With the Author's Compliments. Urethroscopy in Chronic Urethritis. The Largest Catheter Always. BY FERD. C. VALENTINE, M.D., NEW VnRK. GENITOURINARY SURGEON WEST SIDE GERMAN DISPENSARY, ETC. Reprinted from the Medical Record, August 3, 1895. G. A. SYKES, PUBLISHER and PRINTER, 66 World Building, NEW YORK. 1895. Reprinted from the Medical Record, August 3d 1893. urethroscopy in chronic urethritis.1 By FERD. c. VALENTINE, M. D., . NEW YORK. GENlTO-URINARY SURGEON WEST SIDE GERMAN DISPENSARY, ETC. It would be absurd to hold that all cases of chronic urethritis must necessarily be treated by the specialist. The majority can be successfully managed by the gen- eral practitioner, who, however, as a rule, cannot de- vote the time necessary for that careful individualiza- tion which each case requires. Furthermore, the gen- eral practitioner can hardly be expected to provide himself with cumbersome and expensive apparatus and instruments, for which he has but occasional use. The many pathological elements upon which chronic urethritis may depend, need not now be discussed. This paper's object will be subserved in mentioning the conditions found by urethral endoscopy, without which no chronic urethritis can be intelligently treated. Time was when every chronic urethritis was deemed dependent upon a stricture. The urethra was un- mercifully slashed, true enough, with good effect in many cases, but it needed the superior skill of an Otis to have genuine cicatricial warrant for such pro- cedure. The three casts of normal urethrae I have the pleas- ure of showing, evince the fact that nature never in- tended the urethra to be a tube of equal calibre throughout its entire length. On the contrary, there are so many variations that it is absolutely impossible to even suggest an average diameter for any one case. But this is not very important for the present con- 1 Read before the Harlem Medical Association, June 5,1895. 2 sideration, save in the sense that to judge intelli- gently of what we find in the urethra, we must know that at almost every hair's-breadth its calibre differs materially. We know to-day that chronic urethritis does not at all necessarily depend upon stricture; nor need it manifest itself in goutte-militaire, or even slight agglu- tination of the lips of the meatus. Indeed, a chronic urethritis can exist with no further manifestation than clap-filaments, whose presence should be a warning to many men. To others these " Tripper-faden " are a source of grief with all the usual mental concomit- ants of sexual diseases. Early this year, in a paper on "Gonorrhoeal Hypochondriasis," read before the Berlin Anglo-American Medical Society, I went so far as to claim for chronic gonorrhoea the possible ability to evoking insanity, and suggested the advis- ability of unexplained suicides being examined for the presence of inflammatory foci of gonococci long retained within urethral crypts, glands, or follicles. Subsequent investigation, study and thought have con- vinced me that the possibility is not so remote as might at first appear. Aside, then, of local effects and readi- ness for contagion, chronic urethritis merits consider- ation for its direct influence upon the patient's sen- sorium commune. The need, therefore, of most thorough searching of the urethra fcr a diseased condition is too evident for discussion. Tactile exploration, so useful when grosser constrictions are the cause, is necessarily limited in its revelations. Considering that most diseased processes take place beneath the mucous membrane, they are entirely obscured from what the sound can communi- cate to even the most sensitive touch. This fact, that the vast majority of pathological processes in the urethra are situated beneath the mucosa, has been used 3 as an argument against urethroscopy. It has been held that their submucous location necessarily excludes them from visual detection. Were this invariably true, we would have to depend exclusively upon the sound for diagnostic purposes. How often it can yield un- satisfactory results need not be recited. Our other alternative, then, without urethroscopy, would be to treat chronic urethritis empirically. This, to paraphrase an old adage, would be to literally ' ' thrust into a urethra of which we know nothing, remedies of whose effect we consequently can know less." In a measure, the unavailability of urethroscopy holds good when reflected or projected light is used. It is in this that I differ from my friend, W. K. Otis, whose most ingenious aero-urethroscope offers everything that can be desired in that class of instruments. But the instrument which I shall have the privilege of