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THE CREATION OF THE AMERICAN UROLOGIST, I 9 0 2 - I 9 1 2 ADRIAN W. ZoRGNIoTrI, M.D. Clinical Professor of Urology New York University School of Medicine New York, N.Y.
X the turn of the present century American urology, after lagging far behind its French and German counterparts, quite suddenly became a respectable independent surgical specialty which went on to achieve a position of prominence on the world urologic scene. My thesis is that this was not an accident of evolution but was willed by a small but determined band of medical statesmen during the decade that followed the founding of the American Urological Association (AUA) in I902. While the urologist will always carry the stigmata of the oldtime "clap" doctor, the colorful practicing urologist has all but disappeared, to be replaced in our times by a serious, dedicated surgeon who practices along lines originally intended by our urological forebears. THE VENEREAL ORIGINS OF UROLOGY The origins of urology are deeply embedded in venereology and surgery. For centuries the syphilitic had been a patient of the surgeon, who in turn was regarded by the physician as some sort of lesser being. This state of affairs continued into the i9th century; in France about the I 840s syphilis came to be treated by the specialist in skin diseases, as is indicated by the appearance of a short-lived journal, Annales des Maladies de la Peau et Syphilis (i843). The surgeon continued to treat syphilis because there were, as yet, no clearcut lines of specialization and because there were not enough dermatologists to handle the large case load.' In the United States the change came much later; in 1912 syphilis was incorporated into dermatology at the College of Physicians and Surgeons in New York City. Prior to that year, Robert A. Taylor was professor of genito-urinary diseases and syphilis, while George Henry Fox was professor of dermatology. Both were charter members of the American Dermatological Association. In I912, when Fox retired, he was succeeded by John A. Fordyce, who acVol. 52, No. 3, March-April 1976
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The image of the urologist as a "clap doctor" is well illustrated in this figure showing the irrigation treatment for gonorrheal urethritis. Reproduced from Valentine, F. C.: The Irrigation Treatment of Gonorrhoea. New York, Wood, 1900.
cepted the post on condition that syphilis would be transferred to dermatology.2 Thus, a movement was begun whereby departments of genito-urinary disease divested themselves of responsibility for this entity. The change must have been gradual. I remember that, during my own residency training at the Long Island College Hospital in the early 1950s, the urologists diagnosed and treated primary and secondary syphilis in direct competition with the dermatologists. As resident in urology, I was responsible for a male venereal ward in addition to the usual large urological ward. That syphilis and gonorrhea were part of genito-urinary practice in the i9th century is well illustrated by the activities of William H. Van Buren, who in 185I was made the first clinical professor of genitourinary disease at what is now the New York University School of Medicine. When Freeman J. Bumstead resigned as chief of the Syphilis Clinic at Bellevue Hospital Medical College, Van Buren, who had Bull. N. Y. Acad. Med.
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transferred to that school in i866, became clinic chief in addition to being professor of genito-urinary diseases.3 The term "genito-urinary" survives as the abbreviation GU, which is used to designate the urinary and reproductive tracts (GU system), the practitioner (GU man), or a group of practitioners in a hospital (GU service).4 THE COMING OF AGE OF UROLOGY It is believed that in the i 82zs the pioneer French lithotryptist James Leroy (D'1Etiolles) first used the term "urology."5 Not until 90 years later was a concerted effort made in the United States to use this designation for our specialty. In the United States organizations of urologists had existed before i900. Those which survive today all used the term "genito-urinary" in their names. The American Association of Genito-Urinary Surgeons (AAGUS) was begun in i886 by E. L. Keyes. There are also the Section on Urology of the American Medical Association (AMA), which in the early years was referred to as the Genito-Urinary Section, and the Section on Urology of the New York Academy of Medicine, started in i890 as the Section on Genito-Urinary Surgery.6 What was the state of the art about the year igoo? The world was on the threshold of one of the most extraordinary series of medical events. Within a period of five years the organism of syphilis was identified (1905), a serological test of great specificity was perfected (i906), and these twin achievements were crowned by the announcement of chemotherapy (i91o) for this disease, which had scourged families for centuries. Small wonder that these advances were followed by a great surge in interest in syphilis. This explains the acquisitive moves of the United States dermatologists which occurred at about that time. Surgery also was making strides, and progress in diseases of the urinary tract was no exception. Gustav Simon's nephrectomy (i869)still the sovereign operation of urology-was on its way to universal acceptance. By I879 15 such operations were recorded; by i885 the total had risen to 233.7 Nitze's cystoscope (i 879) had more immediate success, although here again a truly acceptable instrument did not become an actuality until the Edison incandescent bulb (developed in i88o) was miniaturized in I 898 by Charles Preston of Rochester, N.Y., who reduced it to a size whereby it could traverse the urethra to illuVol. 52, No. 3, March.April 1976
2 86
286
