Cystoscopy and urethroscopy for general practitioners

Front matter

o

^Atfnmtt Htbrarg

LEWIS and MARK

Preface

*

Developments in cystoscopy and urethroscopy have been so rapid and far-reaching in recent years that there has been ample room and need for the several excellent text-books on these subjects that have appeared during the same period. These books have but comported with the kaleidoscopic changes in methods, technique and instrumental equipment which they have described.

A similar demand has impelled the production of the present contribution.

Views on pyelography, on local anesthesia of the urinary tract, on the technical and other features of cystoscopy and urethroscopy have been modernized to a degree that demands the attention and accurate description that have been accorded them.

While no large share of the book is devoted to historical considerations, certain features and events are made clear that have been the subject of confusion and error in genito-urinary literature. The facts related are based on historical data that are irrefutable and are confirmed by references accessible to anyone interested in attesting them.

It has been the desire of the authors to portray the technique of cystoscopy and urethroscopy so graphically, by both text and illustration, that the book might prove of real value to the novice in furthering his endeavors in this line, as well as of advantage to the experienced who may be interested in studying the methods of others besides his own. Who may not learn something by studying the work of his confreres, no matter how skilled or original he may be? In harmony with this aim, resort is had to photography in numerous instances, and to diagrams where necessary. The steps and phases of cystoscopy, ureteral vi PREFACE

catheterization and of urethroscopy are depicted from every angle conceivable; so that the student can hardly escape a fair understanding of these, even if he does nothing more than follow and study the illustrations.

It is felt that the need of plain teaching in this regard is greater because of the relative lack of opportunities provided in this country for personal instruction and clinical demonstration. Europe has been the Mecca of students in this department, but scientific Europe is now otherwise engaged and bids fair to be thus diverted for some time to come.

It would seem opportune, therefore, for our country not only to make its own cystoscopes and allied appliances, as it has been doing so successfully, but also to foster and develop its own literature along these lines.

The Authors.

Chapter II The Cystoscope. A Historical Review

Bozzini, Lichtleiter, Segalas' Urethro-cystic Speculum; Bruck's stomatoscope; Rutenberg's air-inflation cystoscope; Nitze's cystoscope; First use of incandescent lamp; Boisseau du Rocher's cystoscope; Brenner's direct catheterizing cystoscope; Albarran's lever device; Low amperage lamp; Tilden Brown's cystoscope; Bransford Lewis' cystoscope; Brown-Buerger cystoscope; Pawlik-Kelly cystoscope; Cystoscopic Armanentarium; Selection of a cystoscope; Cystoscopic accessories; Care and sterilization of instruments 4-21

Chapter III Operative Technique

Preparation of the patient; Cystoscopy of the normal bladder; Technique of air-inflation cystoscopy; The Pawlik-Kelly method; The appearance of the normal bladder; The coloring of the normal bladder; The vascularity of the normal bladder; The luster of the normal bladder; The trigone; Fallacies in cystoscopic findings; The interpretation of the cystoscopic picture 22-36

Chapter IV Ureteral Catheterization

Various methods for segregation of the two urines; Purposes of ureteral catheterization in diagnosis and treatment; Selection between direct and indirect methods; Technique of the two methods; Selection of ureteral catheter; Catheterization under forced air-inflation; Pawlik- Kelly method; Difficulties encountered in ureteral catheterization; Dangers of infection and traumatism; Tests for kidney functionation. 37-70

vii

Vlll TABLE OF CONTENTS

CHAPTER V URETERO -PYELO GRAPHY Pages

Technique of; Pathologic conditions of kidney and ureter; Normal pelvis; Hydronephrosis; Inflammatory pelvic dilatation; Tumor differentiation in upper lateral abdomen; The cystic kidney; Localization of renal shadows; Identification of intra- and extrarenal shadows; Renal tuberculosis; Congenital malformations; Supernumerary ureters; Solitary kidney; Ureteral dilatation; Contraindications to uretero-pyelography 7i~93

Chapter VI

Congestion of bladder; Various forms of cystitis; Stones; Tumors; Cystoscopy of. Contraindications to cystoscopy in tumors; Cysts; Bilharzia disease; Varices; Tuberculosis; Lymphoid tubercle; Edema buUosum; Diverticulation and trabeculation; Tabetic trabeculation; Ureteric meatoscopy; Eversion or prolapse of ureteral orifices; Cystic distention of lower end of ureter 94-121

