few remarks on the use of some agents, such as benzoic acid, thymol, and others, which might possibly be useful in therapeutics. Our first object being to obtain an antiseptic vapor of definite strength; when it was observed, I believe by myself for the first time, that carbolic acid apparently evaporated at the same rate as the water with which it was mixed, it was clear that we had thus presented to our use the most simple and accurate means of testing this question. When I say that vapor of carbolic acid appeared to come off equally with the water, you will understand that I was using the only tests that I could apply personally, and that this observation arose, not by accident, but the result of a series of experiments made with several substances, of which the volatile oils were the most important-the oils of turpentine, eucalyptus, cloves, cubebs, cinnamon, and many others, the experiments being made simply to determine this question of how they acted when boiled with water. There were no data to assist; as you can easily understand, this question would not offer much attraction to any one but a medical practitioner who had a special object in view. Having found that none of the substances had this peculiar property of carbolic acid, I felt impressed with the importance of submitting my own results to further experiment conducted by scientific chemists. It appeared to me most necessary that there should be no mistake upon this point, and I must take advantage of this opportunity to express my obligations to Dr. Piesse, and Mr. Johnston, for the care and trouble they took in deciding a question of some difficulty in chemical. analysis. acid mixed with water evaporates in constant ratio, a fact observed, I believe, by Professor Roscoe. The experiments of Dr. Piesse and Mr. Johnston were entirely confirmatory of those I had made in a different manner, so that now I am in a position to assert that for the purposes of testing the antiseptic method in the treatment of pulmonary disorders we have a reliable, accurate and convenient plan at our disposal. I will read you the letter in which Dr. Piesse states the results of his experiments: "January 1, 1884. "The experiments consisted of three sets, each of six experiments. "The strength of the solution of carbolic acid in Set 1 was 5 per cent.; in Set 2, 22 per cent.; in Set 3, 0.5, 1⁄2 per cent. "The modus operandi was as follows: "Six flasks were taken, numbered 1 to 6, and into each a solution containing 10 grammes (150 grains) of pure cystallized carbolic acid (absolute phenol) was poured, and the bulk of fluid made up to 200 centimetres by the addition of distilled water. They were then set to boil, and were boiled vigorously: "No. I for 10 minutes respectively. In each after cooling and restoring to its original bulk with distilled water, the amount of phenol remaining was estimated by pouring in a standardized solution of hypobromate of soda, containing a trace of free bromine." Then follow the actual figures in a tabular form, from which it will be clear when we consider the nature of this analysis that for practical purposes the vapor is constant in its quality. I will not trouble with these figures as they would more suitably be submitted in a printed form. you The determination of the quantity of carbolic acid in a given solution is not a very easy matter. What was done was this: A certain measured quantity of water was taken, and to this a certain definite quantity of pure carbolic acid was added. This was boiled until a certain quantity of the solution had evaporated, and the remainder was then tested. Again, another quantity was evaporated and the remainder tested in the same way as before; and this operation was repeated until the solution had been entirely used. It was thus easy to determine whether the carbolic acid kept a constant proportion to the water or not. If the solution contains carbolic acid in It is known to chemists that hydrochloric ❘ the proportion of 1 to 80 as the strongest, The next question which arises is this, What proportion of carbolic acid and water should be used to afford a vapor of certain value as an antiseptic, in which the carbolic acid is reduced to a minimum? for there is clearly a disadvantage in using a vapor stronger than necessary; or, worse than that, injurious effects might follow from it. and from that to 1 in 150, we can be certain of obtaining a vapor of high antiseptic properties. A vapor stronger than 1 in 80 acts as a solution would upon the skin and produces the usual irritating effects which follow the application of carbolic acid. A drachm of carbolic acid, that which is known as Calvert's No. 2, added to from fourteen to sixteen ounces of water, will be found to supply a vapor of proper qualities for the purposes required. I would suggest now a simple plan by which the vapor can be exhaled. Instead of boiling the solution in a small vessel or in a kettle from which the steam would pass off at a high temperature, and thus considerable danger might arise of accidental scalding of the mouth or throat, the steam may be made to issue in a jet at a certain tension. As the steam in this state escapes it carries with it a current of air which quickly reduces its temperature, and reduces very considerably the possibility of the danger arising from the use of vapor at low tension. Some years ago I explained the use of this principle for the supply of warm vapor, as distinguished from steam at high temperature. By the addition to our knowledge of the property of carbolic acid which I have been pointing out, we obtain a current of antiseptic vapor, and we obtain it in such a form that we can use it very conveniently for the purposes of testing clinically the value of the antiseptic theory in the treatment of pulmonary disorders. It has been thought by some that the best