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            THE


   ENDOSCOPE,


AND ITS APPLICATION TO THE DIAGNOSIS AND TREATMENT
        OP AFFECTIONS OF THE
GENITO-URINARY PASSAGES.
LESSONS GIVEN AT NECKER HOSPITAL.
  A. J. DESOEMEAUX,
surgeon of the hospital, member of the surgical and anatomical
         societies of paris.
    TRANSLATED BY

R. P.  HUNT, M.D.
Reprinted from the Chicago Medical Journal.
     CHICAGO:
ROBERT FERGUS' SONS, PRINTERS,
    12 & 14 CLARK STREET.
       1867. 

    Entered, according  to Act of Congress, in the year 1867, by
                 J. Adams  Allen,  M.D., LL.D.,
In the Clerk's Office of the District Court of the United States, for the
                   Northern District of Illinois. 
THE  ENDOSCOPE.
                  PREFATORY NOTE.
  Any method of observation which enlarges the certainty and
facility of diagnosis cannot fail to be of interest to the physi-
cian.  Among the novelties of the present time, the Endoscope,
like  the  Microscope, offers  a view of  the real pathology  of
many local affections heretofore supposed to be removed  from
direct observation.   It may not find its  way into general  prac-
tical use- by the  busy every-day practitioner, but in the  hands
of experts it has already, and we predict will  hereafter  throw
.light upon many previously obscure points in pathology.
  Desormeatjx's Lectures,  here presented, aside from  their
illustrations of the Endoscope, will be found to afford the best
series of experimental  observations,  with practical inferences,
on urethral affections that has yet been published.
   With this idea, the Editor of the Chicago Medical Journal,
in whose pages the translation originally appeared, has thought
fit to collect  the pages  and give them to the profession in per-
manent form.                                  \
  The lamentable death of Dr. Hunt, the amiable and accom-
plished translator, prior to completion of the work, will account
for the change in style  of  expression  in the  last few  pages,
which were  kindly translated for the Journal  by H.  Ralls
Smith,  A.M., M.D., of this city.
   Chicago, January, 1868.                      J. A.  A. 
 
THE   ENDOSCOPE.
                          DEDICATION.

To Mons. Rayer :—                        '
    Much Honored Master:—According to your advice, I have given these
lessons.  You thought they might be useful, and encouraged their publication.
Permit me here, to place them under your protection and thank you, in ad-
vance, for the aid your name will give them.
                                         A. J. DESORMEAUX.
                  TRANSLATOR'S DEDICATION.