Chapter II

Desormeaux' urethroscope, Griinf eld's urethroscope; Nitze-Oberlander's instruments; The exposed platinum-loop urethroscope; The low amperage lamp; Various types of modern urethroscopes; Air-inflation urethroscopes; KoUmann's operative urethroscope; Mark's operative urethroscope; Water inflation instruments of Walker, Goldschmidt, Buerger and McCarthy; Care and sterilization of instruments. . . 162-169

TABLE OF CONTENTS IX

Chapter III

Pages Urethroscopy of the anterior urethra; Technique of; The points to be observed in the central figure; The elasticity of the urethra; The vascularity of the mucosa ; The luster of the mucosa ; The appearance of the lacunae of Morgagni and the glands of Littre; The value of air-inflation in tirethroscopy ; Urethroscopy of the posterior urethra; Urethroscopy of the female urethra 170-185

Chapter IV

Chronic urethritis; Oberlander's classification; The changes in elasticity; Modifications in vascularity ; Changes in luster ; Appearance of lacunae of Morgagni and the glands of Littre; Chronic posterior urethritis; Stricture; Valves and diverticula; Tumors of the urethra; Varices of the urethra; Tuberculosis of the urethra; Herpes of the urethra; Chancroid of the urethra; Syphilis of the urethra; Leukokeratosis of the urethra; Calculi of the urethra; Cysts of the prostatic utricle; Argyria 186-221

Chapter V Operative Urethroscopy

Air-inflation practically indispensable; The treatment of cystic follicles and suppurating glands; Stricture, methods of treatment in cases of extreme difficulty; Papilloma, Oberlander's method; Schwartz' method; Author's method; Removal of other tumors; Removal of the verumontanum ; Treatment of strictures of the ejaculatory ducts; Treatment of valves and diverticula by author's method; Removal of foreign bodies; Warning against over air-inflation 222-229

Index 231

LIST OF ILLUSTRATIONS

Fig. Page

1. Floor of bladder and urethra (Pedersen) 2

2. Roof of bladder and urethra (Pedersen) 2

3. Boisseau du Rocher's cystoscope 8

4. Brenner's cystoscope 9

5. Tilden Brown's modification of Brenner's cystoscope 10

6. Bransford Lewis' universal cystoscope 12

7. Buerger's indirect- view cystoscope 14

8. Convenient plan and equipment of cystoscopic room 19

9. Application of local anesthetic 23

10. Introduction of cystoscope 24

11. Author's urethral tablet depositor for male 25

12. Author's urethral tablet depositor for female 26

13. Anterior cystoscopic view showing normal vesical mucosa (Facing page) 32

14. Anterior cystoscopic view showing transitional mucosa between sphincter and vesical membrane (Facing page) 32

15. Schematic bottom of Valentine's box phantom 35

16. Valentine's box phantom 35

17. Irrigation of bladder through cystoscopic sheath 41

18. Irrigation of bladder. Thumb removed, water escaping 42

19. Observ^ation cystoscopy. With bladder fuU of water 46

20. Ureteral catheterization (direct method), insertion of catheter into left orifice 47

21. Ureteral catheterization (direct method), insertion of catheter into right orifice 48

22. Showing inaccessibility of ureteral catheterization by direct method in the presence of precipitate bladder or enlarged prostate 49

