Clinical Observations on 
Endoscopy of the Male 
Urethra. 
BY 
HERMANN G. KLOTZ, M. D., 
ATTENDING SURGEON TO THE DEPARTMENT FOR 8KIN 
AND VENEREAL DISEASES IN THE GERMAN HOSPITAL 
AND DISPEN8ARY, N. Y. 
REPRINTED PROM 
2T1>e Nefcu C'odt ittetn'cal .Journal 
for November 27, 1SS6. Reprinted from the New York Medical Journal 
for November 27, 1886. 
CLINICAL OBSERVATIONS ON 
ENDOSCOPY OF THE MALE URETHRA* 
By HERMANN G. KLOTZ, M. D., 
ATTENDING SURGEON TO THE DEPARTMENT TOR SKIN AND VENEREAL 
DISEASES IN THE GERMAN HOSPITAL AND DISPENSARY, N. Y. 
While it is considered a triumph in every branch of 
medicine and surgery to bring the intricacies of disease and 
its pathological appearances nearer to the eye by mechanical 
means, it seems strange that the direct ocular examination 
of the interior of the male urethra by the endoscope has 
up to the present time met with so little favor from the pro- 
fession. While it is nearly universally conceded that the 
methods commonly employed for the treatment of the 
chronic affections of the urethra still remain unreliable and 
unsatisfactory in a good many cases, yet the endoscope is 
resorted to by but few, as by far the greater part of the 
profession either ignore its existence obstinately, deny its 
efficacy, or even consider and denounce it as dangerous. 
Nearly every author on the subject has had reason to com- 
plain of this apathy or antipathy, and various reasons have 
been adduced for this experience. Perhaps the patrons of 
the endoscope themselves are partly to blame, because some, 
* Read before the physicians of the German Hospital and Dispen- 
sary of New York, April 9, 1886. 2 
CLINICAL OBSERVATIONS ON 
no doubt, were too enthusiastic about its value, and prom- 
ised easy and quick success where, in reality, good results 
can be attained only by long and patient work. Others, 
again, were too hasty in presenting as a complete system 
what really consisted only of valuable fragments of patho- 
logical and therapeutical knowledge. It seems to me that 
the period has not yet passed wherein the single worker 
with the endoscope can best promote the acknowledgment 
of the diagnostic and therapeutical value of that instrument 
by plain and faithful reports of his experience, even though 
some of his observations, and the interpretations there- 
of, should prove erroneous. Errors often tend to bring out 
the truth, mistakes of one explorer may lead the other into 
the right direction, and good results, obtained in even a small 
number of cases, may encourage others to enter this field or 
arduous labor with still better success. 
As soon as I found myself more frequently confronted 
in practice with cases of chronic gonorrhoea in which in- 
jections, internal medicines, and sounds had been tried suf- 
ficiently without any notable effect, I felt the desire to look 
into the urethra for the purpose of ascertaining the cause of 
the persistent discharge. At that time nearly all publica- 
tions on the subject referred to the endoscope of Desor- 
meaux, who, in 1855, had presented his instrument to the 
Academie de medecine, and in 1865 had published his book 
on the same. Although it can not be denied that excel- 
lent results had been obtained with Desormeaux’s instru- 
ment, even its admirers conceded that it was rather cum- 
bersome and too complicated for use in general practice. 
Couriard and Ebermann, in St. Petersburg, as early as 1 865, 
had employed less complicated instruments—viz., the laryn- 
geal mirror and separate tubes; but little attention had been 
paid to their observations. But when, during and after 
1874, Gruenfeld and several other Vienna authors began to ENDOSCOPY OF THE MALE URETHRA. 
3 
communicate their experience with still less complicated 
instruments and methods of examination, the possibility of 
exploring the interior of the urethra satisfactorily seemed 
to be within reach, and I at once set to work as soon as I 
could get the necessary instruments. After repeated fruit- 
less efforts, I gradually began to be more and more success- 
ful, so that in 1880 I was able to detect a group of poly- 
pous growths in the membranous urethra, and to remove 
the same by means of an instrument which was described 
in a paper published in the New York “Medical Record” 
in August, 1881. Unfortunately, I have kept but scanty 
notes of my early cases ; but since 1882 I have kept a record 
of nearly all of my patients. From these notes I have taken 
(without selecting) one hundred cases of chronic disease 
of the male urethra, brought to a close by January, 1886, 
in which the endoscope had been employed, to form the 
material on which this paper is based. 
The mechanical apparatus which I have made use of de- 
serves to be described first. A good light is one of the prin- 
cipal conditions of a successful examination by the endo- 
scope. At first I used a common portable gas-lamp, with 
an Argand burner, but soon found its light deficient in in- 
tensity and in color. Next I tried the direct sunlight, 
caught and reflected by a plain mirror attached to the fron- 
tal elastic bandage. It afforded the most excellent illumi- 
nation even of the deeper parts, so as to permit of observ- 
ing the natural color of the mucous membrane. In fact, I 
believe that some details, particularly finer vascular changes 
during the formation of new capillary blood-vessels, for in- 
stance, can hardly be recognized by any other light. Its 
main drawback, however, is that it can not be had at all 
times, especially during winter-time, so as to occasionally 
necessitate a delay of the examinations for a whole week; 
while the heat in summer makes its application very trying, 4 
CLINICAL OHSERVATIONS ON 
not to forget passing clouds obstructing the view, and thus 
extending the examination over an unduly long time. Dif- 
fused daylight I did not find of sufficient intensity, and 
white clouds, which afford a strong enough light, are not 
always at hand when desired. Finally, through the kind- 
ness of Dr. F. Zinsser, I came into possession of a Vienna 
kerosene-lamp of peculiar construction, having twelve solid 
wicks of the caliber of a pencil circularly arranged around 
a carbon plate, which deflects the flame somewhat out- 
wardly. It affords a slightly yellow, but brilliant, steady, 
and reliable light, is always ready for use, and has been 
found to answer all general purposes during constant use 
for several years. A common laryngeal mirror attached 
to the frontal bandage is used as a reflector. 