  Monsieur Rayer—To you, from  whom I have learned so much of the
little that I do know, permit me, as a mark of gratitude, to place your name
at the head of this paragraph.                         R. P. HUNT.
                         PREFACE.
          Nos quoque oculos eruditos habemus.—Cic. Parrad. v.
  A most characteristic progression of  the  medical art, as it
exists  at  present,  consists in the endeavor to find out means
adapted  to the direct exploration of the different organs, the
careful study of local affections by the aid of these means,  and
the use we can make  of the physical  sciences, from which we
ask no more empty theories,  but  the application of their exact-
ness and  the means by which to procure  instruments calculated 
2
THE  ENDOSCOPE.
  to increase and perfect the action of our organs. • Percussion,
  instituted by Avenbrugger, popularized  by Corvisart, seems to
  be the initiative of this path into medicine.  We all know to
  what extent this method has reached at present;  but  yet it was
  only in its young infancy when auscultation was discovered and
  comes,  scarcely yet invented, to revolutionize the curing art.
  Lsennec, a master of sciences, without counting this  invention,
  which has immortalized his name, has had the glory, possibly
  unique, of creating, unaided, an  entire branch of the art, which
 numerous and learned physicians, by constant study and effort,
 have only been able to  extend and perfect since his time.
   At the same time, Recamier, taking up the speculum, at that
 time unused, made from it his invention,  rather, from  the infor-
 mation it afforded him  than from giving it a simpler  and more
 convenient form.   Collaborators  were not wanting to complete
 his work:—First,  I will mention my father,  Professor Desor-
 meaux, who found in this instrument  a means of still  further
 extending his knowledge, already great, in this branch of medi-
 cine.  Later,  M. Ricord, applying the  speculum to the necessi-
 ties  of his specialty, used it  for the purpose of establishing a
 fundamental point of doctrine.   In a memoir read to the Acad-
 emy of Medicine, he showed the possibility of discovering, even
 within the uterine neck, the characteristic ulceration of syphilis.
 which he distinctly separates from menorrhagia.   At the  same
 time, Mr.  Milier modified the instrument, so  as  to adopt it to
 the various indications  which it  can well fulfil, used  it for the
 purpose  of enriching, by new means, therapeutics, as applied to
 affections of the tissues.
   It was much,  doubtless, to subject the  interior  organs  to a
 free access of light, but still it was not sufficient;  there are
 some parts so arranged  that they cannot be  examined in  so
 simple a mode; the eye  can only reach  them, so to speak, by
forcing its light upon them, and light borrowed from the science
of physics.  For the eye, the ophthalmoscope has been invented
laryngoscopes for  the study of  the upper  part of the aeriferous
tubes,  and, for those cavities too narrow to admit the  introduc-
tion of a speculum,  I propose the endoscope.  The first I drew 
THE  ENDOSCOPE.
3
from it, was separating blenorrhagia from  other urethral dis-
charges,  and if M.  Ricord should  see these lessons, he will
recognize, I hope, that the endoscope has furnished what he de-
sired, in his letters, from the urethroscope, to a former pupil.
  When, in 1862, I was made surgeon to  Necker  Hospital, I
found many occasions on which to continue  my researches, and
the endoscope, up to that time an experiment, soon became an
instrument of practical importance,  as relates to diagnosis and
treatment,  and was, the following year, the subject of several
articles in the medical journals.
  I owe, here, a special mention  of  a thesis made this year, \>j
my friend and former pupil, Dr. Portella (de Fernambouc), upon
endoscopic urethrotomy.   This  is the  first publication on the new
method of incision for stricture.
                                 J.  A.  DESORMEAFX.
                   THE ENDOSCOPE.
                      first lecture.
  The Endoscope.—The Healthy Urethra.—Acute Urethritis.
  Gentlemen :—When we consider all the improvements  and
inventions, having  in view diseases of the urinary organs,  it
may be supposed that this is one of the most advanced parts of
surgery; but a judicious examination of the subject proves the
reverse.
  Really, despite the improvements added to this branch of our
art, despite  the numerous researches so long continued, there
are still  many obscurities, many diagnostic  uncertainties, and
much risk in the treatment.  Of this, the following pages will
furnish abundant proof.   But,  at present, let me call  your at-
tention  to calculi sacked (enchatonnee), the frequence of which
is so often disputed; some believe these cases very rare, others
are of an opposite opinion.  One, of long and extensive prac-
tice  tells me that they do not exist, and another, of great spe-
cial experience, regards them as very rare.   If this is so, I have
been most singularly favored, for twice  I have  found  them  in
operating, and twice, in the last year, the endoscope has shown 
4
THE  endoscope.
 them; once  upon a patient of Mr.  Howel, at the clinic, and
 once upon a  patient of M. Jarjavay, at St. Antoine.   M. Howel
 proved his case by an autopsy, M. Jarjavay verified his by an
 an operation.  Now, is it probable, if these cases are reported
 as so rare, that it is owing to imperfect means of discovering
 them ?
   Let us  take, as another example, a  very  frequent disease.
 Nothing is more common than chronic urethral discharge.  In
 general language, blenorrhoea,  the  dread of surgeons,  and of
 patients until  they determine  to  forget their  disease and live
 tranquilly, thoughtless of such acccidents as may one day awake
 them from their security; for if there are cases of blenorrhoea
 which  spontaneously  cure,  or  which disappear to  soon return
 without producing much damage, there  are others, and many,
 which  end only by producing most of the grave affections of the
 urinary organs.
   Why have we not distinguished  between these different kinds
 of blenorrhoea?
   When a surgeon is consulted for an eye, red, painful, weep-
 ing, he seeks to discover the nature of the disease, he desires to
 know if he is  to treat  an ophthalmia blenorrhagic, syphilitic,
 catarrhal, rheumatismal, scrofulous, or simply traumatic; he is
 never content to diagnose simply an ophthalmia, and still less a
 hyper-secretion of the conjunctiva.  In chronic discharges  from
 the vagina, leucorrhoea furnishes  a very insufficient term for
 diagnosis.
  Why then  should we be less difficult to be satisfied as regards
 urethral discharges, and apply to them, indiscriminately, the
 term of blenorrhoea, or confound them with catarrh, as if it was
 not an affection sui generis,  in  the urethra as in other organs
 rarer only  on the urethral than other mucous surfaces?   It  is
 because in ophthalmia, by opening the lids to see the diseased
 organ,  we see and conjoin the physical and rational signs.   In
 vaginal discharge, the  speculum and  actual touch combined, is
 sufficient.   In  the  urethra, however, sight has not, until re-
cently, aided  us to complete a diagnosis firmly based.   We stand
where  the  profession stood,  on  the question of leucorrhoea, be- 
THE  ENDOSCOPE.
5
fore  Recamier used the speculum in the study of  affections of
the vagina and uterus, with the difference that in place  of a
finely exquisite finger, touch  can only be applied by means  of
inert instruments.
  We spoke, a few moments since, of the different ophthalmias,
to show what difference exists  in the pathology of organs as they
may  be more or less accessible to view.  Deep-seated affections
of the eye will  furnish a still better illustration.   A few years
since, every patient devoid of sight, without opacity of the pu-
pil, was pronounced to  have  amaurosis if  the pupil was black,
glaucoma  if the pupil had  a greenish  tint.  The diagnosis was
not difficult, but what is glaucoma, and what amaurosis?   This
was not known.  As to glaucoma, there was complete ignorance.
As to amaurosis, we know that the term covered  many different
affections, some seated in the eye, others elsewhere.  Pathologi-
cal anatomy demonstrated some of them, but they could not be
distinguished on the living subject,  and a haphazard, empirical
treatment was resorted to.  Until Helmtroty invented the oph-
thalmoscope, this  uncertainty continued.  This instrument was
used for deep-seated  affections  of  the  eyes which, up  to that
date, could only be diagnosed by rational signs—the result is
well  known.
  Glaucoma is at present considered a well-determined and well-
decided lesion, easily understood by its symptoms, and of which
a rational treatment  has  been  instituted with some  success.
Under that term, many different affections  have bean  discov-
ered, which, studied separately, have much narrowed the domain
of amaurosis, and will still more  restrict it.   Ask a countryman
of Helmtrothy, to-day,  what  is amaurosis, and  he will  not tell
you "that it is a disease of the eyes, in which the  surgeon sees
no more than the patient."
  At the same time that  the ophthalmoscope was  commencing
to be employed in Germany, a lucky circumstance, unnecessary
to relate here, caused  me too  seek for  an instrument that would
permit of ocular examination  of  the urethra and bladder.  The
principle  was  soon  found,  but months passed  before the  URE-
THROSCOPE became the endoscope.  I ought to state that I was 
6
the  endoscope.
 not the first to make attempts on this road.  At the time the
 speculum commenced its revolution in uterine diseases, M. Sig-
 elas attempted  to obtain,  for  the bladder, similar advantages,
 by means ef two concentric  sounds, the  inner  one  to permit
 light to reach to the depth of the viscous, and  the exterior to
 transmit  the light of two candles reflected  from  a concave mir-
 ror.   The results were not very satisfaatory; yet, the inventor,
 by modifying  his instrument, might have gained his end, if
 other work had not taken his time and attention.  I learn from
 M. Segalas, that when he presented to the Academy of Sciences
 his urethro-cystic speculum, Fresnel, on leaving, said to him, by
 placing the light at the side, and, by means of an inclined mir-
 ror,  reflecting it according to the axis of the  instrument, you
 will  succeed.  Such is the  arrangement in the endoscope.
   So far  as  I can learn, an English surgeon, M. Every, imag-
 ined an instrument mnch like mine,  but it was never used.  Of
 this  instrument, I have never  been able to procure a  detailed
 account.
   Then, Dr. Ag. Hacken,  of  Riga, has published the  descrip-
 tion of a  dilator of the urethra, for  the urethroscope.  This
 instrument is composed  of three metallic rods, all introduced
 together,  and capable of being separated, with  the ocular  ex-
 tremity surrounded with a  funnel.  The dilatation made, light
 was  to be thrown through  the funnel  by means  of a reflecting
 mirror.  When a description of this instrument appeared, it had
 then not been tried, and I  think that since  it could have given
 no useful results.   The  inventor, moreover, only suggests its
 use for the anterior portion of the urethra, in front of the pubis.
 M. Hacken also proposed  to  examine  the female bladder by
 means of  tubes and a funnel, by which light might be  transmit-
 ted as in the preceding case.  Both of these experiments I feel
justified in saying, are unavailable.
   Thirty  years, at  least, have  passed since the efforts of M.
 Segalas were made, and  no one, to my knowledge, thought fur-
 ther of the possibility of using vision in the study of urinary
 diseases, until, in the fall of 1852, I commenced to investigate
 them.   Towards the end of the same year, I placed in the hands 
THE  ENDOSCOPE.                     7
of the Imperial Academy of Medicine, a sealed paper, and on
the 29th of November, 1853,1 showed the instrument, about as it
at present is used.   I  continued my attempts, and two years
later, in a new communication, I gave the results of my first
experiments.   In 1855, the Imperial Academy of Medicine, ap-
preciating the endoscope and what might be gained by it, rather
than  my services, already  recognized, gave me the honor of
dividing the Argenteuil prize, after  experiments  made before
the committee.
   The instrument was known, but it was necessary to prove its
efficacy and adaptability.  When, in its infancy, it was shown
to some  of my colleagues, one of whom remarked:—"We can
see well  with your instrument, but what is  the  use  of  seeing?"
This was a question I was not prepared to answer, save by gen-
eralities, and  so I thought it  best  to keep quiet for the time
being.  Now, however,  after longer experience, I  can  sa,y what
good sight does in the  study and treatment of these diseases.
   The principle upon which the endoscope is constructed is
very simple.  A sound suited to the passage it  traverses, to
transmit the rays of light, a mirror  pierced in its centre and
placed obliquely at the face of the sound, for the purpose of
throwing a faggot (so to speak) of luminous rays parallel to its
axis—such are the essential parts  of the  endoscope.  But, as
this instrument is designed to  aid  the  investigation  of deep-
seated organs too narrow for  the speculum to penetrate, it is
necessary to throw as much light as possible, and  at the  same
time guard the eye of the examiner from that light.  Indeed,
the instrument,  for examination,  and especially for operations,
should be manageable to a high degree, and  easily directed in
every way.
   For the purpose of increasing the light,  a plano-convex lens
should be placed between the light and mirror,  so as to concen-
trate the rays of light upon the parts of the lower  extremity of
the sound or catheter.  Opposite to the lens, there is a concave
mirror, the centre of whose spherical  surface coincides with the
lighting points, so as  to reflect the rays of  light received by it,
according to their angle  of incidence,  and to cause  them to
strike the lens as if directly thrown upon it. 
8                     THE ENDOSCOPE.
  The means of lighting are of great importance.  The lumin-
ous points near the focus of the lens are useful, the  others are
useless, if not injurious.  Hence, it  follows that we must  have
an intense  light of small volume.   Large  flames will  not do;
candles, oil-lamps,  and petroleum are useless; gazogene (a mix-
ture of alcohol and turpentine) seems to me the best, its flame
is intense but small, and the lamp well adapted to the instru-
ment.  Before I settled upon this lamp, I  thought of the elec-
tric light, but it is too  cumbersome to be carried around, and
requires an assistant.   It would, moreover, double the price of
the instrument.  Sunlight, so convenient for the laryngoscope,
would not answer for the endoscope, because its rays cannot be
controlled, and we must  control light to make  it useful in the
employment of the endoscope.
  There  is yet another  light that I believe may be  good, but
that I have never tried,  it is the Drummond light.  It might be
useful in an amphitheatre, but would be difficult to use in pri-
vate practice.   Gazogene is, at present, according to my idea,
the best.
  [The author  then goes on to describe1 the endoscope.   To do
this effectually, many terms, mechanical and physical, have to
be used.   Of some of these the  dictionaries are often silent,
others are so abstractly  defined that none but a mechanician or
student in natural  science could understand them.]
  (He says it is adapted to the study of the urethra and  blad-
der ;  also of the neck  of the uterus, but not of the internal sur-
face of that  organ, which cannot be explored without  previous
dilatation.
  In the rectum, he says, this instrument lets us make profound,
deep-seated examination, "so that I  have been  able to examine
strictures beyond reach, and ulcerations also beyond the finger's
touch."
  He expects to publish, at some future time,  the results of a
pilous cyst  of the ovary, with a fistulous  opening,  frequently
examined by the  endoscope.  In wounds, this instrument  he
says, may be very useful.  Though  a bullet may be  recognized
by the common sound, we may be called on to see it.) 
THE  ENDOSCOPE.
9
  Now let vs commence the study of the urethra:—
  In the commencement of this subject, let me call your atten-
tion to the fact that the endoscope does not act as a substitute
for  all other means of  exploration, but  only completes them, in
adding touch  to  sight.  Thus, before using the endoscope, we
shonld use all other means of exploration, and especially of me-
tallic  sounds and of bougies with rounded ends.  This examina-
tion will  prove useful,  not only as to our diagnosis, but will also
direct us as to our use of the endoscope.  Thus we will  find out
the sensibility of the canal,  its  deviations, and  the obstacles
which  it presents; we can pursue the  points upon which we
should especially direct our attention.
  If the  canal is free and readily admits the sound of the endo-
scope up to the  bladder, we should  take  advantage of it, and
examine  its whole length.   If there is nothing to  indicate to us
the seat of the lesion,  we may rest assured  that we will find it,
and if any sign,  such  as exalted sensibility, denotes a  local af-
fection, a complete examination will serve to show if any other
point is affected.
  An endoscopic examination should, as far as practicable, be
made in  a darkened room,  as should all other examinations re-
quiring  artificial light;  though a  demi-obscurity  will often
answer,  complete darkness is the best.   As for  position, the
patient should be placed as if to be examined by  the speculum.
That  position  is well understood by all.
  Before proceeding to the examination, preparation  must  be
made for cleaning out  the part examined.  This  is  done  by
carded cotton so carried in as  to wipe out all fluids calculated
to obscure the view and keep it off the diseased structure.
  All being ready and the patient properly placed, the  sound is
gently introduced  as  far as the  vesical orifice.  This we can
judge of by the direction it has taken, by the depth it  has pen-
etrated, and  also by the resistance it  has to  overcome before
going  farther.  This  resistance once perceived,  we should be
careful not to overcome it, for  fear  of going into the bladder
and filling the sound with urine, and  to empty it is an operation
fatiguing alike to surgeon and patient. 
10
THE  ENDOSCOPE.
   It  is unnecessary to say aught about the introduction of  the
 sound.   The introduction of the endoscope must first be based
 upon a knowledge of introducing this  common and important
 instrument.
   In moving the  endoscopic sound  forth  and back, it will be
 found necessary to remove, by pledgets of lint or of cotton, such
 fluids as may obscure the view of the mucous membrane, be they
 mucosities, or only the oil used in greasing the instrument.
   Whenever anything diseased is  thought  to be seen, it is
 necessary to clean out, and sometimes it may be well to pass
 the instrument near the bladder.  By such movement, there is
 a change in the appearance of the mucosity  under the lights,
 and certain  details may  be detected which  wTould otherwise
 escape notice.
   It  sometimes  happens that, in removing mucosities,  the cot-
 ton, badly fixed, slips off.  If the examination is over, Avithdraw
 the instrument  and the cotton is throAvn  out at the first urinal
 emission; but if the examination is not over, if it is feared that
 the stream of urine may be too wreak to throw it  out, or if it is
 impregnated  with  a caustic which we do not wish to  continue
 too long in the  canal, it can be easily removed.   In case of a
 preconceived obstacle, once reached, do not attempt to pass it.
 That  is generally the point to study it, and  the anterior portion
 of the canal can be investigated in withdrawing the sound.
  To understand  the diseased  condition  of  the urethra,  we
 must first understand its healthy appearance, and then we will
 commence.
  The internal surface of  the urethra, in its healthy condition
is smooth and polished; the endoscope shows neither the lacunre
 of Morgagni, nor the orifices of the excretory ducts which cover
its surface.  This can be readily understood by the difficulty of
finding  them, even when  the canal is largely opened;  fortu-
nately,  it is  not necessary to  see  them unless diseased.  The
 same  is true with reference to the ejaculatory  canals.   I know
it has been claimed that they could be seen  by  means of the en-
doscope, but I have never done so,  and I  must think that  an
observer, in such cases, has been a victim to illusions which  he 
THE  ENDOSCOPE.
11
might  have avoided if he had kept more in mind  the rules of
examinations and dissections.  The verumontanum is not visi-
ble;  at least, I have never seen it, and  I think its lack of con-
sistence renders it liable to be obliterated by the sound.
  Generally, authors describe  the  appearance of  the  urethra
according to its appearance after death, thus, according to them,
its color varies in its different  portions.   These "different color-
ations are all of cadaveric origin.  The blood, obeying its weight,
collects in the most dependent parts, and soon, by imbibition,
stains  parts less elevated,  whilst  all  others, more elevated,
remain uninjected.
  M. Sappey understands this; by removing the blood from the
veins, by means of water injections, he has, in a manner, proved
that the mucous membrane is without color throughout its whole
course, MM. Rickert and Jarjavay describe it as slightly yellow.
Such is,  undoubtedly, its color during life; only this yellowish
tinge, which is the foundation of  the coloration, is more or less
intense in different persons.  It thus takes on very much the
complexion tint of  the skin, a circumstance often mentioned by
those to  whom I have shown the healthy urethra.  This tint
is uniform from near the meatus, where it is more red.
  It is generally believed that  the  mucous membrane of the
urethra forms longitudinal pleats.  This opinion is the result of
opening the canal lengthwise, or  else by dividing it  transversely
by  sections.  This last  is certainly  the truest  method, as the
first-mentioned permits the mucous membrane to  pleat in any
but a natural way.   Transversal pleats have also been described:
M.  Sappey denies their existence, and attributes their discovery
to a desire to make a name.   I must say that such reasons have
often been used  to excuse  the difficulty of  penetrating  to
the bladder with a small-pointed sound, and that too though a
healthy condition of the canal  existed—these pleats  may  be
produced  by the improper introduction  of this sound.   I must
confess to have sometimes, formerly, encountered  them, but I
attribute  them to the before-mentioned  cause.  The  endoscope
has never shown me anything like them.   As to the  longitudi-
nal pleats, they are  not  very marked, but they can be seen  by 
12
THE  ENDOSCOPE.
the endoscope.  In withdrawing the instrument and following the
axis of the canal, the mucous membrane can be seen to contract
upon the end of the sound, but when these pleats form after the
urethra has lost its elasticity, they are at a certain distance from
the instrument.   Thus the walls of the urethra, in  closing, form
a funnel,  the  summit  of  which is  truly pleated  like a (cul de
poule) pullet's tail.
  These pleats are not so regular as anatomists generally state
them to be; their number and disposition is irregular, they vary
according to the direction of the sound, and  by  pressing  the
sound upon different  points of the urethral  circumference, this
linear  contraction can be caused in the part pressed.  It is
necessary to  be familiar with the manner  in which the urethra
closes  over the sound, for if it  does not do so uniformly and
regularly, we must believe that there  is a pathological altera-
tion, by which the suppleness of the walls of the urethra is
impaired.
  Now that we know the normal condition of the urethral mu-
cous membrane, as shown by the endoscope, we can  investigate
the  diseases  of the  same membrane.  Let us commence  by
acute urethritis,  a disease which plays  an important  part in
urethral pathology, and which may, in some means, be consid-
ered as the father of many complaints.
  Writers have frequently  confounded urethritis with Menor-
rhagia,  this, I  think, is a great error.   Urethritis is a disease,
an inflammation,  produced by many causes.   Blenorrhagia is a
disease produced by a special or specific cause, and transmissible
contagiously,  always  preserving its peculiar  characteristic of
transmitting effect to cause, or, if you wish, cause to effect.
  Blennorrhagia being more frequent than all  other urethrites
may possibly be  the cause of  all the confusion existing in  this
diagnosis.  Now  we must state that, according  to the symptoms
alone, the difference is slight, and only found out  in the  march
of the disease,  and its cause, when chronic and when the lesions
are  consecutive.   So long as  the acute stage  continues inflam-
mation  dominates and masks the peculiar characteristics of each
affection. 
THE  ENDOSCOPE.
13
  In this respect, urethritis is like other inflammations; similar
examples exist in all the organs.   Suppose, in a case of orchi-
tis,  seen for the first time, you wish to distinguish, at once, the
class to which it belongs, many times you  cannot  tell whether
it  is due to  a contusion,  a blennorrhagia, to  epidemy—or
mumps  and consequent inflammation of the testicle, or if it
is the commencement  of a  tuberculous  orchitis; if closer and
more  decided  examination  of  causes,  and  of  other  organs,
does not enlighten  the diagnosis, it will be  necessary to  abide
your time, until the progress of the disease may enlighten you.
Is another example needed,  the pathology of arthritic blennor-
rhagia  differs  but little  from orchitis, and it is not difficult to
find cases in  which wTe  cannot tell the origin  of  the disease.
When a knee is painfully inflamed,  with  acute or sub-acute effu-
sion, attempt,  throwing aside causes, relying  only on the local
symptoms, to decide if the arthritis  is rheumatic, traumatic, or
blennorrhagic; this  you can but rarely do,  and oftentimes  the
march of the disease will not enlighten you.   I recollect a case
at the  Cochin Hospital, embarasscd with such symptoms as to
render it almost impossible  to distinguish the kind of arthritis
I was treating;  the inflammation Avas not very acute, there was
but little fever, and, though the knee was the seat of a painful
effusion,  the patient, according to  his  say-so, had only felt a
sensation of Aveariness, the result of ovenvork, by which to ex-
plain his  feverishness.   The  local  symptoms  consisted in  a
hydarthrus, with considerable pain, caused either  by motion or
pressure;  at first, the skin a little warm, but not red.  Now for
the cause: the patient had an old blennorrhagia, had frequently
felt rheumatic pains, and, when attacked as I mention, was en-
gaged in weeding in damp ground, the affected knee being doAvn.
I must confess that the patient was cured Avithout my ability to
diagnose Avhether the arthritis was blennorrhagic, rheumatismal,
or traumatic.
  These examples are sufficient to sIioav that in relying alone,
as has been  proposed, upon  a concurrence of the symptoms, for
the purpose of establishing  the nature of urethritis, Ave may be
deceived, as has happened,  and confound under the same name 
14
THE  ENDOSCOPE.
traumatic, hepatic, catarrhal, blenorrhagic, and other discharges.
If the term blennorrhagia is to be employed  as the designation
of all urethral  discharges, then I cannot tell Iioav to  term that
species of urethritis Avhich is the common,  the most important,
and the best characterized,  that Avhich  is generally understood
by blennorrhagia.  We will acknoAvledge inflammation of the mu-
cous membrane of the urethra can be caused by Avhatever may
give rise to inflammation of other mucous surfaces, but at pre-
sent our attention m\\ be especially directed to  blennorrhagia,
the most important, and we will only touch upon the others, for
the purpose of  distinguishing.   It is not intended  to  give  here
a complete history of this disease, but  to seek what lights the
endoscope can add to  those already possessed by science.
  What I just said of the different inflammations of the urethra
will find its proof  in Avhat is to follow on the same subject, bu
for  the present, we must admit, in anticipation, that by Menor-
rhagia, we understand a disease ahvays due  to contagion, and
which, in its complete development, if it does not cure spontane-
ously, or by  proper  treatment, passes  to  a chronic stage, and
finally terminates  in stricture of the urethra, Avhich is its last
stage, as a cicatrix is  the last stage of ulceration.
  Some days after contamination, the patient feels a burning
towards the meatus, then itching, and  then pain, which rapidly
increases.   The lips,  too, of the meatus are glued together by
thick mucus.   The pain soon extends up the urethra, the entire
length of Avhich it  invades in a feAV days; and it can even reach
the neck of the bladder, where it produces symptoms which we are
not here called upon to study.  We only mention the tendency
of the  inflammation,  commencing  at the meatus, to extend  to
the superior parts of  the canal.   In proportion as the disease
extends, the discharge increases, becoming yellowish  or green-
ish, according to the intensity of the  inflammation,  to a^ain
assume  the  Avhite color of  muco-pus  as  the pain diminishes.
Endoscopic observations have enabled  me  to follow the march
of the disease, and to recognize by the sight [de visu) the char-
acters of the inflammation.   During the first few days, whilst
the disease is in its most acute stage, the examination is impos- 
THE  ENDOSCOPE.
15
sible, on account of the intense pain caused by the introduction
of the sound.  The most recent case that I have examined was
of eight days standing, and it is rarely we can explore the ure-
thra so  soon as that.   At that  period, the inflammation extend-
ed to the anterior  half of the  canal;  through  this extent the
mucous  membrane  was of an intense redness, it is Avithout polish,
and presents the appearance of the superficial which form upon
the glans in balanitis; in other words,  it had the appearance  of
a mucous membrane inflamed and derived of its epithelium.  In
more advanced cases, the lesion does not change its character,
but extends nearer the posterior portion of the  canal.  It fin-
ished, in this way, by successively reaching the bulb, the  mem-
branous portion, and  the  prostate portion, which  I have only
found diseased  after six Aveeks or tAvo  months duration. At
this  period, an important  phenomenon takes place, one which
all of the exterior symptoms would not lead us to anticipate.
The anterior part  of  the  urethra reassumes  its healthy condi-
tion.  In sonrc cases, indeed, whilst the inflammation possessed
all of its peculiar characters in the bulb and membranous re-
gion, the anterior  portion of the canal presents a polished sur-
face and natural  color.  The  prostatic portion, in which this
disease  may also locate itself, Avas also  cured  in many cases, for
it  has frequently happened that I have found the characteristic
lesion confined  to the  bulb, whilst  the  anterior and posterior
portions Avere healthy, in cases which  had presented all the
si^ns of an extension of  the disease to  the prostate  and neck
of the  bladder.   I have several times had occasion  to exhibit
analogous cases in this amphitheatre.
   Reduced  to a limited extent, the inflammation seems  to be-
come deeper seated,  the  redness  of the mucous membrane  is
more pronounced, its  surface  more uneven, its surface  is not
simply unpolished, it  presents salient points more and more nu-
merous, and tends, too, to take on the  characters of the lesion,
that we will soon study in speaking of  chronic blennorrhcea and
of commencing  strictures.  In a word, at  this period  of its
march,  blennorrhagia is  upon the  point  of passing  into the
chronic  state, if it has not already reached it.   We will follow
its ulterior evolutions in our next  meeting. 
16
THE  ENDOSCOPE.
   But I must, at once, cause you  to observe that it is difficult
, jo admit, as has been attempted to be established, that blennor-
 rhagia  propagates itself  by an inoculation, step by step, little
 by little, of the secreted  matter, since Ave see parts retake their
 healthy status and not again become diseased, though constantly
 bathed by the muco-pus coming from uncured portions.
   We can conclude, from these observations, that those authors
 who, like M. Cruveilhier, state that the discharge comes from
 ulceration,  are entirely right, as the mucous membrane presents
 all of the characters of superficial ulceration.  But let us pass
 to  the study of the lesions which may be confounded Avith  the
 one Ave have just described, and let us  commence by recalling
 the fact  that  in  acute  inflammation the local  mucous lesion
 varies little or  none, according to circumstances, and the  dis-
 tinctive local characters scarcely commence  to shoAV themselves
 until the malady passes into the chronic stage.
   Acute urethral inflammations, not blennorrhagic, are due to
 causes  traumatic, herpetic, or catarrhal.  Traumatic urethritis
 is almost always caused  by solid foreign substances introduced
 into  the canal, either accidentally or with a surgical intention,
 sucli as sounds or  bougies, or by  fluids, as injections.   Such
 cases of inflammation are  rarely very  acute; often the  endo-
 scope shoAvs only a simple  redness of the mucous  lining, which
 otherwise retains  its natural smooth condition; if greater acute-
 ness  occurs, the epithelium becomes detached and the red sur-
 face  is at the same  time roughened, as in blennorrhagia.   The
 tendency of the disease is towards cure as soon  as  the cause is
 removed, it  does  not migrate towards the  interior, as Ave just
 described, and becomes extinct through its whole extent at  the
 same time, Avithout contracting upon one point  of the urethra.
 It must be  understood that we are noAV speaking of simple trau-
 matic urethritis, and not  of that which, finding in the membrane
 alterations  consecutive to blennorrhagia,  excites  their reappear-
 ance and leaves them to  continue after they (the traumatic) are
 removed.   This subject will soon be rendered clear by the study
 of the endoscope in blennorrhea.
   Herpetic  affections can,  undoubtedly,  cause acute urethritis. 
THE  ENDOSCOPE.
17
Acute herpes, especially in children and men who have not had
sexual intercourse, is one of the most common causes of balano-
posthitis, and discharges are  frequently met with which it seenl's*
impossible to refer to aught  else than herpetic patches in the
canal.  But, up to  the  present, I have  not directly observed
them, at least in acute discharges, though they may be seen in
the chronic  flow.  I Avill only remark that,  in such a case, the
affection presents all the mobility of acute herpetic  diseases,
and there is such difference in the march and irregularity in the
seat, as sometimes to guide in the diagnosis.
   Catarrhal urethritis seems  to be rare, as I have already stated.
I have only met with two cases in the acute  state, or, if I have
seen it  in other cases, twice I have observed it under  such cir-
cumstances that I Avas perfectly sure contagion had nothing to
do with its etiology.  In my two cases, it seemed like the last
phase of an acute general catarrhal affection;  in one  of them,
then  my  companion and  now  my confrere, the disease com-
menced as a coryza, then extended to the bronchia, then to the
digestive organs; at last, after more  than three weeks, just at
the moment when,  the  intestines throAving  it  off,  the patient
thought himself cured, the fever greatly increased, accompanied
by pain in the kidneys, then a vesical catarrh, and, at last, by
an acute urethritis,  which, in  its turn, disappeared, having re-
sisted both copaiba  and  cubebs.   In this case, and in the other,
which it is unnecessary to  relate, the  urethral pain, starting
from  the neck of  the  bladder,  extended  through the whole
length of the canal, following  a  route inverse to that demon-
strated as usual in  blennorrhagia.  This march, I think, may
be considered as constant in urethral catarrh, and can serve as
a  diagnostic base.
   Though, in  acute urethritis, Avith which  Ave have just been
occupied, the endoscope does not play so important a part as in
the chronic affections Avhich will  be the subject of the ensuing
lectures, I believe,  however, that Ave owe to it the ability to es-
tablish a marked separation between  affections generally con-
founded, and of the diversity  of which,  I  think,  you can no
longer  be doubtful.   This distinction will soon be more clearly
        2 
18
THE  ENDOSCOPE.
drawn, and will enable us to comprehend how an affection, hith-
erto regarded as unique, in spite of the absence of  sufficient
signs, is sometimes contagious and sometimes not, disappears in
one case not  to reappear, and in another returns without appa-
rent cause,  and continues indefinitely without giving rise to
grave lesions, and  at other times terminates in stricture and its
consequences.
                      SECOND LECTURE.
             Blennorrhoea.—Granular  Urethritis.
   Gentlemen :—In our last lecture, we studied the lesions pro-
duced by blennorrhagia, from its inception to the moment when
it  loses  its acuteness.  We will  now proceed to investigate the
chronic discharges  from the urethra, and, as we  reserved  the
name blennorrhagia for  the contagious affection for which it
was created,  so we will call blennorrhoea the chronic discharge,
only, Avhich springs from the same cause, and we will  endeavor
to distinguish from it especially the herpetic discharges, Avhich
have often been confounded with  them, and  which,  by their
lightness,  should be to us only a secondary consideration.
   Discharges of a blennorrhagic character,  though  often so
slight as to attract but little attention,  are  the cause of almost
all strictures, by a mechanism, the study of which we can make
by the endoscope.   If authors have not insisted more upon  this
fact, and if some have not  even perceived  it, it is not only be-
cause blennorrhagia generally presents symptoms too slight to
attract  attention, but it  is also  because discharges  from other
causes, and especially herpetic, confounded with them but with-
out the same consequences, obscured the question and rendered
it  difficult to  perceive the connections.   And this confusion, we
must acknowledge, was difficult to avoid, for, without endoscopic
aid, the symptomatic differences are almost null, and  certainly
not sufficient to establish a diagnosis;  so nothing was  left  but
the march of the disease and the concomitants give us any clue
to its nature.
   We  left blennorrhagia when  it was confined to  the  deep-
seated  urethra, when it was fixed upon the bulbous, membran- 
THE  ENDOSCOPE.
19
ous, and prostatic portions, Avhen, at the same  time, its acute
symptoms were  gone.   According  as  it may persist in either
of these regions, its sequences differ; so we will, at present, in-
vestigate the evils attendant upon the bulbous and membranous
regions, reserving until later those peculiar to the prostate.
  Blennorrhagic symptoms, when once weakened, become more
and more so, so as  ultimately to be  scarcely recognizable or
perceptible.   The pain becomes  more  disagreeable  than  truly
painful, so much so that patients  often compare it to a disagree-
able  heat or burning, to  a weary tickling, deep seated in the
perineum, to  points corresponding  to the bulbo-membranous
portion of the urethra.  This sensation is rarely continuous;  it
generally occurs when  the urine  is about to  be evacuated, and
continues for some time afterwards.  Often it is perceived be-
fore and after but not during  micturition.   Some patients do
not feel it at all; but  most frequently when they say it is not
felt it is for want of attention, which, once called to the fact,
they perceive it,  as do others.
  The discharge follows, in its decrease, the same march as does
the pain; in some lymphatic temperaments, there are a few
drops  of a  turbid, whitish, slightly opaque liquid, which  may
spontaneously escape  from the meatus and not  soil the linen;
but generally this matter  is so scarce that, without  exacerba-
tion, it is completely cleaned out by the urine.  Sometimes  it
can be recognized in the  form of filaments thrown out by the
first jet of urine and found swimming in the urinal.   If we wish
to be  assured of the  existence of this  discharge, it must be
sought for when  the patient has not for some time urinated, and
especially in the morning on awaking; then, in pressing from
behind forwards  it is rare that we do not bring out a  drop of
tenacious  fluid,  limpid, or slightly turbid, small,  usually, but
visible between   the lips  of  the  meatus, which we  also  find
generally glued together by a dry mucus, be it  during the day
or only in  the  morning; or there may exist no trace of dis-
charge, other than viscous filaments, which extend between the
lips of the meatus when they are separated.
  A last sign experienced by the blennorrhagic  patient, is diffi- 
20
THE  ENDOSCOPE.
culty in emitting urine.   This difficulty, often very great in the
acute stage, diminishes and finally disappears, so that the  only
trouble A\rhich remains for some time is the bifurcation and  gim-
let twist of the urinary jet.   These two phenomena, Avhich  only
occur  accidentally in the healthy state, are due to the viscous
mucus which sticks to the walls of the urethra and resists the
first impulsion of urine,  but this is only temporary;  after an
uncertain and unfixed time, the urine is thrown not so far, the
jet  is smaller, the bladder is more slowly emptied, the patient
experiences  a dysuria, which, if left to itself, goes on increasing.
  To the acute  inflammatory  SAvelling which  caused  the  first
stricture,  a chronic  lesion  succeeds,  Avhich favors a  swelling
slow in its  march, but continuous in its progress, and which
will, sooner  or  later, produce stricture  with  all of its conse-
quences.  Hence, we  can foresee that,  in  every blennorrhoea,
there will be stricture.  Indeed, such is the case, whenever the
lesion  is not confined to  the prostate; but we must expect  to
find  a stricture,  as it is  generally  understood, from  the  com-
mencement.  A  stricture, such  as will arrest  sounds and  bou-
gies, is only found at a more advanced period.    When blennor-
rhagia is  near its commencement, the swelling is slight, there
is, possibly, only a rigidity of the inflamed surface instead  of
its natural suppleness and rigidity; it is necessary, for the  pur-
pose of finding an obstacle, to use a bougie of  proper  size,  Avith
a bullet end, and to use it dexterously and carefully; then,  in
advancing upon,  or withdrawing towards, from behind the lesion,
a gentle resistance is felt, and the patient complains of a slight
pain which  he does not experience, save when  the bullet end  of
the bougie is attacking the stricture.
  The bullet bougie also  is capable of aiding us in our diagno-
sis of  urethral ulceration; it is rare that, when it encounters
the characteristic ulceration of blennorrhoea, it does not show
more or less of a bloody tinge, though no violence, sufficient  to
wound the membrane, has been used.
  If we now establish a comparison  between blennorrhoea and
herpetic  discharges, we will  not find, in the symptoms just re-
lated,  sufficient  wherewith to  establish a  positive  diagnosis. 
THE  ENDOSCOPE.
21
The discharge is not different;  the  pain is more itching than
otherwise, but this characteristic, though often well appreciated
by the patient, is too slightly marked for us to attach  much
importance to it.
  The urinary jet is not diminished  by the herpetic plates, and
the bullet bougie does not give evidence of their  existence:  the
first of these signs is absent in commencing blenorrhoea, and the
second is so slightly marked  that its absence should not  affect
the diagnosis.    In  fine, these symptoms,  interesting in  the
study of the disease, cannot enable us to diagnose betAveen the
different species of discharge, if the  endoscope did not aid us in
the discovery of the blennorrhoea.
  In our last lesson, we saw that blennorrhagia, in its chronic
state, fixes itself in the bulbo-membranous portion  of the urethra,
and that the  mucous membrane of the diseased part, at first
simply unpolished, soon  becomes rough and uneven; these ine-
qualities  increase, multiply,  and, in  the end,  become  more
prominent, and  granulations  are formed.  Then the diseased
portion presents a surface dark red,  uneven, sown with rounded
granulations, sometimes  separated far apart,  and then at  other
times so nearly together as to cover  the entire diseased surface.
The membrane,  at this point, presents the appearance of a mul-
berry, according to  the spontaneous remark  of one to whom I
showed the lesion, as well  by reason of its color, as on account
of its  granular aspect.  The granulations vary  in size from a
grain of mustard seed, to that of a grain of millet, or even still
larger; the smallest seem to be of more recent origin.
  In the cases we are now speaking  of, the lesion confines itself
to the bulbous and  membranous  portions of the canal.  They
constitute what  we  may call granular urethritis, which shows
some resemblance to granular metritis, and still  more to granu-
lar conjunctivitis, owing, doubtless, to the fact that, in anatom-
ical disposition and vital condition, the urethral membrane more
nearly resembles the conjunctiva than the  membrane of  the
uterine neck.  It is impossible, when we examine these  three
affections, not to perceive a similar lesion in all,  the expression
of a like malady in three different  organs.   The granulations 
22
THE  ENDOSCOPE.
are almost always of a dark red color, often like wine settlings;
but sometimes I have found in their midst other  granulations,
less numerous, small, and of apparently a greyish  color, such as
might  bring  it still  nearer to the conjunctival  granulations, as
described by M. Wecker.  We will return to this  similitude.
  These granulations may occupy more or less of the length of
the canal, most frequently from a quarter to half an inch, some-
times the  AAhole posterior part, from the termination of  the
spongy portion to the vesical orifice;  but there is one charac-
teristic almost ever present, it  is a unique lesion, be  it ever so
much or so little extended, there is no interruption betAveen its
two  extremities, there  are no isolated  places,  separated  by
healthy surface.  The  granular ulceration is  only found in a
single point, more or less extensive; before and behind the dis-
eased portion there is a redness that diminishes as it  recedes
from the seat of the granulations.
  The herpetic  ulceration is very different, and, with some  at-
tention,  it can  be readily  recognized.   But,  before  entering
upon  this subject, gentlemen, I ought to advise you, that if I
use the word herpetic, it is only because  this species of ulcera-
tion corresponds exactly with the herpetic plates that we observe
upon  the skin,  upon the  lips, and  the neck of the uterus, and
not because I regard them as products of the dartrous affection.
On the contrary, I think that  many of these ulcerations are of
an arthritic nature, according to the circumstances under which
they are produced,  and the characters of the external eruptions
with which they are often allied.  I adopt in this, the ideas of
M.  Bazin upon gouty affections.
  Not yet having the local signs which will enable me to distin-
guish betAveen  arthritic  and herpetic ulcerations,  I  confound
them  together  under the most popular denomination.  Gener-
ally, the herpetic  ulcerations are multiple, they  are found  in
different parts of the canal;  besides, they have a  fleeting char-
acter, such as ajre seen  in aphthous affections of  the mouth  or
on  the uterine  neck.  The  patch which we have  found in our
examination  is not often re-found, but others are found in dif-
ferent  places.   These ulcerations differ from  the  granular spe- 
THE  ENDOSCOPE.
23
cies, by being  generally of much less  extent.  We must add
that the characteristics are different; their surface is not gran-
ular, often it  is only unpolished, as in the case  of aphtha at-
tacking the inside of  the jaws, or in those cases where plates of
epithelium are removed from the mucous membrane, as is fre-
quently the case in the buccal membrane with those who smoke
much.   They  approximate, then,  blennorrhagic  ulcerations  of
recent date, but the characteristics which I have just given you
are distinguishing, and, moreover, we cannot confound  them, if
we remember that in blennorrhagia the  ulceration appears to its
best advantage when  the  inflammation  Is still at its most acute
stage.
  There is still another form of herpetic urethritis, which seems
to be more deeply seated;  of this I have just shoAvn you a case.
The ulcerations presented by this affection vary less, as to their
seat, than the preceding;  they are of uneven surface, and, with-
out  attending  circumstances, a superficial examination  would
induce us to call them blennorrhagic ulcerations, just forming;
but  a more considerate examination shows us that, instead of
prominences,  the  irregularities  are  caused  by  depressions.
Whilst the granular surface may be compared to a mulberry, it
is more  like the depressions which we find  in an  orange skin,
or  in a tailor's thimble.   Before going further, permit  me to
compare  these affections of the urethra with similar  affections
of  the uterine neck.   In this last  organ, granular ulceration is
the same as in the urethra.   Since I commenced studying the
distinctive characters of  this affection, about five years ago, at
the  Loucaine  Hospital, I have never seen, upon  the same sub-
ject, but one  kind of granular ulceration, commencing  in the
lips, or else in the cavity of the neck, and  extending more or
less, but never separated  by healthy surfaces.
   The herpetic plates are most frequently multiple, and irregu-
larly scattered upon the surface of the neck, and often show
depressions and  small cavities, such as we have just described,
and such as we  have compared to  those on a thimble. l When
we examine, on the uterine neck, very recent herpetic eruptions,
we frequently find small vesicles grouped;  but  if on the mor- 
24
THE  ENDOSCOPE.
row an  examination is made, the vesicles are not seen, but, m
their stead, gutters, {papules,) the  formation of which is, to my
understanding, very  comprehensible.   Though  I have  never
seen these vesicles  in the urethra, I  think these same gutters
(capules) should form there by the same mechanical influence;
but they  must be less  persistent, on  account of the  different
anatomical formation of the two  different  organs, and, conse-
quently, less  easily found.   But they constitute, no less, a de
cided point in differential  diagnosis.  The distinction which we
just  established amongst the different characters of discharge,
often confounded, and Avhich the employment of the endoscope
enables us to refer to  lesions of very different  natures, will ena-
ble us to comprehend  the peculiarities which have been observed
in the march of blennorrhoea, as it has  generally been under-
stood.   Blennorrhoea, or granular  urethritis, synonyms, accord-
ing to my view, are partially chronic  in their nature and  tend
decidedly towards stricture.
   The pain, or rather the tenderness, which replaces  it, aug-
ments or decreases with time only; the same is true with  refer-
to the discharge, but  the trouble in discharging  the urine goes
on increasing,  and  dysuria, at first slight, insensibly increases
to an  extreme degree, until stricture is  entire  and  complete.
The course of this disease is affected and influenced by but few
extraneous circumstances.  Atmospheric influences and changes
of the seasons  are without visible effect;  improper diet and fa-
tigue are alike  inert to produce an increase of  pain or discharge,
but sexual intercourse will  increase the violence of the symp-
toms, and often re-bring, for some  days, a sub-acute inflamma-
tion.   When the affection is of long standing, and a stricture,
already formed, is surrounded by an inflammatory engorgement,
too much driving, horseback, or carriage  exercise may increase
the dysuria.  The same is true, with  reference to an excess at
table at  any time, but a few days puts all right, and all goes
on in its uniform order.
   We see, also, discharges which completely disappear and then
reappear, with  all  of the  accompanying pains,  and know  no
reason for it; we see them, not very rarely, break out  once or 
THE  ENDOSCOPE.                    25
tAvice a year, sometimes more frequently, but always about the
same epoch, most frequently in the spring, and  then in the
autumn; and  then, if I follow my own  experience, winter suc-
ceeds, third in order—the hot season is least of others prolific
in such cases.   I  have met with cases  recurring every spring,
for several years, forming Avhat is called repeated blennorrhagia
(blennorrhagia ei repetition); others, I have seen,  after a con-
siderable lapse of time, and especially after a decided change of
weather, to harsh, cold, or damp.   In  similar cases, the endo-
scope will  shoAV in some  part of the urethra, be  it  above or
below, frequently  in  many points, herpetic  patches  such  as  I
have described, but it will not show granulations.   The season
most favorable to the production of rheumatismal  affections is
most favorable to the production of this, thus  I Avill call  your
attention  to the propriety of connecting  these affections Avith
those of the  tegumentary system,  classed by  M. Bazin as ar-
thritic {arthritides).
   Does true blennorrhoea ever reappear?   Decidedly not, pro-
vided  the cure has been  complete; but if  granulations remain
after the external symptoms  have almost entirely  disappeared,
we often find a variety of repeated blennorrhagia (blennorrhagia
a" repetition.)
   For a long time, I  saAV a patient who had left off treatment
before the cure of the granulations.  According to his own ex-
pression, there was a slight humidity of the urethral canal, and
the emission of urine  Avas slightly disagreeable, but so little as
not  to  cause any  especial  annoyance.  Each time, however,
that he had concupiscent connection, he asked of me the aid of
the  endoscope, which always showed  granulations as  large as
ever.  TraAreling,  drives,  and horseback exercise  produced no
effect, but, invariably, sexual connection brought on a relapse.
Similar cases  are not very rare, you have all seen men who can-
not  employ their genital  functions without  becoming subject to
a discharge; whenever I have examined such, I have inevitably
found urethral granulations.
   As I have  already  said, the march  of blennorrhoea  is essen-
tially chronic; we will follow it in our next lecture, up to the 
26
THE  ENDOSCOPE.
moment of its disappearance, after having produced stricture;
but without proceeding  so  far  it may last  months, and  even
years, Avithout losing its granular character.   I will here men-
tion  the particulars of a case in which the granulations contin-
ued for above eleven  (11) years.  I have  seen cases of longer
date, but the following, the first of the kind subjected to an en-
doscopic  examination, furnishes  a  complete example of  the
affection:—
  D. came to me in October, 1855, with an acute orchitis.   He
assured me that  for a long time he had not had blennorrhagia,
but a slight and  clear  discharge remained  as a sequence of an
acute blennorrhagia contracted in 1846.   Generally he paid no
attention to it, but whenever he  squeezed his  urethra before
urinating  in the morning, some  drops of clear but stringy  fluid
were discharged.  I soon found  out  that his urinary jet was
very small, twisted, and fell almost vertically.  The epididymi-
tis once cured, the patient, somewhat embarassed  by dysuria,
submitted to a full examination.   In the bulbous portion of the
urethra, I found, by aid of a bougie, a stricture, the passage of
which Avas  painful and blood came back on the bougie, the re-
tracted  part of  the urethra was about four lines in extent.  I
applied the  endoscope, and found, at the point of the stricture,
an inflamed surface, red, and covered with granulations of the
size of a grain of millet, some larger, some  smaller.   In a word,
the case was similar  to an  affection of the  uterine neck.   In
withdrawing the sound, the granulations disappeared and a tem-
porary redness only remained;  all other  parts  of  the urethra
were healthy to  the meatus.
  Once this lesion found out,  it strikes me  that the nature of
the disease  is explained;  it is easy to comprehend  the persist-
ence of a discharge  kept up by granulations similar to  those
often found in the conjunctiva and uterine neck.   This ulcera-
tion also accounts for the chronic subjacent engorgement AA'hich
produces  the  stricture.   These granulations,  so  often found
notwithstanding what many authors say,  these persisting  dis-
charges often complete dilatation of the strictures to which they
were attributed, and which reappear as soon  as  the use of bcv,
gies is stopped, are the cause of this trouble. 
THE  ENDOSCOPE.
27
  Although I concluded  to treat this lesion of the urethra as I
would  a similar one in the uterine neck, and following from
cause to effect, as existing between ulceration and stricture, I
concluded to use no direct means against the last named.
  The endoscope, moreover, enabled me to act  upon the dis-
eased part, as we do by means of the speculum upon a diseased
uterine neck.  A concentrated solution of nitrate  of silver,
placed upon the diseased points by means of a canula, and the
effects of which I could verify by sight, sufficed.   These cauter-
izations were  repeated every three or four days.  During the
interval, the patient used an injection  of the decoction  of roses
(de peonies).   Though the injection was one  part  of silver  to
three of water, the pain  was moderate.
   This treatment, commenced the 5th  December, 1855, was
continued  more  than a month, when, on  the  25th January,
1856,  I passed the sound into the bladder.  It passed the stric-
ture without  my perceiving any  obstacle, and filled, entirely,
the whole  anterior portion of the urethra.  Thus, it was evi-
dent  that  the stricture  had  disappeared,  simply  because the
granulations had.  I could then examine the whole of  the ure-
rethral mucous  membrane,  from  end to  end.   The prostatic
region was slightly red; this redness was never decided in the
membranous portion, and  towards  its union with the bulbous;
granulations, somewhat ulcerated, were found, but scarcely vis-
ible.   Moreover,  the  patient assured me that he urinated as
well  as  when young.  These  cicatrizations were  sufficient  to
abolish all trace of these  granulations;  then he continued the
treatment  for two days and then  stopped.  A few days after-
wards, the discharge ceased entirely, and  the bougie, upon  its
introduction, met with no obstacle.   The endoscope showed only
a slight redness  in the affected part, and  at the same  time the
stricture had disappeared without any special treatment.  This
case I have watched for eight years, the cure is complete.
    I have  described  to  you,  gentlemen, the normal form and
 appearance of the urethral granulations; but they do not always
 present the  same characters, as  you will see  in the future.
 Really, in many of the granular affections of the urethra, the 
28
THE  ENDOSCOPE.
granulations swell, lose their  hemispheric  form, become softer,
and  take on the appearance of fleshy granulations.   Then, in
the field of  the instrument, we find a surface similar to that of
a suppurating sore.  The movement of the sound will enable us
to judge of the consistence of these conical formations (bour-
geons).   When this transformation  takes  place,  the discharge
becomes more abundant and more purulent, so much so as to
stain the linen.  It seems that the erosion is deeper seated, even
ulcerated, at the same time it much more readily bleeds.   This
alteration may be much more complicated:  the depressions may
become larger, softer, more unequal, nearer  together, and of a
dark red color (lie de vin), the  ulceration takes  on a fungous
form, bleeding at the slightest touch, and of  sweating blood, as
it were, so as to conceal  the other parts;  wiped off, it almost
immediately reappears,  scarcely giving time to see the ulcerated
surface.   It is not  even rare to see these  fungosities bleed so
readily, that the gentle  passage of a bougie may  cause  the dis-
charge of blood from the meatus.   This same form of granula-
tion  is  found in  the conjunctiva, but it is especially and  fre-
quently found in cases of granular metritis.  Thus, we find this
same granular affection in  the  same  organs most frequently
attacked.   When, by means of caustic applications,  the vegetat-
ing character of the surface is lessened, the granulations retake
their ordinary appearance and  furnish  evidence  of the  true
character of the disease.
  We have seen that these granulations last long; left to them-
selves,  they cure, leaving  after them a lesion which remains as
long as a cicatrix after a wound.   Let us now proceed to study
their termination.   They cannot exist without a sub-acute in-
flammation in the mucous and sub-mucous tissues; hence, the
SAvelling of these parts,  and, consequently,  the stricture, a stric-
ture at  first scarcely observable, but which,  gradually increas-
ing,  ends  by becoming  a decided obstacle to  the  emission of
urine.   During an uncertain period, this  swelling, increased by
the infiltration of lymph, not yet organized,  forms  of itself the
stricture.   If, at this time, the granular  ulceration is cured
the ulceration disappears and, consequently, the infiltration and 
THE  ENDOSCOPE.
29
stricture are relieved.  The length of time during Avhich the
tissues may retake their normal  condition is, sometimes  great.
You may remember a case I mentioned to you, in which the
coarctation  yielded  upon the cure of the granulations, after a
continuance of more than eleven years.   Howrever, so long as
this condition lasts, during Avhich the infiltrated fluids are sus-
ceptible of reabsorption, it is impossible that they remain indef-
initely in the tissues without producing  changes analogous to
those which are produced in external  parts vfhich may be the
seat of chronic irritation, such as  indurations or callosities.
Besides, the inflammatory action will have reached the fibrous
tissues which  partly compose the urethra.  Noav we knowr that
the fibrous  tissue contracts under the  influence of slow inflam-
mation ; thus, here is another cause of stricture,  as demonstrated
by M. Guerin.
   When blennorrhoea has reached this point, the endoscope still
shows the existence of granulations, but to cure  them will not
suffice to relieve  the coarctation; the granular  ulceration no
longer controls the morbid effects which it has caused,  and these
effects continue to progress, independent of their exciting cause.
In addition, without proper treatment, the granulations will not
yet disappear.  The infiltrated fluid becomes slowly organized,
new fibrous elements are developed, as also elastic fibres,  which,
added to the fibrous tissue already retracted  by the existing
inflammation, causes the formation of a tissue similar  to that of
a cicatrix,  or, rather,  a true inodular tissue which  takes the
place of the healthy one.
   In this transformation, the vascular element considerably les-
sens, so that the mucous membrane in that part loses its inflam-
matory redness and  becomes paler than natural.  But  this is
not the only change.  The granulations disappear from absorp-
tion,  ulceration, or because of the  atrophy  of the vessels which
nourished them.   As  they  disappear,  the membrane,  whose
structure they have destroyed, takes  on the  appearance  of  a
cicatrix, similar to a subjacent layers.   Then the blennorrhoea
is  ended, the granular urethritis has terminated, and inodular
strictnre takes its place.   It is useless to press upon your atten- 
30
THE  ENDOSCOPE.
tion the parallel Avhich exists betAveen these granular affections
of the urethra and those of the conjunctiva.   Keeping in view
the different  functions of these two organs, we readily  see that
the march of the disease, its  effects, and its termination are
essentially the same in the two cases.   It is impossible to state
the time necessary to heal the affected parts.
   Sometimes, a  year or more  may pass  before  the  infiltrated
material proves  itself perfectly organized;  again, several years
may pass  before the  disorganization of the affection  can repro-
duce disease in Avhich  the termination shoAvs a decided  change.
We have already mentioned a remarkable case, in which granu-
lations continued for over eleven years, Avhich yielded at length
to proper treatment.  But, on the other  hand,  we  have seen
cases with a remarkable slowness in adapting  themselves to
their cause.
   A lieutenant in the French army, contracted a blennorrhagia
in Bohemia, when this proAdnce was in the possession of France,
say in  1813.   When he consulted  me, in 1860, he had  a reten-
tion of urine, which had increased for some years.   Moreover,
since  his  first clap he had no other, but he had always  had
a  slight discharge, to which he had  paid no attention.   His
stricture yielded readily to the passage of bougies; but  from
day to day all that was gained was lost.  I then supposed that
the endoscope would be necessary for  a correct examination and
that ulceration existed.  I really found the membrane very red,
and many granulations, without the characteristic signs of stric-
ture.   In  the  treatment of the  granular affection, attention
must, of necessity, be paid to the ulceration;  but for  the pur-
pose of conquering the stricture, dilatation must  be resorted to.
After  the cure of  these granulations, there is no rapid return,
and thence patients are satisfied in passing, at  long intervals, a
large-sized bougie, which rarely meets an obstacle.   Sometimes
this granular urethritis  may run on  for  forty  years, without
reaching its period of stricture, except at  its second  period or
stricture, where the former effusion is dependent upon  a  perni-
cious affection.   I mention this fact as the longest limit of the
disease, as reported by M.  Ricord. 
                      THE ENDOSCOPE.                    31
                                                           ■
                      THIRD LECTURE.
          Complications of Blennorrhoea.—Strictures.
  Gentlemen :—We have followed blennorrhoea from its com-
mencement up to its disappearance and when stricture succeeds
it.  Before  examining and describing this disease, let us  give
some  time to those cases which may complicate the preceding
periods.   The peculiar complications of blennorrhagia are cys-
titis, ophthalmia, arthritis, and orchitis.   I shall spend but lit-
tle time upon the first three named affections.
  Cystitis is a frequent complication, and  it is well knoAvn that
it does  not  rarely  occur  during  a case of blennorrhagia, and
especially when  this disease takes on a chronic form; but its
connection with blennorrhoea has not been  so decidedly marked.
It sometimes happens, hoAvever, that the inflammation which
accompanies urethral  granulations, extends, by continuity,  to
the mucous membrane of the bladder.   Many times you have
seen patients, treated  for  granulations, attacked Avith cystitis.
There are more than one  case of cystitis that I could mention to
you, Avhich  has  been treated, after longer or shorter intervals,
in various methods, Avithout  good effect,  until the  endoscope
enabled us to see granulations in the bulbous or prostatic  por-
tion of the urethra.  Often it occurs that the cystitis does not
continue after the granulations have been  removed, but in  such
cases  the disease should not have continued very long, for the
vesical inflammation would be too deep seated to cure itself.
Many of the so-called vesical catarrhs are owing to  the same
cause, and are only called so because the  blennorrhoea produc-
ing them has been overlooked.  The herpetic and arthritic dis-
eases may also give rise  to cystitis, such as we have spoken of,
and which reappear from time to time;  a careful study of the
circumstances attending their development may afford us pre-
sumptive evidence of their character, but a very correct diagno-
sis can only be made by means of Avhat the endoscope will show.
  I have mentioned to you a case of arthritis of the knee, the
cause of which Avas veiled  in doubt; this is not often the case;
the  existence of arthritis, when blennorrhagia takes on a chronic 
32
THE  ENDOSCOPE.
form is well knoAvn; granular urethritis, once well set up, may
produce  arthritis, the  cause  of which will be difficult  to.  dis-
cover unless the discharge,  not always easy  to  be found,  is
suspected.
  There  is another  affection,  intimately connected  with urethral
granulations, I  mean  conjunctival  granulations, or, to express
it better, these two  diseases are only one, attacking, at the same
time, different organs.   We have seen that  the cliaracters of the
lesions are the same, and  frequently, Avhen showing to ophthal-
mologists the disease, by aid  of the  endoscope, they have recog-
nized it as similar to the disease they were accustomed to study
and  treat  on  the  eyelids.  There are at present, in Ward St.
Peter, several cases of granular ophthalmia, so  that you  can see
for yourselves that the  appearance of the conjunctiva, thus
affected,  is precisely similar to the urethral surface, subject  to
blennorrhoea.  Appearance,  however, is  not all  that identifies
them;  these tAAro different maladies  will each produce the other.
It is a well-known fact, that the blennorrhagic urethral discharge
will  produce a  blennorrhagic  ophthalmia; this ophthalmia,  if
prolonged, becomes granular, as in the urethra.   I have several
times been enabled  to observe this.
  Amongst others,  was a woman, treated in the special  dispen-
sary, for blennorrhagic ophthalmia.  The  treatment applied  at
each consultation, but remitted in the interval, certainly much
relieved the disease without curing it, and it commenced to take
on  a more chronic condition, when she was admitted  into my
wards at the Cochin  hospital, with double pannus and  corneal
ulceration.  A continued and energetic treatment brought about
a cure, but conjunctival granulations were observable.
   The contagion is not confined to the acute stage,  it can take
place during its chronicity, as Professor Thircgtias amply and
ably demonstrated.  He  has reported cases of conjunctival ul-
ceration, produced by accidental inoculation from urethral gran-
ular inflammation, and he has also produced granulations in the
uterine neck and in the urethra by thus inoculating the secre-
tion from  the conjunctiva.   I have already draAvn  your atten-
tion to the identity of these two  affections; the same is true 
THE  ENDOSCOPE.
33
with reference to their symptoms.  In the case of  each, there
is much pain, and considerable discharge of the same appear-
ance in the acute stage; in the chronic stage, the pains are ab-
sent, the secretion  scarcely observable, unless some  accidental
cause occurs to increase  the affection.  Thus the disease may
often pass unperceived until its grave effects are made evident.
  The affections most frequently complicating blennorrhagia are
orchitis or  epididymitis.   Since my attention has been  called
to this subject, and  I have been  enabled  to closely investigate
the characteristics  of blennorrhoea, I have not seen  a  single
case of epididymitis connected with urethral discharge,  unless
such  discharge  was connected with bulbous, membranous, or
prostatic granulous inflammation.   Under the effect  of catheter-
isms, the  testicle often becomes painful and inflamed,  but  this
inflammation is generally slight, and Avhen it does become severe
is generally caused  by irritation  due to the passage of sounds.
Epididymitis, does  not come on until  the blennorrhagia takes
up  its chronic character.  You have  studied it in this  phase,
and it is needless for me to speak to you more about it, but let
us look for a moment to the course of granular urethritis in its
full chronic state.   It may present its acute or chronic symp-
toms so far as granulations are concerned.   The first subject of
urethral granulation  which fell  under my  observation, com-
plained only of epididymitis, the blennorrhceal  cause was  so
ancient that it dated back eleven  years.
   In such  cases, Avhere the specific symptoms are  not readily
perceived,  it not rarely occurs  that orchitis  is attributed  to
mechanical irritation or to epidemic influence, most frequently,
however, the epididymitis, of blennorrhagic origin, is as chronic
as its cause.  It may continue for an indefinite time, apparently
relieved, again  to appear, taking on a sub-acute  character and
simulating  tubercule of the testicle.   Often have I seen such an
error  committed, and that too by distinguished surgeons, and
without the aid of the endoscope it may occur to all and  at any
time.
   A person affected with clap, so slight as not to be perceived,
       3 
34
THE  ENDOSCOPE.
may be  taken, without apparent  cause, with scrotal  pain, the
epididymis becomes swollen, effusions often form in the vaginal
tunic, and the skin  becomes red;  but instead of increasing, all
of these symptoms soon decrease; however, pain of  slight de-
gree continues for some days, and the tumefaction may remain
for two, three, or even more weeks.  At length the  inflamma-
tion disappears, but the testicle  long remains tender, and the
swelling leaves behind an induration, not so well determined as
in inflammatory epididymitis.   We may conceive that the cure
is perfected, but it is  only temporary;  it  may continue for a
greater  or  less length  of time, be it weeks or  years, but sud-
denly the  disease reappears, follows the same phases,  and, in
again disappearing,  leaves a fresh  inodulation, the seat of which
is not so well defined as in  the acute affection.   The result is,
that after  several relapses, the testicle  takes  on a  condition
peculiar and  not easily described (englobi  dans une masse  bos-
siler), or in other words, it becomes more or less a tuberculous
or  nodular  mass, bound together, hard,  often insensible, then
painful, and then increasing in size.
   When the disease commences, it is more or less similar to a
case of  tubercular orchitis;  later on, it  is difficult to tell if or
not it is a case of tuberculous testicle.   The only circumstance
that can be used as a diagnostic remedy for this error, is the
fact that  tubercles rarely last so long without  becoming soft-
ened and ulcerated.   But  it  is not  rare that  these symptoms
are so simple, they  sometimes become more serious, the  inflam-
mation  may become phlegmonous, in them there is  formed a
swelling of red  appearance, shortly becoming fluctuant, which
opens spontaneously or is opened by art, pus escapes,  the  in-
flammation subsides, the pus becomes serous, and the opening,
for weeks, remains fistulous.   I  have  seen many such cases.
Years ago, such cases were pronounced  tuberculous, and only
after long study have I been able to correct an error  into which
I had fallen.  It must be conceded that the symptoms in these
cases are more or less  deceptive.   Let me call your  attention
however, to the nature of the pus, as bearing upon  correct di-
agnosis;  cicatrization  is  slower than  in  softened  tubercles; 
THE  ENDOSCOPE.
35
and, lastly, after cure of blennorrhagic orchitis we do not find
these hard cords which enable us to trace  tubercular fistulas,
even  long after they are cured.   This, however, does not fur-
nish sufficient  ground upon which to base a  diagnosis.  The
watery discharge from  the urethra, be it ever so  little, might
be  relied upon, but, unfortunately, when tubercle takes  hold
of the testicle, it often, at the same time, attacks  the prostate,
and this causes a discharge similar to that in simple granular
urethritis.
  Now, the endoscope comes into play and  clears up the ques-
tion, brings light out of darkness;  there can be no doubt as to
presumptive  signs, when we are able  to see the granular ero-
sions in  the urethra.  In such cases, with a sure diagnosis, the
treatment is readily fixed upon—combat the testicular engorge-
ment, and attack the disease  in the canal.  In every case that
I have seen, the epididymitis ceased upon the cure of the ure-
thral granulations.
  We will now resume the history of blennorrhoea.  The endo-
scope furnishes us  the means of recognizing the characteristic
local lesion, and by its aid we are enabled  to  separate  it from
affections simulating it in their exterior symptoms, not very
defined.   Once the  disease well defined  and  disembarrassed
from all that obscures its history, we are enabled to decide upon
its march, its  termination, and  its  peculiar complications, and
also to distinguish  between it and such affections as may simu-
late it.   Now we will pass  on to the study of its etiology.
  The different authors assign many causes  for  blennorrhoea
and blennorrhagia, about the same thing.   First, comes conta-
gion,  or intercourse with  an  affected person, excessive inter-
course with a well person,  onanism, traumatic  irritation, cathe-
ism, irritating  injections,  any and all  female discharges, chan-
crous pus, irritating or relaxing food, and especially asparagus,
which I think most innocent, drinks, such as beer and tea, and
some  such medicines as cantharides.  You may add to these
the  internal causes, such as the development of the teeth, worms,
dartrous affections, certain different temperaments,  the different
seasons, and variations of temperature. 
36
THE  ENDOSCOPE.
   We might say that the causes of blennorrhagia are as multi-
ple as general pathology reports in its chapter on etiology, and
we may well be astonished  that every one is not affected with
it, or, at least, that  it is not more frequent  than coryza, which
recognizes but  one  cause.   If Ave properly appreciate these
causes, and apply to them  the knowledge we possess, we Avill
perceive  that  some  have only an imaginary influence,  and
others, though capable of producing a urethral discharge, do
not give rise to specific blennorrhagia, either acute or chronic.
This can only be brought about by contagion, by direct contact
with the fluid secreted by a  similar nature.
   I have  shown you hoAv I became  acquainted Avith urethral
granulations,  the characteristic anatomical  lesion of blennor-
rhagia or  its synonym, granular urethritis.   I have been able,
often, to recognize the presence of granulations in the urethra
and in the uterine neck, in cases of persons cohabiting together,
and reason has taught me that in such cases they were conta-
gious, even when I was first acquainted with the work of M.
Thiry, of which I have spoken.   This learned surgeon, who had
in view,  especially,  diseases of the  eye, recognized  the  con-
tagious  character of conjunctival granulations.   M.  Wecker,
and other ophthalmologists,  admit  this contagion, but as one of
the numerous causes of trachoma,  whilst M.  Thiry considers it
as the only cause, and he  has seen it carried  not only from  one
eye to another, but also  transferred from  the genitals  to  the
eyes.   Accidents have shown to him  that this disease of  the
conjunctiva is produced by the  inoculation of the muco-pus fur-
nished by the urethra, or  uterine granulations.   By  way of
experiment, he has  transposed the muco-pus from the eye to
the urethra and also  to  the uterine  neck, and the result  has
been  the appearance, in  each  case, of  similar erosions.   I do
not think he was supplied with means to examine  the interior
of the canal, and, consequently, could only infer the existence
of a disease  identical  in its nature, producing granulations in
different  organs susceptible of  attack,  and  proved that  these
granulations were the result  of a contagion whose agent was the
granular virus (virus granuleux). 
THE  ENDOSCOPE.
37
   M. Thiry's ideas and mine are alike, only his ideas are based
upon a more general and direct experience.   Mine are founded
upon clinical observation, aided by the endoscope.
   My first observations demonstrated to me granulations caused
(remontant) by blennorrhagia.   I also Jfound  this affection the
basis of  all granular urethritis, and when I followed it by the
aid of the endoscope, as you can also do, I saw the development
of the granulations  at a certain period  of the disease.  Often,
at the Lourcine Hospital, in patients affected with blennorrha-
gia, granulations of the uterine neck have visibly formed.  You
may have often observed this, and I  have already called  your
attention to the fact that non-specific affections of the neck do
not give  rise to it.   Hence, the natural  indication is, that  blen-
norrhagia, blennorrhoea, and granular urethritis are the  same
disease.   This disease is transmitted  by a virus, a virus which
is the active hypothetical principle of  the contagious pus;  it
might be called  granular virus, but as we generally distinguish
the virus by the produced  disease, and not by the anatomical
lesions, I prefer the term  blennorrhagic virus (virus  blennor-
rhagic).
   In its acute stage, the contagion is by no means doubtful;
but such is not  the  case in the chronic  state.  Unfortunately,
blennorrhagia is  not  generally regarded as  contagious,  and
hence it results that the evil, wherever  its seat may  be, in the
conjunctiva, the urethra,  or the uterine neck,  propagates itself,
unless the necessary precautions are used.  This contagion  is
certain, and especially in acute blennorrhagia.   M.  Thiry has
demonstrated that, be the secretion of conjunctival granulations
as feeble as possible, it  is  inoculable as soon as enough  of  it
can be collected; and, with my experience, I can state that the
chronic form of  the  granular affection is transmissible from one
sex  to the other.  From man  to woman,  I have so often  seen
uterine granulations appear, as a consequence of granular ure-
thritis, that no  doubt  can  exist, in my mind, on the  subject;
from the woman to  the man, many times, I have seen patients
affected with blennorrhagic discharge, contracted from women
who  were not exposed, and who were only subject  to  a slight 
38
THE  ENDOSCOPE.
leucorrhoea, and  in whom  I have been able to  find, by aid of
the  speculum,  evident  marks  of granular metritis.   So  the
granular affection, in its chronic state, is inoculable, and though
such is frequently the fact, it would occur much more often if
the secretion Avas not so much attenuated as sometimes  to  be
incapable of reproduction.   You can readily imagine that after
the canal is well washed by the Aoav of urine,  it may require
several hours for the discharge to become so virulent as to  be
able to reproduce the disease, in other words, to become  inocu-
lable.
   The chronic  affection often transmits its chronic virus;  but
it  sometimes gives rise to acute blennorrhagia, most frequently,
however, from various causes, or  from  the excitation accompa-
nying  the act of  infection, the disease takes  on  its acute char-
acter and thus  transmits it to healthy persons.   The return of
the affection from chronic to acute is not a necessary result, for
we often  see blennorrhoea producing blennorrhagia.   I have
seen several examples of it, but will only mention the following,
because the circumstances caused me to  doubt the possibility of
transmission:—
   T., aged twenty-eight, an employe, after several badly treated
blennorrhagias, was subject to a slight continuous gleet, accom-
panied by a tickling sensation in the urethra.   These symptoms
always increased  after connection.   Having gone through sev-
eral different courses of treatment, he took, for  two  days, Cho-
part's  lotion, and  then  entered the hospital with an orchitis.
Of the testicular  affection he was soon cured, and left with  the
blennorrhoea still  on him.  Some months after,  persuaded that
the discharge,  scarcely visible, could not be contagious, he mar-
ried.   Shortly after, I was called to see the bride, a woman of
irreproachable character, and I at once saw she  had  one  of  the
most violent  cases of  blennorrhagia I  had  ever  seen.   The
vulva,  the vagina, and the  uterine neck were all attacked, and
in every point accessible to sight,  there were  the  superficial
erosions  characteristic  of lost  epithelium, the loss  caused by
blennorrhagic  inflammation.   The diagnosis  was very evident.
After  a  few days, granulations  commenced to  appear on  the 
THE  ENDOSCOPE.
39
uterine  neck.   When I saw the husband, he was only affected
with a blennorrhoea, for which he had previously consulted me.
He assured me his  disease had never been followed by acute
sequences, which, moreover, could not have  disappeared in  that
time; by  an endoscopic examination, I  found extensive  granu-
lations  in the  bulbous  portion of the urethra.  Thus, we  see
that a  blennorrhoea, without retaining  its acute character, has
caused  a true blennorrhagia, or, if you prefer the expression,  a
chronic granular urethritis,  the  contagion  of which produced
upon the  woman the acute granular  affection.
   If we  take a retrospect of what we have said upon the eti-
ology of  blennorrhoea, we must conclude that it is always the
result of contagion, whether it commences in its acute or chronic
form, or if the  virus is blennorrhoeic  or blennorrhagic.  If other
causes  than contagion  have been assigned, it is that different
affections have been confounded,  but  the endoscope  always
shows  the characteristic granulations.   We have already seen
that, in these  cases, the discharge is often  kept up by an  her-
petic or  arthritic cause.  But, perhaps, the error is more fre-
 quently caused by the fact that  the patient was the subject  of
 granulations which might be called latent, and which  excite-
 ment might bring into  the acute stage; and thus may be  natu-
 rally explained those cases  quoted  of  true blennorrhagia  con-
 tracted by intercourse with a healthy person.  In addition, I
 have often seen persons  believing  themselves cured  of an old
 affection, who dated their present  attack to only a few  days
 back, but the  endoscope has shown, in such cases, granulations
 of a date evidently anterior.
    There  is, however, a block here,  gentlemen; some  of you
 may tell me that you have observed granular  metritis  in cases
 where blennorrhagic influence could not  be  suspected.   How
 do you know  this?  Your patients were above suspicion.   Are
 you very sure that  their husbands had not  preserved an old dis-
 charge,  of slight sweating character, the result of former affec-
 tion, forgotten and difficult  to discover?   Have you examined
 them?  Are  you sure  there were no granulations in the deep-
 seated portions of the  urethra?  For  my  part, I am sure that 
40
THE  ENDOSCOPE.
your patients are affected with granulations, and I am equallv
certain they have been contracted by contagion.
  But call to mind, if you please, what  I told you  in my last
lecture, and see if you have not mistaken for these granulations
others of a fleshy kind, caused by a very natural, but very differ-
ent species of  complaint, the appearance  of which  may be
changed  by accident, or may you  have been deceived  by an
optical delusion, such as I have advised you of, and of which I
was long the victim, and Avhich makes  us mistake  the granular
concave  depressions of an herpetic eruption for hemispheric
enlargements.  At  present, I will drop  this subject, as  it will
necessarily come up again when we take  up  the uterus;  only I
will call upon the testimony of my oAvn students to testify that
they have rarely seen  granular metritis since  they  have been
able to recognize herpetic ulcerations on  the uterine neck.
  Before stating a  treatment for a  disease, it is  necessary to
have it defined, to eliminate  all that can simulate it,  because,
no matter Avhat name it takes on, in these affections of  different
natures, it is easy to understand that what is well in  one case is
bad in another;  we  mean  that, generally, therapeutics become
more simple as  the  disease,  better  studied, disconnects  itself
from all that might  be  confounded with it.   When I was a stu-
dent of medicine, one  of  our professors said  that, "the  more
remedies proposed to  cure any  one disease,  it was sure  that
none good  had been found;"  and this  just reflection is appro-
priate to such a disease as the blennorrhoea of the authors, in
which they have united many different affections  having only
one common symptom and one common seat.   If you are of the
opinion of this professor, you  must believe that there is no good
remedy against blennorrhoea.   I will not mention here all the
various articles used in injections, nor  the different formulas of
cubebs,  copaiva, or  turpentine, doubtless very good when the
disease has lost its violence, but which  I  have never seen cure
the granulations once established.  These authorities have been
imposed  upon by the fact  that  the remedies used temporarily
checked  the discharge,  and thus thought it to be cured; but
for  my part, I have always seen it recur upon the cessation of 
THE  ENDOSCOPE.
41
the treatment.   Question your patients, and you will learn that
most  of them  have  uselessly  employed  such means  during
months, and sometimes years.   The inability of ordinary treat-
ment  led to irritating injections, called caustic, in hopes of pro-
ducing  a  neAV  inflammation to supersede  the original chronic
one, and thus to bring about a cure.  This mode has been pro-
nounced successful, I have never seen it so; and, often, patients
tell us that after cruel suffering, when the artificial inflammation
ceased,  the blennorrhoea reappeared with  increased vigor.   It
is easy  to account for this Avant of  success; in fact, the injec-
tions  are  too weak to  modify the granular  surface, and  too
painful  for the patient to submit  to them  as often and  as con-
tinuously as  may be necessary, for it must be borne in mind
that  granulations yield only after a long  time.  The inability
of these rational means has caused the admission of others, the
constant  failure of which has alone been able to  preserve.
It has  been stated  that a new blennorrhagia  in its acute form
will overpower  an old one, and that both will cure  together.
It is difficult to understand  such  an idea; for my  part,  the
result of  my observation shows that  the  patient who  grafts a
blennorrhagia  upon  an old  blennorrhoea  is very fortunate if,
the blennorrhagia  passed, he  does not  find  himself  worse off
than  before.   It has also been stated that, once the disease has
reached its entire  chronic state,  it may be cured by cohabita-
tion; some authors  add,  that  all contagion  has disappeared.
The discharge  is always contagious, as much  so as  is granular
ophthalmia;  and, besides, occasion is not wanting to the result
of this practice, so pleasing to the patient.  Never  have I seen
a cure  by such  advice, but, on the  contrary, a few  days will
show the  disease to be aggravated and  prolonged.   Thus we
say, by force, that urethral granulations are not subject to or-
dinary  therapeutics as a means of cure.   This compels us to
agree with Chomel,  Avho  said  of uterine  granulations,  " they
will not yield except to certain topical remedies, and especially
to  cauterization."   Once knoAving the  lesion which  keeps up
blennorrhoea, it should be easy to treat  it.  It is the  same  that
* pplies to other granular affections,  such as  are successful in 
42
THE  ENDOSCOPE.
granular metritis or conjunctivitis, in other Avords, cauterization.
  How should  this cauterization be practiced?  To this  end,
strong injections have been employed, even of  nitrate of silver
passed into the canal in its fused state.  We have already spo-
ken of injections;  they are too feeble to act efficiently, and too
painful  to be continued, and, if made more strong,  they would
increase rather than diminish the disease, by attacking healthy
parts.   So far  as  the porte caustic  goes, it blindly attacks all
parts,  those  Avell  and  those affected, and  this  the  surgeon
cannot foresee;  even the granulations, if it should reach them,
are but slightly affected, too strong at one place and nothing at
another.   I must  add, that I do not believe that any surgeon
is sufficiently courageous,  or any subject sufficiently patient to
submit to such  treatment, as  long as might be necessary for a
cure.
  What we cannot find out by ordinary means, the endoscope
will afford us surely and easily.   The instrument, made to  bear
upon  the  diseased parts, permits us  to judge of  the portion
attacked and to cauterize it; it is enough to reach the diseased
parts  and then  to apply the caustic direct, thus preventing its
contact Avith others not  affected.   I  prefer, as  a  caustic, the
nitrate of silver, one which I have often used in like diseases of
the womb, after having tried many others.  The liquid caustic
has the advantage of reaching the  anfractuosities, of acting
upon  all without  touching any too much.  I have tried the
solid  stick, applied  through the sound of the endoscope, but  it
burned too deeply, and caused eschars upon the points touched,
whilst others were not affected in this way.  So it  has the in-
convenience of  acting incompletely,  and of causing  loss of sub-
stance, and  of  thus causing  the patient to become a victim of
almost certain  stricture.   All of these I have abandoned, and
now use the azotate of silver  in solution, say from one-third to
equal portions.   (Iy.  Azot. arg. chrys.  5 or 15 grammes to 15
grammes of water.)  This solution never produces eschars, it  is
rather catharitic than caustic, and,  if I do use  the word caustic
in speaking of its  employment, it is only that none other more
appropriate, has yet been adopted. 
THE  ENDOSCOPE.
43
  The application is very simple:—When the lesion to be at-
tacked has been discovered  at  the  end of the sound, clean it
well with dry cotton wool, carried in on a probe more or less
long, then, in like manner, cotton saturated with the solution
may be applied directly to the parts and left in contact with
them for some moments before being withdrawn.   This  opera-
tion should be employed whenever  granulations are found.   The
points touched immediately become whiter and the granulations
more apparent.   One fact, Avell worthy of mention, is, that the
patients experience  but slight pain;  frequently they only com-
plain of slight heat in the touched part.   M. Wecker also
makes the same remark in reference  to the cauterization of the
conjunctiva.   After each cauterization the emission of urine is
painful, but  this pain,  always  bearable, though sometimes se-
vere, diminishes with each discharge, and most frequently dis-
appears on the following day.   Cold lotions, applied externally,
tend much  to calm it.  It is, moreover, necessary to bear in
mind that a certain  degree of inflammation is necessary for the
destruction of the granulations.   At the commencement of the
treatment, the cauterizations should be repeated every three or
four days; later, when  the granulations have  disappeared and
only a roughened surface, caused by erosion, once a week will
be often enough to  apply them.   If  the ulceration is covered
with fleshy  granulations,  especially if they  are fungous and
easily bleed, they should  be touched with a strong solution; in
such cases,  equal parts of nitrate of silver and distilled water
become necessary.
   As a consequence of  this cauterization, I have but rarely met
with a slight febrile  attack, or a commencing orchitis.  A little
sulphate of  quinine will  meet  all the exigencies of the  first,
without  interrupting the  treatment; for the  second, I  have
never been called upon to suspend  the cauterizations for any
length of time.
   Repeated  cauterization is undoubtedly  the most essential
part of the treatment, without which  a cure cannot be obtained,
still it is well to join to it other adjuvants, which are not want-
ing in efficacy and utility.   In uterine and  conjunctival granu- 
44
THE  ENDOSCOPE.
lations, injections and collyria are useful aids; so injections
into the urethra  should  be added to the  cauterization, though
the frequent washing of  the canal by the urinal discharge ren-
ders it less  necessary in the urethra than in the vagina.  I
have tried many injections and have concluded the almost exclu-
sive adoption of the decoction of roses of Provins (a French town)
the best.  Though of slight astringency, this injection seems to
be capable of producing as much effect as  more powerful astrin-
gents,  and  it has, besides,  calming qualities which diminish the
pain of the  treatment.  It may  be  said, in  addition, that,  if
some of it should  reach the bladder, no harm will result, and,
after what we have said as to the seat of  the granulations, it is
evident that an injection limited only to the anterior portion of
the urethra is simply useless.  When the granulations have dis-
appeared  and a   kind of watery discharge  alone  continues,
stronger astringent injections may be advantageously used.   In
such cases,  I employ  sulphate of zinc, acetate  of  lead, alum,
krameria, and tannin,  in one word, all the substances employed
in like cases, but  of a weak strength.   Baths, also, are useful.
I generally recommend one to be taken  after each  operation.
They bring  back  the  local and general calmness, disturbed by
cauterization, and most especially in nervous patients.
  Generally, I do not advise any interior treatment.  I  have
tried diuretics and alkalines, for the purpose of acting upon the
local affection through but without avail, unless the liquid (urine)
is so charged  with salts as to be unusually irritating.   In such
cases, mineral water, of an alkaline character, to my thinking,
is the best.
  As  for  diet, such  as is generally  used  is  the best, and,  if
necessary, tonic, in weak or lymphatic cases;  liquor, wine, and
strong coffee are   to be avoided.   These  excitants  are always
injurious.   I have often seen the case set back by  improper
indulgence.
  But  this is not  all, sexual intercourse must  be forbidden not
only a  little, but any.  A single infraction of this law will often
materially interfere with the cure, and loses all the good done by
previous treatment.   I have often seen that when the patients 
THE  ENDOSCOPE.
45
were not continent, simply by the  inspection of an ulceration,
previously in the way of rapid cure, thrown back, very red, and
bleeding at the slightest touch.  I have also seen patients keep
up the disease for a long time, and render all treatment inert,
until  they have  consented to be utterly abstinent in all sexual
relations.  Thus,  you  will  see how  I differ from those  who
recommend this  as a curative  means.
  This  treatment, Avell and   thoroughly  carried  out, all  of
your cases will be cured.   Up to the present, I have yet to see
the first resisting case, Avhen it has  been sufficiently continuous;
but you must bear in mind that the cure requires a long time,
so inform your  patients and demand their aid.  The  granular
affection does not change its character in changing its seat, and
in the urethra, as in the conjunctiva, or  in the uterus, a cure
must not be expected in less than two or three  years.   (Sic.—
Is it not months?  Trans.)
  To fix the period for  the cessation of the treatment, is a del-
icate matter; as long as the sound is  introduced, or nitrate  of
silver is applied, so long the discharge will not cease, injections
even will keep it up to a certain extent.   The only guide is the
appearance  of the ulceration.  When the mucous membrane
has retaken  its naturally  smooth and polished  appearance,
though  still slightly red, when the nitrate only pales without
much whitening its surface, all cauterizations may be  stopped.
Then I  continue, for a short period, injections, soon to  quit
them, for the  purpose  of keeping  up only the  hygienic treat-
ment  before spoken of,  and  that as long as possible.   The dis-
charge  soon ceases of itself.
  Up to the present time, we  have only studied discharges due
to granular affections.   I do not, however, wish to stop without
a few words on  the  treatment of herpetic  and arthritic affec-
tions.   I have already  shown  you  how the endoscope  exposes
true blennorrhagia; you  will naturally recollect that, without
the aid  of this instrument, the distinction between the different
discharges is impossible, and  you can only reach them by pre-
sumption.
  The diagnosis in such cases is still more difficult and impor- 
46
THE  ENDOSCOPE.
tant,  from the fact that the herpetic affection often follows
granular urethritis.   We often  see herpetic plates  developed
upon  the  vulva, the vagina, the  glans  penis, and the  prepuce
as a consequence of vaginal blennorrhagia and balano-posthitis,
or of  the  irritation kept up in those parts  by chancre.  The
relation existing between these diseases is, one acts as the cause
of the consequence, and  causes  the  second; it  does not less
certainly follow that a  discharge continues and  distresses the
patient, Avho cannot tell the difference which has taken place in
his condition;  moreover, the herpetic discharge is one to be rid
of.  In this discharge, the treatment should not be the same as
in granular urethritis.   In one,  the general  treatment is sec-
ondary in effect; in the herpetic, it is primary.  It is necessary
to attack the dartrous element at once, and  by the most appro-
priate remedies;  alkaline baths,  depuratives, alkaline  mineral
waters, Fowler's solution, etc.  I do not propose  to insist upon
the same  treatment  that may be found  necessary in herpetic
and arthritic affections located differently.  As a local applica-
tion, the nitrate of silver does not do well in these cases; fre-
quently I have seen it increase rather than diminish the disease.
So I have quit its use and now employ the oil  of juniper, (cade,)
applied to  the herpetic  plates, the effect of which seems to  be
favorable.  As for injections, astringents seem to answer well;
but the best  are composed of oil of  cade and oil of almonds,
compounded in the proportion of one-fifth or one-tenth of the
oil of cade, otherwise, employ mild alkaline injections; sulphur-
ous injections are also beneficial.   Heat, completely inert in
granular urethritis, is very useful in this form of the  disease.
  I must press upon your attention here,  the fact that blennor-
rhoea  is an important element in many severe affections of the
urethra, and also because the endoscope furnishes means of dis-
tinguishing granular urethritis from other discharges.
  In some  patients, of  a soft and lymphatic  temperament, the
mucous membrane of the urethra and of the vagina becomes the
seat of hypersecretion, which may often simulate blennorrhagia.
  The endoscope will aid us to a correct diagnosis.  Astringent
injections  will stop the discharge in such cases, but  it will re- 
THE  ENDOSCOPE.
47
appear  on the cessation of the treatment.  The only rational
treatment is the use of general and generous tonics, and, Avhen
possible, sea-bathing, stimulating mineral waters, reconstituents,
sulphurous, iodic, or saline; the choice of these must depend
upon the temperament of the patient.
  I have treated  long upon this disease, blennorrhoea, because
of its important  bearing upon many urethral diseases, and be-
cause the endoscope will  enable us  to study it  by a  ucav light,
showing us  the granulations giving rise  to the discharge, and
enabling  us  to apply  directly the  proper remedy.   We  must
now study the strictures  it produces, when not arrested  suffi-
ciently  early.  In my  next lecture, I will take up that subject
and  demonstrate to you the use of  the endoscope  in the prem-
ises, as to exploring and treating confirmed strictures.
  Up to the present time we have been entirely occupied with
the consideration of granular  urethritis, and no  mention has
been made of  strictures as a  consequence.  I have kept  back
their history, so as  to  present it all at once, and draw the line
of demarcation between  those and  others of a traumatic  char-
acter, lesions, different in their origin but like  in their conse-
quences, symptoms, and indications of treatment.
  If, in investigating  blennorrhagia, and  the consequent  stric-
tures, as a single affection, commencing  at the time of conta-
gion, you Avill  necessarily be led  to the  conclusion that  there
are three different grades  in the  march of the disease, each of
which tend to stricture.
  The  first stage is blennorrhagia, or acute inflammatory  stric-
ture.   The last makes a fibrous, inodular, organic  stricture.
  Intermediate, between  these, a condition occurs, which  pre-
pares the transition from the first to the third.  As Alph. Robert
said, in  his report to  the  Medical Academy, in 1852:—"Be-
tween the acute primitive  inflammation, characterized by redness
and swelling of the membrane of the urethra, and the consecutive
stricture, characterized by a fibrous cicatrix, there is a period
transitory, which is neither inflammatory  or  that of properly so-
called stricture."
  This period, indicated by Alph.  Robert, can only  be recog- 
48
THE  ENDOSCOPE.
nized by sight; to do so, the- endoscope is essentially necessary.
It has taught  us  the existence of a granular urethritis, which
could only be taught by an instrument  like the endoscope.   Let
us rapidly run  over the three different species of stricture, one
folloAving the other, and all preceding  the inodular.
  During the acute period of blennorrhagia, the swelling of the
mucous and subjacent textures form a  decided temporary stric-
ture, and the Aoav of the  liquid is so  painful  that it causes a
spasm, adding  to  the difficulties of emission.   Thence, a  com-
plete retention  occurs.   It may happen that the passage of the
urine becomes  impossible, and the interruption become  com-
plete;  we call this acute inflammatory stricture.   Except  in
such cases, rare,  Avhich demand a decided  and especial  treat-
ment, catheterism  Avas all  that  Avas necessary.
  It so happens, however, without going back to granular ure-
thritis  that blennorrhagia  gives rise to permanent stricture.   In
these cases, the inflammation  in some  points becomes intense,
and  is readily  observed  externally  by  its painful nodosities.
The tissues are too profoundly changed to again take on their
natural formation; sometimes the urethra becomes  inextensible
and forms what is  often called a chordee, the cord  breaks, and
the urethra  is torn.  In each  case, strictures form, which be-
come inodular; these strictures occur  early; they  are more or
less spasmodic  in character;  sometimes  persistent and then,
again,  retractile;  they  are organized under  the  influence  of
much irritation, and the inodular tissue retracts  in the irritated
parts as  in a burn.  At  this  period,  so far as  the endoscope
shows us, the urethritis has not  reached the bulb, but is confined
to the spongy portion of the urethra.   This, I think, will fullv
explain the remarks of many  surgeons, who have stated that
stricture of the  spongy part of the urethra  Avas more difficult to
dilate,  and more liable to be torn than  in other parts of the ca-
nal.  In other  respects, all strictures  are of an inodular char-
acter.
  Granular urethritis  once set up, we have seen  how it con-
tinues the swelling of the  urethral  walls, and the inflammatory
retraction of their  fibrous elements; the resulting stricture may
well be called chronic inflammatory stricture. 
THE  ENDOSCOPE.
49
   The disease may long remain in this condition; the granular
ulceration  may exist  at  the  same time  that  there  is decided
stricture, as  I  have told you, and as you have opportunities of
seeing for yourselves.   So long  as  the  endoscope  shows the
characteristic ulceration, we are  apt to hope, in causing  it to
disappear, that the disease is cured.   But it sometimes happens,
that the  consecutive lesions, already well rooted, continue after
the cause has disappeared, and  strictures, often, are only  cura-
ble by dilatation.   Thus, the affection consists in two elements:
stricture, to be evercome by mechanical means; and  ulceration,
perceivable by means of the endoscope, which, if cured by pro-
per means, will soon bring on, or reproduce, the retraction.
   This may  explain one fact, often  observed, and  of which I
vainly sought an  explanation, until the endoscope enabled me
to follow the disease in all its phases.
   I  have seen recent strictures,  not  extensive,  easily dilated.
After a  few days  they disappeared, but, the treatment stopped,
they  soon  reappeared, and as  often  as  they were  dilated, so
often did they recur, upon the cessation of the dilatation.   Use-
lessly, have I continued this treatment;  I have kept a healthy
calibre for months, but, once the dilatation stopped, the  stric-
ture would return.  I have concluded that new strictures are
more apt to  recur than those of  more ancient date; the  cause
of this I cannot explain.   I held this opinion, in common with
many  others, equally  ignorant  as to the cause.  At present,
the explanation is easy,  as you  have already seen.   The ulcer-
ation, which continues, reproduces the swelling.  Its persistence,
formed upon  a plate  of chronic  eczema, may, by dilation, be
soon removed, to come back, so long as the eczema is not cured.
   When  the thickened parts disappear simultaneously with the
discharge, the cure  is complete.   You" recollect the case of D.,
cured  by a single  cauterization, and  remaining cured for  eight
years.  Many other cases, similar, are present in my memory,
and  you will see them at each consultation.  For a  long  time,
the stricture  was not attacked directly; the only treatment was
applied to the granulations.  When the alteration of  the tissues
       4 
50
THE  ENDOSCOPE.
continues so long as to persist  independently of the producing
cause, such is not the case, and dilatation should be added to
other treatment,   In such cases,  relapse  is frequent;  excep-
tions to this rule are rare,  I know of but few.   If the patients
did not, as a general rule, disappear after treatment, such cases
would be less rare.
  We now reach  the third period of the disease: the  granula-
tions disappear, as do those of the conjunctiva, when they have
destroyed the  structure of that  membrane.   Possibly, the oblit-
eration of the vessels may  play a great part in the case.  But
as the granular affection passes off, the stricture keeps up  its
onward march upon the retraction of the fibrous tissues extend-
ing to the mucous, the  mechanism  of which  M. Guerin  has
well shown, the mucous and sub-mucous tissues take on a char-
acter cicatricial  in its results.   Before  informing you as to the
results of the endoscopic examination, I will relate to you  the
details of an autopsy which enabled me to study the disposition
of this inodular tissue.  The stricture never having been treated,
the alterations found were  evidently the result of the affection
itself.
  The patient entered my  wards, in the Necker Hospital, with
an affection of the foot, necessitating the amputation of a toe.
During his sickness  he told me that he had had a blennorrha-
gia which had never been treated, and  the result of which was
difficulty in emitting the urine.   After curing the foot I found
a stricture.
  The patient died of  purulent  infection, and the autopsy
showed metastastic abscess in the lungs, and also the following
lesions in the urethra:—
  The portion of the canal strictured is generally the bulbous
and the extent of the stricture is about half an inch in length
(2 centimetres).   In this portion, the color is of a whitish or
slightly yellowish color,  whilst  the remainder of the urethra is
very red,  rough,  and of the appearance  generally  seen in
corpses.   The diseased  mucous is  attached to  the  subjacent
membrane, from which it is not  easily detached, the layers of
which are  thicker than  natural.  Below  the  cavernous part 
THE  ENDOSCOPE.
51
the bulb presents a healthy and  natural appearance.   Micro-
scopically examined, the mucous membrane shows an epithelial
layer, formed by cells more irregular than  the rest of the ure-
thra.   Below this epithelium, the mucous tissue affords fibres
similar  to  those in a  healthy state,  but  mixed with abundant
elastic fibres, many cytoblasts,  and granulations  such as we
find in  the primary  organization.   The sub-mucous tissue is
especially formed of bundles of fibres, in the intervals of which
the cytoblasts and  granulations are very abundant, many more
than  in  the mucous;  there are  also many elastic  fibres  and
fibro-cellular cells in different stages  of granulation.
   This confirms the general opinion as to the  inodular  charac-
ter of stricture  of long  standing, where  caustic had not been
used; no traumatic cause was present, and yet the elements of
cicatrization and the fibro-elastic  element were both more abun-
dant than  in the normal state.
   The identity  existing between this formation and that of the
cytoplastic tissue, readily explains how strictures of long stand-
ing, and organized, may rebel at dilatation, be retractile, and
present  the  same  appearance of elasticity  as do cicatrices.
Really, the  structure is the same, and, paradoxical as  it may
seem, the  stricture is, at its last  period, less a disease than the
effects of  anterior treatment for a disease; so  the  inodular fila-
ments,  no  matter the trouble caused, are  only the  result  of  a
wound.
   Similarly endowed  inodular strictures resist  dilatation,  only
 obtainable by much time and much fatigue to the patient.  This
 is not, however, the greatest  inconvenience.   The urethra once
 brought back to its original  size, once  the treatment stopped,
 the retraction reappears and  the stricture returns.   In severe
 cases, a few days may  produce that which  Aveeks or  months
 Avill not replace.  There is no reason to hope, in such cases, for
 a durable cure, by prolonging the use of dilating instruments,
 for in  such cases, as in the sequences of  burns, the cicatrices
 object  to  extension.  In extreme cases, the  patients  may not
 be cured, but  a bougie may be passed now and then.  They
 must be placed upon a  continuous  treatment, not to be inter- 
52
THE  ENDOSCOPE.
 rupted without  being forced to recommence the dilatation.   A
 similar case  is scarcely bearable,  in  addition, once the malady
 has taken its course, urethral inflammation, or vesical, urethral
 fever, or  other  accidents will aggravate it and render it more
 difficult to treat.
   These  are the reasons causing us to admit  the  principle of
 incision in the third degree of stricture.   It is well known that
 the resulting cicatrix is  thinner than cut tissue, it  does not re-
 produce the  stricture, and enables the patient to  introduce the
 bougie at long intervals.
   From what we have said, it results that there are three differ-
 ent kinds of stricture, to be met  by different  treatments.  In
 the acute inflammatory, cure the blennorrhagia; in the chronic
 inflammatory, it must  be, for a  long time, against granulation,
 but later, dilatation comes  into  play;  in the inodular,  it  is
 necessary to attack the  fibroid tissue and, consequently, fall
 upon  an appropriate treatment.
   These indications admitted, the  endoscope enables us to see,
 at once, the character of the stricture.

