By Dr. MAX NITZE.
In the following lines I wish to direct the attention of my English
_confreres_ to the value of the electro-endoscopic mode of examination of
the male urinary bladder, invented by me. I believe I could not have
chosen a more suitable theme for that purpose than a short report of the
bladder tumors diagnosed by me cystoscopically; for the diagnosis of these
new formations offers the greatest difficulty, and in most cases it has
been impossible till now to prove their existence with accuracy without
digital exploration of the bladder. By the new method of cystoscopical
examination the conditions have entirely changed. One look into the
bladder, illuminated as if by daylight, is generally sufficient to afford
means for forming an opinion of all the questions coming into
consideration--viz., size, form, and site of the tumor. The accompanying
diagrams (Figs. 1, 2, 3, 4) may give an idea of the appearances which the
different forms of bladder tumors present endoscopically. I regret that
they cannot show the brightness of the light by which one sees the tumors
during examination. The celebrated Vienna specialist, V. Dittel, is right
in saying that "they offer sometimes truly charming pictures;" especially
certain kinds of villous tumors, whose long slender villi floating in the
liquid often present a splendid appearance. The following are the cases
cystoscopically diagnosed by me.
[Illustration: FIG. 1.]
_Case 1._--A man, aged fifty-five, under the care of Dr. Ch. Mayer,
suffered from attacks of haematuria for thirty years. During the last six
years he has had dysuria and inability to empty the bladder completely.
The patient had been examined by the sound repeatedly by eminent surgeons
and specialists, but none could give a certain diagnosis. On Nov. 11,
1886, I undertook the cystoscopic examination. I found on the anterior
wall of the bladder a puffy swelling covered with white masses of mucus.
(See Fig. 1.) The trigone was covered by a mass consisting of pointed
papillae. On account of the weakness of the patient extirpation was
impossible. The patient became weaker and weaker, and died in June, 1887.
The post mortem examination showed the internal orifice of the urethra
surrounded by a swelling representing a continuous tumor as large as a
small apple. It was found that the instrument had penetrated through the
middle of this swelling, which bled easily on pressure. In spite of this,
the clearness of the picture was not interfered with in the least.
[Illustration: FIG. 2.]
_Case 2._--A man, aged fifty, was obliged to exert a strong pressure in
order to empty the bladder. The flow of urine often stopped. He himself
introduced a catheter, and on withdrawing it a piece of villous tissue was
found. On Dec. 10, 1886, I saw, on cystoscopical examination, directly and
immediately over the internal orifice of the urethra, a villous swelling
hanging from the anterior wall of the bladder. (See Fig. 2.) On Jan. 15,
1887, extirpation of the tumor by means of the high section was performed
by Professor v. Bergmann. The size of the tumor (which was as large as a
pigeon's egg) and its position corresponded exactly to the endoscopic
picture. The patient recovered.
[Illustration: FIG. 3.]
_Case 3._--A patient under the care of Professor Madelung, aged
fifty-five, suffered from attacks of haematuria. Examination by sound and
rectal palpation had given me negative results. On Feb. 20, 1887,
cystoscopical examination was made. On the left side of the trigone a
tumor with a broad base was seen, which resembled somewhat a strawberry in
size and form. (See Fig. 3.) On March 1, Professor Madelung undertook the
extirpation of the tumor. The appearance corresponded exactly to the
cystoscopic picture. The patient recovered.
[Illustration: FIG. 4.]
_Case 4._--This was a patient on whom Dr. Israel had performed the high
section a long time before, on account of a bladder tumor. The extent was
so great that only its most prominent part could be removed. The
microscopical examination proved the diagnosis of cancer. Quick healing
took place. The patient became free from pain, and the urine became clear.
In order to see what had become of the remaining part, the cystoscopical
examination was undertaken on April 3. It was easy to see that the right
lateral wall was covered to an extent of from three to four centimeters
with thick masses of verrucous and fungiform excrescences. (See Fig. 4.)
[We omit the description of the additional cases.]
