic cys- titis I have l>cen surprised when examining patients with this complication to see how readily the bladder may lx* washed out so that for the time being the distending fluid remains sufficiently clear. I will not dwell upon the appearance of the diseased and normal bladder wall under varying conditions. Suffice it to say that in the normal bladder wall we always readily see the bright-colored vessels run- ning through "their bed in the pale-pinkish mucous membrane. The uretal orifices are readily made out, and with moderate distention a few traliecula; may be present. In the diseased bladder, on the contrary, the mucous membrane may be deeply con- gested and colored, or even covered throughout with slimy, adherent mucus, which floats alxmt in the distention fluid. The trabecula; are exaggerated according to the nature of the affection. All this is seen as a varying panorama in the cir- cular field of the instrument according sis it is moved in different directions, and thus what has l>een called a combination picture of the whole field is obtained. Such pictures :is are seen in the field at one time are popularly represented its I have drawn them below. The dark line represents the margin of the field and the drawing within a characteristic view of some part of the growth or 3 object seen. Small growths or objects may be seen in a single field. fig. I. Fig. I. represents a portion of the first tumor diagnosed by me with the cystoscope. The growth Fig. II. was a fibrous papilloma about three times the size of the portion shown in the figure, and was from a patient of Dr. M. H. Richardson’s, at the Massachu- setts General Hospital, 4 Fig. II. is from the second case and shows part of a recurrent growth floating up from tin* base of the bladder. This was a case of I)r. C. II. Porter’s, also seen at the al>ove hospital. There were no symp- toms to indicate need of another operation. The man had married and had children since the first operation. Fio. Ill Fig. III. shows view of portion of h tumor diag- nosed for Dr. .T. C. Warren at the same hospital. The growth was a large one and in the left prosta- tic portion of the bladder, extending toward the fundus and lateral wall. The patient was not in- clined to operation and the symptoms were not imj>erative. In diagnosing bladder tumors it is well to remem- ber that a tumor on the posterior wall, or where not hindering urination, may l>e unaccompanied by pain. Palpation may enable us to detect firm fibrous growths, but not soft papillomatous ones; moreover, with a thick hypertrophied bladder wall and an enlarged prostate, palpation is apt to be very decep- tive; renal tumors may, when breaking down, fur- nisli particles of growth pointing to tumor in the bladder where none exists. Small pediculated growths may be removed from the bladder with forceps introduced through the urethra. Antal in his recent work figures two such cases. The interior of the bladder may be photo- graphed, although this is perhaps of more value in the study of its normal condition than for the por- trayal of growths, which may be drawn as made out in the examination, where the field is too often apt to soon become cloudy. With our fearless ether anaesthesia 1 believe we have a great advantage over our foreign colleagues in the examination of these cases. They appear to be too much afraid of chloro- Fig. IV. form to use it frequently for the production of profound anaesthesia such as is needed for the satisfactory examination of a sensitive bladder. In conclusion I wish to speak of the value of the cystoscope in the diagnosis of stone. Certainly any one who possesses this instrument would never think of searching for stone except by its aid. A bladder containing a calculus may be readily washed so as 6 to keep a clear distention fluid and the stone or other foreign body readily seen and located. At the same time the character of it and its surround- ings may l>e readily determined, and anything com- plicating its removal, such as saculation, prostate formation, or tumor readily made out. Fig. IV. shows a small stone as seen in the field in a ease diagnosed by me some time ago at the hospital. THE BOSTON Medical and Surgical Journal. A First-class Weekly Medical Newspaper. This Journal has now nearly reached its sixtieth year as a weekly Journal under its present title. Such a record makes superfluous the elaborate prospec- tus and profuse advertisments as to enormous circulation, etc., etc., required by younger aspirants for professional and public confidence. It is, however, no less incumbent upon this Journal than upon others to assure its patrons from time to time, as the occasion arises, of its desire, its ability, and its determin- ation to meet all the requirements of the most active medi- cal journalism of the day, without sacrificing any of that enviable reputation which is an inheritance from the past. It is under the editorial management of Dr. George B. Shattuck assisted by a large staff of competent coadjutors. Communications from all quarters of the country are ac- ceptable. Liberal arrangements are made for reprints of original articles, and for such illustrations as serve to in- crease their value or interest. The word “ Boston ” is retained in the title, as it was in the original name, but every occurence of professional im- portance whether within or without the borders of New England, will receive prompt and impartial notice. The circulation is large and steadily increasing; the sub- scription-list covering almost every nook and corner of the United States and Canada, and extending to foieign coun- tries. All communications for the Editor, and all books for review, should be addressed to the Editor. Subscriptions and advertisements received by the under- signed, to whom remittances by mail should be sent by money-order, draft, or registered letter. Terms *5.00 a year, or *3.50 a half year, in advance. CUPPLF.S AND HURD, Publishers, BOSTON.