23. Direct catheterization, side view 49

24. Direct catheterization, side view 50

25. Direct catheterization, cystoscopic view 51

26. Direct catheterization, catheter inserted into left ureter 52

27. Direct catheterization, both catheters in place 53

28. Indirect catheterization, side view 54

29. Indirect catheterization, catheter inserted into left ureter 54

30. Indirect catheterization, side view, control of catheter by lever .... 55

31. Indirect catheterization, side view, showing angulation of cystoscope. . 55

32. Indirect catheterization of left ureter. Approach of catheter 56

33. Indirect catheterization, catheter inserted into left ureter 57

34. Indirect catheterization, beak pointing downward 58

35. Withdrawal of lens system leaving catheter in place 59

36. Cystoscope sheath is being withdrawn with one hand, while catheters are fed in by the other 61

xi

XII LIST OF ILLUSTRATIONS

Fig. Page

37. Cystoscope withdrawn, catheters draining into sterile test-tubes. ... 62

38. Lavage of left kidney pelvis 65

39. Irregtilar, tortuous outline of the right ureter caused by blood clot falling pelvis and upper ureter 72

40. Irregular inflammatory dilatation of the pelvis of kidney caused by bleeding pyelitis 73

41. Dilatation of right ureter caused by stone lodged in that part of the ureter at entrance of bladder 74

42. Beginning of small hydronephrosis 76

43. Outline of normal pelvis 78

44. Dilated ureter and pelvis caused by stone in lower ureter 79

45. Colloidal silver outlining right ureter rules out shadow which might have been taken as stone 80

46. Three-ureter case of author 87

47. Post mortem specimen probably analogous to the condition shown in Fig. 46 88

48. Radiogram of duplicated ureter and pelvis 89

49. Comparison of sound and cystoscope for detection of stone 98

50. Multiple stones (over 1700) removed through cystoscope . 99

51. Cystoscopic view of tumor of bladder (Facing page) 100

52. Cystic granulosa or lymphoid tubercle (after Kneise) 113

53. Cystic granulosa (after Kneise) 113

54. Edema buUosum in connection with bilateral hypertrophied prostate

(Facing page) 117

55. Trabeculation and diverticula of bladder wall (Facing page) 119

56. Constricted ureteral orifice and resulting uretero- vesical cyst (Knorr) . 121

57. Side view of above, catheter introduced (Knorr) 121

58. Bransford Lewis' operating cystoscope 126

59. Accessories to Lewis' operating cystoscope 126

60. Bransford Lewis' air cystoscope 129

61. Appurtenances to Lewis' universal operating cystoscope 131

62. Combined universal and operating cystoscope (191 4) 131

63. Dr. Leo Buerger's ureteral dilator 131

64. Bransford Lewis' induction rheostat 135

65. Bransford Lewis' electric controller 136

66. Bransford Lewis' fulguration apparatus 139

67. Mode of fulguration of papilloma, direct method 140

68. Mode of applying fulguration of papilloma, indirect method 141

69. Benign papilloma (Facing page) 142

70. Benign papilloma after 5 fulgurations (Facing page) 142

71. Benign papilloma after 8 fulgurations (Facing page) 142

72. Dilated ureter due to stricture 145

73. Stone in orifice of left ureter 147

74. Removing stone by alligator forceps 148

75. Stone lodged in mid ureter 151

76. Showing cystoscope, X-ray catheter and stone in lower end of ureter, after descent from position shown in Fig. 75 152