                      FOURTH LECTURE.
           Inodular Stricture.— Urethral Fistulas.
   Gentlemen:—Before touching  upon the treatment of inodu-
 lar stricture, it  is necessary to acquaint you with the means of
 exploration which can  furnish the indications for the therapeu-
 tics demanded in their treatment.
   The means of exploration usually employed, furnish a certain
 number of useful signs, both  for  diagnosis and for  treatment.
 We must  expect the same  from  the endoscope;  it does not
 double other  means, as I have already told you, it only adds to
their efficiency, in enabling us to complete the study of the dis-
 ease.   Other instruments furnish all  the knowledge that is
 attainable by mediate touch  (toucher), the endoscope adds to
them that knowledge derivable from sight.
   The sound, ordinarily, reveals  the  existence of a stricture
and its seat; even  if it  passes one stricture, it can tell  us  if
there are others  beyond it.  Simple bougies, bougies with bullet 
THE  endoscope.
53
ends, and other similar and analogous instruments, may ac-
quaint us with the degree  of retraction of the strictured point.
The ball-pointed instruments enable us, moreover, to determine
the number and extent of the strictures.
   The bougie and the curved stylet will also, sometimes, enable
us to judge upon which side of the coarctation the opening may
be found, this by the direction it may be necessary to give the
instrument for the purpose of meeting it.   Also, the consistency
of the fibroid tissue may be appreciated by the more or less dif-
ficulty experienced in passing a  conical  bougie, the  point of
which has entered into the channel still left in the stricture;  its
elasticity, by the resistance  experienced  on endeavoring to re-
introduce it, after having once  withdrawn it;  its retractility, by
the  rapidity with  which it  loses its  acquired  diameter, when
dilatation has been suspended.
   Such are about the opinions  drawn from the means generally
employed.  It is, I think, useless to  add  to them the results of
explorations made Avith bougies  for impression (a empreintes).
It is useless to repeat here, all  that has been said of the falla-
cies they are  guilty of; the  little use made of them at present
is sufficient  evidence of their uselessness.
   To resume,  the different means employed  by  the surgery of
the  present time enable us  to appreciate:—1st,  the existence
and seat of the stricture;  2d,  their number; 3d, their extent;
4th, their calibre;  5th, their elasticity; 6th, their retractility;
7th, their consistency.
   To these, the endoscope enables us to add coloration and the
configuration  of the surface anterior to the coarctation, and,
also, the exact  position of the orifice.  It  also affords us the
means to  decide at once if it is inodular, and also to positively
say what should be the treatment.
  We have seen that  at  the  intermediary  stage, the mucous
membrane loses  its red color; and also its ulcerous appearance,
at the same time the stricture  is being organized; it  can also
retake its normal appearance.
  This condition, which has terminated with the second period,
changes  at  the  commencement of the third.  With length of 
54
THE  ENDOSCOPE.
time, the infiltrated  lymph  continues to organize; the tissues
increase their inodular appearance, and, when examined by the
endoscope,  instead  of the rosy  color of the  healthy  urethral
mucous, or of  the red  color  presented at the commencement of
this  stage, when  irritated by the introduction of instruments,
the retracted  point  shows a paler hue than  natural,  and one
which  becomes  yellowish or greyish,  often  dull,  sometimes
mother of pearl (nacre), and simulating the cicatrices  that are
the sequences of burns, and  such as  the pathological  anatomy
of stricture enables us to describe.
   The configurations presented at the end of the endoscope by
inodular stricture, vary much, as do all other pathological  cases
in the case of  disparritees, still we can  form them into almost
three principal classes.
   Some commence  funnel-shaped, in Avhich  the most retracted
point is at the lower  extremity of the coarctation.   Unfortu-
nately, this is rare  in hard  or  in ancient strictures, because it
facilitates the introduction  of the instrument.  Another  form,
already recognized  in the preceding stage, and often occurring
in this, is the mamellonated. In this we find, at the end of the
sound, mamelons formed of  indurated tissue, readily discovered
by the resistance offered to  the introduction of the instrument,
Avith  difficulty bent  upon their  surface.  It may happen that
the mamelon is unique, circumscribed by a  groove and tongue,
causing the introduction of  the  sound  to be difficult, the  open-
ing  being  hard of access, generally found  in the middle, and
opposite the salient point of the mamelon, but sometimes  to  its
side.   Generally, the orifice is where  it appears most large and
most deep.
   If there are several mamelons, their summits verge towards
the centre, and it is towards their convergence that the opening
is found.  Sometimes, these mamelons are so irregularly  dis-
posed that the orifice is hidden from all researches made with
the stylet.  In such, the bougie is often difficult  to introduce,
because  it  does  not find the funnel-shaped orifice which  will
 direct it.
   Sometimes, between the affected  points, there are parts more 
THE  ENDOSCOPE.
55
or less  healthy and vascular,  showing more or  less red  or
inflamed tissue.
  Finally, I  may say, that in a last  form of this disease most
rebellious to catheterism, by the ordinary modes of treatment,
the sound showed  an obstacle like a  diaphragm, the surface of
which  showed  plates  unequal,  anfractuese, with  many  small
anfractuosities  and some greater ones; the eye  could  not dis-
cern all, and especially those which corresponded to the entrance
through the stricture.   To recognize  it, we must examine these
depressions mechanically, until we  find  one softened.   But
when the stricture  is  hard, the stylet does not free it readily,
even after several  efforts, though  it may  have  entered  the
retracted canal.
  There is a variety of this form which I have rarely seen, and
always in old  and  hard  strictures.  In  this, the orifice, be it
situated  in the centre or other parts  found at the point of  the
sound, is  gaping, and simulates a small  rounded opening, into
which  one could easily introduce the end of the stylet.  But,
though  the stylet  or  the whalebone  bougie might be readily
introduced, it is often very difficult  to pass through  the con-
traction, and especially to dilate it;  in those cases the  tissue is
very resistant.
  In addition to the color and configuration of the obstacle, the
sound pushes them  before it,  instead of  repressing, as  in cases
of healthy or simply inflamed mucous membrane.  This sign is
especially useful in those cases  where the transformation, com-
mencing in the exterior tissues,  has not yet reached the mucous
surface, still  red or ulcerated, and thus we may think  the evil
less  advanced  than it really  is.  But, in  such  case, touch,  by
aid of the sound, exposes to us, under the red surface, an indu-
rated and resisting base; it is  thus  evident that the  inodular
tissue has formed, though not yet come to the surface.
  It has been stated that sudden strictures are caused traumat-
ically,  and are  thus  distinguished  from those caused by blen-
norrhagia, of which the anterior portion  is funnel-shaped; but
the endoscope shows us that these last often come on suddenly,
and the first may be gradual. 
56
THE  ENDOSCOPE.
   Whatever may be the appearance of the coarctation, it does
 not change on the withdrawal of the sound, because the  tissue
 has not lost its suppleness and cannot pleat and  close over the
 end of the instrument.   On Avithdrawing the canula, the healthy
 parts close over its end, like a curtain, but the indurated  parts
 remain unchanged in appearance.
   You  see, gentlemen, the facility and precision the endoscope
 brings  to the diagnosis of inodular  stricture.   Without this
 instrument,  we could only  admit them,  except in traumatic
 cases, by reason of the  continuance of the malady, or of the
 difficulty of dilatation  and the  rapidity of the  return of the
 stricture, but the duration furnishes only deceptive probabilities,
 for if strictures caused  by blennorrhagia are sometimes fibrous
 after a  feAv months, you may remember that in the case of D.,
 spoken of in a former lecture, he, after a continuance of the
 affection  for eleven years, had  only a  chronic  inflammatory
 coarctation, which disappeared with  the granulations; and, in
 another case which I have reported, the disease yielded rapidly
 to  dilatation and  a treatment of the ulceration still existing.
 Then there only remains, as a sign, unsuccessful dilatation, and
 so  Ave can  only  after  unsuccessful  treatment and lost  time
 recognize the lesion.  By aid of the endoscope, on the contrary,
 we can immediately tell the differences; whenever there is found
 at the end of the  instrument, an inflamed or ulcerated instead
 of a healthy membrane,  a white surface, mamellonated, anfrac-
 tuous, or  of fibroid appearance, it  is certain an inodular stric-
 ture is present, and the therapeutical indications are immediately
 understood.
   We will now take up  the treatment of the coarctations, and
 of the indications to be  met.  They consist in  two principal
 ones:—1st.   Pass through  the  stricture;  2d.   Destroy  the
 obstacle.