demon- strating on the patients whom I brought here for that purpose, carries the light mA? the urethra, to each and every point it may be desirable to examine. This, the Nitze-Oberliinder urethroscope, not only satisfies the physical demand for visual acuity by the greatest in- tensity of illumination, but it also renders much of the lower part of the urethra translucent. Thus it can aid the experienced eye in at least locating a covered dis- eased process. This by no means implies that every chronic urethri- tis depends upon a submucous diseased spot, which need but be cauterized, incised, or excised to cure the infection. On the contrary, there are many other con- ditions which the urethroscope exposes to sight. These require as much study as do the pathological changes which are found in other parts of the body. Thus we may have variations in the color ol the mucous mem- brane, loss of normal striation, increase or diminu- tion of the normal urethral folds, gaping glands, and numerous other conditions. All these and combina- tions of them indicate various etiological factors. Epi- thelial denudations, ulcers, circumscribed or general diseased conditions of a catarrhal or specific character, neoplasms, etc., are discoverable only by means of the urethroscope. Oberlander, if he deserved no other credit, merits immortalization for his industrious studies of the urethra and devising methods of treatment for chronic urethritis. Incidentally, it may be mentioned here that he was the first to diagnose carcinoma of the urethra by means of the endoscope. Oberlander found an active coadjutor in Kollmann, who did, and is doing, much original work in urethro- scopy. At some future time I hope to show photo- graphs taken by him of the urethra. These demon- strate that chronic urethritis, which is only a generic term, is of sufficiently varying origin to merit all that Oberlander, Kollmann and others have written on the subject. In this connection it must not be forgotten that the urethroscope often proves useful in finding the hidden lumen of severe strictures-another condition provo- cative of chronic urethritis. It is certainly true that the mere presence of the ure- tliroscopic tube can produce apparent anaemias or hy- peraemias. To the inexperienced eye they may convey pathological changes where none exist. But study and practice do away with this source of errror. They also teach the selection of the proper calibre of tube for each urethra, and so holding it that the examined parts are rendered neither paler nor darker than in reality they are. We are met, then, by three self-evident propositions: i, Chronic urethritis is a generic term, covering many diseases; 2, most of these diseases cannot be discovered 4 by intra-urethral touch or by external manifestations ; 3, they can be located, studied, and treated only through the urethroscope. A discussion of the various kinds of urethroscopes would lead beyond the purposes of this paper. In one presented by me to the American Medical Association on May, 7, 1895, they were described- Careful ex- amination of all, causes me to advocate the Nitz- Ober- lander urethroscope, whose intensity of direct illumina- tion compensates fully for whatever may at first appear cumbersome in the apparatus. The one I have the privilege of showing now, and which I will demonstrate in use on the patients here for the purpose, is naturally not of the dimensions which I would advise the general practitioner to ac- quire. The smaller forms amply suffice for all general purposes. They consist essentially of a small accumu- lator, connected through a simple rheostat with wires which conduct to the light-carrier. This light -carrier has a tube which carries water to it, and another which carries water from it. By means of this flow, the un- covered wire, made incandescent, is kept cold, no mat- ter how long it rests in the urethra. This apparatus, in its simpler or more complex forms, is made by Heynemann, of Leipzig. The form I use is one in- tended for specialists. I abstain from recording a more detailed description of the instrument, as it is soon to be published in an article, in English, on Urethroscopy by Wossidlo, of Berlin. For the same reason I do not now mention anything of the technique of urethroscopy ; further- more, it will be evident to those to whom I have the pleasure of showing the very few and simple manipula- tions required. The appearance of the urethra varies in accord with the region examined, as well as with the pathological 5 6 conditions that may prevail. Oberlander, Kollmann, Posner, Griinfeld, Burckhardt have described these in their works, whose study cannot