THE COMPOUND CIRCULAR CATHETER AND MR. T. WAKLEY'S STRICTURE INSTRUMENTS.

The following note was prepared byMr. MARTIX, by desire over a probe-pointed silver wire. The largest of these has the diameter of a No. 12, and each of the outer tubes of the series of Lord METCALFE, and handed by him to Lieut.-General GEORGE MURRAY, at a meeting held at the Colonial Office by is an inch shorter than the one coming next in order. The whole has the form of an arc of a large circle. Instruments order of Lord STANLEY, on the 16th of July, 1842:with a more extensive series of tubes have been tried by Dr. 1. " The author of this note has satisfied himself, from an Buchanan ; but this merely renders the manipulation less easy extensive range of observation in the East Indies, that great without conferring any practical advantage. loss of life, injury to health, and sacrifice of the public money, When the instrument is about to be used, it is adjusted. so haveresulted from the present modes of locating and construct- as to have a conical point; each tube projecting about a line ing barracks and hospitals for the European troops there; and beyond that immediately larger in size. The patient is laid his information, derived from printed and other sources, leads across the bed on his back, with his shoulders slightly raised, him to conclude that similarly injurious results are also pro- his limbs separated, and his feet supported. The surgeon, duced in various of her v,,tjesty’s colonies, from similar causes. seated in front, introduces and pushes on the instrument with 2. " To obviate for the future such extensive waste of life his right hand, while the lingers of his left follow the point of and money, and with a view, likewise, to improve such exist- it, directing it, and giving support to the urethra. This last ing buildings as may admit of amendment, it is proposed that step is more especially necessary if the stricture be in the standard plans and models be prepared for barrack and hospital membranous part of the urethra, when the index finger of the accommodation, in scale proportioned to certain given numbers left hand oughc always to be introduced into the rectum, supof men, and suited to the various and contrasted climates occu- porting the point of the instrument, and preventing it from pied by British troops. The most cursory observation will deviating from the line of the urethra. The instrument is introduced as a whole down to the first satisfy us, that of certain given plans one only will proveexcellent ; whereas now all over the British possessions we find I obstruction. The Largest tube can now be advanced no farin existence every conceivable plan, ending in no approved or ther ; but it still serves the important purposes of keeping the the smaller tubes in fixed plan whatever; so that, in fact, that which ought to 1)e urethra fully distended, and maintaining settled, and is very easily capable of being settled by regula- the axis of the passage. These smaller tubes, and if necessary tion, is up to this day left, as I have stated, to the fancy of the central probe, can now be pressed in succession with the individuals. right forefinger and thumb, or with the nail of the forefinger 3. "It is not apprehended that either difficulty or the ex- alone. When one tube ]HlbS.:.S on till it meets with fresh regenerally be passed a little penditure of much time would be encountered by carrying out sistance, the next less in sizeas crin it advances, becomes a guide the proposed plan, provided it were undertaken by persons farther; while each of them, competent to the task; for the same plan of barrack and hos- to those of lan!er size which are to follow; the whole thus of the wedge in dilating and breaking pital accommodation would suit the climates of the East and acting on the West Indies, the Cape of Good Hope, Mauritius, Ceylon, up the contracted tissues of the urethra. In this way most China, and Australia, the stations of Gibraltar and Malta., and ordinary strictures are overcome at once without difficulty; the Ionian Isles, while plans for the other colonies would be while those which are more than usually callous, or long and tortuous, may demand several sittings. The occasional introeasy of settlement. 4. "To arrange and complete so desirable an object, it is duction of a full-sized catheter will afterwards be enough to respectfully suggested that a committee of engineers and preserve the calibre of the urethraduring the re-absorption of medical officers be assembled in London, and that power be effused matters, and the healing of the longitudinal ruptures in given, in furtherance of the purposes in view, to call in evidence the indurated walls by which the dilatation has operated in such persons as may be supposed to possess experience and a removing the stricture. A most important practical fact which has been ascertained knowledge of the subject. J. R. MARTIN." MARTix." by Dr. Buchanan is, that a, stricture removed in the way just (Signed) described is not apt to return. The patient on whom Dr. Sir GEORGE BALLINGALL, in the last edition of his admirable Buchanan first operated, and for w-hom he had his instrument " Outlines of Military Surgery," saysof the memorandum just constructed, died last year, at the advanced age of eighty-seven, quoted :-" This excellent suggestion has not been as yet acted and the day before his death a fall-sized catheter was introupon, and consequently no established plan has been adopted duced without difficulty into the bladder. The stricture under for the construction of barracks and hospitals either at home which this gentleman laboured was a very tight one and of long duration, and the breaking it up caused a profuse haemoror abroad." rhage ; but after a lapse of ti,,-eiatv -five years there had been no return of it. Many similar instances have occurred of complete immunity for less periods. Dr. Buchanan ascribes this permanence in the cure to the mode in which it is effected, of which he considers the principle to be, not dilatation, in the usual sense of that term, but disruption: the larger tubes " Audi alternm partem." passed over the smaller ones tearins’ un the indurated tissues all round, without occasioning any serious lesion at a single