                1st.— Traverse the Stricture.
  This is often easily done; it is only necessary to introduce a
sound or bougie, sufficiently fine  to pass through  the obstacle.
If the opening is not readily found, the bougie is to be drawn 
THE  ENDOSCOPE.
57
back and  again gently readvanced, with  these  precautions  it
generally occurs that the point of  the  instrument will, at some
moment, gain the opening, then, gently pressing it  onward, it
reaches the  bladder.   I  shall delay no longer  on this  point,
which is not  exactly allied to the subject at present under con-
sideration.   Success  almost always  attends  it,  but there are
cases where patience and hability,  no matter how great, fail to
discover the  opening, the point of the bougie will butt against
the surface precedingly described, and, do what we may,  it will
always stop  there.   After continued efforts, the attempt is de-
ferred to another day, when  the insuccess  is the same; even
days and  weeks may pass in  futile  attempts  and in failure.
Many means  have been recommended for such cases: whalebone
bougies, bougies very  fine,  introduced side by side, so as to
cover  the whole obstacle with  points, one of which might be
lucky enough to pass,  the  sound open at both ends  (a  deux
bou) passed  up  to the  retraction, to serve as a conductor of a
fine  bougie.   I  have tried  all of these means, they sometimes
succeeded, but I prefer a conical bougie,  twisted at its point;
but I must add that, in some of these cases, none of these treat-
ments are  successful.  It is doubtless rare that, with time and
patience, success does not folloAv; but patience  has its bounds,
and  we will soon come  to cases where  it has been necessary to
relinquish  futile attempts at cure.
   These fruitless attempts cannot be long continued without
danger, and  especially  so when the urine  does not Aoav at all,
or only by driblets;  the distended bladder threatens  rupture,
the patient experiences intense  anxiety, the urinary infection
manifests itself;  or if less severe, the distension less prolonged,
it  may at  least  cause inertia or paralysis of the organ again,
the superior  portion of  the urethra becomes fatigued, inflames,
softens, urinary abscesses  form, which,  after  many dangers,
result in  urinary fistulas.  In  such cases,  not  very  common,
temporization and continuous treatment will not answer.   It is
necessary to  act, and to act quickly.   What shall we do ?   Sur-
gery has but  one resource, the puncture of the bladder, because
forced catheterism is properly rejected  for  all cases of this kind 
58
THE  ENDOSCOPE.
on account of the bad effects it causes.   The puncture of the
bladder is made but, say Avhat you may, experience teaches that
it is not without danger.   Its effects are, moreover, only tempo-
rary, they do not  reach the cause,  which still continues, and if
the coarctation remains, the danger is from one day to another.
This was the case with the patient whose history I will give you:
  For several years he had a stricture, which followed the usual
march, increased more or  less rapidly, and finally caused  com-
plete stoppage of  the urine.  The patient placed himself in the
hospital, under the care of one of the most able of our masters.
At the time of entrance, the bladder reached as high up as the
umbilicus, the danger  was great, the fever violent, and pain and
tumefaction had already reached the perineum.
  All attempts at catheterism were fruitless, and the incision  of
the swollen perineum  bringing off  but little water, hypogastric
puncture of the bladder was resorted to.   This produced  ease,
but the stricture was not relieved; it  so happened, however,
that the urine passed, slightly by the urethra, and much by the
punctured  fistula, the puncture in  the  hypogastrium  having
healed,  the patient went  about his business.   Soon,  however,
the urine ceased  to pass through the canal,  and the fistula
becoming  more contracted, the bladder could  not empty itself,
and so the patient entered Cochin Hospital, of which I was then
the surgeon.  This was in 1861, when I was experimenting with
the endoscope, but had never  yet used  it for the purpose  of
passing strictures.   The fistula, though not permitting sufficient
urine to pass, was still sufficient to postpone danger, and  for
several  days I tried to introduce  the smallest conical bougies.
In this  I was neither  more expert  nor more fortunate than my
former teacher.   I then decided to try  the  endoscope; by its
aid, I perceived the obstacle and an opening into which a stylet
could be passed, then I had not thought of the whalebone bou-
gie (this  patient  caused me  to imagine it).   I  withdrew the
instrument, and,  after several  efforts, a  fine  bougie (filiform)
traversed the stricture,  previously passed by  a sound.  This
was much, but  for a long time  I was compelled  to employ the
endoscope as a preparation for  the bougie.   At length the dila- 
THE  ENDOSCOPE.
59
tation went on regularly;  but when bougies of a low  number
readily  passed, the patient pressed by his vocation, and satis-
fied with his then condition, wished to leave the hospital.
  The following year,  1862, he found  me in the Necker Hospi-
tal.  The  same fistula existed,  and the incompletely dilated
stricture had  returned.  I had uselessly wasted time in cathe-
terism without the endoscopic aid, but now I concluded to com-
bine the two.  I employed  endoscopic  urethrotomy, and  the
obstacle was removed in less time than we had previously spent
in vain attempts.   We will return to the subject of urethrotomy,
but I will state that in this case,  in absence of the endoscope, I
would have been compelled to  puncture the bladder, as had been
done before, or else to an  incision (boutonniere), that is to say,
to urethrotomy without a conductor, the  difficulties and dangers
of which I will not now recall.
  This  case will  enable you to appreciate  the utility of the
endoscope  as  a means of passing difficult strictures.  Now for
the manner of its  use  as I employ it:—
  The endoscopic  sound is passed forward to the obstacle, and,
the instrument being arranged,  we can perceive the condition
that I  have described, and,  frequently, the orifice in the re-
tracted  part.  In this examination, care must  be taken to keep
the sound  in the direction leading  to  the affected part, so that
its  anterior face coincides, through its whole  extent, with the
end of  the instrument.  As the examination is almost  impossi-
ble if the  instrument is vertical, it is necessary to place the
patient  in  such  position  that the  axis  of  the diseased part
nearly assumes the horizontal line.   To act upon the membran-
ous portion, dorsal decubitus is  preferable;  but for the bulb,
and especially its anterior part, it  is  best to raise the patient
to almost a sitting posture.  When the diseased surface is thus
brought fully before the end of the sound, the orifice  is almost
always  in  the field  of the instrument, but it sometimes hides
itself under the edges of the wounds; then  the direction must
be  changed to discover it.   Frequently, in like cases, I  have
found it towards the lower portion of the canal, and the indu-
rations  existing upon the superior portion. 
60
THE  ENDOSCOPE.
   The orifice once found, a stylet must be introduced, to make
 sure  that we are right, and  also for  the purpose of  traversing
 the retracted part.  This is  easier done with a metallic instru-
 ment than with the whalebone bougie, which is not  so conven-
 iently managed.   The stylet usually employed is shaped  like
 the  ordinary probe,  mounted upon  an elboAV-shaped  handle
 (manch coude) of the forceps character  (en form de palette), by
 which it is held at the exterior of the sound; it is well to have
 at least two of different sizes.
   The patient being then placed in the  proper position, and the
 penis held by  an assistant, who at the same time may steady
 the sound in the axis of  the canal and firmly hold  the parts,
 the stylet is then introduced  through the lateral opening in the
 sound, and we try to make it enter into the orifice of the coarc-
 tation.   I have already said  that,  if the snrface of the obstacle
 is irregular, with several depressions, try each until one is found
 that the  probe will enter.   Sometimes, the first attempt is suc-
 cessful,  and the instrument is only arrested on the farther side
 by a  mucous pleat; but sometimes it  stops after a short  en-
 trance, in the sinuosities of the stricture, wThich rarely furnishes
 a uniform calibre.   In such cases,  the stylet  may be  carried in
 different directions, and we may even move the sound so as to
 permit the passage of  the probe.   Once the obstacle passed, it
 can be dilated  by changing the stylet  for  a  bougie,  which  can
remain in situ.   We can, as I have just said,  Avithdraw  the
 endoscope, and try to introduce an elastic bougie; this is, how-
ever,  an  uncertain process, and it  is best, whilst  the  endoscope
is in  place, to  take advantage of it  for the purpose of  well
placing the bougie.
   For this, a whalebone bougie must be used, soft ones cannot
be properly directed.   I have sometimes used bougies of catgut,
but they are worse than whalebone.   These should be elbowed
like  the  probe, so that they may be  kept at the sides of  the
sound.   We  then  substitute  the  whalebone  bougie  which  we
cause to follow the same  way.  Like  the first,  it  sometimes
stops after passing the stricture, because it catches in the cur-
vature of the urethra.  Without effort  to go farther, the endo- 
THE  ENDOSCOPE.
61
scope  is to be withdrawn, leaving the probe" in its place.  To
do  this, press it gently whilst  the  instrument is retracted.
Once isolated, it  can  be made to enter the bladder;  but, in dif-
ficult cases, where success is not immediate, fix it in its position,
and, after a few hours,  it rarely happens that the attempt does
not succeed.   I will not rest on  the subject of  dilatation, only
saying, the first bougie must give way to a larger, patience and
dexterity are alone  necessary.   To  demonstrate to you the
advantages of the endoscope, and especially  where ordinary
means fail, I will recount a case of M. Civiale, with his given
permission;—

