METHOD OF EXAMINING THE BLADDER AND Catheterizmg the Ureters in Women. CLAIM TO ITS DISCOVERY. BY PROF. DR. PAWLIK, PRAGUE. WITH A REPLY BY HOWARD A. KELLY, M.D., Professor of Gynecology in the Johns Hopkins University, BALTIMORE, MD. 1 Reprinted from the AMERICAN JOURNAL OP OBSTETRICS, You XXXIV, No. 2 NEWYORK : WILLIAM WOOD & COMPANY, 1896. PAWLIK vs. KELLY: A QUESTION OF PRIORITY.1 To the Editor of the American Journal op obstetrics, etc. Dear Sir :—ln The American Journal of Obstetrics, vol. xxxiii., No. 3, Prof. Kelly replies to the article of Prof. Rubeska in the same number and attempts to disprove the statements contained therein. At the very beginning he expresses his regret that I. instead of entering the lists myself, leave my defence and that of my labors to my assistant. This view of Rubeska’s article is not correct. On perusing the successive publications of Prof. Kelly upon the new method of endoscopy of the female bladder I noticed with surprise that my name was not once mentioned in them. It was repugnant to me to enter a controversy, and I waited in the hope that Prof. Kelly would eventually give the true origin of this method. As this did not occur, I read my paper in Rome, expecting that the friendly hint it contained would suf- fice to remind Prof. Kelly of his duty to mention my name ; I thought I had in this way acted correctly and professionally toward Prof. Kelly, But this expectation was in vain. Still I was averse to commence a controversy, particularly because it was likely to become very embarrassing, since Prof. Kelly, by constantly suppressing my name, had cut off his every re- treat, and hence the admission of the true state of the case could not be looked for from him. This is fully borne out by his above-mentioned reply to Prof. Rubeska’s article I was disgusted with the whole affair, and was about to leave it as it was, when I met Prof. Rubeska, who expressed his sur- prise at Prof. Kelly’s behavior to me and stated that he was willing to publish what he knew of the matter. I accepted his offer, Prof. Rubeska having been a witness of my labors and his word was sure of being given full weight. What he has written is not the product of my inspiration, but his own work and testimony. The points to be discussed have been presented by Prof, Rubeska in his article, namely : 1. “ That there is no ureteral catheter of Kelly.” 2 PAWLIK VS. KELLY : A QUESTION OF PRIORITY. 2. “ That the so-called cystoscopy of Kelly is entirely and solely that of Prof. Pawlik.” The first point is quite correct. The one catheter illustrated by Prof. Kelly in his article entitled “ The Ureteral Catheter”1 is my original catheter, figured in Leiter’s catalogue of the year 1883, in Collin’s catalogue, and also in Le Dentil’s book en- titled “Affections chir. des Reins des Ureteres et des Capsules surrenales, ’ Paris, 1889. His second catheter, the picture of which appears in the article on “ The Direct Examination of the Female Bladder,”2 is my later model, illustrated in my paper “ Ueber die Harnleitersondirung beim Weibe ” (v. Langenbeck’s Archiv, Bd. xxxiii., H. 3), in Pozzi, LeDentu, Leiter, etc. Prof. Kelly’s modification consists in his having four openings instead of one at the inner end of the catheter, and in a stopper pro- vided with a small chain for the outer end. Any one may con- vince himself of this by comparing the illustrations here men- tioned. Whether these modifications justify one to name the catheter after Prof. Kelly I leave to the judgment of the pro- fession. Prof. Kelly’s objection to the long slit on my catheter, which he replaces by four small openings, that it frequently catches and cuts the mucous membrane, does not hold good for well- made instruments in which the edges of the slit are bent inward and hence cannot cut. That my catheter is based upon that of Simon is correct in so far as it is a thin tube, as is indeed every catheter ; it is certain, however, that the difference between my catheter and that of Simon is much greater than that between that of Prof. Kelly and my own. But, aside from the catheter, I have also devised a method of my own of catheterizing the ureters which differs altogether from that of Simon, and thus, taken all in all, have produced something entirely new, which as such and in its details has the right to bear my name. This is not the case with Prof. Kelly. Prof. Rubeska’s second point is equally correct. The method of endoscopy of the female bladder, based on the dilatation of the urethra, the introduction of a sufficiently large urethral speculum, filling the bladder with air in the knee-elbow position, and inspection of the interior of the organ by direct or reflected sunlight, has been used by me since 1886. At first I employed the ordinary tubular urethral speculum of Simon. In the year 1887 I had a handle attached to it, so as 1 American Journal of Obstetrics, vol. xxv., No. 6, 1892. 