plan would be to place the patient in a room the air of which was charged with the vapor of carbolic acid, and theoretically this plan has much to be said in its favor; but I need hardly point out that such a plan must be so greatly limited in its application as to make its general adoption impossible. It has no advantage practically over the plan I have suggested. Now, if you ask the question, What proof is there that the vapor or steam given off by water and carbolic acid when boiled together in the proportions I have stated is surely antiseptic? The answer is simply this, that by experimentally exposing to its action solutions which under ordinary circumstances are found to putrefy, such putrefaction does not occur. The general plan adopted in such experiments is the same in principle as that we employ when testing the solution; it is only modified to suit the altered conditions. It is easy to vaporize many substances by heating them in their pure state, and I promised to make a remark upon some of these. For example, benzoic acid, as we all know, is very volatile. It a piece of dry gum benzoin be heated it parts with the benzoic acid. The same thing happens when a piece of gum benzoin is boiled in water. The benzoic acid evaporates very quickly with the steam. Eucalyptus oil does the same. Here we have two substances which are converted into vapor at very different temperatures. Benzoic acid vaporizes below the temperature of boiling water, while oil of eucalyptus must be raised to a much higher temperature; and yet they both vaporize in much the same way when boiled with water. They differ entirely, however, from carbolic acid. The reason is not apparent, but the fact must be clearly recognized if we use any particular substance in clinical practice. You can easily understand that one person may say that he has obtained such and such results, while another has obtained very different ones, and useless discussion may arise; that is to say, if the methods of vaporizing the substance in question are not stated the real explanation of the disagreements is overlooked. It is therefore necessary if we desire to use any volatile substance for clinical purposes to ascertain the proper conditions for its use. I would advise that we should work for some time with carbolic acid alone and test the antiseptic principle as generally as possible. There may, after all, be no value in it. I am inclined to think from personal experience that there is a great deal in it if it is carried out on accurate and scientific principles. We are too apt at the present day to sacrifice our independence to assumed authority in matters of therapeutics, and I think there is a degree of credulity in our profession which we ought to be on our guard against. We do not trust enough to our own experience, and we are rather too apt to adopt new remedies on insufficient evidence of their merits, and then we are disappointed and discard them. I have been anxious this evening to place before you the question of the antiseptic treatment of a certain class of diseases in such a way as to prepare you to judge independently of the question and to criticise any statments which are submitted to you. SURGERY. IMPORTANT POINTS IN CONNECTION WITH THE SURGERY OF THE URINARY ORGANS. By SIR HENRY THOMPSON, F. R.C.S., in the British Medicial Journal. The Treatment of Stricture of the Urethra by Internal Urethrotomy.-There are two considerations which I am bound to submit to you, since they are those which have influenced my own mind as in some degree a justification for my presence here, and which sustain me in view of the task imposed. The first is, that a period of twenty-five years at least of very active engagement in the practical observation and treatment of the diseases in question has furnished an experience which, I believe, is almost without parallel at the present day. The second consideration is, that it has been my habit from the very first carefully to record at the time, in writing, every case I have had; and that such notes are systematically arranged and preserved, so that they can be produced and referred to whenever required. It is my sincere desire now to offer to my professional brethen a faithful epitome of these facts, so far as they relate to the subjects treated in this course of lectures. a career which I had never dreamed of thus shaping for myself. I claim, therefore, the honor, of being in an especial sense-and it is a legitimate source of pride, I trust, within these walls, to do so-a son of our noble College; and after the third of a century continuously devoted to studies thus initated, I am here to report myself at the paternal hearth to-day, happily finding one of my earliest teachers and college-friends worthily occupying the presidental chair. The seeds were sown, sir, by your predecessors here; and they selected the variety which was distinct. The gathered harvest could only correspend thereto; and, such it is, I desire, with your permission, to garner it here. [The lecturer then gave a brief but carefully considered historical sketch of the treatment of stricture of the urethra, in England and abroad, during the present century, with a view of "tracing the formation of opinion respecting it, and of pointing out a growing concurrence in opinion among practicing surgeons that, in dealing with stricture by operation, free incision of all the opposing structures must be adopted or the result will be temporary only, and disappointing.] I have just alluded to Professor Syme's One word more I venture to utter regard- early enunciation of this principle, which ing myself, and I do so only for the purpose he decided could only be effectively reof explaining how it is that the experience alised in practice by an operation perreferred to has been so ample in regard to formed in the