A Case of Primary Tuberculosis of the 
> Female Bladder 
Diagnosed and Treated by 
Howard Kelly s New Method of Direct 
Inspection with Large Endoscopes. 
BY 
J '"y ', 
W. L. BURR AGE, M.D. 
Reprinted from the Boston Medical and Surgical Journal of 
fitly 26, iSgp.. 
BOSTON: 
DAMRELL & UITIAM, PUBLISHERS, 
No. 283 Washington Street, 
1894. S. J. PARKHILL & CO., PRINTERS 
BOSTON A CASE OF PRIMARY TUBERCULOSIS OF 
THE FEMALE BLADDER DIAGNOSED AND 
TREATED BY HOWARD KELLY’S NEW 
METHOD OF DIRECT INSPECTION WITH 
LARGE ENDOSCOPES.1 
AV. L. BURBAGE, M.D., 
Surgeon to Diseases of Women, St. Elizabeth’s Hospital; Gynecolo- 
gist to Out-Patients, Carney Hospital; Clinical Instructor 
in Gynecology, Harvard University. 
The case 1 have to present to-night is of especial 
interest, both on account of the rarity of the disease, 
and, as illustrating the successful employment of a 
new method of investigating and treating diseases of 
the bladder and ureters in women, a method that is, 
in my opinion, as much superior to all former methods 
as the electric cystoscope was to digital exploration. 
Our ability to see and treat all parts of the bladder 
interior directly, as I am about to describe, is destined 
to revolutionize diagnosis and treatment in bladder, 
ureteral and kidney diseases in women. We must see 
as well as feel ulcerated areas and new growths, and 
define their jimits. The diagnosis, for instance, of 
urinary tuberculosis will no longer be deemed sufficient. 
We must be able to say whether or not the disease is 
confined to the bladder, or is located in one or the 
other ureter or kidney, or in all. 
Before reporting the case it is my purpose to say a 
few words as to the usual methods of bladder explora- 
tion, and then briefly describe the new method, and 
show you the instruments. 
The previous recognized methods of exploration of 
the female bladder have been, 
1 Read before the Boston Society for Medical Improvement, April 
9, 1894. 2 
(1) Bimanual examination, with the uterine sound 
in the bladder, the finger in the vagina, and the other 
hand on the abdomen ; or, without the sound. 
(2) Digital exploration, the urethra being first 
dilated to not more than twenty millimetres by means 
of graduated dilators and the finger. 
(3) Endoscopy, by means of a straight tube of hard 
rubber about seven centimetres long and ten millimetres 
in diameter, open at its inner end and carrying a glass- 
tube closed at its inner extremity. The glass-tube 
projects a little beyond the hard-rubber sheath and has 
in it a little mirror inclined at an angle of one hundred 
degrees. The mirror being attached to a long handle 
may be moved forward or backward and turned around. 
Light from an Argand burner, or direct sunlight, is 
reflected from a head mirror to the little mirror in the 
tube and thence into different parts of the bladder 
wall. The rays of light pursue the same path back 
to the operator’s eye at the focus of the head mirror. 
(4) Cystoscopy, by means of an instrument made 
on the same plan as the endoscope, except that the 
source of the light is an electric lamp in the end of 
the instrument in the bladder. 
(5) We must enumerate also examination of the 
interior of the bladder through a vesico-vaginal fistula 
or opening made by supra-pubic cystotomy. 
Examination by touch has been of great use, and 
will continue to be; but it cannot rival in value, 
either from a diagnostic or therapeutic point of view, 
examination by sight. With the endoscope and cysto- 
scopethe bladder has to be partly filled with a perfectly 
clear, transparent fluid in order to be inspected. In 
most bladder affections the urine is cloudy, and the 
walls can be cleansed with difficulty; besides, the 
urine constantly coming into the bladder from the 
ureters may tend to render it cloudy; and also only 3 
a portion of the bladder interior can be inspected, 
owing to the necessary obliquity of the mirror in the 
instrument. We must add, as a further objection to 
endoscopy and cystoscopy, the distortion of the image, 
due to errors of refraction of the fluid media through 
which the light passes. Our knowledge of the appear- 
ance of the interior of the living bladder both in health 
and disease is largely due to the investigations of Mr. 