The above shortly described fifteen[9] cases of bladder tumors have been
diagnosed by me cystoscopically during the last sixteen months. This is a
proof, on the one hand, of the value of the cystoscopic examination; on
the other hand, of the fact that the new formations in question are not of
so rare occurrence as has been hitherto thought. I would like to emphasize
that the important results were often obtained under the most difficult
circumstances. In several cases the external orifice of the urethra was
found abnormally small; in others (Cases 8 and 11) the examination was
made during the occurrence of a continuous hemorrhage from the tumor; in
one case (Case 1) I introduced the instrument through the center of the
tumor, which bled on the slightest pressure. In spite of this the
appearances were seen satisfactorily. In the first case a post mortem
examination was made; in eight other cases (Cases 2, 3, 9, 10, 11, 13, 14,
and 15) the tumor was extirpated, seven times by the high section--in one
case, that of a woman, through the dilated urethra. In these nine cases
the endoscopic appearances were in every important respect confirmed in
the most perfect manner. In every case my opinion regarding the size,
position, and form was found to be correct. It is only in those cases
where the edges of the tumor overlap the short pedicle that the latter
cannot be observed. Besides, the relative good results of the operations
undertaken on account of the cystoscopic appearance may be emphasized. Of
the eight patients from whom the tumors had been extirpated, none died
from the result of the operation. Case 9 proved fatal on account of the
progressive extension of the growth. In the eleventh case there was a
recurrence, but the patient is still alive. Five patients (Cases 2, 3, 10,
13, 14) must be considered entirely cured. Case 15 is still under
treatment, and, as the conditions of the patient are at present (ninth day
after operation) in every way satisfactory, a complete recovery is
anticipated.
[9] The first eight cases are more fully described in the Arch. fur
Chirurgie, vol. xxxvi., Part 3 (Dr. Nitze, Beitrage zur Endoscopie der
mannlichen Harnblase). The full account of the last seven cases will be
published soon.
Finally, on comparing the above cystoscopic appearances with the results
obtained by other methods of examination, it must be observed that the
examination of the urine, in most cases carefully made, had only in two
cases shown the presence of villous tissue, which in one instance was
brought out by the catheter. The rectal palpation, when made, had always
given negative results. Further, the examination by means of the sound had
been made in nine cases before the cystoscopic examination. In none of the
cases had the sound revealed the presence of a tumor (which in two had
attained the size of a small apple), although the examination was made by
most experienced surgeons and eminent specialists. Those cases show how
imperfect an instrument the sound is for the diagnosis of bladder tumors.
Only one method can compare with the cystoscope in giving valuable
information regarding the size and nature of a bladder tumor--viz., the
digital exploration of the internal surface of the bladder after a
previous _boutonniere_, or the high section. The superiority of the
cystoscopic method over the latter, on account of the smaller amount of
inconvenience it causes the patient, need not be insisted on. The latter
involves a cutting operation not free from danger, as well as deep
narcosis, while the cystoscopic method is similar to a simple
catheterization.
[Illustration: FIG. 5.]
The accompanying diagram (Fig. 5) shows the instrument used by me for
cystoscopic examination. It has been made by the Berlin instrument maker,
Hartwig, according to my instructions. The source of the light (Mignon
lamp) is cemented in a silver capsule, which is screwed into the distal
end of the cystoscope. This instrument is superior to that made by Leiter,
the Vienna instrument maker, because of its greater simplicity in
construction, which allows the lamp to be easily replaced when necessary,
and also on account of the greater length of the shaft.
I mention this because it differs from the explanation which Mr. Fenwick
gave in his speech concerning my method of examination at the meeting of
the Medical Society of London on Jan. 23, 1888. I must also strongly
contradict Mr. Fenwick's statements concerning the share which he
attributed to the Vienna instrument maker in the construction of the
instrument. Leiter's connection with our instrument will be best explained
when I say that he had to buy the patent[10] from me first in order to be
allowed to make the instrument. Leiter has had no share in those
peculiarities which characterize it as new. The introduction of the source
of light into the organ had been practically brought about, the optical
apparatus enlarging the view designed, the whole construction perfected,
the instrument had proved itself useful in examining patients, and had
been demonstrated by me in the Saechsisches Landes Medicinal Collegium
before Leiter had any idea of the new invention! Also the eventual
replacement of the first source of light (platinum wire) had been provided
for.[11] Leiter has only made a few technical modifications on the
finished instrument. I protest most emphatically against the incorrect
explanations given by Mr. Fenwick, and against every connection of
Leiter's name with my instruments. I hope to obtain in England the same
generous recognition of my labors in this field that has been accorded to
me in Germany.--_Lancet._
[10] Deutsche Patentschrifte, No. 6, 853.
[11] Ibid.
PAPILLOMATOUS TUMOR OF THE BLADDER, DEMONSTRATED BY
MEANS OF LISTER'S ELECTRO-CYSTOSCOPE.
By F. N. Otis, M.D., Clinical Professor, College of Physicians and
Surgeons, New York.