SirI

principle

Correspondence. THE

point.

COMPOUND CIRCULAR CATHETER AND MR. Dr. Buchanan’s instrument was devised by him in the year 1822, but he did not get it constructed till 1831. Since then, T. WAKLEY’S STRICTURE INSTRUMENTS. or for nearly thirty years, he has used it constantly both in [LETTER FROM DR. ANDREW BUCHANAN, JUN.] hospital and private practice, has advocated its employment To the Editor of THE LANCET. in his clinical courses, and professes himself at the present moment well satisfied with the results he has obtained. An SiR,—Seeing that Mr. Wakley continues to draw public with an engraving, was first pubattention in your columns to the treatment of urethral stricture account of it, accompanied lished in the JJ1 edical Gazette for March, 1841. In France, M. that and this by rapid dilatation, considering procedure pos- Gerdy had before employed a series of canulee in the treatment sesses great advantages in enabling any surgeon, endowed with stricture; but these canulse were all of the same length, the ordinary care and perseverance, to dispense, in ninety-nine of smaller ones (callules de remplissages) being merely intended cases out of a hundred, with the use of the bistoury, and in fill up the void in the larger, and so to form a single cona in of a few cure days, that, according to completing, the space to the ordinary routine, would take as many weeks to accom- ductor to the stricture for a small sound or bougie, by which dilatation was effected. Dr. Buchanan was therefore plish, I think it only fair to Dr. Buchanan, of Glasgow, to alone remind your readers of the instrument" hich he has long ago the first, as far as I know, to introduce into the practice of surgery an instrument consisting of a series of metallic tubes employed. This instrument is a "compound circular catheter," com- fitting into each other, and capable of projecting one beyond other, so as to effect a forcible passage through strictures posed of three curved metallic tubes, which fit successively the on the principle of the wedge, or to cure them by disi-,tz7)tio?i. the Victoria Cross, to medical officers, would appear to settle their atulus in the army; but their actual position ought not to rest upon chance, or upon the mere occasional circumstance of a decoration. It should be ordered and fixed by a R’)Y:1I Ordinance as one of the permanent sciETinc CORPS of the army. I think that the Medical Corps should rank with the Corps of ltoyal Engineers, and stand next after it in the Army List. The uncertainties which surround the medical oBt.er have at all times proved prejudicial to the interests of the public serviceby occasioning depression and discontent.