E. Hurry Fenwick, of London, with the electric cysto- 
scope. 
Catheterization of the ureters has been practised 
more or less extensively ever since Prof. G. Simon 
published his work on the subject in 1875. He dilated 
the urethra; then, passing his finger into the bladder, 
located the ureteral orifice by touch, and passed the 
catheter along his finger into the ureter. 
Professor Pawlik, later on, improved on this method 
by demonstrating landmarks in the vagina which 
serve to locate the ureters; then passing the catheter 
into the bladder he observed the play of its tip on the 
anterior vaginal wall and directed it into the ureteral 
openings. He also improved the catheter. By 
Pawlik’s method the dilatation of the urethra, with the 
attendant danger of subsequent incontinence, was 
done away with, and the seriousness of the operation 
lessened. 
Professor Sanger at this time demonstrated that the 
ureters in their lower course can be palpated per 
vaginam. 
Prof. Howard A. Kelly of the Johns Hopkins 
University published two valuable papers in the 
Annals of Gynaecology and Pcediatry for May and Au- 
gust, 1893, in which he gave the results of his researches 
on the anatomy of the ureters and formulated exact 
rules for catheterization. He presented a new catheter. 
It was not until January of this year that Howard 4 
Kelly published in the American Journal of Obstetrics 
his article on “ The direct examination of the female 
bladder with elevated pelvis. The catheterization of 
the ureters under direct inspection, with and without 
elevation of the pelvis.” I hand you a reprint of this 
article, which is the basis of my work. As you see 
the very good illustrations do away with the need of 
much explanation. 
The main steps of the procedure consist in empty- 
ing the bladder with a catheter; in elevating the pa- 
tient’s hips from eight to twelve inches, so that the 
residual urine will run up to the fundus, and the 
weight of the abdominal viscera being removed the 
bladder is distended with air ; in the gradual dilatation 
of the urethra and the employment of large, straight, 
open endoscopes, which, by the way, are fitted with 
handles for ease of manipulation ; and in the use of a 
strong light from an Argand burner or electric lamp 
held near the pubes, and reflected into the bladder by 
a head mirror. The graduated dilators are passed 
until sufficient calibre has been obtained. Kelly says 
many take No. 16. I have found Nos. 12 and 14 to 
pass easily in most cases. Suppose a No. 12 dilator 
passes, then introduce the speculum of the same size 
and remove the obturator. Thus by means of a simple 
speculum and proper posture all parts of the air-dis- 
tended bladder are rendered visible. To inspect the 
upper and anterior zones the patient is placed in the 
knee-chest position. If there is a pool of urine in 
the bladder it is removed by a simple suction apparatus. 
Applications may be made to all parts of the bladder 
and urethra. Small quantities of urine are removed 
by pledgets of cotton held in delicate mouse-toothed 
forceps, and applications are made with a cotton-wound 
applicator. The ureteral openings are seen as little 
slits in the mucous membrane, and if watched urine 5 
may be seen issuing from them. A probe with a long 
handle bent at an obtuse angle is of use in verifying 
the position of the orifices. The ureters are catheter- 
ized with Kelly’s catheter, the patient in position with 
hips raised, or flat on the table. 
The necessary instruments are, four specula with 
obturators, Nos. 8, 10, 12 and 14; and four dilators, 
Nos. 7 and 8, 9 and 10, 11 and 12, and 13 and 14; 
mouse-toothed forceps ; ureteral searcher, or long, bent 
probe ; ordinary applicator; and one ureteral catheter. 
The dilators and specula are calibrated in millimetres; 
for example, No. 10 is ten millimetres in diameter, 
No. 12, twelve millimetres, and so on; a good light 
held near the pubes, is essential to success in this field 
of work. 
I show you my set of instruments. I find two ure- 
teral catheters more convenient than one, because the 
operator does not always care to spend the time to 
clean one catheter before catheterizing the second ureter. 