Traumatic Stricture.—Futile  Attempts at  Catheterism.—The
  Introduction of a Bougie  by means of the Endoscope.
  M., (Paul,) aged 36, a cook,  and a  patient in the Necker
Hospital.  The patient is  healthy, has never  been very  sick.
When about  28, he contracted  a  blennorrhagia, Avhich Avas Avell
cared for and cured.
  About  five  years  since, he slipped on  the stairway  and
wounded the perineum; a physician,  called at the time of the
accident to stop the abundant bleeding,  tried, fruitlessly, to
pass a  catheter; an  able surgeon, later called  upon, was  not
more successful.  The  hemorrhage ceased of itself,  the patient
easily urinated, the jet was notably diminished, but the patient
did not complain.
  Some  months  afterwards, the diminution of  the jet became
great,  and  soon the urine was  discharged only  by drops; later
on the discharge  was  involuntary, and this condition continued
for  about  four years.  As a  consequence  of excessive work,
total retention came on, and it  lasted two days.
  The patient then decided to enter the hospital in which the
surgeon who  had ineffectually  attempted to sound him was on
service.  A stricture of four months standing, under the pubic
arch is found; it cannot be traversed.  Urethrotomy is prac-
ticed;  the  operation  lasts twenty minutes; the opening into
the  canal cannot be found;  the wound is soon cicatrized.
  Shortly after  his exit from the  hospital, as a consequence of 
62
THE  ENDOSCOPE.
drink,  it  returned, with  fever, retention, loss of mind,  and
delirium.   Catheterism was again vainly essayed.
  Three days after, Dec. 22d, 1862, the patient came to the
Necker Hospital, with slight  fever, sleepiness, and small appe-
tite; the urine passed only by drops, and when he was up the
passage was  involuntary.  M. Civiale tried for twenty-eight
days, without success, to produce a cure.   Bougies of all kinds
and  of all sizes, wax, whalebone, caoutchouc, and metallic, all
in vain.  These bougies and sounds could never strike the open-
ing.  No accident occurred and not much pain was  felt.
  8th Jan.  I, with the help of the endoscope,  tried to find the
opening in the stricture; a  medium-sized canula Avas  readily
introduced to the retracted point;  the membrane was white and
shining, cushion-shaped  (bourrelet); many depressions were also
seen, which I tried to pass Avith the  probe and with bougies of
whalebone; the attempt was futile, the pain great, and  further
examination postponed.
  On the  11th Jan., I found  an orifice, into which I introduced
the stylet, to the extent of about  one-third of an  inch; the
whalebone bougie was left in situ.   On the morrow there were
some symptoms of fever, which disappeared the  next day ;  there
were also vague pains in the region of the right kidney.
  On the  13th Jan., the stylet was again  introduced and  pene-
trated  farther; a Avhalebone bougie was left in its place; in the
evening it became deranged, and the nurse, in attempting to
bring it right, passed it into the  bladder, without  difficulty or
pain.
  The  bougie was fixed  and kept so until  the 19th of January,
when,  during the night, slight fever and  difficult  urination
caused  the patient to withdraw the bougie, which was the next
day replaced by a small  sound.   The patient experienced no
inconvenience from the presence of the sound;  the urine passed
between the sound and the canal.
  On the 29th Jan., the sound was withdrawn and a larger one
inserted.                                     '
  All  efforts were made by those  whose ability  none  could
doubt,  and unsuccessfully.  Then, M.  Civiale asked  me to try 
THE  ENDOSCOPE.
63
the endoscope, thinking, with me, that if it failed, there only
remained  urethrotomy to  be resorted to, and you all  know the
result of that operation.  I found the orifice, and proposed to
to incise upon the stricture, but M. Civiale preferred the means
he generally employed.
   I will no longer press  upon you attention the advantage of
the  endoscope in  such  cases;  you must  have seized them
before now.  But there are other cases, where this instrument
has enabled me to avoid opening the bladder either by puncture
or by the knife.
   The  obstacle once  overcome, dilatation by bougies may well
be employed, and I have long used this method.  At first sight
it seems the least dangerous treatment, if used gently and  pa-
tiently, but a more careful investigation will  cause another opin-
ion.   In inodular strictures, the  dilatation often requires time;
at the  commencement, especially, it may be necessary to pass
the same  bougie  several times without  changing  it for a larger
one.   Moreover,  the treatment may bring on an attack of fever;
some patients are subject to it after the most easy catheterism.
The sulphate of quinine, given at each  introduction, will, neces-
sarily prevent this.   But if this  course has to be persevered in,
the  treatment will not do.  In other cases, urethritis, cystitis,
and nephritis are a consequence; and when resumed after sev-
eral days, we find we have lost part of  what we had gained, the
tissue has again  retracted, and we are lucky if  we do not find
the  parts  in  the same condition in which we commenced  the
treatment.   Well,  suppose these accidents do  not  occur, or,
after having passed  them, is the patient nearer a cure?  No!
Many of our patients have been cured several times.   Really,
these retractions are, as I have told you, inodular in form  and
analogous to a cicatrix, and, when once dilated, they return as
do the contractions  occurring after a burn.   The following
observation will show this:—