Mr. Wakley’s instrument is the same in principle with Dr. Buchanan’s. But there are two differences: the one in form, the other in the mode of using it. Dr. Buchanan’s instrument is an arc of a circle ; Mr. Wakley’s is straight. Dr. Buchanan always uses his instrument as a whole, both to secure the wedge action and to keen the smaller nieces in the axis of the

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urethra; Mr. Wakley uses separately his central pieces or difference is not local but personal, the divergence not being guides, in the same way as a silver sound of small size is em- greater between Mr. Syme and M. Ricord than between the ployed-to pass into the bladder at first, while he only uses two professors of clinical and systematic surgery respectively his tubes to complete the dilatation thus obtained. in the University of Edinburgh. I am, Sir, your obedient servant, Without attempting to form a comparative estimate of the J. B. SANDERSON, M.D. D. two instruments and operative processes, I shall content mySANDERSOX, M. Gloucester-place, March, 1853. self by saying that there are probably cases where each instrument and mode of operating may have its advantages. It is useful in the meantime to urge the importance of the principle on which both instruments depend for their efficacy. The cases of Mr. Wakley, which have been brought more prominently before the public eye, prove of themselves the correctness of that principle : they show that it saves both time and irritation to cure a stricture quickly, and that, while success is just as attainable, it is much less dangerous to dilate a stricture than to employ internal or external incisions. I remain, Sir, your obedient servant, ANDREW BUCHANAN, Jun., M. M.D. D. Paris, Rue de Vaugirard, Feb. 1858. more

common

THE INFLAMMATION AND BLOODLETTING CONTROVERSY. [LETTER

FROM

DR. J.

To t7te Editor

B.

SANDERSON. ]

THE LANCET.

OXYGEN

GAS

IN

SCARLATINA.

To the Editor of THE LANCET. SIR,—A few weeks ago, when attached to the H.E.I.Co.’t depot at Warley, I had an opportunity of testing the efficacy of oxygen gas, in a very bad attack of malignant scarlatina, with its accompanying putrid sore-throat. The post hoc, ergo propter hoc was so emphatically marked in this case, that I have no hesitation in attributing the patient’s ultimate recovery to the vivifying effect of oxygen upon his system ; an effect which (to say nothing of the gas’s inherent renovating influence) permitted the successfuloperation of those remedies which would have utterly failed to exert their therapeutic efficacy without it. A livid countenance, delirium, hurried and laborious respi. ration, with an almost imperceptible wrist-pulse, too surely indicated the rapid approach of death by a mixture of coma and

of apnœa. The first few inspirations of the gas reddened his cheeks, the SiR,—Your correspondent, Dr. Markham, having substituted for the important question which was the subject of discussion radial artery pulsated freely under the finger, and consciousbetween us another which appears to have little relation to it, ness so far returned that he begged the tube might be removed I should have been glad to have withdrawn from the field alto- from his month, "for that he was being burnt up with this gether had I not been compelled to the opposite course by an new stuff which we were giving him !" Slight cough, too, was implication of mis-statement. Dr. Markham has attributed to induced ; indeed, this result was a source of considerable annoy. me an intention of "screwing" out of the writings of his friend, ance throughout. Mr. Syme, a sentiment which they are not intended to convey. The gas was administered on six separate occasions, (extend. I shall place side by side the short sentence in which I ing over a period of two days,) each administration comprising .alluded to Mr. Syme’s practice and Dr. Markham’s reading from four to ten inhalations. During this time the following of it. remedies had opportunity to act : Disulphate of quinine, ten Mr. Syme uses mercury, " Mr. Syme is a giver of grains ; dilute sulphuric acid, two minims ; tincture of berberry, and directs us how to use it mercury in syphilis, just as half an ounce ; arsenical liquor, five minims ; water, an ounce in his book-."-THE LANCET, vigorous as the best of mer- and a half. To be taken every three hours. Five doses of this THE LANCET were administered, and (the improvement being decided and Feb. 27th. curializers." March 6th. persistent) the same prescription, minus the berberry, was conMy statement was founded on my recollections as well of tinued, in diminished quantities, fer several days longer. The Mr. Syme’s practice as of his writings ; and to enable your patient had, previously, been well supported, moreover, with readers to judge of its accuracy, I shall quote the following lime, beef-tea, and diffusible stimulants; and chlorine, both as passage from the third edition of the " Principles of Surgery," a drink and by injections along the floor of the nares, had been published in 1842, which, for further illustration, may be com- freely administered. The case was one admirably adapted for the exhibition of pared with Dr. Markham’s passage taken from the last edition of that work :oxygen. There was no complication, but simply a tendency The modified use of mer- to extinction of life from the overpowering noxiousness of the Mercury ought not to be ,abstained from altogether in cury, which is at present so poison ; and I apprehend that it is in just such cases in practice "

