A more important advantage over the Cabot or Clark bridge arrangement than this was met in practice, when in manipulating a catheter it was withdrawn from under the bridge. Instead of readily and invariably finding its way back into the channel, then pushed forward, it would often become engaged against the bridge, finally requiring the withdrawal of the whole telescope with its catheters to place them again under the bridge. I have seen this happen in the hands of experts with the instrument, so that it is not merely a theoretical objection. In my double grooved channels, no obstacle presents to the progress of the catheters at any point after they are introduced into the channels.

With reference to the other telescopes, I have insisted that sufficient space be preserved between the telescope and sheath wall to permit of free exchange of fluid during the work of the operator, whether that be effort at catheterisation or universal inspection. with the several telescopes.

In his 1905 reprint, previously mentioned, page 370, Brown says of his composite pattern: "In this the sheath is cylindrical and the examining telescopes fit its lumen snugly, but the catheterising telescope has here to be reduced to a size less than the diameter of the two catheter canals." It is obvious that the snug filling of the sheath by the telescopes leaves no room for the passage of fluid between the two, and that a factor of much value during manipulation is lost thereby.

The retrospective telescope that is common to both instruments has apparently been the occasion of much heat and worriment to Dr. Brown. Whether Dr. Brown or I first suggested the adaptation of the globular lens to a telescope to secure the retro

spective view, I know not and care little. I have never made any particular effort to substantiate a claim on the subject, and do not wish to do so now; but I submit the following extract from a letter written under date of June 14, 1904, by the Wappler Electric Controller Company, who made both of our instruments, and should be in position to know the facts: "Dr. Brown and Dr. Cabot are laying the greatest stress on the catheterising feature, and we think the credit belongs to you (Lewis) of suggesting an instrument with the highest grade of retrovision. This we tell every physician who wants to know it. As an examining and irrigating instrument. pure and simple, we can produce one

1

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Fig.16. Bransford Lewis Universal Cystoscope 1906.

in which your name can be sustained, and we propose to advertise it as the Bransford Lewis Examining Cystoscope."

My first published reference to this retrograde telescope was in 1904. in the Saint Louis Medical Review, of December 24, in "Report of a case of hypertrophied prostate." If Dr. Brown published the use of that telescope prior to that time I am not aware of it, and should be glad to have him inform me on the point.

But whether he did or did not, would not invalidate the individuality of my universal cystoscope. Without originality being proclaimed for it, this instrument had at least as much to distinguish it from others as Dr. Brown's instrument, for which claims for unique originality have repeatedly been made.-even to the extent of declaring that it "involved a wholly novel departure from all the preexisting types."

One more feature connected with my universal cystoscope requires explanation, that is, with reference to the indirect catheterising telescope. Directions and specifications for the making of this feature to be used in the same universal sheath, were given to the Wappler Electric Controller Company in January. 1907. The comparatively simple mechanical difficulties connected with the feature have been overcome in a number of other instruments, both of the direct and indirect catheterising plan, for the past several years.-notably Freudenberg's, Wossidlo's, Casper with Schifka's modification, etc; so that there was no reason to expect undue delay in the production of the feature. Working models were evolved and submitted to me, some being found acceptable, with slight corrections; and so confident was Mr. Wappler of his ability to bring it to prompt completion that the following note was written me on the subject, under date of

April 2, 1907: "Replying to your favor of 30th ult., beg to state we can furnish the new sheath with indirect catheterising arrangement in about two weeks." Signed, Wappler Electric Controller Co.

What motives or influences have prevailed to prevent the production of this feature of my instrument I can not say; but the unreasonable and inconceivable delay finally resulted in a severance of our relationship and my authorisation of the Kny-Scheerer Company to make the instrument. This tempest in the cystoscopic tea-pot has occurred since that time.

From the above considerations it would seem that the relative positions of Dr. Brown and myself are, that he has been claiming originality and priority that were never due him; and has, after two years, suddenly waxed indignant, and now reproaches me for having used, in accordance with my own ideas, individual cystoscopic features that were present in his instruments and also antedated his from three to ten years. Finally, that the introduction of my cystoscope was unaccompanied by any proclamation of originality, but was submitted wholly and only on the basis of utility.

1050 CENTURY BUILDING.

Obstetric Surgery.'