 Coarctation of the Bulbo-Membranous Portion of the Urethra.—
   Dilatation.—Rapid Relapse.— Urethrotomy.—Cure.
   B., (Louis Joseph,)  aged  60,  potter by trade, was in  the 
64
THE  ENDOSCOPE.
Necker Hospital.   He was pale, thin, with soft flesh; had been
a soldier in Africa; had had tertian fever; also,  at 36, clap,
treated and cured, at the end of six Aveeks, by injections of sul-
phate  of zinc.   No new case was contracted, according to his
account, since then.  From time to time, he did drink too much,
but otherwise his life Avas regular.   Some  five or six years since,
he was retaken with his tertian, at Paris, and entered this hos-
pital.  He was treated with the shoAver bath.
  About twelve or  fifteen months ago, he first observed a diffi-
culty in his  micturation;  he could  not long retain his urine,
and, whenever  pressed,  was forced  to evacuate  it at  once.
Gradually the jet became finer, of less force, and, notwithstand-
ing his efforts, it was difficult to completely empty the bladder,
even after  long, continuous  attempts.  These symptoms were
most marked  after his meals and  especially so if he had taken
too much wine.  He, fearing catheterism, never Avas willing  to
subject himself to treatment.
  On  the morning of the  29th  November, upon waking up,  he
could not pass one  drop of urine, and could not attribute this
misfortune  to any cause.   He remained in bed, Avith slight and
repeated chills, nausea, great thirst, pain in the gland, the peri-
neum,  and  great tenderness  in the belly.   Thus  he passed the
day at home,  hoping that  he would  soon be Avell,  but the symp-
toms increased  in violence and about midnight he concluded  to
ask hospital  aid.   The assistant  on duty tried to  introduce a
metallic sound,  which Avas stopped in the perineal region.   A
considerable  hemorrhage occurred, the  patient returned to  his
home,  and the next morning came to the consultation.
  30th November.   The patient was much frightened and suffer-
ing, there wras also  great pain caused  by the pressing desire  to
make water;  the least movement caused a revival of the intense
pains,  his  face was contracted and  anxious, his mouth  dry  his
belly tender and swollen from the effects of the distended blad-
der, which  reached the umbilicus.  The testicles were retracted
towards the inguinal ring, in half erection, slightly turned upon
themselves; the pulse was accelerated; the respiration irregular
and rude.  I introduced a conical  bougie No. 4, which  after 
THE  ENDOSCOPE.
65
several trials, pierced the stricture, located on the bulbous por-
tion of the urethra.  There it was pinched and could go no far-
ther.   Then, the bougie withdrawn, the patient passed about a
cupful of urine, with great difficulty and in scattering drops.
The bougie was then reintroduced, left  for fifteen minutes, and
then urination,  like the previous, again took place.   Cataplasms
Avere ordered for the lower belly and perineum, and in  the even-
ing the  patient was somewhat relieved, and passed, by drops,
about a  half glass of urine; the bougie was  reintroduced.   He
objected to an  operation.
   2d Dec.  The same bougie introduced  twice during the day;
the micturition easier; the bladder sensibly  emptied, and occu-
pying only two-thirds of the space between  the pubis and um-
bilicus;  sometimes the  jet is continuous,  but  filiform.  The
urine, however, passes involuntarily in the bed.
   Dec.  3d.  During the  night a  chill.   We left  the patient
quiet.
   Dec.  10th.   No more  chills.  The urine is sufficient.   There
is no complaint of the bladder, and when the desire to urinate
occurs, the passage of a few drops  gives relief; still dullness on
percussion continues over the pubis, there is no fever, the skin
is moist and even sweaty.   His appetite is  gone, a little weak
tea (tisane) is his only diet; food is disgusting  to him.   His
lips  are swollen, and salivation is abundant.  An examination
revealed great swelling  of the entire mucous membrane, which
was covered by a pultaceous layer, surrounded by a red circle,
and the parts are very painful.
   A  portion  of chlorate  of potash as a gargle, and  honey of
roses, with chlorhydric acid as a collutorium, are needed.
   Dec. 11th.   By the endoscope,  we reached the retracted part
of the mucous membrane.  It was of a mother of  pearl white.
In its centre there was  a small red point, the opening into the
coarctation, very  free by the passage of a sound.
   The  following  day the dilatation was continued; Nos. 6, 7,
and  8  bougies were used.  An erysipelatous  phlegmon of the
right eyelid occurred and was cured.   The patient, however,
        5 
66
THE  ENDOSCOPE.
was always broken down in spirits, and suffering; nevertheless,
he passed sufficient urine to keep the bladder more or less free.
  1863, Jan.   During this month, the condition of the patient
did not improve, on account of the difficulty offered the treat-
ment, much by the  coarctation, which would only admit a fili-
form bougie (say from two to  four-fifths of a line),  and by the
indocility of the patient.
  Feb. 3d.  The elastic bougies were replaced  by the finest of
Benique's sounds, and gradual dilatation  permitted the intro-
duction of No. 35.
  Twice, during the month of  February, the patient was taken
with chills, as at the commencement  of the attack, and which
yielded to quinine.
  The general condition of the patient is bad, the feebleness
extreme,  there  is no appetite,  the stools are diarrhceic in their
character, so  much  so, that at the end of February the local
treatment had to be suspended to prevent a return of the fever.
  March 10th.   The coarctation is so great that bougies of the
elastic gum,vused early in January, have not been able  to pen-
etrate the bladder.  In this first effort we have sometimes been
compelled to leave the bougie  in front of  the retraction.  The
next day, they  cleared  it, and gradual dilatation was  recom-
menced with the sounds of Benique.
  March 17th.   No. 32 has been reached, but then the  patient
executes his threat,  many  times repeated, and demands his exit
from the hospital.
  March 21st.   He  comes to  the consultation,  and begs to  be
permitted to reenter the wards. The stricture is so much repro-
duced, that the most fine bougies will not penetrate.
  April 3d.  Urethrotomy is practised by  aid of the endoscope.
This operation  presents no difficulty, and  is not  accompanied
with any  hemmorrhage; an elastic sound, of medium  size is
immediately introduced and fixed in the canal.   During  the
day, the patient withdrew the  sound, and  no  further accidents
were presented.
  On the morrow, dilatation,  or, rather, separation of the lips
of the urethral wound, is easily continued. 
THE  ENDOSCOPE.
67
  From this time, his strength, appetite, and  a better color of
the stools, all unexpected,  are evident, and, at the same time,
the urethra remains sufficiently dilated without daily catheterism.
  April  20th.   The  patient  wishes to go to Vincennes,  the
general condition is not changed and is very satisfactory.  The
local condition may be appreciated by the fact that, at the time
of his departure, a sound No.  41 penetrated the bladder without
difficulty.
   We  have already said that strictures once formed  are rarely
cured without danger of a relapse;  a like cure is almost impos-
sible if the period of  granular urethritis is once  passed.   Re-
lapse, in such cases, is slow to occur; the cure generally lasts
for some years; and to keep  it up, it  is only necessary to pass,
at long intervals,  a large-sized bougie.  On the contrary, when
the fibrous retraction  occurs, a few days, as  in  the preceding
observation, or  a few weeks  will suffice  to  reproduce it  after
dilatation, and each day, thus to speak, the patient should be
sounded.   Thus, this is not, properly speaking, a disease threat-
ening a  relapse, but one that never  cures, and condemns the
patient to continual treatment.  The first condition is support-
able, this  is not: and,  moreover,  when the  patient willingly
submits himself to it,  circumstances of some kind, an intercur-
rent affection, or some other, occur to compel the cessation  of
treatment, and  then the disease assumes the mastery.   It thus
becomes necessary to find some more efficacious treatment.   To
this end, rapid dilatation,  cauterization, incision,  and excision
have been  proposed.    Of all these  means,  excision alone  is
retained.  In sudden  dilatation, two  effects may happen, there
is either simple dilatation and a relapse comes on, as  after slow
dilatation;  else there is a tearing of the tissue, and in such
 case the danger is as  great, if not greater, than after urethrot-
 omy.  You  may recollect a patient, brought  here  some months
 since.  The next day quick  dilatation was resorted  to by the
 inventor of an ingenious instrument;  a large urinous phlegmon
 was the result,  and also gangrenous eschars.   The patient died
 in two or three days after entering the hospital.
    I have but little to  say upon the subject  of  cauterization as a 
68
THE  ENDOSCOPE.
means of radical cure of coarctation, or of reestablishing the
canal by destroying the new tissues, when the obstacle  cannot
be passed.  I will  not repeat all of the opprobrium justly as-
signed it; one will be sufficient.   If it destroys the morbid for-
mation, it is only to replace it by another, more retractile.   I
do not now call to mind one of my  colleagues avIio is a partisan
of so irrational a means.   Several times have I encountered the
victims of this operation, and  never have I seen  strictures more
difficult to treat, and more rebellious.   In all of them the cau-
terization left them worse than when in the primitive state.
   I  also throAV aside excisions,  notwithstanding the injurious
inventions  to which they owe  their  birth.  They are especially
addressed to hypothetical lesions, to very thin valves, the exist-
ence of which is not  proved,  and Avhich must be very rare, in
any and every case.   This has never assumed  a scientific status.
   Incision remains to be discussed.  As you know, there are
two  methods by which it may be  practiced:—In one, all the
parts, from the skin to the urethra, are traversed, this is exter-
nal urethrotomy;  in the other, the tissues forming the retraction
are cut by instruments introduced  into the canal, this is inter-
nal urethrotomy.
   For the  first, there are two processes:—It can be performed
by directing a cutting instrument upon a conductor; or else in
seeking the canal  through the soft parts without a conductor.
In the first case, it is necessary that the stricture will admit of
the introduction of a catheter, whence dilatation is commenced,
so that its passage  is made possible; and in such case, internal
urethrotomy may  be performed in the ordinary manner, and
with less danger and pain.   True,  it has been stated that the
cures of external urethrotomy are  more durable; others,  how-
ever, have denied  this result,  and for my part, in two cases  in
which  I have performed this operation, the relapse was not long
in taking place;  so to speak, it occurred at  the same  time as
the healing of the  perineal  wound.  In a  third  case, operated
upon by one of my colleagues, I Avas forced to perform the ope-
ration of internal urethrotomy  for the purpose of  removing a
coarctation produced immediately after an external urethrotomy 
THE  ENDOSCOPE.                    69
had  been made.  These three examples have been sufficient to
debar me from performing this operation.
  But external urethrotomy is  an operation  sometimes neces-
sary, and one which should not be rejected, for it may happen
to be the only resource left when all others have failed; it is,
however, dangerous, difficult,  and, what is worse, uncertain, as
you  have seen  by my observations, when it was tried by a sur-
geon, who, despite his ability,  could not terminate the operation.
I thus am forced to  believe  that one of the  greatest merits of
the endoscope will often be to replace external urethrotomy, by
a process but slightly dangerous.
  Now let us turn our  attention to  internal urethrotomy.  Its
advantages are calculated to  procure a more prompt  and cer-
tain cure, to afford less chance of relapse, much less severe, in
substituting upon the retracted part, a someAvhat  retractile tis-
sue, for one  thick, hard,  inodular, and  difficult of retracticity.
Thus you see that this method should not be resorted to, except
in the last stages of coarctation, for inodular retractions.
  The modes  of internal urethrotomy are, naturally, divided
into tAvo, incision from front to rear, and its reverse; let us  add
a third,  endoscopic urethrotomy, the  principles  of Avhich  are
different, and which present many special advantages.
  To incise a retraction from behind forwards, it is necessary
to  pass  an  instrument  sufficiently  large, and  one which is
brought  forward after the passage of the blade previously con-
cealed.  This cannot be used  save  in coarctations of  a certain
size, or where  dilatation  has  been effected  to a certain  extent,
of which the length or extent, and accidents found at the com-
mencement of the  cure,  are  not avoided by this method.   It
does not serve to render the cure  quicker, but only more  cer-
tain.  It has been preferred  until the incision  from front to
rear, made by  sure instruments, such as those of  MM. Sedillat
and Maisaneve, made the operation sure.  The last  instrument
you have seen me employ, and you can judge of its excellencies.
  It will be of great  service;  it can  act upon very restricted
coarctations, and, consequently, without previous preparation
in many  cases,  thanks to the size of it.  It requires a conductor, 
70
THE  ENDOSCOPE.
and in some cases, where the opening cannot be found, a  long
search may be necessary.  Small as may be the passage it re-
quires, that passage requires  preparation, and this is the  most
difficult and the longest treatment of the most decided coarcta-
tions.  Be the treatment what it may,  a conductor must be first
passed, and often, so as to prepare the  passage.  The endoscope
alone enables us to decide if other instruments will permit us to
diagnose correctly.  No other method  furnishes a certain means
of recognizing the disposition of  the obstacle.  No other  pro-
cess furnishes any means of surely knowing the situation of the
obstacle, and, consequently, of judging upon which  side  it is
best to turn the cutting edge of the instrument, whence it often
happens, if the accidental tissue  only  occupies one side of the
canal, the incision  is made upon  the healthy portion.  Now, I
think it best to cut, in such cases, the diseased parts;  they are
less sensitive, less vascular, less disposed to immediate  adhesion;
on this account, I always attack  the thickest part for the  pur-
pose of making the incision, and, possibly,  owing to a strict
adherence  to this rule, I may owe my  success, never having
had a serious accident from twenty cases of endoscopic urethrot-
omy.  Before speaking of the advantages possessed  by these
means, I will describe to you the way  of employing them:—
  The instruments (urethrotomes) which I  employ are simple
probe-pointed bistouries,  with a  cutting edge  of about  four
lines, the blade small and thin (deiie),  and  in a handle bent at
an angle in the stylet I have already described.  Having vision
to aid us, it is not necessary to employ  the same means required
by like instruments to  conduct the cutting edge and to protect
the healthy parts  from their action, as without  the endoscopic
aid.   It is necessary to have urethrotomes of two kinds, one  with
the cutting edge below the  handle, the other with the cutting
edge above and opposed  to the handle.  The button or  probe
point should be no larger than that on  the stylet.
  Before incising, the opening must  be found  by means  of a
stylet, as previously said; then the stylet being withdrawn, the
urethrotome  is  passed to the  previously recognized orifice.
Once there, by gentle  pressure, not by jerks and thrusts, the 
THE  ENDOSCOPE.
71
instrument readily and easily passes.   If the passage is tortu-
ous, its cutting edge acting on the more salient points, it makes
its own way.  Once  introduced  entirely through the extent  of
the obstacle, we withdraw it, pressing slightly so that the blade
may completely divide the inodular tissue; this done, no more
pressure must be used.
  If it becomes necessary to  reintroduce  the instrument,  to
make a  new incision, or to enlarge the previous  one, press it
towards it  back, so that its probe point, in passing the wound,
cannot pass from the bounds of the urethra.
  Formerly, I made two, and sometimes four incisions; recog-
nizing the  futility of this, I now never make but one.  When I
see tAvo  inodular masses at the end of the instrument, I  may
deem it necessary to divide both.
  When we see masses or  fibrous filaments  at  any one point,
towards  this point the cutting  edge must  be turned, and we
should  endeavor to  completely  divide  the  pathological struc-
ture.   If nothing indicates  the  side to be cut, I  choose the
upper  part of the canal, for, upon this surface, there are less
dangers, as Reybard remarks, and, besides, should it become
necessary to again operate, there is less chance of the urethrot-
ome passing through the wound, and less danger if it does.
  The incision thus made  is not very painful;  it is slightly, if
at all so, when the tissue is inodular.   It is also a fact, that in
such  cases little  or no blood  is  lost, and what  is may be
promptly arrested.
  The only accident I have  yet seen, as a consequence of ure-
throtomy,  is an  access of  intermitting fever, and  this I  have
never found, save in such  cases Avhere  it had been induced by
previous catheterism; so,  when  compelled  to  operate upon a
patient previously thus  affected, I order  to be given in the
morning, 11J grains (60 centigrammes) of  the sulphate of qui-
nine, and 10 drops of laudanum in an  infusion  of valerian, all
by injection. By this treatment, but one  accident has supervened,
and  this though nothing else has been done to prevent a recur-
rence.  There is  a  curious  fact connected with  this urethral
fever.   At certain times,  almost  all patients sounded are at- 
72
THE  ENDOSCOPE.
tacked; at others, scarcely any are affected; so it seems to be
under epidemic influence, and is  genarally most  common when
intermittents otherwise prevail.  In  our wards  last year, for
several months, intermittent affections prevailed, they attacked,
indifferently, patients affected in all  sorts  of  ways, fractures,
contusions,  white-swelling (tumour  blanch),  ophthalmia,  etc.
The form  assumed was  sometimes neuralgic, then  febrile ac-
cesses of fever, generally of the quotidian type, rarely tertian.
Whilst this epidemic  lasted, the urethral fever affected  almost
all who had a retention of urine; after urethrotomy, after sim-
ple catheterism, after any violent effort  to expel the urine, an
access Avould occur.   I could,  hoAvever,  continue the treatment,
aided by the effect of the quinine, the  action of which seemed
to be as powerful in such  cases as in marsh fever.
  As to the care given after  an  operation, I  introduce, imme-
diately after the  incision, a large-sized  sound, not  sufficiently
to distend the cut violently, but  large enough to keep the  inci-
sion open, and also to give issue to the urine.  I am Avell aware
that some surgeons object to a permanent sound in the urethra,
and accuse it of many accidents.   So far as I am concerned, I
have not observed them.   I, moreover,  think too much  impor-
tance has been given to such  cases; the resting sound, in such
cases, does not seem to me to exert so much influence as is gen_
erally attributed  to it; it neither possesses the merit some as-
cribe to it,  nor the dangers expected by others; suffice it to say
it  is painful and  its presence  inconveniences the sick person, I
do not, therefore  employ it.
  I  generally withdraw the sound on the fourth or  fifth  day;
then I complete  the cure by the metallic  bougies of Benique.
These bougies are not well  adapted to  general dilatation, but
they seem to act  especially upon the affected point.
  Urethrotomy, effected  by means  of the endoscope, partakes
of the advantages of the other processes, it has also its peculiar
advantages.  Like the other treatments, it may cause a radical
cure, but more time is necessary after dilatation.   There is rea-
son why I should insist upon urethrotomy, a single case that I
will  shortly report, will  fully exemplify that, in certain  cases, 
THE  ENDOSCOPE.
73
dilatation affords but temporary relief, whilst  incision alone
produces a cure.
  Endoscopic urethrotomy is preferable to all other means in
this, it  shortens  the  treatment, as it does not necessitate  any
treatment of a preliminary kind to pass the coarctation, and in
itself furnishes the means to go through the obstacle, Avhile the
methods aiming  to act  from rear to front require, first,  the
introduction of  a conductor;  at the same time,  this method
enables us  to see exactly the position of the stricture, and, of
necessity, to properly direct the  cutting blade.   We  have al-
ready seen  that the endoscope  often  enables us  to decide if
urethrotomy is necessary,  and to be certain of the fact.
  Really, the greatest advantage of this method is, that it  fur-
nishes a means  to overcome an obstacle, rebellious to all other
means.   I am convinced, and think you are, that the endoscope
will often  enable us to discover coarctations, and to  practice
immediate urethrotomy, in cases Avhere other means would  not
only require time, but might fail entirely.   The endoscope may
render  unnecessary,  or, at least, the necessity  very rare,  for
the puncture of  the bladder and external urethrotomy without a
conductor.
  The  following cases, in addition to those due to  M. Civiale,
will suffice, I think,  to demonstrate the advantages of  the  new
method.  It is necessary to state that, in several of these cases,
the stricture could not  be  passed  by ordinary means, and,  con-
sequently, intra-urethral incision could  only be used by means
of the endoscope.

Stricture  of the  Urethra.—Catheterism, by  Ordinary Means,
         Impossible.—Endoscopic Urethrotomy.—Cure.
  On the 22d of February, 1863,  Charles F., 34 years of  age,
a mechanician, married, came to Necker Hospital.
  This man was of a vigorous constitution;  as to anterior affec-
tions of the urinary  passages, he only admits of a slight blen-
norrhagia, contracted fourteen years previously,  and cured  in a
few days without sequences.
  The  actual disease was caused by  a traumatic effect.   In 
74
THE  ENDOSCOPE.
February, 1862, the man stumbled  and fell from  half a yard
(demi metre) in height, upon a bar of iron, striking heavily upon
his  perineum.   Spite of this, he continued his work, but soon
the pain  became so great that he Avas compelled to go  home.
There Avas weight in the perineum  and anxiety to  urinate, an
anxiety that could not be  obeyed.   A physician was called,
introduced a catheter, and brought  off clots  of blood.   For
some days, the sound was introduced  from time to time, then
its use was suspended, the patient urinating with facility.
  The cure seemed complete, there only remained slight pain
near the bulb; but  in four or  five months micturition became
painful; the stream  diminished  daily; and in  September, the
Avater passed only by drops.
  M.  Chaudemont was  consulted.  He tried, with failure, to
introduce  bougies, and ultimately recommended external  ure-
throtomy, a process rejected by the  patient.   Soon the patient,
ever tormented Avith dysuria, went  again  to  M.  Chaudemont.
Catheterism could  not be  performed then.  After a month of
fruitless  efforts, M.  Chaudemont sent him  to  me.  I several
times attempted to  introduce the bougie, with  like success, or
the want of it.
  In the first and second explorations of the endoscope, I  found
the orifice  in  the bulbous  portion, and,  on consultation, M.
Chaudemont and myself concluded,  if  another examination Avas
not more  happy, an external  urethrotomy made by this able
surgeon, without a conductor would be necessary, an operation
to be practised by him.
  So, on the 28th February, a third  exploration exhibited, in
an irregular surface, mammelonoid of the dead white of coarcta-
tion, with restricted  orifice at the left  inferior par; of the ure-
thra.   The orifice Avas much contracted, and  I substituted for
the former treatment the whalebone  bougie, which I left in
place, withdrawing  the endoscope.  The folloAving day, a very
fine bougie could be introduced in the  ordinary way.
  On the 5th March, the pain forced a cessation of any attempt
at catheterism.
  March 8th.   Aftet a renewed and fruitless attempt at  cathe- 
THE  ENDOSCOPE.
75
terism, urethrotomy was decided on.   By aid of the endoscope,
I passed a stylet, introduced an urethrotome, and completely
divided the inodular tissue, above and to the right, in its densest
part.   But feAv drops were lost.   An elastic sound No.  13, Avas
then introduced, to remain some time.
  Up to the 13th March, the sound was retained without any
accident;  then it was withdrawn, and a No. 34 Benique bougie
introduced.   Gradually, the  size of the  bougie was  increased;
at the end of eight days, No. 54 (jplus de 8 millimetres de diam-
eter),  say three  and one-fifth lines English measure, passed
readily.  The patient having educated himself to pass the sound
and his urine readily passing, left  the  hospital, recommended,
however, to  occasionally introduce a bougie of large size.

     Stricture of the Urethra without Previous Dilatation.
  T., aged  60 years, a  shoemaker and married, was in  the
Necker Hospital.
  This  man had  been a  soldier, and,  naturally,  addicted to
women  and wine.  When  21 years  of age, he contracted  his
first blennorrhagia, and entered a hospital  at Strasbourg,  there
he was  treated by lotions and injections.  Two years after, he
had a second.  He went into a Montpelier hospital,  staid there
about a month, and left without  being cured.  The  discharge
continued for some four  months,  abundant, accompanied  by
long and painful  erections; he made no change  in his habijts, as
regards coition and the imbibing of alcoholic drinks;  he  thought
he could cure the disease by these excesses.  There was neither
chancre nor bubo.  He kept up, and does still, this mode of life.
He has had clap, he knows not how long, and may even have it
now.   Whenever he drinks too much, urination is difficult,  and
a white drop appears at the meatus before the urinary emission;
little by little, the difficulty of micturition becomes permanently
established.   In  1849, he entered  the hospital at Brest, where
he learned  to sound himself, and  whenever urination became
difficult he introduced the sound  himself.  After that,  micturi-
tion was easier, but he was not sure that the bougie entered the
bladder. 
76
TnE  ENDOSCOPE.
   It is now several years since  the  stricture  has reached its
present point, that is  to  say, the man cannot hold  his  urine
when the desire  to pass it seizes him; he cannot stop, once its
flow has commenced; there is no pain in this, no great effort,
but its duration is more or less long;  the jet is very fine, some-
times bifurcated,  one portion  being projected, ejaculated, whilst
the other follows vertically.   The ejaculation  is  always made
normally.   For three years, his condition  has been the same.
   Upon his entry into  the hospital, I attempted to pass bougies
Nos. 6, 5,  4,  but ineffectually;  they could not  clear a  first
coarctation in the spongy portion, but were arrested under the
symphysis.   Large wax bougies were  introduced up  to  this
point;  the patient retained them as long as possible, and from
them he experienced relief; he urinated more easily,  but since
the catheterism experiences almost constant pain  in the gland;
drops of blood flowed from the meatus on the withdrawal of the
bougie.   During  the day, the urethragia continued,  his shirt
was  blood  spotted, and, squeezing the  urethra,  drops  would
appear.
   26th Feb.   Every day a large bougie was  introduced and
moved  back and  forth (a frottement) in  the  spongy  portion.
This day,  an  endoscopic examination was made.  The tube
passed  up to the second retraction, demonstrated a very  con-
tracted condition, so much so that  the stylet  nor a whalebone
bougie  could pass, save by the point into  the orifice;  the bou-
gie was left in place; a considerable discharge of blood occurred
upon the withdrawal of the instrument;  the blood must have
come from the first stricture, for the second  Avas seen to be
fibrous and not vascular; no blood was seen to come from it.
All day the blood flowed drop by drop.
   Injections Avere ordered, say 17.434 Troy grains (5 grammes)
of the  perchloride  of  iron in  3086.800  parts of water (200
grammes).   In the evening he complained of chilliness, turkey
flesh feeling (chair de poule),  and headache.
   During the month of March he was left quiet, the injections
were continued on account of a  slight muco-sanguineous dis-
charge, which  persisted and was increased by each exploration. 
THE  ENDOSCOPE.
77
  3d April.  This  day, the  patient  being in good condition,
the stricture was cut.   The  tube was put in place, a bistoury
with a superior cutting edge Avas introduced, and two superior
incisions made upward, one to the right the other to  the left,
the discharge of blood and the pain Avere but slight.  A sound
of large size was introduced  readily into the bladder and there
fixed,  with but little  pain  and no  chills.   The evening was
comfortably  passed,  with some muco-sanguineous  discharge
between the borders of the meatus and of the sound.
   5th April.  All goes well,  the patient scarcely feels the effects
of the operation.  The sound is withdrawn;  urination is facile.
   April 6th.  He complains of  lively pains at the meatus,  in-
creased  by the passage of urine, slightly difficult at this point.
There is some oedema of the bridle and, in separating the lips
of  the  orifice, a  small patch of herpetic vesicles.  They were
cauterized by the nitrate of  silver.
   8th April.  The pain  is  calmed, and  there is a renewal of
the cauterization.
   9th April.  He urinates well; a  bougie of Benique, No. 39,
is easily introduced into the bladder.
   10th April.   Exit.

 Coarctation of the Bulbous Portion.—Ordinary Catheterism Im-
             possible.—Endoscopic Urethrotomy.
   B. (Desire),  50 years of age, married, and a house porter.
   This man, pale, thin,  of a feeble and lymphatic constitution,
 easily worn out by work and prolonged vigils, had never been
 guilty of any excess.   When 31 years of age, a few days after
 sexual intercourse,  a  tumor, the size of a pullet's egg, formed
 in  his right groin.   It was red and painful, did  not suppurate,
 and continued for two weeks without preventing work, and that
 too without either chancre or discharge.   He continued to lead
 an irregular life.   Four years since, for the first and  last time.
 he experienced a slight blennorrhagic discharge, a little painful,
 and one curing itself  in from fifteen to  twenty days, and that
 without treatment.
   He found himself well until three or four months since, when 
78
THE  ENDOSCOPE.
he  perceived  his  urinary jet slow and  very short.  Little by
little, he was  obliged, during the night, to  discharge his urine
every tAvo hours, with but little at a time, and that voided with
difficulty.  On the 31st December, after a slight excess, that is,
a cup of coffee and a half bottle of Avine, urinating became im-
possible ; he also experienced much suffering through the length
of the penis and in the perineum, and Avas forced to keep abed.
The pain increased with the mictatory efforts.
  When he entered the hospital,  8th January, 1862, the patient
suffered  somewhat; there Avas a bearing down Aveight, also  las-
situde  in the perineum; micturition  took place either as a thin
thread, or else drop by drop.
  Catheterism shoAved a coarctation  near  the  bulbous part.
Bougie No. 4 penetrated it and then rested, pinched  by  its
point.   In the perineum, a tolerably hard nodosity Avas  felt.
  An  endoscopic  examination showed a stricture, into Avhich
the stylet might be introduced, and upon its left wall an ulcer-
ation giving issue to some blood.   The catheterism gave rise to
no accident.
  11th Jan.   A No. 3 bougie will not penetrate, it  comes out
twisted and bent upon itself.
  16th.  Every attempt to introduce the same  bougie  is fruit-
less.  With the  endoscope, the stylet was introduced, and then
the whalebone bougie, Avhich was fixed  in  the retracted part,
the patient to  retain it until the desire to urinate was felt.
  17th.  Yesterday,  after having withdrawn the bougie,  the
patient could  urinate more readily, in fact, there was  a great
amelioration;  but  in  the morning the  retraction returned, and
at the same point.  The  bougie  could, however, enter  and re-
main, pinched at its point.  In the evening, the patient  said he
was able, during the day, to pass  it entirely.
  22d.   Endoscopic  examination.  Introduction of the whale-
bone bougie, well  protected  (bougie de balein garder),  for  two
hours.   The patient does not suffer, the urinal jet is more easy,
but scattering.
  23d.   The  endoscopic sound was introduced  up to  the re-
tracted point; at  this point  a bistoury  was  inserted, and  the 
THE  ENDOSCOPE.
79
indurated tissues, in all of their superior surface, divided.   The
discharge of blood was but little.  Immediately after, a No* 20
sound  could pass;  it was stopped by an  obstacle beyond the
prostate, but ultimately reached the bladder.   The urine freely
flowed, the subject  was relieved, though, as a result of the oper-
ation, he was  chilly, and, with a feeling  of faintness, returned
to his bed.  Cataplasms Avere applied to the lower abdomen and
to the  perineum.   Soon, heat and good feeling sensations reap-
peared.   A conditional  injection of  sulphate of quinine was
prescribed.   In the evening, the patient Avas in good condition,
had urinated well, suffered but little, had  no chills,  and was in
a state of gentle moisture.  The injection Avas  not given.
   24-th.   Same satisfactory condition.   The sound  remains in
place.
   25th.   Doing well in the morning.   Going  twice,  during the
day, to the  privy, was seized with a violent chill of about tAvo
hours  duration, and followed by fever, sweating, indisposition,
prostration, and headache.  Ordered the following enema:—ly.
Valerian 2 gram, (say grs. 804^), quin. sulph. 50 centgram. (grs.
8), camphor 2 gram. (grs. 804;), Laudanum of  Rousseau gtt. 10
   27th  The patient has done well  these two  days past, suffer-
ing but little, Avith  neither chills nor fever.  The sound is with-
drawn; the discharge is sero-purulent.
   28th.   The  patient urinates easily,  and, according to him,
with a larger jet  than  ever before; he  might be  considered
cured, were it not  for a slight muco-purulent  discharge, and
still some pain during, but especially after, micturition.
   3d Feb.  A bougie of white  metal, No. 28, (equal to Car-
riere's 21,) was passed into the bladder.
   Jfth.  Bougie 29
   13th.   The  same bougie introduced  each  morning, and re-
tained for an instant.   An endoscopic examination  reveals no
cicatrices from the  incisions.  The condition, general and local,
is excellent.
   llfth.   Discharged. 
80
THE  ENDOSCOPE.
        Stricture of the Spongy Portion of the Urethra.
   B. (John), aged 42 years, a shoemaker by  trade, married,
 and in the Necker Hospital.
   This man is of good constitution, and has never  been sick.
 At the age of 21, he  had an intense blennorrhagia, which ap-
 peared after nine days'  incubation.  He was  accustomed  to
 drink  largely of beer  and wine, Avithout,  however, committing
 many excesses, and exercised himself as a baker, Avhich fatigued
 him much.  He did not change his habits and  used no  treat-
 ment but  tisanes;  the discharge Avas abundant, the pains severe,
 the  nights  tormented  by  prolonged  erections.  Three weeks
 after, not yet cured, he had new intercourse Avith Avomen, and
 renewed them oftener tAA'ice than once a Aveek.  He also opened
 a Avine store, AArhich did not tend to prevent his drinking.   One
 year after its commencement, the discharge was still abundant.
 During the second year, it diminished little by little, and existed
 only in the form of a  drop of pus, which he forced  out in the
 morning.   This, too, soon  left of itself, though he gave up nei-
 ther wine  nor women.   He then  passed fifteen years without
 inconvenience.   In 1857, he  perceived, for the  first time, after
 a slight debauch,  that it  was difficult for him to urinate, the
 stream was small, and only voided  by great effort.   The follow-
 ing days the micturition was more  facile,  but after every excess,
 say on an average each eight days,  there was a  new retention.
 He consulted  a physician, who, fruitlessly, attempted to  pass
 bougies into the bladder, and had  caused but little relief; the
 dysuria increased with  each and every excess.   The ejaculation
 was with  difficulty made, and meantime  the sperm  flowed like
 saliva.   During the  past  two months, these last symptoms are
 especially manifest.  The retention  of urine is more complete
 and  accompanied by acute pain.   The urine only passes in a
fine jet, and that  falling perpendicularly,  and  sometimes  in a
spiral formation.  His  general health becoming  affected, he
concluded, by the advice of his physician, to enter the hospital.
  Jfth Jan.  A large sound was introduced into the urethra  it
passed along the spongy portion, but Avas checked  at  the junc-
tion of the bulbous and membranous parts; it caused to project 
THE  ENDOSCOPE.
81
into  the  perineum hard  nodosities, readily felt by the fingers.
A No. 5  bougie could be readily passed, with a slight discharge
of blood;  it was kept in  situ for about two hours, then, on be-
ing withdrawn, the patient urinated somewhat more readily.
  5th Jan.  A No. 7 bougie is readily introduced, but remains
pinched by the coarctation; it was left about two hours.   The
urinary function is more easy.
  6th Jan.  The patient is fatigued;  he has had  no stools since
his entrance into the hospital; a bottle of Seidlitz water was
ordered.   The result was, not large  evacuations, slight  chills,
and  pain in the loins.  He remains in bed, and takes  only a
light soup.
  7th Jan.  Leave him quiet, and give an enema, as follows:
fy.  Valerian, gram. 2 (grs. 80), quin. sulph. 1 gram. (grs. 40),
laudanum, Rousseau's, 10 gtt., camphor, 2 gram. (80 grs.)
   8th Jan.   This morning, the patient seeming well, the endo-
scope was introduced, it showed a retraction of the canal of the
normal color;  the stylet was passed, the mucous membrane in
front of the coarctation was perfectly healthy.   He passed the
day well.  At 3J P.M., he took an enema of  quinine, after
having first taken a simple one which brought away much faecal
matter;  immediately he was seized  with  dizziness, palpitation,
nausea, cold sweats,  vertigo, and  ringing in  the ears.   A few
glasses of Seidlitz water  and coffee without milk, and the sickness
was allayed.
   9th.   This morning the patient does well;  rest is given him.
 He  is purged with a bottle of Seidlitz water,  and  takes an
 enema of 10 grs. (50 centigrammes) of the sulphate of quinine.
 In the evening her experienced  the  same symptoms as  on the
 previous day, but less decided.
   11th and 12th.  The injections are repeated,  and no return
 of the sickness;  the febrile symptoms have not reappeared.  A
 No. 4 bougie was  introduced  and left in for two hours.  He
 experienced a pricking  sensation in the canal, and  some drops
 of blood came out with the first drops of  urine  after  the Avith-
 drawal of the bougie.  The flow is somewhat larger.
        6 
82
THE  ENDOSCOPE.
   13th.  This day was well passed;  the enema was  counter-
 manded.
   llfth.  The endoscope  was again  employed  this  morning.
 About 3 P.M, he had an intense chill, faintness, thirst, nausea,
 and pain in the kidneys;  micturition was very painful, and for
 some hours left a condition of sickness.
   15th.  He was better.   A bougie, No. 21, was introduced as
 far as the stricture and left for fifteen minutes, for the purpose
 of decreasing the sensibility of the canal and of dilating  the
 coarctated  spongy portion.   The evening found him  slightly
 fatigued,  the bougie was reintroduced, and the  injection dis-
 continued.
   16th.  Same condition.   Seidlitz  water.
   30th.  Every day a large bougie  has been introduced  as far
 as the stricture;  the general health  is good.   The endoscope is
 now applied, and a superior incision  made the length and  thick-
 ness of the  coarctation.   The discharge of blood is  but slight.
 Immediately after, a No 20 bougie is introduced and fixed; the
 urine flows, the inconvenience to the patient is slight.  In the
 evening he complains of sharp pains in the part operated upon,
 radiating  towards the anus, but without either chills or  fever.
 An enema of quinine is prescribed.   The urine is freely passed,
 and there is a sero-purulent and somewhat sanguinolent  dis-
 charge between the sound  and meatus.
   Feb. 1st.   Condition satisfactory; sound  withdrawn; bowels
 costive; tongue white;  loss of appetite.   Seidlitz water.
   2d.   Discharge diminished; still some pain in urinating, the
 flow being neither strong nor rapid, but better  than  before the
 operation.   There is some suffering in  the perineum  and in the
 lower belly.   Cataplasms.
   5th.  A No. 22 bougie introduced  and left in  place for ten
 minutes.
   6th.  Bougie No. 23.   In the evening, chills and discomfort.
   7th.  Pass a smaller bougie and withdraw  it  immediately.
 During the  day,  he experiences slight  chills, indisposition, a
 natural condition, and considerable pain in the parts cut.  In-
jection of quinine. 
THE  ENDOSCOPE.
83
  11th.  Each day, a metallic bougie is introduced and at once
Avithdrawn;  the urine passes well, but  he is  fatigued; his eyes
are encircled,  and almost every day he experiences slight chills.
  20th.  Sounds of Benique, Nos. 30 to 37, successively intro-
duced without difficulty or pain.   The condition of the patient,
and by his own acknowledgment, is much improved.
  22d.  Bougies 35 to 41 sufficiently large.   The patient com-
plains of nothing, is up, eats heartily, urinates easily and with-
out pain, and  may be considered as cured.
  Among the accidents which may be the consequence either of
stricture or of traumatic lesion of the urethra, but few are more
serious or more distressing  than urinary fistula.   To give their
entire history would  lead us from our legitimate  subject; thus
we must be content to confine ourselves to the results of endo-
scopic aid in their cure.
   The usual treatment of urethral fistula consists  in the  em-
ployment of  permanent  sounds  or repeated catheterism, after
dilatation.  By these  means, it  is proposed  to prevent the  flow
of  urine through the fistula, which most frequently cicatrizes
when this secretion  does not tend, by  its passage, to keep up
the abnormal opening.   Often it is  unnecessary to keep the
sound in permanent place, as the fistula may cicatrize  as soon
as  the urethra offers no  further  obstacle to the  flow of urine.
Unfortunately, it is not always thus,  some of these fistulas re-
main, though the canal may be  perfectly free.  This  persist-
ence may  be  owing to the  presence of gravel in the fistulous
tract, or else  to more or  less separation of adjacent and subja-
cent tissues.   In such cases, extract  the gravel,  and cause the
adhesion of the separated parts.  These are the evident indica-
tions to be fulfilled.  I  have succeeded in  curing multiple fis-
tulas by the buttonhole treatment of  Syme, being careful  to
 incise each sinus.  But this is a grave operation, and, more-
 over, there are some cases kept up by neither gravel  nor by
 decollement,  but  by  the  continuous  passage of a few drops  of
 urine.  Cauterization of the urinal orifice will not avail, for the
 urine is  introduced  from  above, and nothing can impede its
 effect upon cicitrization; or, if the  lower orifice should close, 
84
THE  ENDOSCOPE.
the effusion will soon reopen it.   What, then, must  Ave do  to
cause the closure of these fistulas ?   What, then, must we do  to
cause cicatrization.  Modify the internal orifice.   Cauterization
of this orifice furnishes the most proper means to bring about
this  result, by freshening the parts, bringing  about a healthy
granulation, and also producing a temporary obliteration of the
opening by the swelling of its borders and by the eschar which
protects  the  farther parts of the urethra and permits them  to
rejoin.
  Such are the ideas that induced me to apply, by means of the
endoscope, the nitrate of silver  to  the urethral orifice of stub-
born fistulas.  The process for doing this is most simple:—
  Having, by proper  treatment, caused  the disappearance  of
all obstacles to the flow of urine and  the passage  of the sound,
by the aid of the endoscope,  Ave  examine the urethra from back
forwards, until we find the opening of the fistula.   This is some-
times difficult  to do, because  its  edges may touch, or it may be
located in the midst of an ulceration, but it may generally be
discovered by means of  a small  violet red  spot  or one of the
color of wine  dregs.   Often, a  stylet or bougie can  be  intro-
duced  into the  fistula and will  show itself  at the end  of the
endoscope, thus  indicating its urethral opening.
  In  a case  now  in my service, traumatic in its  origin,  the
orifice was  recognized  by  means of  a fungous vegetation,
similar  to  those   often  found  at the  external opening of
urinary fistulas.   Two cauterizations  destroyed this vegetation
and laid bare the opening.  The patient is still under treatment.
In this operation, eschars, so far from being  feared, must be
hoped for, they are necessary.   A small pencil of solid nitrate
of silver,  placed  in an appropriate porte, should be used; in the
absence of a proper instrument, melt the nitrate upon the  end
of the endoscopic stylet.
  When the orifice of the fistula is  discovered,  nitrate of silver
is to  be  applied, care being taken not to touch  neighboring
parts;  it is to  be left a short time, and efforts made to introduce
it into the orifice.   When it is thought that sufficient action has
accrued, the caustic is to  be  withdrawn, and, to prevent exces- 
THE  ENDOSCOPE.
85
sive  action  upon  the neighboring  parts, cotton impregnated
Avith marine salt should be introduced, to transform the nitrate
into an inoffensive chloride.
  After the operation, there is but little pain, rather more, per-
haps, than after the application of a  solution of nitrate of silver,
but still  very bearable.   The day following the cauterization,
the passage of  urine through the fistula is generally diminished
and  sometimes completely  checked; yet, for all  that, it must
not be supposed that the patient  is Avell, though such effects, to
my great surprise, I  have more  than once experienced.   The
swelling which  succeeds the action of the caustic soon subsides,
the eschar  falls, and  the urine recommences to pass.   Thus it
is necessary to wait  for some  days  so as to give  the work of
reparation  time to set up the recommencement.   The  urine
gradually ceases to pass  through the fistulous  opening, which
ends by drying up (se tarir), and the cure is complete.
  The following case will show the march of the cure:—