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minate the interior of the bladder.8 Prior to that, the Nitze instrument relied on a water-cooled, high-amperage, incandescent platinum wire, which was mounted on its tip; this was cumbersome and hazardous. Another major development which found quick application to diseases of the urinary tract was Roentgen's discovery of the x ray (i895). Within a year of publication it had been used to record the presence of a urinary calculus. In the same year another vexatious problem which confronted the surgeon found a genial solution at the hands of a New York urologist, Eugene Fuller. Efforts to operate on the prevalent disease of the aging male, benign prostatic hyperplasia, gave unsatisfactory results until suprapubic enucleation of the adenoma was developed, an operation which in its essentials is performed today as it has been since I895.' The latter part of the igth century saw the development of surgical solutions for a variety of urological problems. The would-be innovator of today may be confronted by the dismaying discovery that his idea had already been tried 8o or 90 years before by a surgeon graced with a similar understanding of the problem.10 Thus, there were many reasons why talented and well-trained general surgeons found in diseases of the urinary and male genital tracts an ample challenge to their rapidly maturing abilities, even if their work necessitated mastery of urologic diagnosis and urethral instrumentation. The development of urological surgical procedures often depended upon solutions to specific problems in the diagnosis and physiology of the urinary tract. For example, nephrectomy did not become truly practical until retrograde pyelography could identify the diseased kidney and tests of the renal function of the opposite kidney could assure the patient's survival.11 AMERICAN UROLOGY CHARTS ITS COURSE The AUA, founded by Ramon Guiteras, is the largest and most active society of its kind anywhere. The circumstances of its founding in 1902 are lost in the mists of the past. There is even divergence of opinion as to whether the society first saw the light of day in Guiteras' home or in a wine house located on New York City's tough West Side, noted for its highly aromatic limburger cheese as well as for its wine. Certainly the wine-house version would appeal to the romantic side of any urologist.'2 Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
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7
American urology owes much to Guiteras and to those who succeeded him to the presidency of the AUA during its first decade; their decisions have left a mark on the specialty as we practice it today. The travail of those times can be appreciated by a reading of the early presidential speeches of the AUA.13 These men saw to it that, through the bylaws, those who practiced venereology alone would be excluded from membership and that those who did become members were not to be permitted to present venereological papers at the scientific meetings.14 Guiteras wrote in 1905: "The Urological Association cut out most of the genital part of genitourinary diseases."'-5 This was confirmed a year later by Ferd. C. Valentine, who found it necessary to explain that "if we were to add genital and venereal diseases, these would soon overshadow the urinary diseases as they inevitably do."'" However, gonorrhea and its local complications were not excluded; this wise decision paid the rent for countless successful and struggling urologists. The welcome mat of the AUA was out to those who devoted their efforts exclusively to surgical diseases of the urinary tract, to general surgeons who leaned strongly toward urology, and to pathologists and gynecologists interested in urology. Nephrologists also were welcome, for Guiteras in his 1905 speech specifically alluded to "medical men engaged in the study of nephritis and in the urinary diseases dependent upon changes in the urine."'17 It was not easy to exclude potential duespaying members for a principle, nor could this action by a tiny society of less than 250 members have sent much of a shock wave through the medical establishment in the United States. It also appears that in those days the American Association of Genito-Urinary Surgeons was less fastidious and welcomed venerealists to its otherwise limited mem-
bership.'8 The annual meeting of the AUA quickly became a major social and scientific event, as well as the rostrum from which many reputations were helped significantly. It was eagerly awaited and well attended. In the first decade the two-day function would begin on the day preceding the first day of the annual meeting of the AMA.19 In addition to the scientific sessions there was much entertainment and good fellowship-natural enough when any group of urologists meets. This was to help the young AUA weather a threat to its existence far more serious than the fight over the exclusion of the venerealists. This threat took Vol. 52, No. 3, March-April 1976
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the form of a strong and persistent effort to fuse the AUA into the AMA as its Genito-Urinary Section.20 This proposal was opposed categorically by the officers of the AUA not only because it would reopen the "venereal problem" but also because the dues which were spent for the entertainment of the members were certain to disappear into the coffers of the AMA. As a tertiary consideration, this loss of revenue threatened ripening plans to publish the Transactions, the forerunner of our present Journal of Urology.21 This issue festered for four or five years. It was resolved at the i9io meeting in St. Louis, when the members voted not to amalgamate. After this the AUA ceased to meet concurrently with the AMA. The fact that a much larger and more prestigious organization had sought this amalgamation could not have harmed the young society and the specialty which it represented. Having solved problems of identity within the organization, the leaders of the AUA must have decided that urology now had the right to take its place among the better-established surgical specialties of that time, such as ophthalmology, gynecology, and otolaryngology. This task fell to an old-line Bostonian, Hugh Cabot, whose i 9 I presidential address was titled: "Is Urology Entitled to be Regarded as a Specialty? "22 In this speech Cabot gave all the reasons for specialization which we all know so well.2Y Unlike AUA presidential speeches before or since, this one was followed by discussion from the floor. The results, printed in the Transactions of the AUA for i9ii, provide unique insight into the problems that were uppermost in the minds of the men assembled. The insecurities of urologists who had little ability or lacked surgical training are painfully exposed. The arrogance of those general surgeons who took advantage of these weaknesses was aired, as well as their occasional ineptness in the treatment of urological disease. Problems faced by the beginning practitioner were discussed. Surprisingly enough, fee-splitting (euphemistically called "commission business") was discussed also. A few of the discussants missed the point by staging a squabble over the merits of litholapaxy versus lithotomy. Others, such as J. B. Squier and A. L. Keyes, Jr., appear to have had a more sophisticated and statesmanlike grasp of the problems cited by Cabot. They pointed out that instead of urologists "clamoring for their rights," it was essential for urology to "establish clearly its preeminent capacity to do certain things which other men could not do." This Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
