BUFFALO ACADEMY OF MEDICINE

MEDICAL ASSOCIATION OF CENTRAL NEW YORK

MEDICAL SOCIETY OF THE COUNTY OF ERIE

BUFFALO MEDICAL JOURNAL.

VOL. LXIV.

AUGUST, 1908.

No. I

TIONS.

IN

ORIGINAL COMMUNICATIONS.

Originality and Priority in Modern Cystoscopes.

A REPLY TO DR. F. TILDEN BROWN.

BY BRANSFORD LEWIS, M. D., SAINT LOUIS.

N the Medical Record of February 29, 1908, and in the New York Medical Journal of April 11, 1908, Dr. F. Tilden Brown, of New York, is quoted as presenting a paper on Ureteral Catheterisation, before the meeting of the Medical Association of the Greater City of New York, held January 20, 1908. In this paper the essayist makes certain well-defined claims to originality and priority with respect to his instruments, and also claims that his originality has been trenched upon. The allegations are so worded as to leave no doubt that I am the one accused, and also leave no doubt as to the necessity of a reply, which is herewith presented.

In order that Dr. Brown's position may be correctly stated, his own words shall be used, as found in the publications mentioned, as well as in expressions of his in other contributions. Quotations from the two journals (practically the same in both) follow:

"Dr. Brown's remarks were directed more particularly to instruments and methods with which he himself had to do, and were supplemented by wall drawings and photographs to demonstrate the various developmental forms, since 1900, of his original 'composite cystoscope,' the identical instrument which a St. Louis cystoscopist had recently appropriated, and had been presenting as his own 'universal cystoscope.' This composite cystoscope, made by the Wappler Co., of New York, was a vastly more useful instrument than its immediate predecessor, the author's doublecatheter direct vision cystoscope, which Leiter, of Vienna, made for him in 1898, and which was the first telescopic cystoscope, of any form, to provide for two catheters and effect synchronous catheterism of the ureters. But this Vienna instrument had no reserve channels for irrigation. It was with the end in view of finding a way to add such irrigation channels to the already practicable double-catheter direct vision cystoscope, while, at the same time, not increasing the circumference of the shaft beyond

24 French, that the Brown-Wappler efforts were first directed, in 1900. With what initial success these efforts had met and what constantly added improvements he expected, the present presentation was intended to fully demonstrate. It should be here added that the speaker's first double-catheter instrument was but a modification of the then existing Brenner single cystoscope; whereas his subsequent instruments involved a wholly novel departure from all the preexisting types. The first essential change lay in getting rid of the old-time terminal window at the vesical end of the sheath, which was followed by the use of different kinds of interchangeable telescopic tubes for the same common sheath. Up to the present time its development on this basis. had resulted in giving us at least three complete cystoscopes for different purposes, adjustable in one sheath. Still another tube, of paramount value, to go with this common sheath, was all but completed, in the shape of an indirect vision, double-catheter telescope which would be welcome to those who preferred this method of ureter catheterism to the direct one, and which here in

Fig. 1. Brenner

America had been gaining constantly in favor since the first introduction of the composite cystoscope."

In another contribution1 Dr. Brown expresses his claim to priority regarding the double catheter tubes in the following

terms:

"The speaker may be pardoned if, influenced by an experience of this kind and from a source so little expected, he asks now to place on record the fact that his was the first cystoscope devised for and successfully used to catheterise both ureters at the same time."

From these several quotations from Dr. Brown I believe we can fairly assume that his claims and complaints are embodied in the following three propositions:

I. That in modifying Brenner's (Fig. 1) single catheterising cystoscope in 18992, by supplying it with two catheterising channels instead of the one it already possessed, he promulgated, as he says, his "double catheterising, direct vision cystoscope,

1. Med. and Surg. Reports of Bellevue Hospital, Vol. I., January, 1905, p. 368. 2. So dated by Dr. Brown in his first publication of the instrument in the Annals of Surgery, 1899. p. 661, although he would now lead us to infer that it was 1898 (see first quotation. The composite is attributed to 1901 (instead of 1900) by the Wappler Electric Controller Co., in the following extract from a letter to Dr. Brown: "On April 30, 1901, we made for you [Brown] your first composité cystoscope.-Wapp. E. C. Co."

which was the first telescopic cystoscope, of any form, to provide for two catheters and effect synchronous catheterisation of the ureters."

2. That That his composite cystoscope of 1901" involved a wholly novel departure from all the preëxisting types."

3.

That in planning my universal cystoscope, presented in 1906, I copied his composite instrument.

Before answering these propositions directly, I must advert to some facts of cystoscopic history. Modern cystoscopes are divisible into two groups or classes: (a) those of fixed-lens systems, in which the lenses are inseparably connected with the shaft of the instrument, the whole being permanently assembled into one piece; (b) those in which the cystoscope is separable into A

two principal parts-namely, a sheath, and a telescope or ocular part.

With one exception, to be mentioned later, all of the cystoscopes submitted by the father of modern cystoscopy, Nitze, were of the first group; the departure from this plan, as exhibited in the sheath-and-telescope group. was devised and developed by Boisseau du Rocher, of France, and the full credit for originating it is due to him. His first instrument, devised and used by operators of Paris as early as 1889, was published in the Annales des maladies des organes genito-urinaires, 1890, pp. 65-93. It embodied the following remarkable features, as shown by the description and illustrations (Fig 2) of the author, as well as by numerous writings of others of the succeeding fifteen years -namely, a sheath, bearing a removable electric incandescent lamp in the chamber of its beak, illuminating the field on the convexity of the instrument; in its lower wall two small channels for the definite purpose of conducting two ureteral catheters, and for

effecting change of the fluid in the bladder, or irrigation. The sheath was supplied with an obturator, which facilitated the introduction of the cystoscope into the bladder, after which the obturator was replaced by the telescope or ocular apparatus, that gave the direct view within the bladder.

Describing different features of this sheath, (ibid. p. 73) and proving the definite purpose of double synchronous catheterisation fulfilled by the tubes, the author says: "On the lower side of the straight sheath run two parallel tubes with internal caliber of No. 6, French scale. These tubes open immediately behind the window, o. At the other (ocular) extremity they terminate at the cocks r r; and contain obturators m m to facili

tate the passage of the instrument over the urethral mucous membrane. These small tubes have two different purposes: they serve, in the first place, as conductors for the ureteral catheters. Nothing is simpler, having observed the orifice of the ureters, with the catheter in situ, than to guide the latter and engage it in the ureter. By pushing it from the outside, one may insert it to the depth desired. Finally, these small catheters being controlled and independent, every facility is furnished for catheterising the two ureters without the necessity of withdrawing the instrument or disengaging the first catheter.

"A second purpose, also very important, fulfilled by the two little tubes, is that of irrigation of the bladder. They constitute, in reality, a double-current catheter, by means of which one may effect irrigation, if not complete and rapid, at least sufficient to maintain the transparency of the liquid."

This model of Boisseau's instrument furnished the field of