True Food Values. Under this head the September number of the Dietetic and Hygienic Gazette raises a signal that should attract the attention of every physician. They say, among other things: "It is by no means an uncommon thing to find a patient endeavoring under the advice of his physician to subsist on some liquid food preparations without the ingestion of a sufficient amount of real food to support the needs of the system." The same article refers to Dr. Harrington's report in the Boston Medical and Surgical Journal, of March 12th, in which he says "that most of the liquid food preparations on the market contain a far larger quantity of alcohol than nutritive material; that the quantity of alcohol by volume ranges from 14 per cent to 23 per cent as compared with from 6 per cent to 19 per cent in solids; and, therefore, the administration of full doses of those preparations results in the free use of alcohol and in the administration of small quantities of actual nourishment." A good, sound beef diet, then, would appear to offer a maximum of food value, and while there are good grounds for objections to raw meat, a partially digested product should, in our opinion, offer the most desirable form in which beef may be employed. And this is confirmed by experiments that have recently been made by the medical laboratory of the United States Army in Washington, under the direction of former Surgeon-General Sternberg; this work was carried on for some months, and most exhaustive and careful experiments were made, with the result that Soluble Beef was placed upon the "Supply Table" of the United States Army as representing the maximum of food value in a convenient and concentrated form. The value of Soluble Beef as a food product is generally recognized, and the fact that with it a more nourishing broth may be made than it is possible to make with fresh meat by the usual household methods should recommend it to the busy practitioner and hospital where they still use the meat press. As Soluble Beef is in a paste form and stable, and may be handled without special knowledge or instructions, it commends itself particularly where the family have to be depended upon to feed the patient. It is a product that is certainly worth careful consideration on the part of every practitioner. PACIFIC MEDICAL JOURNAL VOL. XLVII. MARCH, 1904. Original Articles. THE USE OF THE CYSTOSCOPE. No. 3 By H. A. KLUSSMAN, PH. G., M. D., Spokane, Wash. The invention and introduction into practice of the cystoscope has revolutionized our knowledge of urinary disorders and has led to great improvements in their treatment. With the aid of the cystoscope, the diagnosia of bladder and renal diseases have become simplified and have made enormous strides. It plays the same role in bladder diseases that the ophthalmoscope plays in eye diseases, and should become a part of our routine examination when indicated. In this article I wish to demonstrate the conditions necessary for a good cystoscopic examination. The cystoscope most universally employed is that of Nitze, it being the prototype of all the instruments used at the present time. Modifications have been made by Caspar, Fenwick, Albarran, Boisseau du Rocher, Brenner and F. Tilden Brown. Nitze's instrument consists of a metal tube with a bend like a Mercier catheter. Near the concavity of the beak and shaft is a square opening set with a prism. A small Edison incandescent lamp is situated in the beak facing the concavity. Now with a small telescope which is fitted in the tube, everything that is seen by looking through the ocular end is at right angles to the axis of the instrument, as the prism refracts at this angle. Sterilization.-After having made a cystoscopic exam-. ination, the instrument should be well cleansed with a 5 per cent carbolic solution, by rubbing with pledgets of cotton, then it is dipped into equal parts of alcohol and ether for a few minutes, dried, and placed in a glass jar containing formalin tablets. Catheters may be placed in a long glass tube containing 1-2000 bichloride solution. VOL. XLVII-9 Every cystoscopic examination should be preceded by a careful history of the case. The penis and testicles should be inspected and palpated, all malformations and abnormalities noted. A rectal examination should never be neglected, the condition of the prostate and vesicles should be ascertained. An accurate chemical and microscopical examination of the urine should precede a cystoscopic examination, the urethra is explored, and the condition of the bladder and kidneys studied. Four conditions are necessary for a successful cystoscopic examination. (1) The urethra must be of sufficient caliber to admit the instrument. (2) The bladder must be dilatable to at least 90 to 150 cc. (3) The bladder must contain a transparent medium. (4) There must be an absence of contraindications. All narrow strictures are dilated before resorting to a cystoscopic examination. If a Nitze irrigation cystoscope is to be employed, which has a caliber of 24 F., then the urethra should be previously dilated to 25 F. If the meatus is very small it should be opened at the same time. One should refrain from foreing a cystoscope into the bladder, it causes the patient much discomfort, and invariably produces a bleeding which nearly always clouds the lamp or prism. The gentleness with