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meant doing "major surgical work as well as or better than the general surgeon."24 Cabot's speech is one of the most important ever made by a president of the AUA and is mandatory reading for students of the early history of American urology. The manifesto appears to have been heeded; urology grew rapidly thereafter also because the specialty could offer a solid surgical and diagnostic repertory. During this early period men like William N. Wishard and Hugh H. Young abandoned promising careers in general surgery to devote themselves to urology, usually to the outspoken surprise and even the consternation of contemporaries.25 OUR DEBT TO VENEREOLOGY The continued inclusion of gonorrhea and its urethral complications in urological practice must seem somewhat of a contradiction, considering the antivenereal stand of the AUA's founders. It was a rare urologist who, during the first half of this century, did not depend on venereal practice for a significant portion of his income. One such venereal specialist was Valentine, who is best remembered for having modified the Janet urethral irrigation method for gonorrhea.26 Because of his surgical contributions, he survived the proscription and became the third president of the AUA. Other venerealists also made a transition of sorts into urology. For many years there were physicians attached to clinics and in private practice who were skilled in venereology, the treatment of urethral stricture, and cystoscopy. These men did either minor surgery or none at all, and were sometimes referred to as "medical urologists." By the i960s most of them had retired and there has been no replenishment of their ranks. The postwar drop in venereal diseases and the increase in trained urologists probably were the main causes of this decline. The I9th century saw urethral instrumentation for gonorrheal stricture brought to a high art, especially in France, and it is from French pioneers that the urologist learned to negotiate the difficulties sometimes presented by the urethra. In the early years of this century such expertness was to prove both advantageous and disadvantageous. Specialists with talent for instrumenting the urethra could be certain that an effort would be made to shunt them off to the outpatient clinic and to exclude them from the society of surgeons.28 However, these same men Vol. 52, No. 3, March-April 1976
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became the cystoscopists who held the key to urological diagnosis and who, as urology grew up, gained control over the fate of the patient's surgical problem. It is part of the folklore of American urology that some of these cystoscopists responded to their exclusion from open prostatic surgery by developing transurethral prostatectomy, a procedure which, in the 1920S, was usually done in the doctor's officethe patient being transferred subsequently to the hospital for post-
operative care.
29
That these men dealt in so-called "filthy diseases" provides the backdrop for one of the best known stereotypes in medicine: the urologist as a colorful practitioner.30 It is lamentable that this character belongs on the endangered species list, but he probably will never become extinct as long as one patient with the "clap" remains or there is still one nurse who gleefully uses yellow labels to designate urological patients because that color is the signature of urine. During my residency I encountered a cigar-smoking attending urologist whose hair hung far below his shirt collar 25 years before this was fashionable. Another always appeared in the hospital with a flower in his lapel and was known as one of the AUA's outstanding raconteurs. Most memorable of all was our goateed professor emeritus, who still practiced in his 70s. White-haired, lean, and straight, he was sartorially the picture of an elegant southern aristocrat. Yet, on snowy days when the hospital engineer would send up great waves of steam, he cut an astonishing figure; he would remove his tie and the white starched collar of his usual maroon shirt, and also his heavy woollen trousers. He would then don his clinic coat. With his long winter underwear showing between his white coat and unbuckled galoshes, he would make his hospital rounds, dutifully followed by the chief resident. The founder of the AUA also was a colorful man. While a student at Yale, Guiteras knocked down John L. Sullivan during a sparring session. His photograph in boxing trunks graces a wall at the New York Athletic Club-a tribute to his lifelong interest in boxing. Other names crowd the mind at the mention of "colorful urologist," but by far the most memorable was a New Yorker, the late Oswald S. Lowsley. Frequently immersed in controversy, Lowsley had a presence which electrified any gathering, yet he was also an able urologist. He devised a much-publicized operation for impotence. Bull. N. Y. Acad. Med.
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When his marital difficulties later became public knowledge he was a target for the headline writers of every scurrilous tabloid in the city.3' We can but mourn the passing of such men who enlivened the medical scene. The development of the surgical abilities called for by Cabot produced a new breed of surgeon. Except for the treatment of urethral diseases, including gonorrhea, urology was restricted to "capital surgery of the kidneys, prostate and bladder."32 As was stated at the outset, the founders of the AUA intended to eliminate the venerealist image. Now, nearly 75 years later, it appears that they may have succeeded-or have they? NOTES AND REFERENCES 1. Philippe Ricord, the father of modern venereology, once characterized Paris as the "capital of the syphilized world." Eginer, C.: Philippe Ricord. Thesis. Paris, 1939. 2. Rosen, I.: The treatment of syphilis in the Salvarsan era. Arch. Derm. 73:47688, 1956. 3. Keyes, E. L.: Early History of Urology in New York. In: History of Urology, Lewis, B., editor. Baltimore, Williams and Wilkins, 1933, vol. 1, p. 72. 4. The recent increase of women in medicine may necessitate the coinage of the term "GU person." New York City has the distinction of being the home of the only board-certified female urologist in the United States. 5. Ackerknecht, E. H.: Medicine at the Paris Hospital. Baltimore, Johns Hopkins Press, 1967, p. 178. 6. Between 1890 and 1894 the AAGUS chose to call itself the American Association of Andrology and Syphilology, but then reverted to its original name. With regard to the AMA, in 1910 (J.A.M.A. 54:1459-60, 1910) E. C. Hay called for 100 signatures from members in order to establish a section on genito-urinary diseases. This group held its first meeting in 1912 under the chairmanship of W. T. Belfield, the pioneer prostatectomist. The program included surgical topics and a sympo-
Vol. 52, No. 3, March-April 1976
7. 8.
