K_5iiy (frAl The Cystoscope HOWARD A. KELLY, M^JW Professor of Gynecology a nd^Ustetrics in Johns HopkiaiJ&nTversity, Baltimore, Md. Thb American Journal of Obstetrics Vol. XXX., No. 1,1804. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS 1894 THE CYSTOSCOPE. I have found it necessary during the past few months to make everal important additions and modifications in the con- struction of my cystoscopes, which I wish briefly to describe in this article in response to numerous inquiries as to the best model. My cystoscope is a nickel-plated metal cylinder eight centi- metres long, equal in diameter from end to end, measuring in the different sizes from five up to twenty millimetres. The outer end of the speculum has a funnel-shaped orifice. The sides of this funnel-shaped orifice are fifteen millimetres long, and are inclined at an angle of sixty degrees to the straight sides of the cylinder. The following improvements have been made upon my first specula: In the first place, the little shoulder (see Fig. 2) which existed between the lower end of the speculum and its obturator has been done away with, making the instrument, when put to- gether ready for introduction, smooth from end to end (see Fig. 3). This alteration can be made upon the first specula. In removing the shoulder care must be taken not to taper the lower end of the speculum down to a knife edge or a ragged edge, rendering it liable to cut the wall of the bladder or urethra at every contact. The edge should for this reason be slightly dulled. The second point of importance to be observed is that the end of the obturator should be a well-defined, well-pointed cone, 2 KELLY : THE CYSTOSCOPE. and not short and obtuse, manifestly facilitating its introduction (see Fig. 1). Thirdly, I have found that it is an un- necessary sacrifice of important space to make the tube of the speculum two millimetres narrower at its lower than at the upper end, slightly funnel-shaped, as in the Simon spe- cula. The external urethral orifice is the part most contracted and most difficult to dilate, and if the maximum calibre of the speculum rests there then no other reason can exist for making the inner end narrower, except it be a desire to use the speculum as a dilator, but this is rendered unnecessary by the series of graduated dilators employed to enlarge the urethra before introducing the specu- lum. Fourthly and perhaps the most important change is to be found in the handle of the present speculum (see Figs. 4 and 5). I soon dis- covered, when a larger number of cases came to me for treatment and I began to consume more time in making minute examinations and dictating the results of such examinations of the bladder, as well as in treating diseased areas, that the small handles on the first specula became exceedingly fatiguing to the fingers endeavoring to hold them. I therefore have had a long handle attached, eight centimetres long by twelve millimetres broad and Fig. 1. — Perfected cystoscope. KELLY' : THE CYSTOSCOPE. 3 five millimetres in thickness, which can be comfortably grasped by the hand ; this is now placed on all the specula. This handle can also be readily placed on the first set of specula with short handles. I commonly prefer for ordinary inspection, treatment, and catheterization of the ureters the No. 10 speculum (ten milli- metres in diameter). I find some of my friends express a preference for a higher number—12. I think, with practice Fig. 2. Fig. 3. and after acquiring some little skill, No. 10 will be found best adapted to general use. The correct method of using the speculum is this: The vulvar orifice, especially the urethra, is carefully cleansed with a warm boric acid solution and cotton, to obviate any risk of infection of the uri- nary tract, which might easily be brought about by successively introducing instru- ments through an unclean urethral orifice into the bladder. The calibrator is then used to measure the diameter of the mea- tus, thus determining the size of the di- lator to be used first. From this up the successive sizes of dilators are used until ure. The lower figure, 4, shows the funnel-shaped the urethra is dilated up to No. 10. This end of the speculum with can be accomplished without pain by twist- the large improved handle. < r r «/ ing absorbent cotton on an applicator and saturating it with a five-per-cent solution of cocaine and laying it just within the urethra for five minutes before dilating. After once dilating the urethra I have been able to introduce the speculum at once at subsequent examinations, without any further Fig. 4. Fig. 2.—The upper left hand corner shows the end of the first speculum con- structed, with its obtura- tor. The shoulder at s s is a fault in the construction, corrected in the improved cystoscope as seen in Fig. 3, the upper right hand fig- 4 KELLY : THE CYSTOSCOPE. preparatory dilatation. Quite often the No. 10 can be intro- duced at once with ease without any dilatation. The bladder is nowcatheterized, unless the patient lias urinated immediately before the examination. A pledget of sterilized cotton is now placed between the labia over the urethra, to pro- tect the latter from contamination during the change of posture, and the patient is placed in the knee-face position, which I al- most invariably prefer for first examinations. The speculum is If the patient cannot well remain as long as desired in the knee-face position, its advantages may often be secured by first placing her for a short time in that position until the viscera gravitate up out of the pelvis toward the diaphragm, and intro- ducing a catheter into the bladder, which at once fills with air. The catheter is now withdrawn, and the patient gently returned KELLY : THE CYSTOSCOPE. 5 Fig. 6 shows method of holding the speculum during introduction, the thumb.'pressing upon the handle of the obturator to prevent the end being forced back into the tube as .it is pushed up through the urethra. Fig. 7 shows the patient in the knee-breast position, the speculum introduced and the long handle conveniently held for examination. 6 KELLY : THE CYSTOSCOPE. to the dorsal position with more or less elevated hips. Upon introducing the speculum the bladder will now be found dis- tended with air, and will remain distended until the viscera again gravitate into the pelvis. This will not occur for a long time in some cases, and can be prevented as long as desired by further elevating the hips. With the speculum introduced, the examination proceeds as Fig. 8.—Electric head light. described in my first articles on this subject, by means of a head mirror reflecting an electric light, from sixteen to thirty-two candle power, in a light room. Weaker artificial lights can be used in a dark room, but nothing is so serviceable as the electric light close at hand, on account of the small angle at which it can be reflected. 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