77. Ureteral stone removed from J. S. F 153

78. Showing strictured right ureteral orifice retaining stone 154

LIST OF ILLUSTRATIONS XIU

Fig. Page

79. Ureteral scissors cutting strictural orifice of ureter 154

80. Orifice widened by scissors 154

81. Ernest G. Mark's aero-urethroscope 166

82. Patient in position for urethroscopy 171

83. Introduction of urethroscope 172

84. Urethroscope introduced and obturator withdrawn 173

85. Attaching observation window preUminary to forced air-inflation ... 174

86. Window attached and observation carried on 175

87. Introduction of urethroscope into posterior urethra 176

88. Urethroscope introduced for intra-urethral operative procedure . . . .177

89. Intra-urethral operation under forced air- inflation 178

90. Normal urethra with vascular mucous membrane .... (Facing page

91. Normal urethra with anemic mucous membrane (Facing page

92. Soft infiltration (acute urethritis) (Facing page

93. Glandular urethritis (Facing page

94. Same form as Fig. 93 (under treatment) (Facing page

95. Same form as Figs. 93 and 94 (nearly cured) (Facing page

96. Mixed urethritis. Hard infiltration second degree .... (Facing page

97. Dry urethritis, infiltration of the second degree (Facing page

98. Dry urethritis, hard infiltration of the first degree . . . . (Facing page

99. Dry urethritis showing large submucous nodosities . . . (Facing page

100. Dry urethritis, infiltration second degree (Facing page

loi. Membranous urethra, in normal state (Facing page

102. Normal prostatic urethra (Facing page

103. Urethritis of the prostatic portion (Facing page

104. Floor of the proximal portion of the supramontanal region 193

105. Normal colliculus with prominent posterior frenula 193

106. Normal colliculus viewed from front 193

107. Atypical colliculus with peculiar utricle 193

108. Small cysts in roof of the supramontana 193

no. Inflammatory excrescences on the colliculus ,. . 193

111. Small papilloma lying against colliculus 193

112. Enlarged prostatic duct in depressed scar tissue 193

PART I

CYSTOSCOPY

Chapter I Anatomy Of The Bladder

The bladder is a hollow muscular organ whose function it is to temporarily hold the urine. It is composed of a serous peritoneal layer which only partially covers it, a muscular covering which is made up of practically three layers, and a mucous lining. Of its external layers or its relations to neighboring structures we are, from a cystoscopic standpoint, concerned but little. Aberrations in such neighboring structures may involve changes in the contour of the bladder as observed through the cystoscope but it is unnecessary to enter into a detailed discussion of such changes.

The mucous coat is covered with a stratified pavement epithelium and richly supplied with blood vessels. The blood supply is finer and more closely woven on the trigonal area, or that area which is formed by the interuretic fold, or ridge, as a base and the internal vesical meatus as an apex. Viewed through the cystoscope the mucosa has a characteristic luster and the branching vessels give it a marked retinal appearance, except on the trigone. Here the fine interweaving of the vessels gives to this area a reddened or a reddish-pink appearance as contrasted with the delicate straw color of the mucosa in other parts of the bladder. Forming the base of the trigone is the interuretic fold or ridge at the ends of which are situated the orifices of the ureters. Normally, these openings appear as slits or dimples, marked by some increase in vascularity.

The sides of the trigone are about one and a quarter inches long, though this is variable within normal limits. Any one of the sides of the trigone may be lengthened or shortened, the variation depending upon the point at which the ureter enters the bladder.

Figs, i and 2.

rLUUK ROOF

Fig. I. Fig. 2.

•Anatomical divdsions of bladder for purposes of cystoscopy. Pedersen.)

(After

In a condition of distention, the bladder assumes a globe-like shape. In collapsing the mucosa falls in numerous folds.

For the purposes of the cystoscopist the bladder has been divided by Dr. V. C. Pedersen,* into four segments or quadrants.

* Topography of the Bladder with Especial Reference to Cystoscopy, V. C. Pedersen, N. Y. Med. Jour., Aug. 23, 1913.

ANATOMY OF THE BLADDER

Our division is obtained by an imaginary plane being passed transversely through the bladder just posterior to the point at which the ureteric folds disappear into the bladder wall. This divides the bladder into superior and inferior halves. Another imaginary plane passed vertically through the bladder and urethra divides the bladder into anterior and posterior halves. The bladder is thus divided into four quadrants or segments, which form excellent divisions for cystoscopic classification and study (see Figs, i and 2).

Pedersen has denoted these divisions as follows :

"First, the posterior lower quadrant, or, better, the ureterotrigonal quadrant, containing the right ureter and its fold, the interureteric fold, the left ureter and its fold, trigonum, and the posterior half of the neck.

"Second, the posterior upper quadrant, or by choice the subperitoneal quadrant, which lies beyond the ureteric and interureteric folds, and is not infrequently called the deep base or deep fundus of the bladder.

"Third, the anterior upper quadrant, or preferably the urachal quadrant, inasmuch as this contains the true apex of the bladder with the remnants of the implantation of the fetal structure, the urachus. This quadrant might also be well known as the apical zone.

"Fourth, the anterior lower quadrant, which might suitably be noted as the retropubic, inasmuch as it lies immediately behind the symphysis pubis and contains the anterior half of the neck of the bladder.

" The importance of the neck of the bladder, and the fact that it is best explored with the retrovision telescope, or with the urethroscope, might be regarded by many as reasons for making it a fifth subdivision for ofhce records and the like."

For the purposes of cystoscopic study and topographical classification these divisions of the bladder are excellent and are to be recommended.