Slight Contraction of the Bulbous Portion—Laceration of the
  Canal behind the Stricture—Infiltration  of  Urine—Incision
  —Fistula—Cauterization of the Urethral Wound—Cure.
  D., aged 35, employed  upon the railway, married.
  His general health good.  Before his marriage he had a light
blennorrhagia,  Avhich lasted fifteen days, and then disappeared,
he says, without taking on the chronic  form.   During the past
five  or six  months,  however,  he has experienced occasionally,
and especially when heated, difficulty in urinating.
  On the 6th of July, 1862, while transporting baggage to  the
cars, a heavy trunk fell upon his left ilio-pectional eminence.
He felt  considerable pain therefrom,  but  still continued his
work.  The  next  day, the pain  continued,  and he perceived a
small tumor formed upon  the  course of the left spermatic cord;
gradually the surrounding  parts  became swollen, and micturi-
tion difficult and  painful.   Still this did not impede his work
for  seven days  yet.  At length he decided to keep his bed,  and
called  in medical  aid.   Hip-baths  and  leeches were ordered;
then he came to the hospital. 
86
THE  ENDOSCOPE.
  On his entrance, he could not possibly urinate; he suffered
much from  this cause and from the  tumor, noAV  the size of  a
hen's egg, vertically elongated, in  front of the  left inguinal
region, now hard and not fluctuating.  Catheterism presents no
great difficulty and gives issue  to much urine, greatly  to  the
relief of the patient.
  The marrow, the scrotum, the penis, the left groin, the  pe-
rineum are the seat of great oedematous swelling.  The patient
is most anxious;  there is pain in  the parts; and  some  febrile
symptoms.  Four incisions are made, two in the perineum,  one
in the left scrotum, and one in the groin; thence, came much
pus and  serosity; the pus without the smell  of urine.   Cata-
plasm.
  The parts disgorge in proportion to the discharge from  the
incisions.   A  feAv days after, the pus takes on a urinous smell.
A sound  is left in the bladder.   His general condition is excel-
lent;  no  chills, no fever, and a good appetite.
  In a fortnight, two of the incisions are cicatrized; the third
requires  two months  to close; the fourth, situated at the  left
antero-superior part of the scrotum, remains fistulous, and, when
the patient urinates, a portion of the liquid passes through it.
He  also  perceives  it  in  the cataplasm used  on the wound.
Bougies of Benique are passed, from No. 34 to No. 51.
  9th Oct.  Endoscopic examination,  A violet red spot, easy
to bleed,  is found in  the  inferior  half-circumference  of  the
canal; this spot seems  to surround the internal orifice.   It is
cauterized with a  concentrated solution  of  nitrate  of  silver,
applied by means of a cotton tampon passed through  the sound
of the endoscope.  The permanent  sound is withdraAvn.  The
urine, the first time, passes with difficulty and in a scattering
stream, but the ensuing day it becomes perfectly natural.  The
urinary discharge through the wound still continues.
  16th.   Second cauterization, by means of the solid stick of
lunar caustic passed through the sound of the endoscope.   Dur-
ing the day, there  is a slight hemorrhage; the micturition is
properly  made about every hour.  The discharge by the fistula
diminishes in quantity. 
THE  ENDOSCOPE.
87
  2Sd—30th.   The  fistulous  opening  in  the canal  is  again
touched with  the stick  of  silver.   Metal bougies are passed
almost every  day.   The  improvement continues, and, on the
I,,th Nov., the  patient  is  discharged, perfectly cured,  the ure-
thral fistula cicatrized, and  the urine passes in a full and copi-
ous jet.

                      FIETH LECTURE.

            The Prostate.— The Bladder.—Calculi.
   Gentlemen:—We have now finished the study of the appli-
cation of the endoscope to the diseases of the urethra; but you
doubtless recollect that,  in speaking  to you of urethral granu-
lations, I  omitted those  affecting the prostate, deferring their
description  to  a  later period.   With these,  we will commence
our lesson to-day.
   Ulcerations  of the  urethra, whether granular, herpetic,  or
arthritic,  present the same characters in the prostatic  as  in
other portions of the canal, only they more readily become fun-
gous, and,  consequently,  it more often  happens their character
is masked, and thus  it  may be more difficult to distinguish  them.
In such cases, diagnosis  must be based upon the progress and
other  symptoms.  We must,  however, remark that, most fre-
quently, the endoscope  will enable us to distinguish between
these ulcerations.
   Granular ulcerations in the bulbous and  membranous region
are, as we have  seen, the most frequent cause of stricture, in
consequence of the  organic changes they cause, and which we
have fully  examined.  In the herpetic region, owing to the dif-
ferent anatomical arrangement, retractions do not  occur, as I
have  before said, but  the congestion, the irritation kept up  by
the granulations, may end in  a chronic engorgement  of the
gland.  It might be said of the prostate as  it has been of the
uterus, that it is not the ulceration which brings about the en-
gorgement, but the  engorgement which supports  the ulceration.
It is certain, that in the prostate, as in the uterine neck, there
are ulcerations kept up  by organic  chronic engorgement; but 
88
THE  ENDOSCOPE.
study them well, and you will find that these ulcerations, Avhich
increase and decrease, disappear, even  under  the  influence of
treatment, and reappear without apparent cause upon the en-
gorged organ, on  ulcerations of an herpetic character, which
can be as readily distinguished here as  in the anterior parts of
the urethra, though they possess  less mobility.  As to the true
granular ulcerations, in the prostate as in the bulb, the uterine
neck,  or  the  conjunctiva, once  cured,  they do not  reappear
without the reapplication  of the exciting cause.
   There is no particular treatment for this  affection,  but  if it
should be necessary to employ special  means, it should  be to
combat certain complications, such  as inflammatory symptoms
of the parenchyma of  the gland,  or of certain accidents caused
by a swelling of this organ.  For the rest, the endoscope gives
us the means of attacking, efficaciously,  ulceration  which is no
longer more difficult  to cure than in any other region.
   We  have seen that the chronic inflammatory stricture  heals
spontaneously at the same time as the granulations  which main-
tain it, but when it arrives at a certain point, whilst the swell-
ing is more or less inflammatory, and the induration  is estab-
lished, it is obstinate in its course, and is the same as  engorge-
ment of the prostate.
   I have often seen the  prostate take on its  volume and its
functions reestablish themselves  in  their normal state, in pro-
portion as the granulations yield to to treatment.   Thus, in the
prostate as in the  rest of the canal, the  granulations  have the
same character, the same progress, and yield to  the same treat-
ment;  they act through a mechanism analogous to  the mucous
and the subjacent tissues.   But here the  analogies end, for  the
effects produced are not the same.   So  long as the contraction
is almost exclusively due to the granulations, the engoro-ement
of the prostate is well known to arise from other causes.   They
appear more frequently to arise  from  arthritic and  herpetic
diathesis,  from scrofula  than from  hygienic influences  whose
actions  are  universally known.   Of all  the causes resulting
from affections differing in their nature, but the symptomatic
expression of which is  somewhat identical, it is almost  impossi- 
THE  ENDOSCOPE.
89
ble to-day to arrive at a diagnosis with anything like certainty.
We only hope that, with the era of endoscopic observations, we
shall be able to elucidate the subject now so obscure to science.
Already, the endoscope has permitted us to  perceive the en-
gorgements  due to granulations.   In  the scrofulous engorge-
ments  Avith  ulcerations, it  gives  also some  positive  charac-
teristics.
   In effect, when these ulcerations remain for some time, they
go  beyond  the limits of the mucous, and then, in  place of  a
superficial denudation, the endoscope reveals to us a true ulcer,
deep and ragged, presenting, in  a Avord, the  appearance of  a
strumous ulcer.
   We  had,  at the  commencement of the year, in our ward,  a
patient afflicted with strumous ulceration and tubercles of the
prostate, with urinary fistula of  the same  nature, upon which
these cliaracters greAV more and more distinct  in proportion as
the lesion progressed.   This man left us, thinking he could find
elseAvhere a cure, which he despaired of obtaining with us.  In
the case of  this gentleman,  you are well aware that  the thera-
peutic  treatment is very limited, but, however, it will be in our
power, thanks to the  endoscope, to convey to  these deep-seated
lesions  the  same topical  treatment  Avhich Ave  have known by
expesience to act favorably upon  lesions of the same nature in
exterior organs.
   A consequence  attending fixed ulcerations  in the prostatic
regions of the urethra, Avhich oftentimes injures the  patient,
are seminal losses.  It happens oftentimes that they constitute
a  constant  symptom,  or  even become habitual, in fact,  they
return  with sufficient frequence to merit special attention; but
so much the more, without  having exaggerated the importance
which Ave have attributed to them, we can but arrive at  the con-
clusion that they may bocome exceedingly grave.  But, whilst
they derive  their existence from  the ulcerations, they seem to
disappear of themselves, or  by simple means after the recovery.
   This lesion may return under tAvo forms, one, which can be
attributed to the  irritation  of the  orifices of the ejaculatory
canals, accompanied by lively sensations, and often by profound 
90
THE  ENDOSCOPE.
pains of the perineum;  the other, which appears atonic, comes
on with little sensation, sometimes in sleep, without the knoAvl-
edge  of the  patient, and  without  aAvaking  him; Avhilst  he is
awake, if  the patient wishes  to accomplish his virile functions,
the least  excitation  will bring on  the emission,  and,  as M.
Trousseau has said  in his lectures, it can but result in a sort of
impotence, to which we ought to give the name of  "spermatic
incontinence."
  In  the  one or in the other case, but  oftentimes in the  first,
the semen which the patient loses is often mixed with blood,
which proves the existence of the ulceration.  This symptom
may appear equally in all ulcerations, but above all in granular
ulcerations; the losses which  accompany tuberculous ulcerations
appear more frequently from  the  atonic form;  those which
proceed from herpetic  ulcerations are  less obstinate than the
others.
  Apropos to this  subject, another very similar  symptom pre-
sents itself, which very much surprises  and astonishes him who
experiences it:  the  patient, in  his  sleep, experiences all the
sensations of a nocturnal pollution, he awakes, and,  with aston-
ishment, perceives that  no  liquid has been emitted.
  The idea which  naturally presents itself, is that of a devia-
tion of the ejaculatory  canals which directs the sperm  towards
the bladder;  but  without taking  into account the disorders
which it  is necessary to admit must arise  from a displacement
or deviation of the  ejaculatory canals, the patients which I have
had under my observation formerly, from normal ejaculations
and elsewhere, the  most minute microscopical researches do not
show any trace of spermatozoa  in the urine.   There had  been
then, in the few cases that I  have observed, a false sensation, a
sensation  without an emission.
  This phenomenon is not, like  the rest,  a  certain index of a
prostatic  affection,  for I have seen  healthy men,  perfectly Avell,
from this country in particular, who had  experienced it; only
in these cases it did not return or rene\v itself, as in the case of
the patients.
  A  symptom oftentimes more rare, and which I  have seen 
THE  ENDOSCOPE.                    91
alike upon patients  affected  with granular ulcerations of the
prostate, is a  sensation analogous  to  that which  accompanies
coition, a sensation which becomes,  for the moment, painful, or,
as a patient  said to me, "a voluptuous pain," which endures
without interruption  during  the entire  coitus, and  oftentimes
for weeks, and horribly fatigues  those who  endure it.  In the
two patients who presented this symptom in the highest degree,
it was  accompanied by a pain sufficiently sharp that the patient
located it at a certain point in the neck of the bladder.  These
two cases prove, beyond  doubt, some  nervous  affections which
have a  great resemblance to hysteria.   The one most gravely
affected, of my two  patients, had become a melancholy hypo-
chondriac and had given  serious uneasiness to  his friends, and
distinguished physicians had  attributed the entire affection to a
nervous disease.
   In these patients, the prostatic region presented  a granular
ulceration; one of them, cured of granulations, was at the same
time embarrassed with pains  and all the other symptoms which
attend an old  catarrh of the bladder.   The other patient, cured
of his  granular ulceration, preserved  his fixed  pain, which he
said had  its seat at  the left  of the opening of the urethra into
the bladder,  at a point where the canal is continued with  the
vesical cavity.   He entreated  me always to pay particular at-
tention to this point, assuring  me that I should find there the
cause of his difficulty.  In fact, when  I commenced, after  hav-
ing emptied the bladder, to examine minutely the border of the
orifice  of the urethra, I  discovered to  the  left  a small, well-
marked, red ulceration as large as the head  of a  large  pin,
which  resembled  a  small  fissure.  I  touched  it Avith a  small
crayon of nitrate of  silver, the pains disappeared almost imme-
diately, obscured  by the pain of the cauterization, and did not
reappear;  the patient became perfectly calm.   The patient
returned  twice, at somewhat long  intervals, for his pains had
revived, and  the same  treatment  allayed  them.   For many
months, the patient  appeared to me to  be  cured.  I  met him
from time to  time, he did not  speak of his difficulty, but from
his exterior or general appearance, I am inclined  to think that 
*
92                    THE ENDOSCOPE.