As no suitable endoscopic tubes, similar to those of the 
Vienna author’s, could then be found in the New York mar- 
ket, I sought the aid of Mr. F. Eissner, of No. 18 Third 
Avenue, to whom I am greatly indebted for the intelligent 
execution of my wishes and for valuable suggestions. In- 
tent on having an instrument as plain and simple as pos- 
sible, after several experiments we agreed upon an endo- 
scopic tube which now has been used constantly by me for 
several years, and which, I understand, has been found use- 
ful and convenient in the hands of several other gentlemen 
of the profession. It represents a modification, or rather a 
simplification, of the straight, simple endoscopes of Gruenfeld 
(Fig. 1 of the adjoining cuts) and Steurer (Fig. 2), being 
more similar to the one described by the latter (in the 
“ Vierteljahresschrift f. Dermatologie u. Syphilis,*’ 1876, 3), 
and consists of a straight tube, with rectangularly cut ends, 
and a disc attached to the ocular end. Fig. 3 shows that I 
have dispensed with the funnel-shaped part of the ocular end, 
which has also been considered rather superfluous by Auspitz 
(“ Vierteljahresschrift f. Dermatologie u. Syphilis,” 1879,1), ENDOSCOPY OF THE MALE URETHRA. 
5 
for, while increasing the distance between the eye of the ob- 
server and the object of examination, it offers no advantages 
by increasing the intensity of the light by deflecting any 
rays, as only nearly parallel rays can reach the end of a 
tube eight to thirteen centimetres long. The disc attached 
by Steurer has been retained, because it serves the purpose 
of compressing the urethra and the entire penis backward 
toward the symphysis, and of reducing its entire length to 
such a degree that, by a tube much shorter than the urethra 
itself, the latter can be examined in every part under more 
Fig. 1. 
Fig. 2. 
Fig. 3. 
favorable circumstances. The tube itself is now made of 
coin silver in preference to cannules made of brass, German 6 
CLINICAL OBSERVATIONS ON 
silver, or hard rubber, because silver can be worked in much 
thinner tubes, which, in consequence of the wider bore, fur- 
nish a wider field of view. Besides, they are much less 
affected by the chemical action of caustic and astringent 
substances, which are used for application through the en- 
doscope, and can be kept clean and smoothly polished much 
easier. Like Auspitz (/. c.), “ I have been taught by experi- 
ence that the dissipated reflexes, dreaded so much by others, 
do not increase in quantity if the inner surface of the tube 
is always kept clean and smooth, while, on the other side, 
in blackened tubes the intensity of the light is greatly 
impaired by a considerable resorption of light-rays.” The 
reflexes from the surface of the disc, however, I found very 
annoying and obstructive to good observation. This was 
obviated by riveting an unpolished hard-rubber plate, 1’5 
millimetre thick, to the metal disc of Steurer, which, being 
clean and less liable to be injured by chemicals, insures 
a firm and comfortable grip, particularly during explora- 
tion of the membranous and prostatic portions, wherein the 
tube has to be kept securely and firmly, and to be moved 
cautiously against the by no means trifling resistance of the 
sphincters. The disc has a diameter of four centimetres— 
somewhat larger than Steurer’s—to prevent the overlapping 
of an abundant prepuce while shoving back the penis over 
the tube. The obturator, conductor, or plug of my instru- 
ments does not differ much from lhat employed by others. 
The silver tubes have been furnished to me by Mr. Eissner 
in different sizes—viz. : 
Charriere’s scale, No. 27, of 11 and 14 ctm. length. 
“ “ “ 25, “11 “ 14 “ 
“ “ “ 24, “ 11 “ 14 “ “ 
“ “ “ 23, “ 8|, 13,15, and 17 “ “ 
“ “ “ 21, “ 8£ “ “ 
“ “ “ 18, “ 8 “ “ ENDOSCOPY OF THE MALE URETHRA. 
7 
As a rule, it is advisable to use the widest and shortest 
tube that passes the meatus, as long as the mucous mem- 
brane is not distended too much ; for the examination of the 
membranous and prostatic portions, however, it is prefera- 
ble to be satisfied with a tube of smaller caliber. The ana- 
tomical formation of those parts renders them more liable 
to slight injuries and to haemorrhage ; only in exceptional 
cases can tubes above 24 Charr. be used with advantage for 
the deeper parts. By soldering a fine silver ring around 
the visceral end of the tube and smoothing it off again to a 
certain degree, the advantage is gained that the edge of the 
tube, thus strengthened, is not bent or made ragged so easily 
by injuries, and that the instrument can be introduced en- 
tirely or at least for some distance without a conductor, thus 
affording a more natural and sometimes more valuable in- 
spection. The thickening of the shell of the tube, however, 
increases the difference between the edge and the bulb of 
the conductor so much that it makes the introduction more 
painful, thereby probably outweighing its advantages. The 
straight, open, rectangularly cut tubes are the only ones I 
have ever used; therefore I can not judge of the usefulness 
of < ther instruments described by Gruenfeld as the straight 
and curved fenestrated and the laterally fenestrated endo- 
scopes. Graduating the tubes for the purpose of locating 
the diseased parts of the urethra distinctly is of doubt- 
ful value, because the urethra is either intentionally or unin- 
tentionally extended or compressed so easily during the ex- 
amination that it becomes rather uncertain to fix the dis- 
tance from the meatus in an exact manner. 
The instruinentarium is completed by a number of 
strong galvanized wire rods, one end of which is bent into 
a ring serving as a handle, the other filed sufficiently rough 
to hold small pledgets or tampons of surgical cotton for 
clearing the surface and for the application of medicinal 8 
CLINICAL OBSERVATIONS ON 
substances. A small ring-shaped curette on a long wire 
handle is an instrument of various usefulness. 
Tlie best position for the patient during endoscopic ex- 
amination of the urethra is that of reclining on a strong, plain 
table, or on a surgical table or chair, the upper part of the 
body moderately elevated, the buttocks as near as possible 
to the edge of the seat, the thighs well separated, the feet 
resting on the round of the chair on which the examiner 
is seated. By adding the pillow of the lower part of my 
Marx exploring chair, the seat reaches a height of thirty- 
three inches from the ground, which enables me to examine 
the pars pendula as well as the deeper parts without chang- 
ing my position or kneeling between the lower extremities 
of the patient, or distorting mv neck too much in following 
the ocular end of the instrument in its movements. The 
lamp is placed to the right on a small table, which holds the 
instruments, cotton-holders, and medicines; the tube is held 
and directed by the left hand, leaving the right one to ad- 
just the light and reach the mucous membrane with the 
cotton pledgets. 