A. G----, aged twenty-three, United States; single; barber.
The young man was referred to me by his former medical attendant, March
16, 1883. His urine was found to be slightly but distinctly tinged with
blood, and contained some small clots as well as some pus and mucus. He
complained of exquisite pain on urination, increased at the close,
recurring every half hour. Through examination per rectum (_a posteriori_)
unusual tenderness was found. Distinct increase in the density and
thickness of the right inferior section of the bladder was recognized by
the bimanual touch; a catheter was introduced, and three ounces of bloody
urine removed. The bladder was then irrigated gently with a saturated
solution of boric acid until the fluid returned clear. The catheter was
then withdrawn, leaving about four ounces of the solution, of a
temperature of 80 deg., in the bladder, as a preparation for its examination
by the electro-cystoscope of Lister. The required current was furnished by
the small six-cell battery of the Galvano-Faradic Co. The cystoscope was
then introduced into the bladder, and the current turned on. The
illumination was complete. Through the slightly rosy medium the small
blood vessels in the bladder mucous membrane were distinctly seen. On the
right side a deep red, granular-looking mass, with a wavy outline, was
then distinctly observed, covering about one-fourth of the cystoscopic
field. This appearance was verified by Drs. Abbe, Bangs, and W. K.
Otis--the unanimous opinion being that it represented a papillomatous
growth, to some extent covered by coagulated blood. Two days later a
similar examination was made, under the influence of an anaesthetic, which
corroborated the previous observations in every particular. (See
illustration.)
[Illustration: DIAGRAM OF BLADDER, SHOWING LOCATION OF TUMOR
AND POSITION OF CYSTOSCOPE.]
Some small filaments were subsequently removed with the lithotrite, but on
microscopical examination nothing of diagnostic importance was discovered.
From lack of the capacity of the bladder, the field was necessarily
limited, nevertheless, a very excellent view of the tumor could be
obtained. This is shown in the illustration, from a sketch made at the
time of the first examination. It represents the position of the tumor and
cystoscope when the best view of it was obtained.
On the following Monday the patient entered St. Luke's Hospital, and was
operated upon by my associate, Dr. L. B. Bangs, Dr. Charles McBurney
assisting. The high operation was performed, and the bladder being
examined by means of an electric light, introduced through the suprapubic
incision, the diagnosis made by the cystoscope was verified in every
particular. The growth was then removed, as far as possible, with the
scissors, and the surface cauterized with the Paquelin cautery. At the
present writing the patient is going on toward a satisfactory recovery.
The pathological examination made by Dr. Frank Ferguson, pathologist of
St. Luke's Hospital, showed the neoplasm to be a simple papilloma.
This case is deserving of especial interest as being the first tumor of
the bladder diagnosticated in this country by means of the cystoscope, and
verified by subsequent operation, and adds one more to the list of
sixteen cases so made out by foreign observers, and two by Dr. Fenwick, of
England. In this instance the instrument deserves particular credit, as
other methods had completely failed in the practice of competent
observers.
This consists of a metal tube, about seven inches long, of a caliber of 22
French, having at the proximal end a funnel shaped ocular opening; at the
distal, a short beak, similar to that of the catheter coude. A window of
rock crystal is set in the end of this beak, behind which a small electric
lamp, controlled by a switch at the ocular end, is placed. A rectangular
prism, the hypothenuse plane of which is silvered, is placed in the end of
the straight portion of the tube, its superior face being seen just
anterior to the angle formed by the beak. The distended bladder is
illuminated by the electric lamp, the rays reflected from its wall falling
on the prism experience total reflection, an inverted image being formed
within the tube. The size of the field thus obtained is greatly increased
by means of a telescope introduced into the tube. The image seen through
the cystoscope is an inverted image, but right and left are not
transposed.
[Illustration: THE CYSTOSCOPE.]
There can be no question as to the great prospective value of the
electro-cystoscope in diagnosis of many difficulties to which the bladder
is subject. A variety of foreign bodies have already been reported as made
out by use of this instrument. The locality, size, and color of vesical
calculi have been demonstrated in my own experience. In one instance two
stones were seen where only one had been previously found, but this of
course might with care have been effected by means of the lithotrite. But
it is in the diagnosis of the tumors, and encysted or impacted calculi,
that the most essential service may be anticipated from the use of the
cystoscope. The orifices of the ureters are quite readily brought into the
cystoscopic field, and it is more than probable that (perhaps through the
introduction of some clear fluid with which blood does not readily
mingle--glycerine, for instance) the true source of a previously doubtful
haematuria will be demonstrated.--_Medical Record._