While house-surgeon at the Woman’s Hospital in 
New York I had the opportunity of following Dr. 
Nathan Boyeman’s work on the bladder and ureters. 
In cases of cystitis and ureteritis he made a vesico- 
vaginal fistula, and irrigated the bladder and catheter- 
ized the ureters through the openings so made. It 
was his routine treatment to irrigate the ureters and 
pelves of the kidneys by means of small English gum- 
elastic catheters. With a catheter in the pelvis of 
each kidney it was a part of my duty to catch the 
urine as it came drop by drop from the catheters 
note the rate of flow on each side and finally analyze 
each specimen chemically and microscopically. To- 
day this work is done without cystotomy, and with 
nearly as great facility. 
Mrs. J. F,, twenty-six years old, married seven 
years, and sterile, was referred to me October 17th, 
1893, by Dr. N. K. Noyes, of Duxbury. 6 
From Dr. Noyes’s notes and from conversation with 
the patient the following history was obtained : Grand- 
mother died of heart-trouble; mother and father and 
two sisters living and well ; uncles and aunts of father 
died of consumption. There was consumption on the 
mother’s side a generation back. The patient was 
not very strong as a child, being subject to coughs and 
colds. At nineteen years of age she had whooping- 
cough and later in the same year rheumatic fever. At 
twenty-one she had pneumonia, and three years ago 
had the grip. Husband is living and well. She suf- 
fered with inflammation of the bowels when she had 
rheumatic fever, and has had an attack each year for 
the last three years, being sick in bed for two or three 
months with each attack; the abdomen during these 
attacks would be swollen and tender. She had abso- 
lutely no trouble with her urine until August, 1893, 
not even with the attacks of inflammation of the 
bowels. A short time before the beginning of Mrs. 
F.’s urinary difficulty she spent the night at a house 
where her sister’s husband was dying of general tuber- 
culosis, and she was in and out at the house a good 
deal at that time. 
Dr. Noyes first saw the patient September 5, 1892, 
when she was suffering with an attack of what he diag- 
nosed as subacute peritonitis. The abdomen was ten- 
der, very slightly swollen, and she had a temperature 
of from 99° to 101° for five or six days. She was in 
bed for a month, the pain and soreness being very 
persistent. 
In December, 1892, she complained of a “bunch 
low down in front passage” and pain in the back. 
Dr. Noyes diagnosed retroversion, and treated her for 
it for three months by packing and then fitted a pes- 
sary. The pessary failed to keep the uterus in good 
position, however. She wore it until August. 7 
August 30, 1893, Dr. Noyes was called to see pa- 
tient, and found her suffering from severe pain in 
lower part of abdomen, associated with swelling and 
great tenderness. Temperature 103°. Large doses of 
morphia relieved the pain, and in two or three days 
the temperature declined to normal. Patient took a 
vaginal injection of a pint of hot water just after the 
beginning of this attack. Two or three hours after, 
she began to have painful micturition, and has had it 
ever since. Pain near the end of micturition, which 
was every hour or two ; urine cloudy and often bloody. 
After a time the pain became nearly continuous, and 
the frequency of micturition was at times as often as 
every few minutes. The bladder was irrigated every 
few days with some relief. She was catheterized for 
the first time in September. 
Previous to the occurrence of the urinary difficulty 
she had made arrangements to enter St. Elizabeth’s 
Hospital for operative treatment for retroversion and 
supposed peritonitis. She entered the hospital Octo- 
ber 17, 1893. I saw her on the following day and 
found a well-developed and nourished woman of large 
frame, and of dark complexion. The uterus was 
retroverted in the third degree, replacable, two-and- 
three-quarters inches deep; ovaries and tubes not felt 
because the vagina was very long and roomy and the 
abdominal walls thick and tense. She was put on 
salol, gr. v., t. i. d., and prepared for exploratory ab- 
dominal section and ventral fixation. Urine slightly 
cloudy ; no albumin. Heart and lungs negative. 