perinæum, a proceeding these particular diseases. I do so with the which met with great opposition here, and less difficulty, because the explanation is was the occasion of a very acrimonious disfound almost solely in connection with our cussion. A cardinal defect in his method Royal College here. I just now spoke of is now, at this distance of time, apparent. twenty-five years of active surgical practice; Recognizing the truth on which I have but thirty-three years have elapsed since been insisting, that the divison of the stricthe Council of our College offered for com- ture must be complete, he limited himself petition, in 1851, as the subject of a Jack to the division of one stricture only, rarely sonian Prize. "The Pathology and Treat- being able to reach or deal with two from ment of Stricture of the Urethra," many the perineal wound, if, indeed, he cared to questions concerning which were at that recognize the existence of multiple stricture; time warmly discussed by the profession or, at all events doing so, he believed in both at home and abroad. The time hap- the disappearance of other or minor conpened to coincide with my entry on profes-tractions, after the principal stricture had sional life, after an active house-surgeoncy at my hospital and elsewhere; and such a proposal offered the very occupation wanted by one whose time was now unoccupied, and who desired nothing so much as a defined object at which to work seriously and laboriously. It was the accident of obtain ing that award, and not long after, another Jacksonian Prize-an essay on the prostate in 1859-which determined the nature of been freely divided. There is no warrant, however, for any such belief; it will not suffice for the purpose of affording substantial relief to a patient, whose urethra is narrowed by stricture in two or three distinct situations, to divide, however freely only the chief of these, and leave the rest untouched. So far from a secondary narrowing disappearing after what has sometimes been termed "the master stricture" has been cut, it often happens, at no distant period, that the points formerly slightly affected seem to assert themselves more obstinately than before. I cannot, therefore, insist too strongly on the value of an axiom, which I will venture thus tersely to formulate "if you cut at all, cut all," that is, all the points in the urethra at which the presence of obstructing deposit is to be demonstrated, and all the obstructing tissue at each point. Such is the unhesitating conviction which a long experience of internal urethrotomy has forced upon me. In the year 1854, I published the Jack sonian essay referred to; and, after much personal intercourse and study with Professor Syme, I adopted his view in relation to the permeability of structure-a circumstance which I now regard as one of the most valuable of the many important lessons I learned from that most able, fearless, and honest man. I have, in the course of my life, met with three instances in which, after much careful manipulation, I have been unable to pass an instrument fairly into the bladder; and in these three instances only have I performed perineal section for the relief of stricture without a guide previously passed. Between 1852 and 1855, I operated by Syme's method of external urethrotomy upon a grooved staff nine times only, thenceforth, exchanging it for internal urethrotomy, which I have practiced systematically ever since; at first, on the very worst forms of the disease only, and gradually, as the result of increased confidence in it and satisfaction with the results, much more frequently than at first. And now and then, but very rarely-for example, when large abscess and perineal fistula af ford the perinæum-the division on a grooved staff has still been resorted to. These remarks on this important subject lead me now to present briefly an epitome of what my experience has led me to regard as the safest and most efficient mode of treating a confirmed example of organic stricture of the urethra. I think it will be agreed by most experienced surgeons that, on. first verifying the presence of an urethral narrowing, the history of which is recent, as a rule, nothing need be done beyond gradually restoring the calibre of the canal to its normal state, or thereabouts, by means of flexible bougies. The well known form styled "olivaire" can scarcely be improved; and if it be desired to carry the process of dilatation as far as possible, the well polished tapering silver or silver-plated steel dilators are very ef ficient, and at the same time unirritating to the passage. Modifications of the flexible bougie are, however, now so numerous, in regard of form, material, and even also of their internal contents that each surgeon will doubtless employ most advantageously that which best accords with his own views, and with his own manner of manipulating. There are, of course, congenital organic as well as acquired narrowings of the external meatus, and near to it, which will not dilate, and which a simple incision suffices to divide. Strictures also affecting the canal within three or four inches of the orifice do not benefit much, or for any prolonged, period, by dilatation. But when, in the ordinary case of recent stricture, the canal has been restored to a full calibre by dilatation, it may be often maintained so by an occasional regular use of the bougie by the patient himself for several, sometimes for many, years. In after life, however, as all the tissues become more rigid, those which form the stricture also dilate less readily, and a smaller instrument than formerly can now only be passed. But sometimes even this sign scarcely shows itself; for which reason I think it unwise, as a rule, to propose an operation in the early stage of stricture, but prefer to afford a patient the chance of its being