9.
10.
11.
sium on syphilis; Hideyo Noguchi was one of the speakers. At the end of World War I the name was changed to the Section of Urology, without much notice being given to this alteration. In New York City the Section on Urology of the New York Academy of Medicine coexists harmoniously with the New York Section of the AUA. This is due to the fact that officers of one society often serve in the other. The Academy section also is financially secure, having been left a sizeable bequest by F. C. Valentine, and hence is able to puruse it goals. Pilcher, L. S.: Development of the surgery of the kidney. Ann. Surg. 31:10018, 1900. Mark, E.: Cystoscopy and Urethroscopy. In: History of Urology, Lewis, B., editor. Baltimore, Williams and Wilkins, 1933, vol. 1, p. 162. Fuller, E.: Six successful and successive cases of prostatectomy. T. COut. G.U. Dis. 13:1-11, 1895. As an example of this, renal cyst puncture was performed by A. T. Cabot in 1890. (Cabot, A. T.: Aspiration of cyst of kidney. J. Cut. G.U. Dis. 8:32930, 1890.) B. Lewis (Dawn and development of
urology. Trans. A.U.A. 1:9,1906) credits Sir Henry Thompson with ". . . formulating an intelligent plan of investi-
2 92
12. 13.
14. 15. 16.
17. 18.
A. W. ZORGNIOTTI
gation of genito-urinary diseases, [and] teaching that questions and physical examination should follow certain prescribed plans which he outlined and adhered to." Surely the young specialty was in urgent need of order. American urology also was to benefit from the literary activities of W. H. Van Buren and E. L. Keyes, Sr., whose textbook (1874) was the first modern codification of extant urologic knowledge into useful form. It went through many editions and had a profound and salutary effect on the practitioner of that era. The influence of the book-later edited by the Keyes (Senior and Junior)cannot be overemphasized. Help also came from a nonmedical source, the American instrument-maker Reinhold Wappler. By having available a welldisciplined cystoscope-making company which at the same time worked closely with inventive practitioners, American urology moved rapidly into the forefront, thanks to the refinement and high quality of the cystoscopes which Wappler manufactured. Twinem, F. P.: A history of the New York Section of the AUA. Urology 3:515-26, 1974. These speeches are to be found in the American Journal of Urology and in the Transactions of the American Urological Association. The former survives today as the popular magazine Sexology. The latter ceased publication when the Journal of Urology began publication as the Official Organ of the AUA. More recently this designation was changed to Official Journal of the AUA. Guiteras, R.: The American Urological Association. Amer. J. Urol. 1:337-39, 1905. Ibid., p. 338. Valentine, F. C.: The American Urological Association. Amer. J. Urol. 2: 425-32, 1906. Guiteras, R., op. cit., p. 338. In his speech as the first president of the AAGUS, E. L. Keyes included syphilis in the activities of the society (J. Cut. G.U. Dis. 5:266-70, 1887); presentations on this topic appear in the
society's programs into the 1890s. 19. Valentine, F. C., op. cit., p. 431. 20. Hay, E. C.: A proposed Section on Genito-Urinary and Venereal Diseases. J.A.M.A. 54:1459-60, 1910. 21. Ibid., p. 1159; Valentine, F. C., op. cit., p. 431. 22. Cabot, H.: Is urology entitled to be
regarded as a specialty? Trans. A.U.A. 5:1-20, 1911. 23. Cabot also left us with an eminently quotable definition of a specialty: "A department of medicine becomes a specialty when our knowledge of the diseases of this department becomes so far developed that it requires the whole time of any individual to keep abreast of the accumulating knowledge, and still have time to devote to the study of the problems presented." Cabot, H., loc. cit. 24. Cabot, H., loc. cit. 25. Wishard, W. N.: Preface. In: History
of Urology, Lewis, B., editor. Balti-
26.
27. 28. 29.
30.
31.
32.
more, Williams and Wilkins, 1933, vol. 1, p. viii; Young, H. H.: A Surgeon's Autobiography. New York, Harcourt, Brace, 1940, p. 75. Valentine, F. C.: The Irrigation Treatment of Gonorrhoea. New York, Wood, 1900. Zorgniotti, A. W.: Jean Zulema Amussat: Forerunner of modern urologic instruments. Invest. Urol. 8:363-65, 1970. Cabot, H., op. cit., pp. 14-15. Davis, T. M.: Experience in transureethral resection. Bull. N.Y. Acad. Med. 43:152-66, 1967. Ackerknecht tells of how early venereologists and urologists in Paris were financially successful but did not enjoy the esteem of their colleagues because of the nature of their work. Ackerknecht, E. H., loc. cit., pp. 176, 178. Headlines are less "gamy" nowadays. Lowsley brought out the full gale force of these journalists: Virility restorer sued as Lothario. N.Y. J. Amer., March 1948; Virility doe denies demonstrating. N.Y. Daily News, April 1948; Surgeon who made men men to take fourth bride at 68. N.Y. Daily News, January 1953. Hay, E. C., op. cit., p. 1159.
Bull. N. Y. Acad. Med.