BY DEWITT G. WILCOX, M. D., Buffalo, N. Y.,

Surgeon to Buffalo Homeopathic Hospital; Gynecologist to Erie County Hospital; Surgeon-in-Chief Lexington Heights Hospital.

ONCE eliminate the preventable defects consequent upon the

parturient stage, plus the diseases resulting from gonorrheal infection, and the gynecologist would be legislated almost out of office. No man should practise obstetrics, who is not enough of a surgeon to meet the ordinary complications which a minimum number of obstetrical cases is bound to present. Not that every man should be able to make a Cesarean section, but every man should possess enough manual dexterity to enable him to leave the parturient woman in such a state of physical perfection, that she would not in a few years be a neurasthenic or victim of the operating table.

The writer is prone to believe that the average obstetrician of the smaller communities does not fully appreciate what percent of his parturient patients eventually become victims of the operating table. He is, in too many instances, content to point with pride to his brilliant record of ten or more years of obstetrical practice without a death, forgetting that nct alone is he responsible for the mother's life, but in a large measure is responsible for the future good health of that mother, so far as her pelvic organs are concerned. The most frequently observed defects consequent upon the parturient stage. are the lacerated perineum. and cervix.

There are instances where a delay of twenty-four hours, or even a week, in repairing the perineum, is not only admissible, but essential to success; but probably in 90 per cent. of instances, immediate repair can and should be made; nor should this repair be done hurriedly and without painstaking effort, for a half healing is but little better than no healing at all and means a subsequent operation. The careful adjustment of each separate muscle and fascia to its fellow of the opposite side, is imperative if good results are to be obtained.

While it is to be assumed that every obstetrician goes to his parturient patient fully prepared to repair a torn perineum,—and anything less than that renders the attendant censurable,-yet there are many instances where through lack of competent assistance, inadequate light, an exhausted patient, and the great tumefaction of the soft parts, due perhaps to a prolonged forceps delivery, that a delay of a day or two may be the means

1. Read at the annual meeting of the Maryland State Homeopathic Medical Society held at Baltimore, October 23, 1907.

of securing better results. But before deciding to postpone the repair, he should thoroughly satisfy himself that there is no bleeding from any sizable artery at the seat of rupture. A few buried sutures of ten-day iodised catgut will suffice in bringing together subcutaneously the ends of the separated muscles; then two or more silkworm-gut sutures passed through and through will hold the entire perineum firm and steady. Under no circumstances should silk be used as suture material, as it readily absorbs the infection from the uterine discharge and carries such infection into the deeper layers of the wound.

The after-care of a repaired perineum, whether it be recent or old, is a matter of prime importance. Upon the nurse or attendant there devolves the responsibility of keeping the perineal wound dry and clean. The uterine discharges from a recently emptied womb are quite likely to infect the wound and retard healing. This can be avoided only by changing the dressings frequently, keeping the wound dry and aseptic, and the parts as free from motion as possible. The oft repeated statements made by our older obstetricians, that they have practised obstetrics, ten, fifteen, or twenty years, without having a ruptured perineum, is an acknowledgment of stupidity, for it proclaims an inability to recognise such a condition when existing. In a certain per cent. of cases, a torn perineum is bound to occur, no matter how much skill is employed to avert it, and those cases are so evenly distributed over the country that it is scarcely possible one man will be so fortunate as to escape finding one in twenty years practice.

The immediate repair of a lacerated cervix is an open question. The weight of opinion is overwhelmingly against such a procedure. We have. in the cervix, a different structure to deal with, as well as one differently located; ordinary laceration tends to heal spontaneously, and those so badly torn that they fail thus to heal, would probably not heal if sewed. The lips are tumefied, the structure soft, and a ligature, especially if tied tightly at first, would soon become loose after the tumefaction subsided. While a late operation is best for repairing the cervix, yet it snould not be postponed longer than is necessary for the woman to gain strength and be in a condition for such an ordeal. The sooner it is done, the less liable is she to suffer reflex irritability. Three months should be the maximum time allowed before repairing a lacerated cervix. There is one condition, however, which calls for immediate repair of the cervix, and that is profuse bleeding from the circular artery or possibly the uterine artery. When such is the case, it is essential to the safety of the mother, that the cervix be repaired immediately.