With the aid of such instruments it is not difficult, after 
some experience, to inspect minutely in every case every spot 
of the mucous membrane from the orifice to the bulbous 
part, and in the majority of cases the membranous and pros- 
tatic portions as far as the neck of the bladder; there are 
cases, however, where it is impossible to pass the external 
sphincter. Of course only a small portion of the lining of 
the urethra can be seen at a time, but as the tube, on being 
withdrawn, passes every point of the canal, the mucous 
membrane comes into view bit by bit. The shape in which 
the interior of the urethral channel presents itself in the 
central portion of the tube has been differently compared 
to a cone or to a funnel; I should rather compare it to a 
paper filter, because the surface generally shows more or ENDOSCOPY OF THE MALE URETHRA. 
9 
fewer fine folds converging to the center. The central posi- 
tion of the tube—i. e., the one parallel to the axis of the 
urethra—is the most favorable one to judge of the general 
condition of the mucous membrane as well as of the sur- 
rounding tissue, as it best reveals the degree of elasticity, 
softness, and swelling of the parts inspected by the changes 
in the folds, and the manner of bulging. The surface of the 
mucous membrane itself, irregularities of the epithelial cov- 
ering, indentations and recesses in the same, particularly the 
lacume of Morgagni, are better shown by an eccentrical posi- 
tion of the visceral end, wherein the part under examination 
presents itself perfectly flat and level to the eye. To get a 
quick summary view of the whole interior lining of the ure- 
thra, I prefer to pass the tube in spiral movements either 
backward from the bulbous part or centripetally, thus gradu- 
ally spreading the entire surface before the eye. It is not 
my intention to give a minute description of the appearance 
of the interior of the urethra, nor to consider the significance 
of the changes in color, nor of the different reflexes. I refer 
those who desire information on all the details to Gruen- 
feld’s excellent book, in which a clear and full account of 
them is given (“ Die Endoskopie der Harnrohre und der 
Blase,” by Joseph Gruenfeld, Stuttgart, 1881). 
I have never examined a urethra which I had reason 
to believe was entirely healthy; but I have often observed 
conditions of the mucous membrane, over its full extent, or 
over a part only, which, to judge from what we know about 
the anatomy of the organ and from descriptions given by 
other observers, I felt justified in assuming as normal. 
The healthy mucous membrane shows a more or less pale- 
pink color, quite often with stripes of a lighter shade, and 
a smooth, glistening surface, giving the appearance of a soft, 
dull, silk tissue. For practical purposes, naturally, it is more 
important to study the appearance of the urethra in the state 10 
CLINICAL OBSERVATIONS ON 
of disease. Most authors have described the local symp- 
toms of several forms of acute urethritis. Generally they 
have been classified together with the chronic cases, not to 
the advantage of clearness in distinguishing the same, I be- 
lieve. I have never felt justified in using the endoscope in a 
case of acute inflammation, not seeing a necessity for doing 
so, and because the introduction of the instrument not only 
is necessarily painful, hut may really do harm. By far the 
greater number of cases in which 1 have employed the en- 
doscope were those of patients who, without any other in- 
convenience, pain, or sensation, showed a more or less copi- 
ous mucous or purulent secretion, visible mostly in the 
morning only, either persisting for months or reappearing 
after short intervals of apparent cure on the slightest provo- 
cation by drinking or sexual irritation —i. e., cases of gleet 
or chronic urethritis or gonorrhoea, if such a classification is 
admissible. Some patients were suffering from stricture 
without a discharge being noticeable; others complained of 
the well-known appearance of a grayish drop during defeca- 
tion or after micturition; finally, there were some who com- 
plained only of pain, burning, itching, or pressure in the 
urethra without the presence of a discharge. Among my 
100 patients, in 84, chronic discharge from the urethra was 
the principal complaint; 8 applied for treatment on account 
of unpleasant sensations, 4 of whom showed a slight dis- 
charge; so that in 88 there existed a chronic secretion, 4 had 
stricture, and 4 prostatorrhoea. The discharge had lasted 
for a more or less continued period—in no case less than 
three months, in some for several years. Nearly all of my 
patients had been previously under the care of other phy- 
sicians, a large percentage having been treated with sounds; 
not a few had been operated upon, mostly “ for stricture.” 
It can be stated in general that endoscopic examinations 
of such cases soon make the erroneousness of some of the ENDOSCOPY OF THE MALE URETHRA. 
11 
old doctrines proclaimed and confirmed in text-books, etc., 
apparent. The first experience is, that the regions pointed 
out by the patients as spontaneously sensitive or particular- 
ly tender to the touch of a bougie a boule, as a rule, show 
no pathological condition of the mucous membrane (as 
might be expected), but these localities are even more fre- 
quently found in healthy condition. Nor is it found to be 
true that the posterior parts of the pendulous urethra, the 
bulbous or membranous portions, are usually or even more 
frequently affected in chronic urethritis, as has heretofore 
been maintained , it appears, on the contrary, that in by far 
the greater number of cases the anterior and central portions 
are the regions principally alfected, that sometimes the two 
inches nearest to the meatus alone are diseased, and that 
these very cases may prove the most obstinate ones. Still, 
on these two doctrines the adversaries of the endoscope have 
mostly relied, as well as on the supposition that the bulbus 
was the usual seat of chronic inflammation, and Guyon and 
his pupils have founded their treatment by “ instillations ” 
in the deeper urethra. Among my 100 cases the seat of 
morbid changes was found to be : the prostatic and membra- 
nous portion alone in 5 cases; the prostatic and spongy alone 
in 2 cases ; the prostatic, membranous, and spongy in 22 
cases ; the membranous and spongy alone in 26 cases ; the 
spongy or pendulous portion alone in 45 cases. There par- 
ticipated at all, the prostatic portion in 29 cases ; the mem- 
branous portion in 53 cases; the spongy in 95 cases; the 
bulbous specially in 44 cases. 
The pathological conditions themselves, as they appear 
through the endoscope, are of great variety and show num- 
berless combinations, so that one meets with great difficulty 
in trying to arrange them systematically into definite groups. 