THE CREATION OF THE AMERICAN UROLOGIST, I 9 0 2 - I 9 1 2 ADRIAN W. ZoRGNIoTrI, M.D. Clinical Professor of Urology New York University School of Medicine New York, N.Y.
X the turn of the present century American urology, after lagging far behind its French and German counterparts, quite suddenly became a respectable independent surgical specialty which went on to achieve a position of prominence on the world urologic scene. My thesis is that this was not an accident of evolution but was willed by a small but determined band of medical statesmen during the decade that followed the founding of the American Urological Association (AUA) in I902. While the urologist will always carry the stigmata of the oldtime "clap" doctor, the colorful practicing urologist has all but disappeared, to be replaced in our times by a serious, dedicated surgeon who practices along lines originally intended by our urological forebears. THE VENEREAL ORIGINS OF UROLOGY The origins of urology are deeply embedded in venereology and surgery. For centuries the syphilitic had been a patient of the surgeon, who in turn was regarded by the physician as some sort of lesser being. This state of affairs continued into the i9th century; in France about the I 840s syphilis came to be treated by the specialist in skin diseases, as is indicated by the appearance of a short-lived journal, Annales des Maladies de la Peau et Syphilis (i843). The surgeon continued to treat syphilis because there were, as yet, no clearcut lines of specialization and because there were not enough dermatologists to handle the large case load.' In the United States the change came much later; in 1912 syphilis was incorporated into dermatology at the College of Physicians and Surgeons in New York City. Prior to that year, Robert A. Taylor was professor of genito-urinary diseases and syphilis, while George Henry Fox was professor of dermatology. Both were charter members of the American Dermatological Association. In I912, when Fox retired, he was succeeded by John A. Fordyce, who acVol. 52, No. 3, March-April 1976
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AV
The image of the urologist as a "clap doctor" is well illustrated in this figure showing the irrigation treatment for gonorrheal urethritis. Reproduced from Valentine, F. C.: The Irrigation Treatment of Gonorrhoea. New York, Wood, 1900.
cepted the post on condition that syphilis would be transferred to dermatology.2 Thus, a movement was begun whereby departments of genito-urinary disease divested themselves of responsibility for this entity. The change must have been gradual. I remember that, during my own residency training at the Long Island College Hospital in the early 1950s, the urologists diagnosed and treated primary and secondary syphilis in direct competition with the dermatologists. As resident in urology, I was responsible for a male venereal ward in addition to the usual large urological ward. That syphilis and gonorrhea were part of genito-urinary practice in the i9th century is well illustrated by the activities of William H. Van Buren, who in 185I was made the first clinical professor of genitourinary disease at what is now the New York University School of Medicine. When Freeman J. Bumstead resigned as chief of the Syphilis Clinic at Bellevue Hospital Medical College, Van Buren, who had Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
2 85
transferred to that school in i866, became clinic chief in addition to being professor of genito-urinary diseases.3 The term "genito-urinary" survives as the abbreviation GU, which is used to designate the urinary and reproductive tracts (GU system), the practitioner (GU man), or a group of practitioners in a hospital (GU service).4 THE COMING OF AGE OF UROLOGY It is believed that in the i 82zs the pioneer French lithotryptist James Leroy (D'1Etiolles) first used the term "urology."5 Not until 90 years later was a concerted effort made in the United States to use this designation for our specialty. In the United States organizations of urologists had existed before i900. Those which survive today all used the term "genito-urinary" in their names. The American Association of Genito-Urinary Surgeons (AAGUS) was begun in i886 by E. L. Keyes. There are also the Section on Urology of the American Medical Association (AMA), which in the early years was referred to as the Genito-Urinary Section, and the Section on Urology of the New York Academy of Medicine, started in i890 as the Section on Genito-Urinary Surgery.6 What was the state of the art about the year igoo? The world was on the threshold of one of the most extraordinary series of medical events. Within a period of five years the organism of syphilis was identified (1905), a serological test of great specificity was perfected (i906), and these twin achievements were crowned by the announcement of chemotherapy (i91o) for this disease, which had scourged families for centuries. Small wonder that these advances were followed by a great surge in interest in syphilis. This explains the acquisitive moves of the United States dermatologists which occurred at about that time. Surgery also was making strides, and progress in diseases of the urinary tract was no exception. Gustav Simon's nephrectomy (i869)still the sovereign operation of urology-was on its way to universal acceptance. By I879 15 such operations were recorded; by i885 the total had risen to 233.7 Nitze's cystoscope (i 879) had more immediate success, although here again a truly acceptable instrument did not become an actuality until the Edison incandescent bulb (developed in i88o) was miniaturized in I 898 by Charles Preston of Rochester, N.Y., who reduced it to a size whereby it could traverse the urethra to illuVol. 52, No. 3, March.April 1976
2 86
286
A. W. ZORGNIOTTI Z0RGNI0F.L