Operation, October 25, 1893. Ether. Curretting 
the uterus brought away very little tissue. On open- 
ing the abdomen with a three-inch incision the uterus 
was found on the floor of the pelvis in the third de- 
gree of retroversion. Ovaries and tubes normal to 
feel and sight. No adhesions anywhere. The bladder 8 
wall felt thickened universally. Both ureters were 
palpated from the broad ligaments to the pelves of the 
kidneys, and nothing abnormal felt. Uterus anchored 
to abdominal wall by two stitches of fine twisted silk 
(No. 1) passed through each round ligament at a point 
one inch from the uterine cornu, and then through 
the parietal peritoneum and overlying fascia one and 
a half inches from the median line and at right angles 
to the incision. Toilet of peritoneum, and wound 
closed in usual manner. 
Patient developed a mural abscess and an attack of 
bronchitis. Temperature not above 100° at any time. 
The painful micturition was a prominent symptom 
soon after the operation, and the bladder was irrigated 
daily with a one-half-per-cent, solution of boracic acid, 
and the salol was continued. Urine slightly alkaline, 
and containing a trace of albumin and much pus. 
November 2d, the bladder was injected with glycer- 
ine (3i) and iodoform (3ss), and this was continued 
every other day until November 24th, with some tem- 
porary relief of pain. She was then convalescent 
from the bronchitis; the wound was healed; the 
uterus was in good position, where it has remained 
since. There was no special tenderness over bladder 
at any time. Urine alkaline when not taking benzoate 
of ammonia or benzoic acid ; cloudy and containing a 
small amount of pus; specific gravity generally about 
1.012 ; a trace of albumin. 
Endoscopic examination November 24th showed in- 
jection of upper urethra and bladder above trigonum. 
The bladder neck and upper urethra were swabbed 
out with nitrate of silver, 1 to 60, every third day for 
two weeks, with relief for twenty-four to thirty-six 
hours after each treatment. Various diluents for the 
urine were tried, and a large variety of drugs to re- 
lieve the pain, but with only temporary benefit. 9 
She was discharged December 22d, and instructed 
to take citrate of potash and buchu. Repeated exami- 
nations of the chest failed to reveal evidence of any- 
thing but bronchitis. 
Mrs. F. entered the hospital for the second time 
January 31, 1894. She complained of the frequent 
and painful micturition about as before. The urine 
was cloudy; of specific gravity of 1.010; slightly al- 
kaline ; albumin absent; twenty-four-hour amount 
only 12 to 14 ounces. 
February sth. Endoscopy by Howard Kelly’s 
method. Not having Kelly’s new specula at that time 
the examination was made with a Skene endoscope 
tube 10 millimetres in diameter, the patient’s hips be- 
ing raised. I made out a reddened area that bled 
easily, situated in the right posterior inferior zone of 
the bladder. It was studded with little grayish, glis- 
tening, translucent bodies the size of the head of a pin 
and raised above the surrounding surface. They 
looked like the miliary tubercles seen in peritoneal 
tuberculosis. The upper urethra was injected also. 
Ether was then given, and the urethra was dilated to 
admit my forefinger, which is 13 millimetres in diam- 
eter at the largest joint; and the patch was scraped 
with my finger-nail, and then touched with a ten-per- 
cent solution of nitrate of silver. Dr. J. M. Jackson 
examined the urine two days after the operation and 
found very numerous tubercle bacilli in a urine typi- 
cal of cystitis. The bladder was irrigated twice daily 
with a warm solution of boracic acid and later with a 
very weak solution of tinct. myrrh. The rnyrrh gave 
more relief from pain than any other local treatment 
except the late effects of the nitrate of silver applica- 
tions. She took oil of sandal wood by the mouth for 
two weeks without benefit, and later belladonna, hyoscy- 
amus and citrate of potash and buchu. Bromide of 10 
potash in 20 grain doses, frequently repeated, gave as 
much relief as any medicine that was taken internally. 