They may pertain to abnormities of color, of the smoothness 
of surface, or of the elasticity and resistance of the tissue of 12 
CLINICAL OBSERVATIONS ON 
the mucous membrane and of its surroundings. The color 
may vary from the natural pale-pink in one direction to the 
pure, glistening white of a tendon, and in the other to scar- 
let, to the darkest shades of bluish or brownish red, or into 
slate-color ; these different shades may extend continuously 
over a large part of the urethra, or may be restricted to 
single spots of the size of a pea or even smaller, quite often 
appearing in radiate or longitudinal stripes. In considering 
the value of changes in the color of the mucous membrane, 
account has to be taken not only of individual differences, 
but also of the effects of the introduction of the instrument, 
of the pressure of the edge of the tube, the touch of a cot- 
ton-wound wire, etc., which are apt to effect a temporary, 
often quite sudden change. However, more permanent dis- 
colorations do exist. In one case I found the upper wall of 
the urethral cavity, to the extent of nearly two inches, of a 
dark-red color, like raw beef, but perfectly smooth, contrast- 
ing strangely with the normal pink of the lower surface, a 
condition which was observed to decrease in intensity at 
several subsequent examinations. Sometimes the dull luster 
of the healthy mucous membrane gives way to a more glis- 
tening, satin-like appearance, while the perfect smoothness 
of the surface is retained. 
More distinct features appear in relation to the smooth- 
ness of the surface of the mucous membrane. Under favor- 
able conditions of light, a tine network of small capillary 
blood-vessels can be distinctly observed. In other cases 
the surface has a more velvety appearance, as if composed 
of numerous, most closely apposed hairy points with light 
reflecting from each of them. But more regularly we meet 
with what has been generally described as the granular con- 
dition of the mucous membrane: the dark-red, uneven sur- 
face is broken by elevations of the size of a rape or millet- 
seed, which are placed more or less closely together, leaving ENDOSCOPY OF THE MALE URETHRA. 
13 
depressions of a deeper, more brownish color between them. 
According to the size of the granulations, but little of the 
smoothness of the surface may be lost, or the affected part 
may look like undressed kid-leather, or like a strawberry. 
The light is reflected in the shape of distinct points from 
the granular elevations. This granular appearance of the 
mucous membrane has been considered by Desormeaux, 
and by the greater number of authors, as the regular and 
constant pathological condition in gleet, so as to identify 
urethritis granulosa and chronic gonorrhoea. Different 
opinions have been given on the origin of these granular 
elevations. To bring them in connection with the normal 
papilla? of the mucous membrane seems hardly justified, as 
they are observed in portions of the urethra to which the 
papillary construction does not normally extend. It appears 
not impossible that the simple mucous glands, which exist 
all over the urethra, may have something to do with the 
granular condition. 
It has been stated that granulations are found more fre- 
quently in certain portions of the urethra, and that they 
follow certain rules as to the extent of the lesion. It is 
true I have seen this condition often enough in the bulbous 
portion, but as well in other parts, from the membranous 
and prostatic tracts to the fossa navicularis, and here my 
experience is in accord with Gruenfeld’s observations. But 
I have been struck by the frequency with which I have met 
with granular patches in connection with dilated and in- 
flamed lacunae of Morgagni, a fact which I have not found 
mentioned distinctly bv any author. I am inclined to at- 
tribute a much greater importance in the pathology of 
chronic urethritis to these organs than has been done by 
the other authors on this subject. According to Henle, 
these recesses or small cavities, visible to the naked eye, 
are passages which are lined by the mucous membrane and 14 
CLINICAL OBSERVATIONS ON 
its epithelium, into which real glands open only in rare in- 
stances. From more recent observations by G. Overdieck, 
however (“ Ueber Epithel and Driisen der Harnblase and 
weiblichen und mannlichen Urethra,” Gottingen, 1884), it 
appears that the lacume of Morgagni should be considered as 
compound glands, which well seem able to take a greater 
part in the pathological conditions of the urethra. In not 
fewer than sixty-three among my one hundred cases I found 
an abnormal condition of the lacunae of Morgagni, or at least 
a distinct presence of the same. Sometimes only after the 
disseminated granular patches of the mucous membrane had 
been under the influence of local treatment did the lacuna) 
make their appearance in the center, often as large as a 
hemp-seed, not seldom partly covered by a semilunar fold of 
the mucous membrane in the shape of a pocket. The edges 
now appear rough, as if eroded, now smooth, like elevated 
walls surrounding the recesses; again they appear as ele- 
vated craters resembling the annular mountains (Ringge- 
birge) on the map of the moon. In accord with Henle, 
I found the lacuna) most frequently along the upper wall 
and in the folds or corners which are formed on both sides 
by the upper and lower half of the membranous lining of 
the urethra in the natural, undistended position; however, 
they are found often enough on the lower surface. As I 
have observed in quite a number of cases that while under 
the proper local treatment the lacume of Morgagni gradu- 
ally changed their appearance by showing smoother and 
lower edges, and diminishing in deepness, the discharge 
gradually became less, and finally disappeared, I feel jus- 
tified in considering these glandular structures as the seat 
of the inflammation and as the source of the discharge, re- 
spectively, of the threads which are found in the urine in 
decreasing quantities. In a paper on latent urethritis 
(“ Annal. des malad. des organes genito-urinaires,” ii, p. 7d EXDOSCOPY OF THE MALE URETHRA 
15 
et seq.), T. P. Guiard, a pupil of Guyon, comes to the con- 
clusion that the urethral glandular apparatus probably plays 
an important part in the pathology of urethritis, and that a 
glandular urethritis really exists. There is no reason, he 
argues, why the small glands should remain intact while 
the larger ones, like the epididymis, Cowper’s glands, and 
the prostate, are known to be frequently attacked, and he 
suspects that the inflammation has extended to the glands 
whenever a case obstinately resists treatment, particularly 
by instillations of nitrate of silver, provided a constitutional 
cause is wanting. And, although he cites Morgagni and 
Terraneus as having actually observed a diseased condition 
of the lacunae, he misses the evident proofs of glandular 
urethritis. Perhaps he would find his suspicions confirmed 
if he only would look through the endoscope, but it seems 
that Desormeaux is entirely forgotten in his own country ! 
I here must mention that in two cases, which, however, 
do not appear among my records, but which I remember 
quite distinctly, I noticed at a distance of about one inch 
from the entrance into the membranous portion, on moving 
the tube forward in a centripetal direction, that suddenly 
a small drop of a white, milky fluid oozed from a minute 
spot in the upper surface of the urethra. This I could dis- 
tinctly observe on several examinations at different times 
and at the very same spot. It is probable, from the local- 
ity, that the opening from which the fluid came was the 
mouth of the duct of one of the glands of Cowper. 