minate the interior of the bladder.8 Prior to that, the Nitze instrument relied on a water-cooled, high-amperage, incandescent platinum wire, which was mounted on its tip; this was cumbersome and hazardous. Another major development which found quick application to diseases of the urinary tract was Roentgen's discovery of the x ray (i895). Within a year of publication it had been used to record the presence of a urinary calculus. In the same year another vexatious problem which confronted the surgeon found a genial solution at the hands of a New York urologist, Eugene Fuller. Efforts to operate on the prevalent disease of the aging male, benign prostatic hyperplasia, gave unsatisfactory results until suprapubic enucleation of the adenoma was developed, an operation which in its essentials is performed today as it has been since I895.' The latter part of the igth century saw the development of surgical solutions for a variety of urological problems. The would-be innovator of today may be confronted by the dismaying discovery that his idea had already been tried 8o or 90 years before by a surgeon graced with a similar understanding of the problem.10 Thus, there were many reasons why talented and well-trained general surgeons found in diseases of the urinary and male genital tracts an ample challenge to their rapidly maturing abilities, even if their work necessitated mastery of urologic diagnosis and urethral instrumentation. The development of urological surgical procedures often depended upon solutions to specific problems in the diagnosis and physiology of the urinary tract. For example, nephrectomy did not become truly practical until retrograde pyelography could identify the diseased kidney and tests of the renal function of the opposite kidney could assure the patient's survival.11 AMERICAN UROLOGY CHARTS ITS COURSE The AUA, founded by Ramon Guiteras, is the largest and most active society of its kind anywhere. The circumstances of its founding in 1902 are lost in the mists of the past. There is even divergence of opinion as to whether the society first saw the light of day in Guiteras' home or in a wine house located on New York City's tough West Side, noted for its highly aromatic limburger cheese as well as for its wine. Certainly the wine-house version would appeal to the romantic side of any urologist.'2 Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
28
7
American urology owes much to Guiteras and to those who succeeded him to the presidency of the AUA during its first decade; their decisions have left a mark on the specialty as we practice it today. The travail of those times can be appreciated by a reading of the early presidential speeches of the AUA.13 These men saw to it that, through the bylaws, those who practiced venereology alone would be excluded from membership and that those who did become members were not to be permitted to present venereological papers at the scientific meetings.14 Guiteras wrote in 1905: "The Urological Association cut out most of the genital part of genitourinary diseases."'-5 This was confirmed a year later by Ferd. C. Valentine, who found it necessary to explain that "if we were to add genital and venereal diseases, these would soon overshadow the urinary diseases as they inevitably do."'" However, gonorrhea and its local complications were not excluded; this wise decision paid the rent for countless successful and struggling urologists. The welcome mat of the AUA was out to those who devoted their efforts exclusively to surgical diseases of the urinary tract, to general surgeons who leaned strongly toward urology, and to pathologists and gynecologists interested in urology. Nephrologists also were welcome, for Guiteras in his 1905 speech specifically alluded to "medical men engaged in the study of nephritis and in the urinary diseases dependent upon changes in the urine."'17 It was not easy to exclude potential duespaying members for a principle, nor could this action by a tiny society of less than 250 members have sent much of a shock wave through the medical establishment in the United States. It also appears that in those days the American Association of Genito-Urinary Surgeons was less fastidious and welcomed venerealists to its otherwise limited mem-
bership.'8 The annual meeting of the AUA quickly became a major social and scientific event, as well as the rostrum from which many reputations were helped significantly. It was eagerly awaited and well attended. In the first decade the two-day function would begin on the day preceding the first day of the annual meeting of the AMA.19 In addition to the scientific sessions there was much entertainment and good fellowship-natural enough when any group of urologists meets. This was to help the young AUA weather a threat to its existence far more serious than the fight over the exclusion of the venerealists. This threat took Vol. 52, No. 3, March-April 1976
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the form of a strong and persistent effort to fuse the AUA into the AMA as its Genito-Urinary Section.20 This proposal was opposed categorically by the officers of the AUA not only because it would reopen the "venereal problem" but also because the dues which were spent for the entertainment of the members were certain to disappear into the coffers of the AMA. As a tertiary consideration, this loss of revenue threatened ripening plans to publish the Transactions, the forerunner of our present Journal of Urology.21 This issue festered for four or five years. It was resolved at the i9io meeting in St. Louis, when the members voted not to amalgamate. After this the AUA ceased to meet concurrently with the AMA. The fact that a much larger and more prestigious organization had sought this amalgamation could not have harmed the young society and the specialty which it represented. Having solved problems of identity within the organization, the leaders of the AUA must have decided that urology now had the right to take its place among the better-established surgical specialties of that time, such as ophthalmology, gynecology, and otolaryngology. This task fell to an old-line Bostonian, Hugh Cabot, whose i 9 I presidential address was titled: "Is Urology Entitled to be Regarded as a Specialty? "22 In this speech Cabot gave all the reasons for specialization which we all know so well.2Y Unlike AUA presidential speeches before or since, this one was followed by discussion from the floor. The results, printed in the Transactions of the AUA for i9ii, provide unique insight into the problems that were uppermost in the minds of the men assembled. The insecurities of urologists who had little ability or lacked surgical training are painfully exposed. The arrogance of those general surgeons who took advantage of these weaknesses was aired, as well as their occasional ineptness in the treatment of urological disease. Problems faced by the beginning practitioner were discussed. Surprisingly enough, fee-splitting (euphemistically called "commission business") was discussed also. A few of the discussants missed the point by staging a squabble over the merits of litholapaxy versus lithotomy. Others, such as J. B. Squier and A. L. Keyes, Jr., appear to have had a more sophisticated and statesmanlike grasp of the problems cited by Cabot. They pointed out that instead of urologists "clamoring for their rights," it was essential for urology to "establish clearly its preeminent capacity to do certain things which other men could not do." This Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