Chapter II The Cystoscope. A Historical Review

The history of cystoscopy and endoscopy in general dates from the pioneer work of Bozzini of Frankfort. Bozzini's instrument, which he termed a "Lichtleiter," was first described by him in the Journal der praktischen Heilkunde, Bd XXIV, 1806. The vesical speculum, which was a part of Bozzini's instrument, was intended only for the female bladder as observation of the male bladder was considered out of the question. This speculum resembled a funnel. The spout of this funnel was one and a half inches long and about one-sixth inch in diameter. A metallic elastic spiral near the distal extremity of the tube permitted some degree of mobility of the bladder end of the tube. A shaded stand contained the source of light — a candle. The report of the Medical Faculty of Vienna and the Josephine Academy that were appointed by the Austrian government to investigate the claims of Bozzini in behalf of his instrument was distinctly unfavorable both as to the invention as it stood and the possibility of its future development.

This pessimistic view discouraged further advance in cystoscopy until December, 1826, at which time Segalas of Strasburg presented his " Urethro-cystic Speculum" before the Royal Academy of Sciences of France. The shape of Segalas' speculum was similar to that of Bozzini's. The endoscopic tube was separable from the funnel which was in reality a conical mirror. A second mirror, concave in shape, through the center of which was a hole for the introduction of an ocular tube, was used as a reflector for the two candles that formed the source of illumination. The instrument had little of practical value to recommend it.

The following year, 1827, John Fisher of Boston described in the Philadelphia Journal of the Medical and Physical Sciences quite a complicated instrument for the purposes of endoscopy. It consisted of three tubes and two mirrors, one of them concave for the purpose of reflecting the light of the candle. It will be readily understood that this instrument found no adherents.

From this time up to the year 1853, very little was accomplished. Avery, Cazenave, Gessler, Malherbe and Espezel were endeavoring to forward the progress of endoscopy but their efforts were without definite results. In 1853, Desormeaux, to whom has been given the title, "the father of endoscopy,'^ following the ideas of Fisher, produced his endoscope and two years later this instrument was presented before the Imperial Academy of Medicine in Paris. The instrument of Desormeaux was in reality the first to receive practical acceptance at the hands of the medical profession, and in recognition of his labors Desormeaux was awarded a portion of the Argenteuil Prize. In Germany, Furstenheim, and in America, Robert Newman, did much to popularize endoscopy as proposed by Desormeaux. In 1865, Cruise of Dublin developed the efficacy of Desormeaux's instrument to a marked degree by improving the reflecting apparatus and the vesical specula.

In 1862, August Haken of Riga proposed in the Wiener medizinische Wochenschrift, March 22, 1862, the use of metallic tubes blackened on the inside and into which the light was reflected by means of a head mirror.

Dating from the work of Desormeaux, endoscopy steadily advanced and with the invention of the Stomatoscope by Dr. Julius Bruck of Breslau in 1867 a new era was inaugurated — the platinum loop period. It seems rather remarkable that the difficulties presented in the exposed platinum loop were not overcome for a period of ten years following its introduction.

In 1874, Grlinfeld, acting on the principles suggested by Haken, presented his vesical specula. These tubes were closed at their vesical extremity by glass windows which allowed the bladder to be distended with water. By means of the view so secured he was enabled to locate the ureteral orifice and succeeded in inserting a small bougie passed alongside the tube into the ureter.

Two years later, 1876, Rutenberg of Vienna (Deutsche Zeitschrift fiir prakt. Medizin, Feb. 12, 1876) presented his cumbersome female vesical speculum to the profession. It deserves mention only by reason of the fact that in its use Rutenberg employed forced inflation of the bladder with air, a principle which remained neglected for a number of years before it was finally accorded a permanent place in cystoscopy.

In 1877, Dr. Max Nitze of Berlin, utilizing Bruck's idea of the incandescent platinum loop devised the first electric cystoscope. This instrument embodied the three principal factors of modern cystoscopy — the electric source of illumination, the placing of the source of light in the instrument near the field to be examined and the use of a lens system. The efforts of all previous laborers in the field of endoscopy pale into insignificance when compared with the signal achievement of Nitze.

The first lens system of Nitze was made for him by Beneche, an optician of Vienna, and was composed of a series of telescopic lenses. This telescopic lens system was pushed down till its distal extremity presented at a window placed at the convexity of the angle of the shaft with the beak of the instrument. The view obtained was direct and was limited to the posterior wall and base of the bladder. The instrument as a whole was the work of Diecke, a Dresden instrument maker, and many of the valuable suggestions toward its building emanated from Oberlander who was one of its earliest exponents.