-

"

"

the treatment of venereal diseases, unless the state of the constitution is peculiarly unfavourable, since, under proper management, it often greatly accelerates recovery."—Prin-

much the fashion in Paris and elsewhere, is nothing but a system of systematic quackery," ...." and injures the health no less effectually than the process of poisoning which it pro3rd Edition, fesses to have superseded."ciples of Surgery, 303 The same quoted by Dr. Markham, last Edition, p. 379. I leave it to your readers to judge how far and in what direction the charge of misinterpretation attaches. In answer to your correspondent’s question, I beg to observe that the admission of his hypothesis that syphilis is curable in Edinburgh without mercury, but incurable in Paris under the same treatment, is equivalent to asserting that the disease is different in the two places. The following passages seem, however, to show that, in the experience of the " highest authority," M. Ricord, it is not less tractable in Paris than elsewhere. After remarking that it is now " definitely proved" that both chancres and secondary symptoms occur which are cured without mercury, and pointing out the danger of yieldremarks, ing to the single indication of administering it, he be accused of " screwing" (I give his own words, lest I should " S’il est souvent indispenM. Ricord as well as Mr. Syme.) sable et sans succedanees, il est des cas ou l’on peut s’en passer, d’autres ou l’on doit s’en abstenir, et des circonstances encore plus nombruses, où il ne constitue qu’un element, parmi les moyens varies qu’on doit employer pour amener un malade i1 parfaite guérison."—Hunter Un Syphilis," French Edition, with Notes, by Ricord, p. 722. In conclusion, I beg that it may be distinctly understood, that I do not maintain that there is no difference between Mr. Syme’s therapeutics and those of other surgeons, but that the r

‘

276

where we shall derive most benefit from the gas. On admission, the patient (M’A——, a recruit) complained of general feverishness, with acute pain (as if plearitic) in the left side. There was no rash then, nor did it appear for several days. Eventually it showed itself, assuming a livid hue, about the trunk and extremities; but it came out very partially, and with a tendency to recede, and reappear, throughout. The most prominent symptom was the sore throat; and on this I would offer a few remarks. On examining the throat, on the third day after admission, the left tonsil was found to be covered with a grey, ash-coloured rubbed over exudation, looking as if it had been recently with nitrate of silver. The other tonsil was red and enlarged, and there was a heightened vascular condition of the soft parts generally; but no further appearance of exudation. That from the left tonsil was detached with a pair of forceps, and found to consist (as shown by its physical, chemical, and microscopic caracters) of plastic lymph. The same substance was subsequently (after extension of the exudatory inflammation) coughed up in shreds; and an acrid fluid was discharged from the nose. Here, then, were the essential characters of dip7it7ti2ite! Eventually, a general sloughing from all the neighbouring soft parts took place; and then the throat was seen as in the condition of ordinary scarlatina maligna. It has fallen to my lot to see several cases of diphtheria, both in the damp hills of India and in Essex, and I am strongly inclined to think that there is a far closer connexion between this disease and the sore-throat of scarlatina maligna than between it and croup, as put forth by some modern writers. They urge that diphtherite is nothing more than croup a little higher up the passage, down which it is apt to extend itself into the larynx and trachea,--(when, indeed, it veritably

freely