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meant doing "major surgical work as well as or better than the general surgeon."24 Cabot's speech is one of the most important ever made by a president of the AUA and is mandatory reading for students of the early history of American urology. The manifesto appears to have been heeded; urology grew rapidly thereafter also because the specialty could offer a solid surgical and diagnostic repertory. During this early period men like William N. Wishard and Hugh H. Young abandoned promising careers in general surgery to devote themselves to urology, usually to the outspoken surprise and even the consternation of contemporaries.25 OUR DEBT TO VENEREOLOGY The continued inclusion of gonorrhea and its urethral complications in urological practice must seem somewhat of a contradiction, considering the antivenereal stand of the AUA's founders. It was a rare urologist who, during the first half of this century, did not depend on venereal practice for a significant portion of his income. One such venereal specialist was Valentine, who is best remembered for having modified the Janet urethral irrigation method for gonorrhea.26 Because of his surgical contributions, he survived the proscription and became the third president of the AUA. Other venerealists also made a transition of sorts into urology. For many years there were physicians attached to clinics and in private practice who were skilled in venereology, the treatment of urethral stricture, and cystoscopy. These men did either minor surgery or none at all, and were sometimes referred to as "medical urologists." By the i960s most of them had retired and there has been no replenishment of their ranks. The postwar drop in venereal diseases and the increase in trained urologists probably were the main causes of this decline. The I9th century saw urethral instrumentation for gonorrheal stricture brought to a high art, especially in France, and it is from French pioneers that the urologist learned to negotiate the difficulties sometimes presented by the urethra. In the early years of this century such expertness was to prove both advantageous and disadvantageous. Specialists with talent for instrumenting the urethra could be certain that an effort would be made to shunt them off to the outpatient clinic and to exclude them from the society of surgeons.28 However, these same men Vol. 52, No. 3, March-April 1976
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became the cystoscopists who held the key to urological diagnosis and who, as urology grew up, gained control over the fate of the patient's surgical problem. It is part of the folklore of American urology that some of these cystoscopists responded to their exclusion from open prostatic surgery by developing transurethral prostatectomy, a procedure which, in the 1920S, was usually done in the doctor's officethe patient being transferred subsequently to the hospital for post-
operative care.
29
That these men dealt in so-called "filthy diseases" provides the backdrop for one of the best known stereotypes in medicine: the urologist as a colorful practitioner.30 It is lamentable that this character belongs on the endangered species list, but he probably will never become extinct as long as one patient with the "clap" remains or there is still one nurse who gleefully uses yellow labels to designate urological patients because that color is the signature of urine. During my residency I encountered a cigar-smoking attending urologist whose hair hung far below his shirt collar 25 years before this was fashionable. Another always appeared in the hospital with a flower in his lapel and was known as one of the AUA's outstanding raconteurs. Most memorable of all was our goateed professor emeritus, who still practiced in his 70s. White-haired, lean, and straight, he was sartorially the picture of an elegant southern aristocrat. Yet, on snowy days when the hospital engineer would send up great waves of steam, he cut an astonishing figure; he would remove his tie and the white starched collar of his usual maroon shirt, and also his heavy woollen trousers. He would then don his clinic coat. With his long winter underwear showing between his white coat and unbuckled galoshes, he would make his hospital rounds, dutifully followed by the chief resident. The founder of the AUA also was a colorful man. While a student at Yale, Guiteras knocked down John L. Sullivan during a sparring session. His photograph in boxing trunks graces a wall at the New York Athletic Club-a tribute to his lifelong interest in boxing. Other names crowd the mind at the mention of "colorful urologist," but by far the most memorable was a New Yorker, the late Oswald S. Lowsley. Frequently immersed in controversy, Lowsley had a presence which electrified any gathering, yet he was also an able urologist. He devised a much-publicized operation for impotence. Bull. N. Y. Acad. Med.
CREATION OF THE AMERICAN UROLOGIST
2 9 I
When his marital difficulties later became public knowledge he was a target for the headline writers of every scurrilous tabloid in the city.3' We can but mourn the passing of such men who enlivened the medical scene. The development of the surgical abilities called for by Cabot produced a new breed of surgeon. Except for the treatment of urethral diseases, including gonorrhea, urology was restricted to "capital surgery of the kidneys, prostate and bladder."32 As was stated at the outset, the founders of the AUA intended to eliminate the venerealist image. Now, nearly 75 years later, it appears that they may have succeeded-or have they? NOTES AND REFERENCES 1. Philippe Ricord, the father of modern venereology, once characterized Paris as the "capital of the syphilized world." Eginer, C.: Philippe Ricord. Thesis. Paris, 1939. 2. Rosen, I.: The treatment of syphilis in the Salvarsan era. Arch. Derm. 73:47688, 1956. 3. Keyes, E. L.: Early History of Urology in New York. In: History of Urology, Lewis, B., editor. Baltimore, Williams and Wilkins, 1933, vol. 1, p. 72. 4. The recent increase of women in medicine may necessitate the coinage of the term "GU person." New York City has the distinction of being the home of the only board-certified female urologist in the United States. 5. Ackerknecht, E. H.: Medicine at the Paris Hospital. Baltimore, Johns Hopkins Press, 1967, p. 178. 6. Between 1890 and 1894 the AAGUS chose to call itself the American Association of Andrology and Syphilology, but then reverted to its original name. With regard to the AMA, in 1910 (J.A.M.A. 54:1459-60, 1910) E. C. Hay called for 100 signatures from members in order to establish a section on genito-urinary diseases. This group held its first meeting in 1912 under the chairmanship of W. T. Belfield, the pioneer prostatectomist. The program included surgical topics and a sympo-
Vol. 52, No. 3, March-April 1976
7. 8.