Quite a peculiar condition, similar to granular formation, 
but of some distinct features, was observed in several cases, 
where the patients complained of a burning pain along the 
urethra without any discharge. It appeared in the shape 
of dark, brownish patches of the size of a pea or a 
bean, the surface of which was dry, slightly eroded, not 
unlike morocco leather, seated principally in the lateral 16 
CLINICAL OBSERVATIONS ON 
folds. Being touched with Lugol’s solution, these patches 
assumed a dark-brown, nearly black color, which made 
them appear much more distinct, the surrounding portions 
of the mucous membrane remaining unchanged by the 
iodine. With the disappearance of the patches under the 
influence of repeated applications of iodine in the watery 
solution, the disagreeable sensations of pain and burning 
gradually gave way. 
Nearly unanimously the authors on the endoscope have 
maintained that granular urethritis is regularly followed by 
a consecutive infiltration or thickening of the mucous mem- 
brane, and that it unavoidably leads to the formation of 
stricture if left to itself. This I decidedly contradict. It 
is true that I have observed the symptoms of thickening of 
the urethral tissue quite often beside a granular surface— 
i. e., disappearance of the folds and distortion of the re- 
flexes, together with resistance on introduction of the tube 
—but, on the other hand, I have ty no means exceptionally 
found the mucous membrane showing normal folds, normal 
reflexes, and not the slightest resistance or bulging-in on 
withdrawing the tube in the presence of granular patches of 
undoubtedly long standing. Again, I have seen the mucous 
membrane perfectly smooth and of a natural pink color, 
where in circumscribed regions (more frequently in the 
central portion of the spongy urethra) the urethral wall 
appeared decidedly infiltrated, bulging in as a rather rigid 
mass into the lumen of the tube. The same condition of 
the surface could be observed over other infiltrations, 
which extended over some distance in the shape of ridges. 
I found those ridges about two or three inches from the 
meatus in three patients with naturally very small and nar- 
row urethras, being very rigid and extremely sensitive; 
the treatment, although finally successful, was tedious and 
laborious. I therefore conclude that a granular condition ENDOSCOPY OF THE MALE URETHRA. 
17 
and infiltration of the mucous membrane may exist inde- 
pendently of each other. 
There exists still another partial thickening of the mu- 
cous membrane in the shape of stripes, now of lighter, now 
of darker, color than the surrounding parts. Gruenfeld 
describes them as formations of new layers of epithelium 
(Epithelauflagerungen), but he seems to be somewhat in 
doubt about their real nature. In some cases the stripes 
appear as prominent white ridges, and then new formation 
seems probable, while in other cases they are depressed, so 
that a shrinkage from cicatrization may be the cause. In 
several instances I have found the mucous membrane of the 
entire spongy urethra perfectly smooth, white, and rigid, with 
sharply defined, small lacunae, giving the impression of con- 
siderable hardening of connective tissue. Rightly, however, 
Gruenfeld has warned us not to take the endoscopic picture 
as sufficient evidence of the nature of pathological changes, 
as it still requires microscopical examination to decide the 
question. This must be particularly maintained of another 
pathological phenomenon, which I have not observed my- 
self, but which has been mentioned by several authors as 
an analogue of the real trachoma of the conjunctiva, where 
large, corn-like substances, imbedded in the mucous mem- 
brane, project over the surface. 
Less frequently than with new formation or thickening 
of tissue I have met with loss of substance. Now and then 
you encounter portions of the urethra which, deprived of 
the epithelial layer, show a yellowish, dirty surface similar 
to superficial defects in the oral cavity; they are extremely 
sensitive to the touch, and I think they would best be des- 
ignated as erosions. I found them as the only substantial 
abnormities in three cases as one of the most obstinate 
forms of disease. They remind me very much of a peculiar 
form of urethritis described by Gruenfeld as urethritis her 18 
CLINICAL OBSERVATIONS ON 
petica or phlyctaenularis; but it seems that such a name 
would rather indicate an acute, typical disease than a 
chronic one. In fact, I have twice observed the appear- 
ance of circumscribed lesions of substance during chronic 
urethritis—once as a simple loss of the epithelial cover, pre- 
senting a clean, red surface with slightly deeper-colored 
margin, and again as an irregular, flat ulcer with distinctly 
yellow ground, which healed without a scar in a compara- 
tively short time under the use of iodoform. These I con- 
sider to have been really attacks of herpes. I shall not 
leave unmentioned the occurrence of several losses of sub- 
stance which were beyond doubt caused by the sharp edge 
of the tube while not being handled with sufficient care, 
but they were found to be healed at the next examination 
without leaving any signs. I have never observed a real 
chronic ulceration or a chancre in the urethra, such as have 
been described by several authors. 
Since the case reported in 1881 I have not met with 
polypi in the urethra, but I have observed in four cases pap- 
illary excrescences or vegetations of the deeper portions of 
the urethra, which, at least in two cases, showed all the char- 
acteristic features of the condyloma acuminatum. In the 
orifice of the urethra, and near to it in the fossa navicularis, 
they are met with quite frequently, but there are no cases 
on record, as far as I know, where they extended in greater 
number for three or four inches backward toward the bul- 
bils. I intend to report these cases more fully in a separate 
paper, together with a case of angeioma cavernosum of the 
upper side of the spongy urethra. Once I saw what I should 
like to call a real surgical granulation of the size of a hemp- 
seed in the posterior part of the spongy urethra. It was 
definitively cured by a single application of nitrate of silver. 
Strictures have always been an object of great interest 
to every one using the endoscope, those of large caliber as ENDOSCOPY OF THE MALE URETHRA. 
19 
well as the narrow, rigid ones. The existence of the former 
is easily proved by the endoscope, but it seems open to 
question whether it is right to call a stricture what really 
is often only a swelling of transitory nature, not a definite 
permanent condition. As stated before, I have frequently 
observed thickening and greater rigidity of the urethral 
walls with or without granular condition of the mucous 
membrane, which, on examination by the bougie a boule, 
produced the very same signs on the presence of which the 
diagnosis of strictures of large caliber is founded. In sev- 
eral cases I have watched these swellings from their very 
beginning, have noticed their steady growth from the time 
of one examination to that of the next, so as to necessitate 
the subsequent use of smaller-sized tubes; but I could just 
as well watch their gradual disappearance under proper 
treatment and their return to normal conditions. I do not 
mean to deny, however, but rather to confirm by other ob- 
servations, that such temporary swellings may become 
permanent indurations, and finally real strictures. 