2 Id., vol. xxix., No. 1, 1894, p. 16. PAWLIK YS. KELLY : A QUESTION OF PRIORITY. 3 to enable me to turn it more easily toward tbe orifice of the ureter, and examined the bladder by sunlight, with and without forehead reflector. Mr, Leiter, the instrument-maker of Vienna, was kind enough to place at my disposal an extract from his account books which confirms that this instrument was fur- nished to me on February Ist, 1887. Sunlight not being always available in sufficient intensity, I subsequently examined the bladder by electric light, using a small lamp on a stem. Finally I combined the urethral specu- lum and the electric light in one instrument, as explained by me at Rome. In order to prevent the heating of the metallic instrument, it is connected with a cooling apparatus. This instrument was furnished to me by Mr. Leiter on May 12th, 1891. The greater portion of this process of development has been observed by Prof. Rubeska ; for when I moved from Vienna to Prague in 1887 I examined invariably with Simon’s speculum provided with a handle, by direct or reflected sun- light, and only in the course of time commenced to work with the electric light in addition. Prof. Maydl, on visiting my clinic in 1891—that is, two years before Prof. Kelly made his “ invention ”■—witnessed my meth- od and was kind enough to confirm the fact, as follows : “ Dear Colleague :—ln compliance with your request I take pleasure in testifying that during my brief stay in Prague in May, 1891, you demonstrated to me at your clinic the direct illumination of the air-distended bladder, in the knee-elbow posi- tion, and I also distinctly recall the case presented (tuberculosis of the bladder). Even at that time I advised you not to delay the publication of the matter, but you preferred to wait until the pictures obtained by the above-mentioned method could be fixed by photography. “ I remain, your sincere friend and colleague, “Prof. Maydl, “ Director of the K. K. Surgical Clinic (Bohemia).” My priority in the inspection of the interior of the air-dis- tended bladder, using the sun or the electric light as the source of illumination, is attested by Leiter. Maydl, and Rubeska, and therefore cannot be questioned. In 1888 Prof. Kelly visited me for the first time, and by his request I showed him the free-hand catheterization of the ure- ters. In the following year Prof. Kelly repeated his visit to the clinic. He spoke of the free-hand catheterization of the 4 PAWLIK YS. KELLY : A QUESTION OF PRIORITY. ureters which he had practised at home, and asked me whether I could catheterize the ureters in every case. I truthfully re- plied in the negative, but added that for such cases I had an- other method. I then showed him my instruments for vesical endoscopy and gave an explanation of the method. Prof. Kelly, however, denies this second visit altogether and thus also this communication. He having acted in such a way, I can enter into no further explanation with Prof. Kelly ; I have nothing more to say to him. For the members of the profession who take an interest in the matter I add the following. That this second visit of Prof. Kelly to my clinic really took place is confirmed by my then gynecological assistant, Dr. Vavra, who writes: “Dear Professor:—I willingly comply with your request to confirm that during the first .year of my assistanceship, 1889, I made the acquaintance of Dr. H. Kelly, of Baltimore, who at the time visited the gynecological clinic alone, unac- companied by any one. On that occasion you showed him your cystoscopic apparatus, urethral speculum with handle, and electric hand lamp, in their form at that time. “ Very respectfully yours, “ Dr. Vavra. “ May 29th, 1896.” My obstetrical assistant at that time, Dr. Slechta, writes as follows: ‘ ‘ The undersigned remembers most clearly the visit of Dr. Howard Kelly, of Baltimore, to the gynecological clinic of Prof. Pawlik, in Prague, in the year 1889. “Dr. Johann Slechta, “ Kostel, May 30th, 1896. “Formerly First Assistant Physician at the Obstetrical Clinic of Prof . Pawlik.” Besides, a former externe of my clinic bears witness: “ Komotau, May 22d, 1896. “Dear Sir:—l hereby declare that I remember very well that Dr. Kelly, of Baltimore (America), visited the gynecologi- cal clinic in the year 1889, during the time when I was con- nected with it as externe. “ With great respect, your grateful pupil, “ Dr. Josef Pollak.” The originals of all the documents cited in this reply I have forwarded to Prof. Fritsch with a copy of this article. PAWLIK VS. KELLY : A QUESTION OF PRIORITY. 