9.
10.
11.
sium on syphilis; Hideyo Noguchi was one of the speakers. At the end of World War I the name was changed to the Section of Urology, without much notice being given to this alteration. In New York City the Section on Urology of the New York Academy of Medicine coexists harmoniously with the New York Section of the AUA. This is due to the fact that officers of one society often serve in the other. The Academy section also is financially secure, having been left a sizeable bequest by F. C. Valentine, and hence is able to puruse it goals. Pilcher, L. S.: Development of the surgery of the kidney. Ann. Surg. 31:10018, 1900. Mark, E.: Cystoscopy and Urethroscopy. In: History of Urology, Lewis, B., editor. Baltimore, Williams and Wilkins, 1933, vol. 1, p. 162. Fuller, E.: Six successful and successive cases of prostatectomy. T. COut. G.U. Dis. 13:1-11, 1895. As an example of this, renal cyst puncture was performed by A. T. Cabot in 1890. (Cabot, A. T.: Aspiration of cyst of kidney. J. Cut. G.U. Dis. 8:32930, 1890.) B. Lewis (Dawn and development of
urology. Trans. A.U.A. 1:9,1906) credits Sir Henry Thompson with ". . . formulating an intelligent plan of investi-
2 92
12. 13.
14. 15. 16.
17. 18.
A. W. ZORGNIOTTI
gation of genito-urinary diseases, [and] teaching that questions and physical examination should follow certain prescribed plans which he outlined and adhered to." Surely the young specialty was in urgent need of order. American urology also was to benefit from the literary activities of W. H. Van Buren and E. L. Keyes, Sr., whose textbook (1874) was the first modern codification of extant urologic knowledge into useful form. It went through many editions and had a profound and salutary effect on the practitioner of that era. The influence of the book-later edited by the Keyes (Senior and Junior)cannot be overemphasized. Help also came from a nonmedical source, the American instrument-maker Reinhold Wappler. By having available a welldisciplined cystoscope-making company which at the same time worked closely with inventive practitioners, American urology moved rapidly into the forefront, thanks to the refinement and high quality of the cystoscopes which Wappler manufactured. Twinem, F. P.: A history of the New York Section of the AUA. Urology 3:515-26, 1974. These speeches are to be found in the American Journal of Urology and in the Transactions of the American Urological Association. The former survives today as the popular magazine Sexology. The latter ceased publication when the Journal of Urology began publication as the Official Organ of the AUA. More recently this designation was changed to Official Journal of the AUA. Guiteras, R.: The American Urological Association. Amer. J. Urol. 1:337-39, 1905. Ibid., p. 338. Valentine, F. C.: The American Urological Association. Amer. J. Urol. 2: 425-32, 1906. Guiteras, R., op. cit., p. 338. In his speech as the first president of the AAGUS, E. L. Keyes included syphilis in the activities of the society (J. Cut. G.U. Dis. 5:266-70, 1887); presentations on this topic appear in the
society's programs into the 1890s. 19. Valentine, F. C., op. cit., p. 431. 20. Hay, E. C.: A proposed Section on Genito-Urinary and Venereal Diseases. J.A.M.A. 54:1459-60, 1910. 21. Ibid., p. 1159; Valentine, F. C., op. cit., p. 431. 22. Cabot, H.: Is urology entitled to be
regarded as a specialty? Trans. A.U.A. 5:1-20, 1911. 23. Cabot also left us with an eminently quotable definition of a specialty: "A department of medicine becomes a specialty when our knowledge of the diseases of this department becomes so far developed that it requires the whole time of any individual to keep abreast of the accumulating knowledge, and still have time to devote to the study of the problems presented." Cabot, H., loc. cit. 24. Cabot, H., loc. cit. 25. Wishard, W. N.: Preface. In: History
of Urology, Lewis, B., editor. Balti-
26.
27. 28. 29.
30.
31.
32.
more, Williams and Wilkins, 1933, vol. 1, p. viii; Young, H. H.: A Surgeon's Autobiography. New York, Harcourt, Brace, 1940, p. 75. Valentine, F. C.: The Irrigation Treatment of Gonorrhoea. New York, Wood, 1900. Zorgniotti, A. W.: Jean Zulema Amussat: Forerunner of modern urologic instruments. Invest. Urol. 8:363-65, 1970. Cabot, H., op. cit., pp. 14-15. Davis, T. M.: Experience in transureethral resection. Bull. N.Y. Acad. Med. 43:152-66, 1967. Ackerknecht tells of how early venereologists and urologists in Paris were financially successful but did not enjoy the esteem of their colleagues because of the nature of their work. Ackerknecht, E. H., loc. cit., pp. 176, 178. Headlines are less "gamy" nowadays. Lowsley brought out the full gale force of these journalists: Virility restorer sued as Lothario. N.Y. J. Amer., March 1948; Virility doe denies demonstrating. N.Y. Daily News, April 1948; Surgeon who made men men to take fourth bride at 68. N.Y. Daily News, January 1953. Hay, E. C., op. cit., p. 1159.
Bull. N. Y. Acad. Med.