The appearance of chronic cicatricial strictures through 
the endoscope is very interesting and of great variety. I 
can not give a better general description of the same than 
that given by Fuerstenheim (“Berl. klin. Woch.,” 1870, p. 
532). “ The configuration of strictures is quite variable ; it is 
either—unfortunately, but very rarely, in old and indurated 
strictures—funnel-shaped, the narrow part directed toward 
the bladder, easily allowing a sound to enter, or they come 
into view as an obstructing surface with a small, wart-like 
prominence in the center, or as a rough, uneven mass with 
many small prominent points, among which it is very diffi- 
cult to find the entrance into the stricture. Sometimes be- 
tween the wart-like elevations small islands of natural but 
red mucous membrane remain intact. On proceeding to 
withdraw the tube, the elastic normal mucous membrane can 20 
CLINICAL OBSERVATIONS ON 
be noticed to close up like a curtain around the immovable, 
rigid face of the stricture. The point of a probe does not 
cause an impression, but moves the whole mass before it.” 
A similar description has been given by Cruise, of Dublin 
(“Dublin Quart. Jour.,” May, 1865). In several instances 
where, on examination by bougies, the diagnosis of stricture 
had been made, endoscopic inspection showed no trace of a 
narrowed channel; in one case evidently a very dilated 
lacuna of Morgagni had invariably caught the point or the 
olive of the bougie and prevented its farther introduction, 
thus simulating stricture. In other cases where the endo- 
scopic tube was arrested at a certain point during introduc- 
tion, nothing but an erosion or a highly inflamed patch of 
lacunae was detected, which probably had caused reflex con- 
traction of the urethral muscles. It was not unusual to 
easily pass the tube (often even without an obturator) 
through a portion of the urethra which was supposed to be 
strictured. Even the membranous portion sometimes al- 
lowed the passage of the endoscopic tube, when sounds and 
bougies had met with insuperable spasm. The prostatic 
portion of the urethra can be inspected in most cases, and 
the colliculus seminalis with the caput gallinaginis easily 
be made out, unless the discharge cf blood, which may take 
place quite easily, obstructs the view. In several instances 
I could distinctly see an oblong fissure on the height of 
the colliculus, which I had to take for the entrance to the 
utriculus masculinus. I could never clearly trace the open- 
ings of the seminal ducts nor of the ducts of the prostatic 
glands, although the location of the same was clearly indi- 
cated by the sudden appearance of a non-bloody fluid in 
the grooves adjoining the colliculus. The difference in the 
appearance of the living organ from that found post mor- 
tem is nowhere so conspicuously prominent as in the pros- 
tatic urethra. It has already been stated that the granular ENDOSCOPY OF THE MALE URETHRA. 
21 
condition is not unusual in the prostatic portion. In other 
cases where impotence and nervous disorders were com- 
plained of I could notice conditions of the colliculus and 
of the caput gallinaginis which probably were pathological, 
but I do not feel justified in drawing any conclusions on the 
strength of my observations. For I believe that in the con- 
figuration of this extremely complicated region there reigns 
a great individual* variety, not less distinct than, for in- 
stance, in the configuration of the nose. Now the colliculus 
appears like a flat, broad, ribbon-like eminence, and again 
the caput is elongated forward into a fine point reaching 
near to the bulbus, or beginning abruptly like a promon- 
tory ; or the colliculus comes into view like a tumor, easily 
to be mistaken for a polypous growth, etc. Besides, the 
erectile nature of some of these parts has to be considered. 
As long as we have not a more exact knowledge about the 
limits of normal individuality, it seems premature to speak 
so decidedly of hypertrophy of the colliculus, etc., as Gruen- 
feld does. I must acknowledge, however, that Gruenfeld 
openly avows that he often found a normal appearance of 
the prostatic urethra, where, from the symptoms present, he 
expected to find pathological conditions. In cases where 
epididymitis had preceded, I have been astonished to but 
seldom find signs of inflammation in the recesses next to the 
colliculus, while in the majority of cases nothing indicated 
a diseased condition of the mucous membrane surrounding 
the entrance of the seminal ducts. I have no doubt that 
by and by we shall gain more distinct knowledge of the 
normal and pathological conditions of the prostatic urethra. 
It is a great advantage of the straight, open endoscopical 
tube over all more complicated instruments of the kind that 
it allows the immediate application of medicinal substances, 
or of surgical manipulations, to any part of the mucous 
membrane found diseased. The medicinal applications are 22 
CLINICAL OHSERVATIONS ON 
made on the same general principles as upon other mucous 
membranes of the human body. All observers agree to 
have been astonished to find the mucous membrane, particu- 
larly the deeper part of the urethra, so tolerant against the 
direct applications of the stronger astringents, and even of 
caustics, considering the extreme sensitiveness of the same 
parts against much milder solutions, as, for instance, of 
nitrate of silver or of the bichloride of mercury, if used as 
injections with the ordinary urethral syringe. Cotton pled- 
gets attached to wire rods are used by me exclusively in 
preference to brushes. They are always fresh and clean, are 
easily replaced, and give absolute security that no other 
spot is touched than the one intended, as its effects are only 
communicated to the mucous membrane by actual contact. 
The solutions which I use most frequently are: Nitrate of 
silver at 2£, 5, 10, 20, and 50 per cent.; sulphate of copper, 
3. 10, and 30 per cent.; bichloride of mercury, 1 per cent. ; 
tannin, 10 percent., in equal parts of glycerin and alcohol; 
liquor plumbi acetici; liquor ferri sesquichlorati, with equal 
parts of glycerin ; chromic acid, 10 and 50 percent. ; tinct- 
ure of iodine; Lugol’s solution of iodine (iodine 1, iodide 
of potash 2, water 12 parts); carbolized iodine (equal parts 
of Lugol’s solution and pure carbolic acid) ; iodoform pow- 
dered, and in a saturated solution in ether; besides nitrate 
of silver and sulphate of copper in substance. It is im- 
possible from present experience to state definitely under 
which conditions the one or the other remedy, the one or 
the other solution of the same substance, is to be preferred. 