be too highly recom- mended. As vastly different as are the pathological conditions which cause and sustain chronic urethritis, so varying must necessarily the treatment be. Shall we inject, irrigate, or cauterize ; shall we incise strictures or dis- eased glands ; shall we perform a species of massage of the entire urethra by Oberlander's or Kollmann's modified Otis dilators ; shall we instill with the Guyon or Ultzmann syringes; shall we use Gschirrhakl's brush or Winternitz's psychrophor; shall we dilate with sounds, or shall we leave the urethra alone and obtain relief by constitutional treatment ? These questions can be answered only after that close individualization, which nothing but the urethro- scope can give. It would be folly to assert that no cases have recover- ed without urethroscopy. In some, accident has given success to crass empiricism ; but these could have been intelligently treated and more quickly cured, if they had been properly examined. It is, therefore, evident that no attempt should ever be made to treat chronic urethritis until the practitioner has ascertained what the diseased condition is and where it is located. No- thing except urethroscopy will furnish these absolute essentials. Reprinted, from the Medical Record, August 3d, 1893. THE LARGEST CATHETER, ALWAYS. By FERD. C. VALENTINE, M. D. NEW YORK GEN ITO-URI NARY SURGEON, WEST SIDE GERMAN DISPENSARY, ETC. It seems surpassingly remarkable, in view of all that is written on catheterization of the urethra, that so many otherwise exceedingly well-informed, skilful general practitioners will persist in endeavoring to pass small catheters. A case brilliantly illustrating this error was brought to my attention May ead of this year. A. B , aged sixty, a hale, well-preserved man, visiting friends in Newark, on Sunday, May 19th, found no convenience for urination and, never having had any difficulty before, reserved emptying his blad- der until he would reach his home in New York. On arriving there some hours later, he discovered that all efforts at extruding urine proved absolutely futile. From Sunday night to Wednesday, several physicians had endeavored to relieve him with small instruments. They succeeded only in giving the patient much pain and drawing considerable blood, whose quantity doubtless was much exaggerated in the family's state- ments. On Wednesday evening Dr. Ludwig Kohn was called and, finding the patient in the condition to be expected after passing no urine for three and one-half days, demanded a consultation. Dr. Henry Roth came for me. His history and description of the case caused me to go with him prepared for supra-pubic puncture at least. On arrival at 10:30 p. m. I found the patient exactly as described by Drs Kohn and Roth, the salient points being a very much distended bladder, whose fundu 8 reached apparently to the umbilicus, a prostate hyper- trophied to about the size of a large fist, with a well- defined middle lode, and a roomy urethra with no less than half a dozen lacerations in its membranous part. Before proceeding to more serious operative measures, we naturally determined to essay the passage of a catheter. The meatus appeared as if it would com- fortably admit a io American. On taking a Tiemann's 12, velvet-eyed, soft catheter, the comparative ease writh which it passed into the bladder would be sur- prising to those not accustomed to such experiences. Dr. Kohn, who continued treating the case, informs me that he had no difficulty in increasing the size of the catheters used by one number daily, having reached No. 15 on Saturday, May 25th, and that the patient is in exceedingly good condition. Manifestly, if a large catheter had at once been used, much suffering would have been spared this man. It is a rule with me to urge upon those who favor me by attendance upon my clinics the following ap- parently paradoxical rule: "In retention from any cause, compare the meatus with your catheters. When you have determined upon the size which promises to pass, make your first endeavors with two sizes larger.'' Posner says in this connection : "In the vast ma- jority of instances, the careful introduction of soft elastic instruments will accomplish the desired end. At all events these instruments are recommendable to those who have not acquired considerable skill and practice. At least no injury can be done with them.'' While the case above sketched contains nothing new, I feel convinced that other genito-urinary special- ists will agree with me in urging upon general practi- tioners that the greatest possible safety lies in always using the largest possible catheter. 242 West Forty-third Street.