Later, Nitze placed the manufacture of the cystoscope in the hands of Leiter of Vienna and the masterly mechanical skill displayed by the latter evolved the Nitze-Leiter cystoscope as it was presented before the Medical Society of Vienna on March 9, 1879.

The instrument was presented in two forms — one similar to the Nitze cystoscope of 1877, and one in which by means of the intervention of a prism in the lens system, a view was obtained of the neck, anterior wall and sides of the bladder. The window in the latter form was placed on the shaft of the instrument at the concavity of the angle formed between the beak and shaft. The aperture for the exit of the light-rays in the back was closed by a piece of rock-crystal.

On account of the great heat generated by the platinum loop, an arrangement for the purpose of keeping a stream of cold water circulating in the instrument was essential. This was accomplished by means of two channels in the shaft which united in the beak. During cystoscopy a constant flow of cold water was maintained.

The complicated character of the instrument required the services of a competent electrician for its management and, even in the most skilled hands, the platinum wire became fused so frequently as to place the instrument beyond the pale of practicability. But with all of its drawbacks its use was urged by practically all of the leading workers in the field of genitourinary surgery. Roswell Park of Buffalo was among the first to advocate its use in this country.

The application of the Edison incandescent lamp, devised in 1880, to other forms of endoscopy was advocated for some time previous to its introduction into cystoscopy. On January 18, 1883, David Newman of Glasgow used the first incandescent-lamp cystoscope and yet it was not until March, 1887 — over four years later — that this form of cystoscopic illumination was presented to the general profession. At this time two incandescent-lamp cystoscopes appeared — one made by Hartwig of Berlin after the suggestions of Nitze (Illustrirte Monatsschrift der arztlichen PolytechnLk, March, 1887), and the other by Leiter of Vienna (Konig. Gesellschaft der Aerzte zu Wien, March, 1887). By means of the use of the incandescent lamp, three distinct factors of advantage were obtained: The discarding of the cumbersome cooling device, the enlargement of the lens system with a consequent enlargement of the cystoscopic field, and the far greater reliability of the source of light. With these advantages there ensued much greater interest in cystoscopy and its far wider acceptance in the field of urology. In the same year (1887) Dittel (ref. Casper's Handbuch der Cystoscopie, 1898, pp. 16-17) modified Nitze's model by placing the illumination lamp on the tip of the beak instead of within the beak.

In 1885 Boisseau du Rocher of Paris showed the first model of his indirect- view, incandescent-lamp " megaloscope, " or

A

SKeaXvT

TeUbCope (mega\oscop?)

Fig. 3.

cystoscope, by which he claimed to give a larger field of vision through his lens system. In 1889 he had further developed and changed the instrument so that, as described* by him in that and succeeding years, it represented the first completed model of composite cystoscope (Fig. 3) presenting the first cystoscope built on the separable sheath-and- telescope plan; the first and original attainment of double, synchronous catheterization of the ureters (by two independent ureteral catheters at the same sitting); the first to afford free irrigation facilities through the cystoscope itself. The two models of the instru-

* Du Rocher, Annales des Mai. des Org. Gen.-Urin., 1890, pp. 65-93.

merit of that year (1889) furnished both the direct and the indirect view of the interior of the bladder; and the successful use of the catheterizing features was reported by Poirier, a surgeon of Paris.* Nine years later (1898), Boisseau du Rocherf had combined the several original features of his instrument into one combination cystoscope the first composite sheath-and- telescope instrument of the kind ever devised, the features of which have since been utilized in the production of a number of the composite cystoscopes now on the market.

In 1889, Brenner modified Leiter's direct view cystoscope for the purpose of irrigation during cystoscopy. The modification consisted of the addition of a small tube on the shaft of the instrument, as is shown in Fig. 4. It was but a step from the y^ yf ^

Breooer

Fig. 4.

utilization of the tube for purposes of irrigation to its adaptation as a catheter channel; the same year (1889) thereby furnishing another ureter-catheterizing cystoscope to the profession. By its means, Zuckerkandl and others were enabled to catheterize successfully the ureter in the male. James Brown of Baltimore is credited with being the first in America to accomplish ureteral catheterization in the male, making use of this instrument.