I must own that I have acted altogether empirically, find- 
ing great individual differences as to sensitiveness and ef- 
fectiveness. In general, the solutions of nitrate of silver 
and sulphate of copper must be considered the most useful 
remedies, the latter principally where the lacunae of Morgagni 
are the obvious seat of the disease. The strongest solutions ENDOSCOPY OF THE MALE URETHRA. 
23 
of silver, chromic acid, and copper, and the crystals of these 
salts, were applied only for the destruction of such papillary 
excrescences as could not be removed by the polypi guillo- 
tine or by the ring-shaped ecraseur. Examinations and 
applications were made at intervals of from three to seven 
days, according to the conditions of the urethra and to the 
strength of the remedy applied, and a subsequent change in 
the condition of the diseased portions could be nearly al- 
ways observed. Generally the immediate effect is an in- 
creased flow from the urethra for twenty-four to thirty-six 
hours, after which time the discharge begins to diminish 
spontaneously to its former or even a diminished quantity. 
Sometimes the urethra becomes perfectly dry for about 
twenty-four hours, to be followed temporarily by more 
copious discharge. At subsequent examinations the mucous 
membrane appears less red, of smoother surface, the granu- 
lations less distinct, the lacunae less excavated, with sjiarply 
defined edges and not as moist as before, until gradually the 
whole appearance becomes more and more of the normal 
color and smoothness. Injections are generally continued 
at first twice a day, but, after some improvement has set in, 
are omitted altogether. In only a small number of cases 
internal medicines were administered; in the greater num- 
ber sole reliance was placed on the local treatment. The 
number of applications and the time over which the treat- 
ment was extended differ very much, depending often on 
the regularity with which the patients were able to attend ; 
in one case a single application effected a cure; in general, 
the applications varied from two to twenty-five in number, 
distributed over several weeks to several months. To close 
the treatment by the introduction of large steel sounds was 
sometimes found beneficial. I have never been able to 
understand why moderate smoking should be detrimental 
to the urethra, nor have I found good reasons given by any 24 
CLINICAL OBSERVATIONS ON 
author why smoking ought to be forbidden to patients suf- 
fering from chronic gonorrhoea; therefore I have allowed 
the moderate use of tobacco to my patients. While I con- 
sider the stronger alcoholic liquors positively injurious, I 
have not interdicted the moderate use of wine, particularly 
light claret, or of good, well-fermented beer, to those pa- 
tients who were addicted to their use; and those who were 
sure to resume this habit as soon as they would consider 
themselves cured were rather encouraged to return to their 
usual way of living before the treatment was closed. Ex- 
perience has shown to me that the results in such cases were 
not different from those where the patients had never been 
used to take any alcoholic drinks whatever, or were abstain- 
ing during treatment. 
New growths like polypi or vegetations require re- 
moval by surgical means or by strong caustics. Gruenteld 
has constructed quite a number of instruments for this pur- 
pose. I have found the instrument described by me in 
1881 for the removal of polypi quite satisfactory in all 
cases where the vegetations were large enough or not too 
remote from the meatus; the ring-shaped curette mentioned 
before was sometimes used to advantage in the anterior 
parts of the urethra. Vegetations or coudylomata acumi- 
nata are just as obstinate, or even more so, to return after 
removal by cutting or burning when they make their ap- 
pearance within the urethra than outside; but I finally 
succeeded in all the cases in thoroughly and permanently 
eradicating the same. 
In cases of stricture the endoscope may prove useful in 
various ways. In a few cases of so-called impermeable 
stricture which were treated in the German Hospital, after 
several unsuccessful trials to enter or pass even the finest 
instruments, I succeeded in discovering the entrance of the 
stricture, in the shape of a narrow recess eccentrically lo- ENDOSCOPY OF THE MALE URETHRA. 
25 
cated among several hard prominences, and in introducing 
a filiform whalebone bougie through the stricture to the 
bladder. Once entrance gained, one of Gouley’s tunneled 
sounds was passed over the whalebone, and thus the path 
was opened for successful further dilatation, so that within 
a few7 weeks I was able to inspect the entire length of the 
urethra as far as the prostatic portion through a tube No. 
23 Charr., and found a smooth, still somewhat rigid, mu- 
cous membrane throughout the former seat of stricture. In 
other cases, which bled on being touched only by bougies 
or sounds of any caliber, so that even the smallest numbers 
could not be passed or entered, endoscopic examination re- 
vealed the presence of small patches of sound mucous mem- 
brane among cicatrized and granulating tissue. Here I in- 
troduced steel sounds No. 16 to 18 Charr., and gradually 
forced them forward through the stricture, being able to 
make absolutely certain that the sound kept within the nor- 
mal urethral channel and avoided false passages. In this 
way I gradually pushed on until the instrument reached the 
bladder; afterward further dilatation to Nos. 23 and 24 
proved quite easy and free of danger. In this way I cured 
a stricture which for fourteen years had baffled all attempts 
to pass an instrument. Its deep location, extending through 
the entire membranous portion into the immediate neigh- 
borhood of the bladder itself, would have rendered any 
urethrotomy, either external or internal, a very precarious 
proceeding. 
In every case of stricture the positive acquaintance with 
the configuration of the impediment to the free passage of 
the urine or to the introduction of a bougie which can be 
obtained by endoscopic examination will prove of great 
value to correctly judge which course of treatment ought 
to be taken. The obstruction of the urethral channel may 
extend to the entire circumference of the urethra, or it may 26 
CLINICAL OBSERVATIONS ON 
be situated in the upper or lower or in the lateral portions 
of the urethral tissue. Internal urethrotomy, and, to a cer- 
tain degree, even external urethrotomy, are executed more 
or less blindly ; in the internal operation the cutting is 
done either upward or downward, and therefore may divide 
perfectly healthy parts and leave the real obstructing mass 
untouched if situated laterally. External urethrotomy may 
leave the indurated upper wall intact while opening a way 
through the normal floor of the urethra. If a stricture has 
to be operated upon, the ideal way would undoubtedly be 
to operate under the eye through the endoscope. That this 
can be done has been shown by Gruenfeld. I have no ex- 
perience of my own so far, but I shall certainly try to follow 
the example of Gruenfeld as soon as I find an occasion, and 
I have no doubt that, sooner or later, ways and means will 
be found to make urethrotomy no longer an uncertain pro- 
cedure. Undoubtedly electrolysis of stricture, too, could be 
applied more effectively if performed after careful inspec- 
tion of the obstruction. 
