view and of manipulation on the convex side. In order to obtain a view on the concavity (the right-angle view) a second sheath was constructed with the lamp exposed by a fenestrum on the concavity (Fig. 2) with another fenestrum at o, opposite to which the prism of the telescope came when it was introduced into the sheath. So that these two instruments of 1889 furnished, together, all of the objects furnished by Brown's first cystoscope of ten years later-namely, by the sheath-and-telescope plan: (1) direct view for inspection; (2) indirect view for inspection; (3) irrigation of the bladder, either through the two catheter tubes during manipulation, or through the sheath when obturator and telescopes were not in place; and finally, (4) double-bar

relled catheter channels for synchronous catheterisation of both ureters at one sitting.

The faithfulness with which Dr. Brown followed the pioneer example here set is an eloquent testimonial of his appreciation of the work of Boisseau,--more eloquent, it must be said, than any written acknowledgment on the subject that I have been able to discover. On the contrary, in his writings we find him claiming. as late as February of this year, the full and complete credit of having introduced "the first telescopic cystoscope, of any form, to provide for two catheters and effect synchronous catheterisation of the ureters." The catheter-tubes of Boisseau were carried within the wall of the sheath; those of Brown in the wall

of the telescope. This involved a difference in the location, merely, of the same features.

That this instrument of Boisseau received wide recognition, and that the definite purposes above mentioned were realised by the profession, is indicated in almost every contribution which discusses cystoscopy in a broad way, written in the next following fifteen years. In speaking of his experience in catheterising ureters with Boisseau's instrument Annales des Maladies des organes genito-urinaires, 1889, p. 626), Poirier mentions that the difficulties that the cystoscope meets with in the case of tumors of the bladder do not exist in applying it to catheterisation of the ureters; that this operation is very easy. After only a small experience, the operator, easily found the orifice of the ureters and

with the small catheter conducted by the particular canal included in the cystoscope, easily penetrated the ureter. He mentions two instances in which both he and his assistant had successfully conducted the manipulations on living individuals in the previous month. His final conclusion was that surgery was henceforth in possession of an easy and practical means of obtaining the separation of the secretions from the two kidneys.

Burckhardt, in Zuelzer's Handbuch der Harn und Sexualorgane, Vol. III., p. 158, describes Boisseau's instrument at length, and speaks of the small channels serving for the purpose of introducing the ureter catheters into the ureters.

In 1898 Annales des maladies des organes genitourinaires. p. 485), Boisseau submitted an additional model of his sheathand-telescope plan, in which, by double fenestration of the beak, and multiple ocular telescopes, views were afforded on both concavity and convexity of the same instrument (Fig. 3). One

year after this presentation of Boisseau's third model, the first one of Brown appeared, a double-barrelled modification of Brenner's, as he terms it (Annals of Surgery, 1899), and in the illustration of the paper, then presented, designates it with the date, 1899, (Fig. 10).

Thus we have in Boisseau's instruments of 1889 and 1898 all of the essential features of Brown's of 1899 and 1901; but especially do we find in them the definite and complete negation of his claim, repeatedly made, that his "double-catheter direct vision cystoscope was the first telescopic cystoscope, of any form, to provide for two catheters and effect synchronous catheterisation of the ureters."

Dr. Brown's claim to this effect is all the more surprising when we observe the evidence of his acquaintance with this feature of Boisseau's instrument, in the allusion he makes to it in his contribution of 1899 to the Annals of Surgery. In speaking of the efforts that had been made to provide the Nitze-Leiter cystoscope with a separate channel for the conveyance of a ureteral catheter, with the belief that such a contrivance could be as successfully used in men as in women, Dr. Brown says: "The first instrument of this class was that of Dr. Brenner (1887), and Boisseau du Rocher's shortly after."

But even more significant and surprising than this is the remark of Dr. Brown, following immediately afterward, in the same paper, that "They (Brenner and Boisseau) utilised the Nitze-Leiter cystoscope which had its window opposite the eye

piece, and a catheter outlet just below the window." "A catheter outlet," forsooth! That is a scant concession to make to Boisseau's instrument, under the circumstances. It looks questionable, to say the least, in connection with the presentation of the so-called "first telescopic cystoscope of any form to provide for two catheters and effect synchronous catheterisation of the ureters." The only alternative would have been to come out frankly and refer to the two catheter outlets of that instrument.

In this connection, I have a confession of my own to make; that previous to my late researches into this subject, in common with many others, I have been accepting Dr. Brown's dictum about this double-barrelled catheter feature, and have been in the habit of ascribing to him the credit of originating it, as applied to Brenner's instrument. But I can conscientiously do that

Sheath

Fig. 8.

Telescope
Koch-Preston-1898 (air)

no longer. Even aside from Boisseau having anticipated him by ten years in presenting the double-barrel feature, his statement does injustice to Casper's cystoscope, which, first introduced in 1894, was improved in 1898 in a manner that presented a means of effecting double synchronous catheterisation by the sliding removable cover to the catheter channel. His directions were that, one catheter being inserted, it was to be extruded from the groove by the withdrawal and reintroduction of the slide, after which the second catheter was to be introduced into the other ureter at the same sitting.

As to proposition 2, that Brown's "composite cystoscope (Fig. 15) involved a wholly novel departure from all preëxisting types,' it would seem proper, first, to search Dr. Brown's writings to learn what those features are that are so startlingly original and wholly novel. We read, immediately after the above declaration, that "The first essential change lay in getting rid of the old-time terminal window at the vesical end of the sheath followed, then, by the use of different kinds of interchangeable telescopic tubes for the same common sheath." It would seem that the duty of supplying a wholly novel departure from all preexisting types is hardly fulfilled by getting rid of an old-time

terminal window. In reviewing the several sheath instruments that preceded Brown's of 1901, as indicated in the accompanying drawings, it is to be observed that the old-time terminal window appeared in only one, the Brenner, certainly not a widespread error, to say the least.

We therefore search further for the originality claimed, on which must hinge the wholly novel departure from all pre-existing types; and the next evidence we find of it (ibid) is in the use, as he says, "Of different kinds of telescopic tubes for the same common sheath. Up to the present time its development on this basis has resulted in giving three complete cystoscopes for different purposes, adjustable to one sheath." Verily, Dr. Brown must not have been acquainted with, or must have forgotten, the

Schlagintweit

Catheter cystoscope. (1899)

sheath cystoscopes that had gone before him, or he would never have made such a claim. Boisseau's instrument presented the sheath and multiple-telescope system as plainly as language and artistry could delineate them; in addition to which there were a number of others who made use of the sheath-and-telescope plan, antedating the 1901 instrument of Brown. Preston, of Rochester, in 1898, submitted a sheath and multiple telescope instrument (Fig. 8) to be used with air distention; an instrument that created wide interest and attention throughout this country, and must necessarily have been brought to Dr. Brown's

attention.

Other instruments of sheath-and-telescope pattern that antedated Dr. Brown's of 1901 may be mentioned as follows:

1.

Güterbock, 1895 (Fig. 4), Berliner Klin Woch., No. 29, 1895. 2. Fenwick, about 1896 (Fig. 5), Clinical Cystoscopy, p. 38.