amenable for many years, if not altogether, to the very simple treatment indicated. But whenever a decided tendency to contract manifests itself, be it sooner or later, I think it is wise to resort to internal urethrotomy without delay. Were this plan always pursued, we should have no perineal abscesses or fistulæ, no consecutive chronic cystitis, with organic changes in the bladder, ureters and kidneys, as a result. Then to advise the delay of an operation until symptoms indicate that such complications are appearing, involves complicity in a course which irretrievably damages the patient's life. Hence I have no hesitation now in advising internal urethrotomy whenever organic stricture, single or multiple, near or distant from the meatus, shows signs of not yielding readily to dilation. No delay is, in these circumstances, of any value as regards the stricture. When cases are first met with in a more advanced stage; when the use of dilating instruments is liable to be followed by temporary retention of urine, or by rigors, then very little question can arise as to the propriety of operating. It is very rarely too late to incur any risk there may be in doing so; and the persistence of the phenomena mentioned must, if not checked, undermine the constitution of those who are the subjects of them. In relation to those cases in which rigors almost always occur after the passing of a bougie, I know nothing so admirable as the results of urethrotomy; since, if completely performed, the operation itself is, in these cases, rarely followed by such an occurrence. I am convinced, therefore, of the necessity of ensuring complete division of all the obstructing tissue; not only in relation to future results, but to the present well-doing of the patient; and thus have an additional support for the value of my maxim: "If you cut at all, cut all.” This brings me to a very important subject. How are we best to ascertain, before undertaking to divide the morbid tissues constituting strictures what are their extent and situation? In other words, what is Lecessary, for our purpose, to be done to diagnose the physical condition of the urethra ? each bulk follows the sizes of the catheterscale employed, will supply accurately the data required, and on the easiest terms possible to be obtained. Such a series I have used for thirty years, and no other except for trial; and I have never seen any plan equal to this for simplicity, efficiency, and for effecting the object without inducing irritation. They are better also than flexible instruments of the same form, which are less easily used, and are far less accurate in the inductions they afford. Suppose, then, the case of a patient for whom it is decided to perform internal urethrotomy. The external meatus is first examined, and is often found to be contracted; a bulb, say No. 12 or 13 in size, passes tightly through it, and stops perhaps at an inch or more from the orifice; after the use of three or four smaller sizes, a No. 9 passes, and meets a check at five inches; and here, after other trials, a No. 2 or 3 goes on into the bladder. On withdrawing the bulbous instrument, the situation of of the contracted parts is again verified by the check which the bulb receives in passing them in its progress outwards. It is clear, therefore, in such a case, that there are at least two chief points requiring incision, besides the orifice. This is all that need be ascertained before the patient is rendered insensible for operation, when the examination may be repeated, if the surgeon desire to do so with more minuteness before incising. It may first of all be remarked that, in a simple and recent case of strictured urethra, and therefore for a large proportion of all the cases of stricture, a very simple proceeding suffices to ascertain where and to what extent the canal has been morbidly narrowed. And as all instrumental interference with the urethra, however delicately effected, is apt to provoke irritation, which in a few persons is serious, we are not war-tance-namely: What is the principle on ranted in introducing large or complicated mechanical contrivances for the purpose of diagnosis, at all events in recent cases. It suffices for the purpose to introduce a full sized bougie, by which I mean one which will pass in a healthy urethra without stretching it, merely separating its walls, to about the same extent as the flow of a full quantity of urine will do, when it passes naturally. Such a stream, in most persons, equals a volume, perhaps, of ten, eleven or twelve of the English scale. If such an instrument fail to pass, we diminish the size until one is found which does pass, after which, dilatation may mostly be speedily and effectually made, and nothing more may be necessary. If more specific information be desired, in an exceptional case, a series of solid bulbous-ended instruments, of which the stem is slender, and Now, at this point, it is necessary to consider some preliminary questions of impor which an intra-urethral incision which is out of sight ought to be made; and what is the best instrument to accomplish the purpose? Is the division of tissue to be complete, and to be made solely according to the judgment of the operator; or, is it to be made by a machine, the action of which is not necessarily to divide all opposing tissue, but simply to do so sufficiently to permit the introduction of a fair-sized catheter through the urethra, when the cutting-instrument is withdrawn? For example, we may introduce a small grooved staff along the urethra into the bladder, and then slide along the directing groove a blade more or less protected, so as to divide such tissues as lie within range of its point or edge, and no more. But this, I contend, is not an efficient mode of dealing with urethral obstruction, if its complete division is the ob |