February 21st, I made an examination of the blad- 
der with Kelly’s instruments, having failed a few days 
before because of the abundant flow of urine follow- 
ing the administration of citrate of potash and buchu. 
No anesthetic was necessary in this or subsequent ex- 
aminations. No. 14 endoscope was easily passed. With 
the hips elevated and with the patient in the knee- 
chest position the entire interior of the bladder was 
inspected. The ureteral orifices were found as slits in 
the slightly elevated papillae. No evidences of inflam- 
mation about either orifice. In the posterior inferior 
zone of the bladder, and situated one centimetre above 
the right ureteral orifice, was a reddened area, circu- 
lar in shape, and one and a half centimetres in diame- 
ter, easily bleeding with slight touch, and studded here 
and there with the glistening, grayish bodies before 
described. I picked off one of these and gave it to 
the pathologist. He said it was too small for exami- 
nation. 1 catheterized each ureter, and obtained 
what appeared to be normal urine from each. Ex- 
amination by Dr. Jackson failed to reveal the pres- 
ence of tubercle bacilli in either specimen. Although 
negative evidence in cases of urinary tuberculosis is 
not conclusive, 1 felt that the risk of carrying conta- 
gion up the ureter on my catheters was good reason 
for not obtaining further specimens. 
Examination of the urine, March 2d, by Dr. Jack- 
sou, showed it to be cloudy, alkaline, 1.017, with a 
faint trace of albumin. In the sediment was a large 
amount of bladder and squamous epithelia, a few small 
round cells, much fresh blood, a considerable number 
of leucocytes, and a great number of bacteria and 
spores. 
March 9th. She had an attack of pain and tender- 11 
ness in the abdomen, associated with a cough. There 
was no temperature. Examination of the chest showed 
a few moist rales and high-pitched respiration in both 
backs, but nothing further. 
March 14. I made another examination of the blad- 
der with the No. 14 speculum, and confirmed my pre- 
vious diagnosis. I curetted the reddened area with a 
Simon’s spoon curette, and touched it with ten-per- 
cent. solution of nitrate of silver. There was moderate 
bleeding at the time. 
Mrs. F. left the hospital March 20th. 
Dr. Noyes writes, under date of April 7th: “At 
present she is in bed about all the time, because to be 
up causes more pain. The bladder is being irrigated 
twice daily through a soft-rubber catheter with four 
ounces of plain boiled and filtered water, and she is 
taking five grains of benzoic acid four to six times daily. 
I saw her. yesterday, and she said she had very little 
pain except during and for a short time after urinat- 
ing. She urinates only every three to four hours dur- 
ing the night, and every one and one-half to two hours 
during the day. She eats well, sleeps fairly well, and 
looks well.” 
The obstacles in the way of diagnosis have made 
the literature of primary tuberculosis of the female 
bladder somewhat meagre. Most of the wmrk in the 
field of vesical tuberculosis has been done on the male. 
The text-books confine themselves to general state- 
ments. They give an unfavorable prognosis, though 
relatively more favorable than in secondary tuberculosis. 
Fozzi says the duration of the disease may be esti- 
mated as from one to two years, but cases have been 
known in which it lasted from five to ten years with- 
out affecting the general health. 
Fenwick said, in 1890, that most cases died in three 
years. But in 1892, in a paper on “The Mimicries 12 
of Primary Urinary Tuberculosis,” published in the 
British Medical Journal for May 28th, he made the 
following statement: “ After having watched the pro- 
gress of over a hundred cases of urinary tuberculosis, 
I have come to the conclusion that when it attacks the 
lower division of the tract, the bladder, prostate and 
urethra, and is wisely treated, it exhibits as marked a 
tendency to obsolescence, or even cure, as the same 
disease when situated in the lungs.” He also said, 
that, even when the disease was situated high up, the 
prognosis was better than was generally admitted. 
J have not time to go into the question of infection 
whether the bacillus is introduced from below, and the 
process ascends from bladder to ureters and kidneys; 
or whether it is excreted by the glomeruli of the kid- 
ney and travels downward to the ureter and bladder. 
Both views are advocated by eminent authorities. 