which it is introduced and the steadiness with which it is held, have much to do with successful results. Prostatic hypertrophy, if extensive, may somewhat interfere with an examination, but in the great majority of cases, the Nitze instrument is passed with ease. The bladder must be sufficiently tolerant to hold 90 to 150 cc, whenever cystoscopes are used, which require dilation with fluids; when with air, the bladder need not be dilated. When the folds of the mucous membrane are greatly increased, 150 ce will not always sufficiently spread them out so as to expose the ureters, as they are covered in; therefore, in the absence of contraindications, 200 cc will be more efficient in certain cases. The best rule to follow in filling bladders is to proceed according to the sensations experienced by the patient; when the desire to urinate becomes pressing, he has had sufficient. Nitze and Caspar of Berlin usually inject 150 cc in the male bladder while Thumim injects 200 cc in the female. Cocaine is often used to increase the bladder capacity, but it should be used with caution, as the pathological bladder absorbs it very readily-10 to 20 cc of a 2 to 4 per cent solution of cocaine or eucaine, as the case demands, is distributed along the urethra into the bladder by means of a small urethral syringe, the bladder having been previously washed; 25 to 50 cc of a 4 per cent solution of antipyrin can be injected into the bladder ten minutes before the examination. In some cases it is necessary to place the patient under the influence of a general anesthetic. The penis should be well cleansed with bichloride solution before an examination. The fluid used to fill the bladder must be clear. If bloody, or turbid, from pus, an examination cannot be carried out. To obtain this condition, the bladder is irrigated with a 3 per cent boric acid solution, the washing being continued until the fluid returns through the catheter perfectly clear. Now 150 cc are injected and left in the bladder. If there is bleeding from the bladder walls, or from a tumor, the examination will perhaps be more difficult. In this case, adrenalin chloride 1-5000 sol. is sometimes effective in controlling the hemorrhage. This is injected into the bladder while it is empty. The irrigating cystoscope should be used when there is hemorrhage and the irrigation kept up throughout the examination. Should the prism or lamp become clouded, the stream of water can be thrown directly on either, by turning the screw at ocular end. There are a group of cases where one should abstain from a cystoscopic examination. These are acute inflammatory cases, such as acute urethritis, acute prostatitis, abscess of prostate, acute cystitis and acute seminal vesiculitis. The cystoscope should not be employed in such cases, where it is evident that operative interference is useless. Where tumors are very large, and when the posterior bladder wall is infiltrated in old people, suffering from symptomless hematuria, cystoscopy is unnecessary, as it usually sets up a cystitis. In tubercular cystitis, instrumentation is also contraindicated, as it augments the painful symptoms, nevertheless the cystoscope alone can give us information as to the extent of the parts involved. Introduction and Manipulation of the Cystoscope.Before introducing the cystoscope, the beak should be placed in a vessel of water and the current turned on, to see that the lamp gives sufficient illumination. Having followed the preceding instructions and filled the bladder with borie acid sol., the cystoscope is lubricated with boro-glyceride or lubrichondrin, and gently introduced into the bladder, as though it were an ordinary sound. The examining room having been moderately darkened, the current is turned on, the instrument being held horizontally, with beak pointing upwards, as indicated by a little round knob, at the ocular end. In some cases the desire to urinate becomes so pressing that the instrument must be withdrawn. If the tenesmus is the result of the bladder containing an excess of fluid, withdrawal of a small quantity will permit the examination to be continued. During the examination we often find that the light suddenly disappears. This is caused by various things: (1) The lamp burning out, or an interruption of the current. (2) By the lamp coming in direct contact with the vesical wall. (3) The lamp becoming buried in the substance of a tumor. (4) By coagulation of blood or pus on the lamp. or prism. (5) By withdrawal of the instrument so the prism lies in the posterior urethra. It is in this last condition that the patient often experiences severe pain, due to the lamp burning the internal vesical sphincter. The lamp should not be allowed to touch the mucous membrane at any time, as it produces a hyperemic condition at such places. In some instances the patient experiences such extreme pains that the current must be turned off for a few moments to relieve them. Now, as before stated, with the cystoscope held horizontally and the beak pointing upwards, the first thing that presents itself to view is a clear, luminous field of vision, of an orange yellow or a yellow gray color, varying in different individuals, as well as in different parts of the bladder. In enemic individuals the gray color preponderates. When the bladder is normal the capillary network is plainly to be |