this melancholy hypochondriac is completely cured, as also the
lesion which produced  it.  I do not know in what  class of  dis-
eases to place the cases of these two men.
  We have seen seminal losses caused by the ulceration of the
prostatic region of the urethra, but it is not necessary to believe
that they always arise from  this cause, for  they may originate
from diseases of different nature and  often remote or  distinct
from the genital organs.
  In the enumeration Avhich we have made of diseases  of the
prostatic portion of the urethra, we have not spoken of cancer,
because  it determines  beyond  doubt some  symptoms which
report  themselves from  the  bladder, and which cannot  be re-
lieved or cured without attention to this organ.  We will, there-
fore, return to this organ at once and speak of affections of the
bladder,  and,  above all, of  those which pertain  to  the neck of
this organ.  We will now occupy ourselves,  gentlemen, with an
endoscopic exploration of the bladder, and, as we did with the
urethra, we will commence  by the study of its healthy condition.
  In order  to examine the bladder with an open sound,  like
those which we used for the urethra, it will be necessary to
clear it, for if the extremity of the sound becomes clogged with
mucus  it will be impossible to  proceed into the cavity of the
organ,  in order to explore all the points.   It  is necessary then
that the  bladder  be full at the moment of exploration, and, in
consequence, we must  employ a sound which will stop the  flow
of urine and, at  the  same  time,  allow  the  rays  of light to
pass in.
  This sound presents the  same form as the urethral, but it has
not a lateral  opening, and  terminates by a little prolongment
around the end, AA'hich separates itself at an obtuse angle;  in a
manner,  it resembles, in its general form,  the prostatic sound of
M.  Mercier,  the  introduction of which is so easy, as we have
said, especially when there is a swelling of the prostate.  At
the angle of  reunion of  the two branches, the sound is pierced
in the axis of the long branch by an oblique opening, closed by
a little plate of glass with  faucets, plain and  parallel, carefully
and solidly set in with mastic.   It is this  glass which  retains 
THE  ENDOSCOPE.
93
the liquid  and allows the light to pass through; it should be
oblique, because if it was perpendicular to the axis of the tube,
it would be less clear before the vesical cavity than  the interior
of the instrument, it would make a mirror and  reflect the illu-
minated points situated  in front of it, and prevent from  distin-
guishing points situated  beyond it.  Thus, also, at night, when
we direct  a strong light  towards the outside of a  window, we
see in the glass, as in a mirror, the  inside of  the  apartment,
whilst the exterior appears entirely obscure.
  The extremity  of the small  branch of  the sound can  be
screAved on, so as to facilitate  the cleaning of the interior face
of the glass, this, however, is  rarely necessary.  We must be
careful that the small addition  be always well screwed on, so as
not to let the liquid pass through it, for  the smallest drop in
the interior of the sound will  interfere with the rays of light.
You  will  easily  understand, gentlemen,  that  if the bladder
should contain a turbid liquid it will  be  impossible  to  distin-
guish anything of its interior structure, whilst  it is diseased it
is  rarely that the urine is not made turbid  by mucus, pus, or
blood, and often by these three liquids mixed in various propor-
tions, it will  then be necessary to empty the bladder by the aid
of an ordinary sound,  which will  serve also  for the purpose of
injections,  so that it may be washed out.
  When  the water of the injections becomes  very clear, then
Ave may withdraw the ordinary sound  and replace  it with the
"sonde a  vera"  which we  have just  described.  Upon  this
sound we shall place the apparatus, which  we have described in
our first lesson, and shall then commence to examine.   In an
open  or clear bladder, there is nothing to constrain the  move-
ments of the instrument, we  can thus explore the smallest part
of the internal surface of this organ, even to the  border  of the
prostate, the vesical triangle, and the superior and inferior fun-
dus.   The  anterior  face escapes the  examination;  I have  es-
sayed to make this  accessible, by means of  a mirror placed at
the extremity of  the long portion of the sound, in front  of the
lateral opening, but the clearness not being sufficient, the field
of vision  is  considerably curtailed, and, in fact, the  result 
94  '
THE  ENDOSCOPE.
 amounts  to nothing.  I have not yet, however, renounced  the
 hope of being successful, but, for the present, we must content
 ourselves with examiuing that portion which is accessible to us,
 then, by a happy coincidence, this portion is  precisely the one
 which is most often diseased, and that Avhich escapes our exam-
 ination very seldom offers anything of interest.
   We shall now learn, through the endoscope,  the physiological
 condition of the bladder.   The mucous membrane of the blad-
' der presents a  healthy and smooth surface, and  a  color analo-
 gous to that of the urethra, but ordinarily a little more pale, it
 is of a yellowish white, slightly rose tinted.
   In certain  subjects it presents, here and there, a number of
 superficial vessels, very minute, Avhich  are seen  to appear  at
 different  points, and ramifying themselves, take  very  tortuous
 courses.  Very often, these vessels are  not  seen in a  bladder
 well filled, and one cannot perceive in the points  which present
 themselves  in  the  field of  the  instrument, that  the surface is
 smooth and the color uniform.   The only particularity that we
 have noted is,  that we can  reconnoitre, whilst  it exists, the
 transverse angle or point which  limits the "trigonus vesicale"
 from behind, and extends between the orifices of the  two ureters.
 In regard to the size of these orifices, I have not cared to speak
 to you, because it is unnecessary.
   In order to  examine the urethral  orifice, it is necessary to
 withdraAV the sound as far  as where the glass commences  to
 reenter the urethra, then we commence to perceive  the  inferior
 part  of the visual  field, the  border of the prostate, under the
 form of a small crossing  from  the  superior  concavity.  This
 part is habitually more red  than the vesical mucous membrane,
 and as the  border  which it forms intercepts the  rays of light
 the surface of the bladder oftentimes  appears of a deeper color.
   If we carry the  extremity of the sound to  the right or left
 we can  follow  the  contour of the urethral orifice; but  as in a
 moment, one loses the borders of this orifice, at the same time
 that it passes away, in place of  appearing circular, its  contour
 forms a crook, elongated transversely.   But the state of health
 as we pass to the disease, commencing with  the case Avhich ap- 
THE  ENDOSCOPE.
95
proaches least  to a normal  state, we shall find  the borders of
the organ anaemic and the congestion characteristic, the one by
its  pallor, the other  by the redness of the membrane, in which
the vessels become oftentimes more apparent.  I have encoun-
tered the anaemic pallor  in chlorotics or very feeble patients,
and oftentimes in some cases of neuralgia of the bladder in
chlorotic or debilitated  subjects, the dilatation of the capillary
vessels, Avith or without  redness of the mucous membrane; some-
times,  likewise, they detach themselves upon the healthy mem-
brane, and oftentimes it is the only lesion which the endoscope
shows  in patients affected  with hematuria, without calculi or
organic  affections.   In  this case, we often diagnose varices of
the neck.  They perhaps  exist sometimes, but more frequent
from my observations, already sufficiently numerous if one can
suppose" that the blood be furnished  by the varices.  There are
some capillary  varices which extend themselves  over the entire
membrane, or at least a great part of it.
   Without these vascular dilatations in the case of hematuria,
we encounter,  sometimes, some ecchymoses  of the membrane,
sometimes considerably large and irregular, sometimes small
and lenticular.   I have observed, in two cases of scorbutic he-
maturia, that the color somewhat  resembled a violet tint.   I
shall reapproach these light affections, grave without doubt, but
more  so in  appearance than reality, the diagnosis of which
would be difficult without the aid of the sight.
   We shall meet with  subjects which are taken, it may be  in
full health, or it may be in the course of some light affection or
habit of the urinary functions, with violent pains of the neck of
the bladder,  with  vesical  tenesmus, hematuria,  retention  of
urine, more or less complete; these symptoms, after a variable
duration, subside rapidly, sometimes suddenly, but often they
return at intervals more or less in length.
   With  like symptoms, and  in spite of their complete subsi-
dence, for sometimes there  is no rest between the attacks, it is
difficult  not  to believe  that probably a  grave and organic dis-
ease of the bladder exists,  then whilst we cannot  diagnose any
tumor by catheterism.  I have often known given, and I myself 
96                    THE  ENDOSCOPE.
have held, in similar cases, an unlucky diagnosis.   It is difficult
to avoid it with the ordinary means of diagnosis;  but apply the
endoscope, examine the bladder with care, and you will find an
exaggerated development of the capillary vessels of the mucous
membrane.
   Whilst I  have had  occasion to  observe some cases of this
kind, it Avas upon patients subject to attacks of gout and  rheu-
matism, and some vesical affections  so closely resemble  arthritic
affections that I have been almost obliged to attribute them to
the same cause, and as I regard this abnormal dilatation of the
capillary vessels as  one of the effects of arthritis, for  the same
reason that the capillary varices of the inferior members and of
some other  parts of the tegumentary system.
   After the congestion of  the mucous membrane, we arrive nat-
urally at its inflammation.  Acute cystitis cannot exist without
danger or Avithout pain, it cannot result in any advantage to the
sick to practice an exploration by the aid of the endoscope, but
if it be only chronic cystitis or  sub-acute, imd  of that which
accompanies  the presence of calculi in the  bladder, then  it is
practicable to examine without danger,  and with utility, and to
make an exact diagnosis of the lesion.  In the first degree, we
find a  general  redness with development of the  vessels, which
are oftentimes more numerous but less dilated than in the affec-
tions of Avhich we have spoken.
   In a degree more advanced, the redness of the mucus is more
intense, and  Ave cease to distinguish the vessels which  are con-
founded in  the general well-grounded tint.   So that, in certain
chronic cystitis, for a long time there is a general ramollisse-
ment of the mucous  membrane which  has  lost  its epithelium,
and the surface of which has  become  uneven, rugged;  in the
autopsy we find it black, in consequence of the alteration which,
after sudden death  takes place in the gorged bloodvessels.  In
this case, it is often difficult to separate the bladder from the
pus that it  contains, and of which the thickest part rests  adher-
ent to the ulcerated surfaces, but if you proceed to fill the organ
with limpid water, you will find the membrane of a deep red in
places, and  presenting the same rugged aspect  that we see in 
THE  ENDOSCOPE.
97
the autopsy.   In the other parts, the pus which  could not  be
washed away by the  injections  hides from you the state of the
membrane; but  the  presence of this purulent layer, AA'hich we
also cannot detach  from the end  of  the  sound, is already a
proof of  the ulceration of the bladder, and a lesion very grave
upon its  surface.
  Before quitting this subject I will call  your attention to a
patient which we have lately examined.   From his entrance he
presented already some time since, some symptoms of cystitis;
the micturition  was  accompanied and,  above all, followed  by
pains; the urine contained pus; and he had had a little hema-
turia.  We suspected a calculus, but  the sound did not show
any foreign body.  The endoscope showed  us the vesical mem-
brane of a deep red, surrounded  by an abundant  network of
vessels of a more lively red, the border of the prostate was red;
but that which was most notable, was a  development of round
red points, larger than granulations  and more regular  than
flesh buds.  I had some difficulty to satisfy myself in regard to
these growths, however, their appearance leads me to  suppose
that they are simply inflammatory.
   The following confirms this diagnosis, for  after some time of
repose, from baths and antiphlogistic treatment, all the symp-
toms  disappeared, and then,  on a last endoscopic examination,
the bladder and the prostate had  recovered their normal ap-
pearance; the prostate, in particular, had again become smooth
and even, as in its natural state.
   We have already  had  occasion to speak of the engorgement
of  the prostate, and also of  urethral ulcerations,  which are
sometimes the cause, but we have said nothing of the endoscopic
character of the swelling which follows.
   The engorged prostate can  acquire a considerable  volume;
and, as you know, makes a lump in the cavity of the bladder.
Its volume can be appreciated by the depth to which it is neces-
sary to pass the sound, in order to penetrate into  the organ and
touch it  through the rectum; its prominence in the bladder and
its measure, with sufficient precision, may be known by meana
       7 
98
THE  ENDOSCOPE.
of the catheter of M.  Mercier, but through the endoscope we
can sometimes know more, the disposition of it.  A first partic-
ularity which  strikes  the observer is, that, in withdrawing the
sound, instead of seeing the border of  the  prostate rise  grad-
ually into the  field  of  the instrument, it follows the surface of
the glass  in the form of a curtain; we see it  from the bottom
to the top, formed at the ena" of the instrument, like the action
of the sucker  of a pump, it relieves itself after being pressed.
If the instrument rests upon the middle portion of  the lobe,
which was thus placed  before the sound, it  turns  from behind
and appears difficult to free  the passage.   It seems like a cover
or lid which  appears  to shut  upon itself and  raises  itself.
When we  have seen this appearance it is  impossible to confound
it with the normal state.
  Whilst  afterwards following the contour of the vesical orifice,
we find that its inferior part, in place of a crescent with a supe-
rior  cavity, presents  a  convex line towards  the top,  and,  in
thus following the border of the middle lobe, where the promi-
nence is situated which it forms in the bladder, the middle lobe,
engorged, offers, in general, a contour uniformly round, whilst
it is not  an organic affection.   However, upon a  patient who
had been operated on several times, by a  section of the prostatic
valvule, and who had had an abscess of the prostate opening into
the bladder, I have found  an irregular  prominence  with deep
holes, which resembled a hard damaged substance, which the
organ had formed in the hypertrophied lobe  by the cicatrization
of the abscess.
   Since the time that I  have applied myself to the endoscope,
I have not had the occasion to apply it  to  tumors of the blad-
der, properly so-called; but, finally, we had in our wards two
cases of cancerous degeneracy of this organ and of the prostate.
These two patients had experienced dysuria, and  had  entered
into the hospital because they had been seized with complete
retention; their urine was very turbid, and  they had considera-
ble hematuria, particularly one of them.  Rest and treatment had
mitigated the pains of the  retention, and then certain specific
pains manifested  themselves, which, above all,  had sometimes a 
THE  ENDOSCOPE.
99
freely lancinating  character.  Upon  one of these patients, the
sound had not detected any tumor, only it  sunk very deeply
before it arrived in the vesical cavity.  On examining with the
endoscope, it was impossible to perceive the border of the pros-
tate and the orifice of the urethra, it was found that only one
surface  continued itself from the prostate to the "bas-fond" of
the bladder, and passing up very high into the organ; this sur-
face, of a yellowish white, with the vessels sufficiently developed,
formed  nipples, large and  very  prominent, and presented at a
place ecchymoses of a deep red, which had all the appearance
of an encephaloid mass.  It appeared to form a large promi-
nence  badly confined or  limited,  in  a manner,  although the
sound not being well  free in the bladder,  could not exactly cir-
cumscribe a tumor.   Upon the  other patient, catheterism did
not discover anything in the bladder, except some inequalities,
which were situated around the  fleshy columns;  but at the neck
there was found, by  the aid of the  endoscope, a  prominence,
considerably large, of the middle lobe of the prostate; you have
seen all the observable face of the bladder strewn with soft veg-
etations, of a reddish yellow, forming small  teats or  nipples,
and  presenting the same aspect and coloration of encephaloid
vegetations.   The prostate makes an inconsiderable prominence
in the bladder, it is true, but presenting  the same aspects as in
the vesical wall.
   The sediment in the urine of these patients, and examined by
the microscope, contains, besides globules of pus, great  nut-like
cellules, which presented  the character  of cancerous  cellules.
These  cellules were very numerous in  the urine of the second
patient.
   The group of symptoms and,  above all, their persistence, the
cachectic appearance  which these patients had acquired by de-
grees,  then likewise  as the local symptoms  appeared  a  little
calm, and  the microscopic examination of the urine could give
some strong presumptions;  but without the endoscope,  there is
but little degree of certainty in  the diagnosis, and I wish  you
to notice that this diagnosis had been made  in the two cases,
after the results  of  the  endoscopic  examination, before  the 
100
THE  ENDOSCOPE.
symptoms had furnished suspicion of the nature of the evil, and
whilst  the tint of the skin did not yet betray the development
of the cachexia.
  If we consider how few means we have in order to assure our-
selves of the nature of a tumor, which the sound has reconnoi-
tred in the  bladder,  how little certitude of differential  signs of
these tumors between themselves, so much so that the cachexia
is not  evident, and with danger of attack from a cancer Avhich
we  cannot completely destroy;  we are really astonished  at the
hardihood of deciding either  for the ecraseur or for  the "arra-
cheur."
  You will  be convinced, I think, that the endoscope has al-
ready rendered a grand service to the surgeon and the patient,
if it prevents the performing an operation on a cancer, of which
the result must be a speedy death.
  It rests with us to speak to you, gentlemen, of an alteration
which  is  the consequence, for  the  most  part, of affections
of this viscera.   You  know that  whilst  the  bladder  empties
itself with difficulty, in consequence  of  some obstacle in the
course of  the urine, it  happens, about a certain  time, that the
bundle of muscular tunic  becomes  hypertrophied and makes a
prominence  upon the internal surface  of the organ, the mucous
membrane being enfolded  in their intervals, and  from it results
that we  call  "bladders  with columns,"  and "bladders with
cellules."
  In this case,  these  columns  hinder the  ordinary catheter,
whilst  its point  passes on the  mucous membrane,  giving the
sensation  of  prominences which it meets,  but it is necessary for
this that  the columns be already sufficiently voluminous;  but,
still further, other prominences can  be diagnosed in the  blad-
der, from tumors, from cancerous vegetations, or otherwise, also
this—mistakes are not very rare, and we arrive at  the  belief,
from columns in the smooth bladder,  of mistaking columns for
tumors, and reciprocally.
  The endoscope enables us to avoid  these errors, and  there-
fore, they have become more rare; it shows the columns under
the form of  "cordons arrondes," as you see them in the  autop- 
THE  ENDOSCOPE.
101
sies, with their more salient points very clear, and the adjoining
parts in  the shade.  Whilst these prominences are large, their
two  borders do not show themselves simultaneously in the field
of the instrument, and it becomes necessary from small move-
ments  to measure the  larger.   It is easy to follow in the way
of their length, and then we see them united, then divide them-
selves, intercepted between  them some depressions in the mu-
cous membrane or the  veritable cellules.
   Whilst we can  thus reconnoitre their form, it will be impossi-
ble to confound them  with  any other  thing, so much the more
as they present the general color of the mucous, whether it be
sound  or inflamed, and  which is  not  the same, frequently, of
tumors, Avhich have in  the bladder, as elsewhere, their particular
coloration.
   We  will terminate this exposition of the results of the  endo-
scopic examination of the urinary passages, by leading you to
a knowledge of the means which can be taken for the explora-
tion of the vesical calculi.  In order that this exploration may
succeed,  it becomes necessary to direct  the axis of  the instru-
ment in  the direction of the  foreign body.  As soon as this
condition is obtained, it is easy to verify the color of the calcu-
lus,  and, from certain  movements, to reconnoitre  the aspect of
its surface, its smoothness, its nipple-like prominences, irregu-
larities,  or uneArenness, if we carry the end of the sound upon
the contour of the calculus,  or can get  an exact idea of its form,
and likewise  appreciate  sufficiently well its volume;  however,
for  persons who  have not yet the proper arrangement of the
instrument, the dimensions of the object appear, frequently, a
little larger  than they really are.  But this error is very far
from attaining the extent of those to whom it is exposed by the
other means of exploration, and, in a  practical point of view,
it is of little  importance.  For, if the exact measure is neces-
sary, it  is easily obtained.   For  that, it suffices  to  mark well
how many times  the  field  is limited  by the extremity of the
sound, how many times  it finds itself  contained  in each of the
principal diameters of the calculus.
   The interior diameter of the sound being known, we can con- 
102
THE  ENDOSCOPE.
elude on the dimensions of the calculus with a quite sufficient
exactitude.  It is very rare that the  surface of the stone be
sufficiently smooth, so as  not to furnish points of observation.
It is thus that our designer, M. Lackenbauer, has  been able to
measure the different calculi which he  has represented, and of
which you  have seen the designs.   These measures  have  been
proven just, upon certain ones after their extraction, and  upon
others whilst they have been taken in the  "litholabe," in order
to be crushed.
   Before going much further, I will give you some details in
regard to the calculi, from which I have made designs after na-
ture, in the bladder of the patients, before they were operated
on.  One represents a group of four calculi, which  brought  a
sick man into my service in the  month of February, 1862.
   In the month of October preceding,  he  had consulted a sur-
geon, who  had  proved the presence of some gravel, and  had
scraped some debris into the grasp of the litholabe.   Some days
after, the  surgeon introduced  the  instrument anew,  and not
finding any fragments,  declared the  patient cured.
   From the first examination by the aid of a sound, I proved
the presence of a small calculus, very moveable; such was also
the diagnostic of  a confrere, well versed in catheterism.  Some
days  after, the endoscope showed us the  four calculi, such as
they have  been designed  by M. Lackenbauer, on the 9th of
March.   The 16th of  March, a new examination  enabled this
artist to design them  in the two groups, in  each of which one
of the small calculi is found hidden.   The endoscope  had per-
mitted,  at  first, to verify, at the "bas-fond" of  the bladder, a
large depression, very  deep, but in  which  the calculi  had col-
lected, so much that the rest of the vesical surface was covered
over by the fleshy columns very much developed.   After two
seances of lithotrity, the endoscope proved the presence of frag-
ments.  It became necessary to seek these  fragments, which the
bladder could not get rid of, on account of  the commencement
of paralysis and hypertrophy of the prostate.
   Some days  later, the patient, who did  not suffer any more,
was taken with  stoppage or extreme difficulty of  breathing, and
succumbed to an old disease of the valves of  the heart. 
THE  ENDOSCOPE.
103
  The autopsy showed the depression of the "bas-fond" of the
bladder and the columns which  the endoscope  had discovered.
At the first seance of lithotrity,  in seeking to measure the cal-
culus, I have always  found by a very great  scattering of the
branches of the litholabe the greatest of the diameters trans-
versely of a large calculus.  This is  the diameter which finds
itself in a sence-antero-posterior.
  After  the configuration of the calculus, it  appears  evident
that they are not fragments of a calculus greater than had been
broken by the first surgeon.
  It is very evident that  the view of a calculus will add some-
thing to the certainty that the touch will give to  its presence.
But you may say that there are  some causes which render very
difficult the  finding a stone in the bladder.  Thus, whilst  it is
small and very mobile in a very large  bladder, in a way  it
flies before the sound, without giving place to a sensible shock.
In this case, the sight cannot leave any doubt, and it suffices by
a coup d'oeil thrown upon the  Fig. 5, to  convince  that a gravel
cannot escape,  provided that the sound can be directed towards
it.   The rugose state, smooth, broken of the surface of the cal-
culus,  display  themselves more  surely than by means of the
sound, and there is no other means of appreciating  the color,
which  often  permits you to presume upon the composition.
  Simple catheterism gives us but a  few precise  ideas of the
dimensions of  the calculus; the  litholabe likewise; but it can-
not comprehend it in one sense,  neither can it give the measure
of all  the diameters, for it is known that each calculus affects,
in general, always  the same  position, determine^ by the rela-
tion which exists  between its form and that  of  the bladder.
The endoscope, on  the  contrary, shows all  the diameters, so
much more than one can accomplish with the aid of the sound,
by displacing  the calculus and  making it present in different
positions.
  The number of the calculi is, again, an important condition
for  the treatment, and difficult to know by the ordinary means.
Beyond  doubt, in seizing  a calculus  in  the  grasp of a "brise
pierre," and in seeking to explore the "bas fond," we can as- 
104
THE  ENDOSCOPE.
sure ourselves  that  there  exists a second.  But, if there are
two, three, four, or more, Ave can perceive them, so long as the
endoscope permits us to count them.
  I have not had other occasions of observing multiple calculi,
but upon the cadaver it is easy to  perceive a great number of
Btones  introduced expressly into the  bladder.  If it is  impor-
tant to verify the presence of a calculus,  and the different par-
ticularities Avhich it  is necessary for  us to  knoAV, it is just as
important for us to  know that it does not exist as it is that it
does.  This error, however,  can present itself,  it  has  had  a
place and it still remains in the annals of medical science, some
cases of patients having been cut Avithout  having a stone.  Au-
thors indicate many  causes of this  terrible error, the principal
ones are,  hard  matter  contained in  the  rectum and pressing
against the base of the bladder, it appears to me  difficult that
in this case the contact should be sufficiently rough to deceive
a Avell  practised hand;  it  is not  the same of an osseous tumor
of the  pelvis making a prominence in the  bladder, and which
can give, well covered by their tunics of this organ, a sensation
of hardness capable  of deceiving the surgeon, or very much to
embarass him.
  A fleshy column, resisting, has also  been noted  as a cause of
error;  it has been well objected, too, that  it had not a hardness
comparable to that of the stone,  but I can tell you  by experi-
ence that it  is  from cases of induration  of the  vesical Avails
when the  fleshy columns  are  sufficiently  hard, that  it is very
difficult to distinguish  the  sensation  which we  experience in
touching with* the end of the sound from that which is  caused
by contact with a calculus.
  In addition to this, sometimes the mucous membrane, in old
affections of the bladder, becomes encrusted with lithic matter.
Then you  have the  resistance of a  hard body  and the  rude
touch of a stone.  In this case, it is almost impossible,  by the
aid of the sound, to assure  ourselves of the truth.
  It can be objected, perhaps, that  the question can be solved
by means of the litholabe,  but, very often, it leads to the belief
of an adherent calculus, and the manoeuvres by which it seizes 
THE  ENDOSCOPE.
105
the vesical prominence and presses it in the grasp of the instru-
ment,  in  seeking to displace  it,  cannot certainly  be Avithout
danger.   I have often had patients who presented this disposi-
tion, and whom  I have observed at the Hotel Dieu, whilst I was
surgeon of the  Central Bureau.   The sensation was that of a
calculus.  I requested Ph. Boyer  and Leroy (d'Etiolles) father,
who had come into the service, to give me their advice, but after
a very attentive examination it was impossible for us to decide
on a certain diagnosis, and we could not decide on anything, if
it Avas not that  the sick man  being in a very bad condition to
be operated on. Ave should have decided on it.  Some da}-s later,
the autopsy showed us the alterations which I  have spoken to
you of.  If I had had the endoscope, you do not doubt, I think,
after all that you have seen in this amphitheatre, that the ques-
tion could have  been decided Avhile the patient Avas living.
  One question which presents itself very often, and which is
of no little importance, is that of the adherence  or enchainment
of the calculi, upon which  often depends the mode of operating.
One suspects this enchainment whilst the stone is always found
at the same point Avhich we can displace, whilst the instrument
glides smoothly over the surface  Avithout moving it; but it is
rare that we arrive at a certainty  Avithout opening the bladder.
If we survey the observations of united or enchained stones you
will perceive that often this disposition had not  been perceived,
except during the operation, Avhilst the forceps could not seize
the calculi, or to hold them after having seized them.
  From it results a very embarrassing position, when the sur-
geons have often given proof of sang froid, of ability, of promp-
titude, and of decision.   But if sublime has been the success, it
will be of more  value in operations less difficult, and  operators
will  prefer to know in advance  the  difficulties they have to
encounter.
  By means  of  the endoscope, we can assure ourselves of the
disposition of the calculus, and of the causes which render it
immoveable.   In effect, in  this case, one finds around the calcu-
lus some clots of mucus, of prominences, of vegetations, which
fix it  in its place.  I have not  yet made sufficient observations 
106
THE  ENDOSCOPE.
in order to give you a description of the different modes of  en-
chainment, but the folloAving observations can  supply them in
part:—
   The first, is that of a calculus, Avhich  I have examined  and
made a design of, from the Hospital Saint Antoine, in the ser-
vice  of Prof.  Jarjavay.  The  patient presented  the rational
signs  of a calculus, which M. Jarjavay found, in fact, by cathe-
terism.   But this calculus was  difficult to reach, the litholabe
could not seize it;  at the same time, it could not be determined
whether  it was fixed or moveable.   However, M. Jarjavay sus-
pected that it was fastened, but not being fully satisfied, he
requested of me the aid of  the endoscope.   The endoscope re-
solved the question completely.   The calculus was, in  effect,
retained  betAveen  the projections of the bladder; the right  ex-
tremity appeared to be free,  the left extremity and the superior
border being surrounded by a ridge of the mucous membrane,
and the inferior border,  finally,  is in part hidden by a veritable
tumor, upon which  is noticed an ecchymosis, which appears to
result from the pressure of the grasp of the litholabe, in the
forceps made to seize the calculus, proving  that if the expert
surgeon had insisted upon his tentatives, it would have resulted
in a Avounding of the vesical mucous membrane.   The endoscope
would have prevented, beyond all question, a similar accident.
   The second observation  was furnished me  by  M. Houel, tem-
porarily in charge of the surgery at the hospital clinics, during
the last vacancies.   The irritation  of the bladder in his patient
prevented me from  making  a design  of this calculus, but  M.
Houel has earnestly requested me  to give the following  obser-
vation, in which the autopsy confirmed  the results of the endo-
scopic examination:—

Calculus fixed to the Bladder—Examined with the Endoscope.
   J.,  aged 58 years, a  paint merchant.   This  man  was very
large  and strong, but he appeared to be suffering much.   He
said to us, that for many years he had suffered  much from the
bladder.   He  is obliged to urinate very often;  the micturition
is painful and very  difficult. 
THE  ENDOSCOPE.
107
  Whilst he walked, he felt a feeling of weight in the perineum;
he often  had pains  of the kidneys.   For five or six months, he
had lost  his appetite and had become thin and poor; his urine
was very turbid and deposited a sediment of mucus, very thick,
sometimes mixed with blood.  Never, in  addition  to what we
have  said,  had  this patient  seen  his  jet  of urine suddenly
arrested,  except to return some moments after.
  Whilst a  sound  is  introduced into  the bladder,  mark  that
which is observed:  the canal  of the  urethra  is free  and
alloAA's the sound to pass easily.  One time that it  penetrated
into  the  bladder,  we could  reconnoitre a  bladder  of  reason-
able dimensions, with columns, a bladder very smooth.  If we
carry the pavilion  of the sound a little  higher  to  the left of
the patient,  we perceive that  the end  of  the sound  is arrested
by a  stone,  which,  by  consequence, ought to be found at the
base of the  bladder and  to the right.   In introducing  a litho-
trity instrument, it is impossible to seize the stone; we  touch it
but it will  not fall into the  grasp of the instrument,  and we
cannot seize it.
   This examination, repeated several times, induced M. Houel
to diagnose  a fixed calculus of the bladder, although M. A.
Richard, in  sounding  this patient, believed the calculus free,
because the end of the instrument dragged the calculus  and the
bladder.   M. Houel solicited M. Desormeaux to dissipate the
doubt, by means of his  endoscope. I will not enter into the
details of his mode of action, which is  known by all surgeons;
I will speak of nothing except the result of the observations.
   In manipulating the instrument into its necessary manoeuvres,
one can see,  in turning the instrument in  divers  ways, a whitish
granular body, strewn with small  blackish points which appear
to be  blood.  This body, which is no other than the calculus,
presents  a  light or small prominence;  and, if we should move
the instrument, we arrive at the edge of the calculus, and we
see very  distinctly  that this  white  body is surrounded and, in
part,  covered by a  reddish membrane, which is continuous with
the vesical mucous  membrane.
   This examination confirmed, very closely, the diagnosis  of 
108
THE  ENDOSCOPE.
calculus fixed in the bladder.   In the face of this condition, M.
Neiaton  had  counselled the sub-pubic  incision, and M. Houel
commenced the operation, when the patient suddenly died.
  The autopsy gives the following signs or appearances:
  The bladder is not very much changed;  the calculus is  well
situated  at the place which the examination  had given to us;
the calculus  is Avell covered by the bladder upon  its  borders,
but at this level the bladder  is a little  hypertrophied, likewise,
the calculus is strongly held by the bladder; furthermore, the
calculus  presented  an eminence, Avhich penetrated  the vesical
walls, where  it was contained, as in a cellule; the calculus had
yet the black points that we have upon  the  living.   One point,
sufficiently curious  to note, is, that to the naked  eye the calcu-
lus  appeared  less voluminous than with  the endoscope.
  If we resume this lesson, we will find that in the affections of
the bladder,  the endoscope  oftentimes  gives more of certainty
in its diagnosis than  the other means;  it permits us to see the
state  of  the  organ, to  reconnoitre  the nature  of  its  tumors,
the disposition,  the number and the  complications of stones,
oftentimes better than simple catheterism; better, and, likewise,
with less danger, than the "litholabe."
  We shall then conclude that if we cannot, in the vesical affec-
tions as in the affections of the urethra, proceed directly to  ope-
rations, it is  not less useful to the treatment,  in  furnishing
valuable  indications to  determine the choice of the  method for
operating, and to direct the instruments in the operation to be
practiced. 
 

 
THE
ENDOSCOPE,
AXD ITS APPLICATION TO THE DIAGNOSIS AND TREATMENT
        OF AFFECTIONS OF THE
Genitourinary Passages.
LESSONS GIVEN AT NECKER HOSPITAL.

             BY    T

    A.  J. DESORMEAUX,
 SURGEON OF THE HOSPITAL, MEMBER OF THE SURGICAL AND ANATOMICAL
          SOCIETIES OF PARIS.


         TRANSLATED BY

     R. P. HUNT, M.D.
Reprinted from the Chicago Medical Journal.
            CHICAGO:
ROBERT FERGUS' SONS, PRINTERS, 12 & 14 CLARK STREET.
              1867. 
 
 
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