Fenwick says primary vesical deposits first appear on 
the posterior wall of the bladder, as in my case. 
The symptoms are frequent micturition, not relieved 
by rest, as is the case in stone; pain, especially at the 
end of micturition ; and blood in the urine. 
The object of treatment in chronic tubercular cysti- 
tis is to render the urine unirritating, and, if possible, 
germicidal by means of diet and drugs ; and to remove 
mucus and uric-acid deposits as sources of irritation by 
irrigation ; also to destroy the bacilli by the direct ap- 
plication of caustics and germicidal agents; and to re- 
lieve pain. The system should be built up by cod 
liver oil and tonics. A milk diet is of great benefit as 
a diuretic, also plenty of water. The drug that has 
the best reputation is benzoic acid. Tyson recom- 
mends it in the form of five-grain pills ; at least 
thirty grains in the course of the day. The potash 
salts, especially the citrate and acetate are of great use. 
In a general way we employ the alkalies to dissolve 13 
uric-acid deposits and to prevent their formation, and 
benzoic and boric acids to dissolve the phosphates. 
Other drugs that are well spoken of, are: buchu, triti- 
cum, repens, corn-silk, sandal-wood, copaiba, eucalyp- 
tus and resorcin. Salol has been found to prevent the 
growth of the staphylococcus in the bladder; but, by 
the statement of Rommelaere, the bacillus of tubercu- 
losis resists it absolutely. It is certainly a valuable 
drug on empirical grounds alone. 
As local treatment, the bladder should be irrigated 
at least once a day. Tyson says that tepid water, four 
to six ounces, is as good as anything, and relieves pain 
better than other injections. He also advises very 
weak bichloride, 1-26,000. 
Other remedies that stand well are borax, one drachm 
to a pint of warm water; common salt in the same 
amount; salicylate of soda, one drachm to the pint; 
alum enough to give an astringent taste; nitrate of 
silver, twenty grains to the ounce ; and creolin, one 
per cent. Guyon uses bichloride, 1-5,000 to 1-1,000, 
twenty to thirty drops at a time. Loumeau also uses 
strong bichloride. 
Guyon and Reverdin have obtained excellent results 
by curetting and cauterizing the ulcerated area through 
an opening in the bladder made by supra-pubic cystot- 
omy. With our new method the cystotomy will often 
prove unnecessary. 
For the relief of pain morphine is to be avoided. 
Skene recommends bromide of potash, twenty grains 
every four hours. I have found it of great use in fre- 
quent and painful micturition in chronic cystitis.  -THE BOSTON 
MedicalandSurgical Journal. 
A FIRST-CLASS WEEKLY MEDICAL NEWSPAPER. PUBLISHED EVERY THURSDAY. 
Two Volumes yearly, beginning with the first Nos. in_ January and July. But 
Subscriptions may begin at any time. 
This Journal has been published for more than sixty years as a weekly journal under its present title. 
Still it is incumbent upon this Journal, no less than upon others to assure its patrons from time to 
time as the occasion arises, of its desire, ability, and determination to meet all the requirements ot the most 
active medical journalism of the day, without sacrificing any of that enviable reputation which is an inheri- 
tance from the past. 
It is under the editorial Management of Dr, George B. Shattuck, assisted by a large staff of competent 
coadjutors. 
Communications from all quarters of the country are acceptable. Liberal arrangements are made for 
reprints of original articles, and for such illustrations as serve to increase their value or interest. 
All editorial communications, and books for review, should be addressed to the Editor. 
Subscriptions and advertisements received by the undersigned, to whom remittances should be sent by 
money-order, draft, or registered letter. 
Terms of Subscription: In the United States, and to Canada and Mexico, $5.00 a year in advance. 
To Foreign Countries embracedyin the Universal Postal Union, $1.56 a year additional. Single numbers, 15c. 
Ten consecutive numbers free by mail on receipt of sl.ou. 
Sample copies sent free on application. 
Published by DAMRELL & UPHAM, 
t283 "Washington St., .Boston.