5 I need not enter upon the remaining contents of Prof. Kelly’s article, as they are immaterial and serve merely for ornamenta- tion. The main declarations of Prof. Eubeska have my full indorsement; Prof. Kelly has iveakened none of them. I do not doubt that Prof. Kelly has experimented in the direction of endoscopy of the bladder; but it is clear that he did not succeed until after his visit to Prague, after my com- munication. Dr. Clark, to whose testimony Prof. Kelly refers, says that the vesical speculum was made on May 4th, 1893; and Dr. Willy Meyer, who is likewise cited as a witness, states that Prof. Kelly had spoken to him about the new method of endoscopy of the female bladder on April 6th, 1893—that is, four years after Prof. Kelly’s visit to my clinic. It is certainly strange that Prof. Kelly should have forgotten the entire visit, but it is not a first occurrence. After the pub- lication of Rubeska’s article in The American Journal of Obstetrics, vol. xxxiii., No. 3, some American friends have called my attention to the following; In the Proceedings of the Philadelphia County Medical Soci- ety, vol. ix., 1888, p. 39, appears a paper by Prof. Kelly under the title, “Rubber Cushions for Surgical Purposes.’’ It deals with an irrigation pad made of rubber, which serves for the convenient removal of large quantities of water used during operations. In the discussion of the paper Dr. J. Price said: “ The only matter about which any question exists, the only thing in controversy, is whether Dr. H. A. Kelly has any claim whatever as the inventor or originator of the irri- gation pad. Such claim he has not only set up here but else- where, without, I claim, a shadow of authority in fact. Intro- ducing the instrument here, he has made it legitimate matter for discussion, not only as to the instrument, but the genuine- ness of its authorship. About five years ago I conceived the importance of an irrigation pad or cushion, and from a design of my own my friend, Dr. John Madison Taylor, made a draw- ing. The instrument, as drawn, was ordered through Kolbe. Dr. PL. A. Kelly saw it not only at the instrument store, but also at my office. He there examined it and ice dis- cussed its merits. I here present a bill from the New York Rubber Company for making this operating cushion, dated January 7th, 1885.” To which Prof. Kelly replied: “ I am sorry that anything so unpleasant should have come before the Society, and I should not have brought up the matter 6 PAWLIK YS. KELLY 1 A QUESTION OF PRIORITY. had not the remarks in reference to it been made so public after the last meeting that I have been forced to defend myself. I can only repeat that I have no recollection that Dr. Price ever spoke to me on this subject.” Here again Prof. Kelly had forgotten the visit to Hr. J. Price and everything that occurred at the time. In his paper entitled “ A New Method of Examination and Treatment of Diseases of the Rectum and Sigmoid Flexure ”1 he describes as his own invention the examination of the lowest portion of the intestine which becomes distended with air and can be inspected when a rectal speculum is introduced in the knee-elbow position. This method is said to have been described in America previous to 1880, some say by Burrall; but it is cer- tain that it was practised by a countryman of Prof. Kelly’s, Dr. Walter J. Otis, of Boston, and was published in 1887 simultaneously in English and German under the title, “Ana- tomical Researches in the Human Rectum and a New Method of Rectal Inspection,” Leipsic, Yeit & Co.; this edition also con- tains illustrations of rectal inspection in the knee-elbow position. In Prof. Kelly’s article there is not the slightest hint as to the originator of the idea. In the same way, in his paper on “ The Palpation of Normal Ovaries ”2 the name of the author of this method of examina- tion is suppressed altogether. I may add, furthermore, that Prof. Kelly, in his papers en- titled “ The Direct Examination of the Female Bladder,” etc.,3 and “Introduction of Bougies into the Ureters preceding Hys- terectomy,”4 etc,, speaks of hysterectomy while bougies are introduced at the same time into the ureters. This method has been published by me in the Internationale klinische Rundschau, 1889, Nos. 26, 27, 29, under the title “Extirpation des Uterus und des Beckenzellgewebes,” and also in the Archives de Tocologie, May, 1890, together with the history of three cases. In this instance likewise Prof. Kelly fails to mention my name. I shall make no comments on these striking facts, but they indicate a deplorable disregard of the labor of others and the rights derived therefrom. Prof. Dr. Pawlik. Prague, June, 1896. 