Following the application by Brenner and du Rocher of the catheterizing principle to the cystoscope, Casper (1894), Nitze (1894), and Albarran (1897) caused the construction of cystoscopes having a similar end in view. To Albarran must be given the credit of originating the lever-device, adopted in so

* Poirier, An. d. Mai. des Org. G.-Urin., 1889, p. 625.

t Du Rocher, An. d. Mai. des Org. G.-Urin., 1898, p. 485.

lO many subsequent instruments, for controlling the angle or direction of the ureteral catheter as it leaves the cystoscope to go to the ureteral orifice, in the indirectcatheterizing instruments.

In 1898 Charles Preston of Rochester, New York, invented his ''cold" lamp, used first in the Valentine urethroscope, and later in the Koch air-cystoscope. In connection with the latter there were sheath and telescopes affording both direct and indirect vision; and a separate tube for carrying a ureteral catheter. In the same year (1898) Casper provided for flight angle vie*/ C direct

Cattieterizing

Fig. 5.

double synchronous ureteral catheterization by having a sliding, removable cover for the catheter groove. In 1899 F. Tilden Brown* modified the Brenner instrument by adding two ureteral catheter tubes instead of the one it possessed, emulating the plan of Boisseau of ten years before, and retaining the direct view only. In 1900 Bransford Lewisf presented his first model of cystoscope (Fig. 60) for both male and female; fixed ureter catheter channel, at first single, shortly afterward

* F. Tilden Brown, Annals of Surgery, 1899, p. 668.

t Bransford Lewis, Jl. of Cutan. and G.-U. Dis., Sept., 1900.

THE CYSTOSCOPE II

double; to be used with air as a distending medium. In 1901 Tilden Brown* presented his first model of composite cystoscope (Fig. 5), with sheath, direct and indirect- view telescopes, and double ureter catheter channels by the direct method only; setting the lamp at the tip of the beak, after the plan of Dittel of 1887.

In 1902 Bierhoff submitted a modification of the Nitze catheterizing instrument that was of materia] advantage, making the sheath and telescope separable, for permitting the removal of the cystoscope from the bladder while the two catheters were left in the ureters — something impracticable with the indirect catheterizing instruments then existing.

In 1903 Schlagintweitf introduced a new idea into cystoscopy by affording a retrospective view (of the neck of the bladder and the prostate) by means of a movable lens. This instrument was non-catheterizing.

In 1904 Bransford LewisJ reported the use of his operative cystoscope (Fig. 58), adapted not only to use within the bladder but also in the ureters. The direct-vision air cystoscopes of Luys,§ and of CathelinU were submitted in 1904 and 1905, and attracted considerable attention in France.

In i9o6# the first model of the Universal cystoscope of Bransford Lewis was presented — at first (March 22) before the Chicago Urological Society, and later before the American Urological Association (June 4). Its distinctive features were: the fenestration of the beak on both concavity dna convexity, with the setting of the cold lamp upside down in the beak, throwing the light to best advantage where desired; free irrigation provided for, both for cleansing the bladder and for the exchange of fluids during the cystoscopic work, even while any

* F. Tilden Brown, Med. and Surg. Reports of Bellevue Hosp., Jan., 1905. t Schlagintweit, Ctralbl. f. d. Krkhtn. d. Harn.-u. Sex. Org., 1900, p. 130. t Lewis, Trans, of Miss. Valley Med. Assn., Oct. 11, 1904.

§ Luys, Trans, de I'Assn. Francaise d'Urol., 1904, p. 522.

II Cathelin, Trans, de la Soc. de Chir. de Paris, May 24, 1905.

# Lewis, American Jour, of Urology, December, 1906.

Fig. 6. — Bransford Lewis's Univer sal Cystoscope (1906).

of the several telescopes were in place or during efforts at catheterization; the application of three different observation telescopes, direct, right-angle, and retrospective, for the one sheath. At this time the direct method of catheterization (double, synchronous) was the only one provided for, but plans were soon completed (1907) for another telescope affording double ureter catheterization by the indirect method, so that, from the standpoint of mechanics, the two methods of ureteral catheterization, the direct and the indirect, were executed with the same degree of precision and satisfaction; and further, as provided for by the present universal instrument (Fig. 6), both telescope and sheath are removable with equal ease, while leaving the two catheters within the ureters.