As to strictures of large caliber, I have previously stated 
that they often can be cured by applications of strong so- 
lutions of nitrate of silver, tincture of iodine, etc., and do 
not always require surgical interference. In two instances 
I observed that I had involuntarily performed divulsion of 
a circumscribed swelling of the mucous membrane by pass- 
ing a somewhat large endoscopic tube, leaving a slightly 
bleeding longitudinal fissure passing through the center. It 
healed quickly under application of powdered iodoform, 
leaving no trace of the wound nor of the swelling. This 
experience seems to prove, indeed, that such “strictures” 
can be cured by cutting, or rather by scarification, the limit 
of which such an operation ought not to surpass. If sur- 
geons would only take the trouble to look at the strictures 
before they begin to operate, I have no doubt many an op- ENDOSCOPY OF TIIE MALE URETHRA. 
27 
eration would be done more cautiously or would be left 
undone, and not to the detriment of the patients. To show 
how lightly and indiscriminately this cutting is done at 
present, I shall cite a passage from a paper published but 
recently (“Medical Record,” May 8, 1886, p. 524), in 
which the author, speaking of an obstinate case, says: “ In 
three weeks the discharge had dwindled down to a watery 
condition, which remained in spite of all I could do. After 
trying all known means, I was compelled to cut him. 
He stood the operation badly and made a slow recovery, 
but in two months the wound had healed and the discharge 
had entirely dried up.” Here is not even a pretense of a 
stricture; it is not mentioned where or what was cut, but 
“ the patient was cut ” simply because he could not be cured 
of his discharge by all known means (including the endo- 
scope ?). If only surgeons would take pains to inspect the 
results of their work some time after operation, they would 
undoubtedly be less reckless and less quick to cut. If they 
could see such deep, furrow-like, inelastic scars, extending 
through the mucous membrane into the corpus cavernosum 
for an inch or more in length, as I have met with in several 
instances, they would understand, on but little reflection, 
that the interruption of the continuity of an elastic tube by 
such rigid masses can not be irrelevant, but that it must act 
as an obstruction or as a contraction whenever the urethral 
channel is extended by the physiological actions of mictu- 
rition, erection, and emission of semen. It is certainly 
not to be wondered at, if constant traction and retraction 
of healthy parts by such a scar cause local as well as reflex 
irritation. 
It is a somewhat delicate matter to speak of the final 
results of the endoscopic treatment of chronic urethral dis- 
charge, and it was not without some apprehension of self- 
delusion that I approached my records for a summary of the 28 
CLINICAL OBSERVATIONS ON 
same. I was agreeably surprised, however, to find a more 
favorable state than 1 had expected myself, even after 
eliminating all cases of doubtful cure, and being as sincere 
and strict as possible in stating a case as cured. Among 
the 88 cases in which a chronic discharge from the urethra 
had been present, 42 were positively cured—i. e., in 42 
cases I have positive evidence that the patients were free 
from any discharge for at least two months after the treat- 
ment had been stopped, and after they had followed their 
usual mode of living without restraint, except avoiding ex- 
cesses in Baccho et Venere. Eleven were apparently cured 
when last seen, but, being without any later information 
about their condition, I have not felt justified in stating 
them as certain cures, but have preferred to put them into a 
separate In 8 cases the discharge was not entirely 
removed until after some other treatment had been substi- 
tuted ; it remains doubtful how much the endoscopic treat- 
ment had really contributed to the final result. That it was 
not without good effect appears from the fact that the same 
treatment that led to a final cure had been ineffectually em- 
ployed before the local treatment had been resorted to. It 
can therefore be fairly maintained that in 61 cases out of 88 
the effect was favorable. There were, further, 16 cases in 
which the endoscopical treatment was not continued suffi- 
ciently long, or where really only one or two examinations 
were made, while in some others improvement had been 
achieved, when for some reason or other tieatment was dis- 
continued. This leaves 11 cases in which either permanent 
advantages could not be obtained in spite of a sufficiently 
extended treatment, or even adverse symptoms appeared 
after the application, which rendered it advisable to discon- 
tinue the method. I am unable to give any reasons for this 
experience. In general, no evil consequences could be ob- 
served to follow the endoscopic treatment except some pain ENDOSCOPY OF THE MALE URETHRA. 
29 
within the first twenty-four hours after the applications, 
and an increase of the discharge for the same period. 
Epididymitis, cystitis, and adenitis, which may complicate 
chronic urethritis during any treatment, either with or with- 
out instruments, have been met with, but certainly not 
more frequently than during the use of steel sounds, injec- 
tions, etc. Except for these complications, my patients 
were always able to attend to their business. 
It remains to briefly consider what claims the endo- 
scopic treatment can make upon the attention and recog- 
nition of the profession. I do not mean to put too much 
weight on the cases of new growths within the urethra, 
which can not be recognized or treated by any other method. 
I shall not repeat what I have stated before about the im- 
portance of endoscopic examination of strictures. The 
nearest and the most important field for the endoscope will 
always be chronic gonorrhoea. Those who consider a 
chronic discharge from the urethra a trifle will not think 
of taking the trouble to apply the endoscope, nor those who 
are not ashamed to treat a patient with the largest possible 
steel sounds without affecting the slightest change for 
months or years, or, in fact, as long as the patient does not 
give it up in disgust himself. But he who has ever under- 
stood what this miserable drop of discharge in the morning 
really is to the patient—how it destroys all enjoyment of life, 
embitters every pleasure, how it estranges him to the society 
of his friends, that it can make a man crazy and drive him 
even to self-destruction—will gladly welcome any means 
that enable him to make one step nearer to the successful 
treatment of that terrible disease. If Reginald Harrison is 
not universally condemned for performing external ure- 
throtomy and drainage of the bladder in a number of cases 
for the sol.e purpose of curing a chronic urethral discharge, 
certainly the use of the endoscope ought not to be consid- 30 
ENDOSCOPY OF THE MALE URETHRA. 
ered audacious or superfluous any longer. While it is 
neither infallible nor the only method by which good re- 
sults can be obtained, it undoubtedly has very often proved 
beneficial where other means have failed, and will continue 
to do so in still higher degree the more its use is de- 
veloped. Like laryngoscopy, rhinoscopy, ophthalmoscopy, 
etc., the endoscopy of the urethra has a rightful claim to 
be called one of the scientific methods of diagnosis and 
therapeutics. 
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