1 Annals of Surgery, April, 1895 sThe American Journal of Obstetrics, vol. xxiv., No. 3, 1891. 3 Idem, vol. xxix., No. 1, 1894, 4 Bull, of the Johns Hopkins Hospital, Baltimore, vol. v., p. 17. A REPLY TO PROF. PAWLIK’S CLAIM TO THE DISCOVERY OF MY METHOD OF EXAMINING THE BLADDER AND CATHETERIZING THE URETERS IN WOMEN. I am glad that Prof. Pawlik has now taken the manly course of making his attack upon me in person. My reply need be but brief, for his communication is merely a reiteration of the statements of his assistant, Prof. Rubeska, to which I have already given a full and satisfactory answer.1 The only fresh matter in Prof. Pawlik’s paper is an effort to fix the date of my meeting him in 1889, a year later than its actual occurrence, and an attempt to prejudice the profession by dragging in extraneous matters. Setting aside the trivialities of this controversy—such as the correct name attaching to the modifications of the Simon ure- teral catheter—the one important question raised is that of my priority in the method of examining the female bladder, dis- tended with air, through an open speculum. Prof. Rubeska begins his paper 3 by asserting that I learned this method of examination from Prof. Pawlik during a visit to his clinic in 1888. I was accompanied at that time by Dr. W. Constantine Goodell, of Philadelphia, who fully corroborates my answer that this statement is false.3 Prof. Pawlik, in view of this fact, now abandons this claim and seeks to establish the date of my visit in 1889 ; he reports a conversation which is wholly imaginary, and to prove the cir- cumstance of the visit at that time he brings forward several letters from his assistants. In answer to this I repeat that I did not even see Prof. Pawlik during that summer, and if I 1 See The American Journal of Obstetrics, vol. xxxiii., No. 8, March, 1896, and Centralbl. f. Gynakologie, May 9th, 1896. 5 See Centralbl. f. Gyn., January 35th, 1896, and The American Jour- nal op Obstetrics, vol. xxxiii., No. 8, March, 1896. 3 See Dr. Goodell’s letter, dated December 36th, 1895, in my reply to Prof. Rubeska. 8 PAWLIK VS. KELLY : A QUESTION OF PRIORITY. have had the pleasure of meeting his assistants it was not then. The unanimity with which these three gentlemen re- member, seven years later, the date of the visit of one among many visitors is somewhat surprising to me; I could have held no conversation with them, in view of the fact that they speak neither English nor German—at least so subsequent visitors have been told. There seems to be a difference in this respect between the American and the Czech memory. I have asked six of my assistants at the Johns Hopkins Hospital whether they can recall the date of the visit of any one physi- cian out of the hundreds who come to see us, and I find them all unable to do it, unless the visit was connected with some special event, such as the annual meeting of the American Medical Association or of the American Gynecological Society. In Prof. Pawlik’s attempt to discredit my statements, his reference to a discussion before the Philadelphia County Medi- cal Society in 1888 is particularly unfortunate, for the judg- ment of the profession on that matter has long since and over- whelmingly been rendered in my favor. If at any time I have not fully recognized the labors of other physicians in my own work and writings, it has been through oversight and without intention, and I shall always be most happy to make good any such error when my attention is called to it. Prof. Pawlik supports his claim to original investigation in the field of vesical cystoscopy by a letter from Prof. Maydl. I have never until recently questioned Prof. Pawlik’s original work; indeed, I could not have done so had I wanted to, because qn his own statement he did not publish it. It is, however, evi- dent from Prof. Rubeska’s statements that his methods were r not what he now claims them to be, for with my instruments it is not a part of the examination to bore the finger into the bladder! I think Prof. Pawlik has been unwise to withhold his important discovery for such trivial reasons as he alleges. I have now given the exact facts of the case, in reply both to Prof Rubeska and to Prof. Pawlik, and I will only add that I do not think it necessary or desirable to answer any further communications from their clinic. Howard A, Kelly. 1418 Eutaw place, Baltimore, Md., Jane 30th, 1896.