uneasiness or pain. The same operation is repeated in a day or two, higher numbers being gradually employed, and in this way very obstinate strictures have been cured in five or six days. Permanent dilatation, as its name implies, is effected by leaving the instrument permanently in the bladder. Some surgeons commence with the gum-elastic catheter, but as the cases to which this method is generally applied are difficult, I believe it will be better to employ a metallic instrument in the first instance. This may be allowed to remain in the bladder from twenty-four to forty-eight hours; it is then withdrawn, and a gum-elastic catheter is substituted for it. When this instrument has been safely passed into the bladder, the stylet is withdrawn, the mouth of the instrument closed with a plug, and the catheter is secured in its place by a proper bandage. According to the effects produced, the gum-elastic catheter is allowed to remain for a longer or shorter period in the bladder before it is removed. Some leave it in for three or four days only. Other surgeons who fear the consequences of too rapid dilatation leave it in for six or eight days. Whichever course you may pursue, the instrument, after the period selected, is withdrawn for twelve hours, and one of larger calibre substituted for it. This is withdrawn in its turn after a few days, a still larger catheter employed, and the operation repeated until the calibre of the structure is dilated to its natural size. But this and the ordinary modes of dilating strictures by the successive introduction of instruments, the calibre, or to use the technical word "number," of which is gradually increased, obviously involves the necessity of withdrawing one instrument before another of larger size can be introduced. Now this is often a very great disadvantage. In certain cases, the surgeon frequently experiences almost insurmountable difficulty in the introduction of an instrument, and when with great patience, skill, and labour he has succeeded, no sooner is the sound introduced than it is withdrawn. This must be frequently done during the course of the treatment, and if the stricture be tight, or any considerable tendency to spasmodic action exist, it may be impossible to pass in the original instrument, much less a larger one. In all our actions it is a great point to retain possession of any advantage once gained, and it is highly important in the treatment of stricture to "keep the command of the urethra when once pervious." To attain this desirable object, Mr. Thomas Wakley has invented several ingenious instruments, the utility of which has been demonstrated by very extensive practical application. Here are Mr. Wakley's instruments, (See "Braithwaite's Retrospect,' vol. xxiii, p. 232, for a full description of the instruments by Mr. Wakley.) They are intended to ensure, as I have said, entire command over the pervious urethra; and they present this additional novelty, that in their effects they combine two methods of treatment commonly employed-viz., rapid and permanent dilatation of the stricture. Mr. Wakley's instruments are simple, and easily understood. They consist of a small silver catheter No. 2, of the ordinary size, which is introduced into the bladder with the usual precautions. A steel index-rod is then screwed on the end of the catheter, and the com α I (a.) The catheter and thumb-slide. (c.) The steel rod. The rod and catheter combined make the index-rod. (d&e.) The silver tubes. (.) The elastic tube. (g.) The elastic tube running over the directing-catheter. (h&i.) Silver tubes running over the director. (k.) The upper part of h & i,-the steel-rod. bined instrument forms what Mr. Wakley calls his "index-rod," which serves as a director for the silver and elastic tubes. The silver tubes are eight in number, of graduated sizes, corresponding to the ordinary bougie. They are about nine inches long, straight, of a conical shape at their distal extremities, and accurately fitted to the surface of the index-rod, along which they glide with perfect ease. The elastic tubes are composed of a flexible metal, covered with a gum-elastic fabric. They are of the same size and shape as the silver tubes, and are passed into the bladder over the directing-catheter, which is then withdrawn. When it is necessary to repeat the dilatation, the indexrod is passed into the bladder through the elastic tube, which is then withdrawn, and the silver tubes introduced along the guide in the manner already noticed. From this brief description you will perceive that permanent dilatation is effected by means of the flexible catheter; while the different sizes of the metal tubes, which are safely guided along the index-rod, enable the surgeon to regulate the degree and rapidity of dilatation according as he may think judicious. From the cases published by Mr. T. Wakley, it would appear that he sometimes introduced his metallic tubes rapidly one after the other up to No. 7, and that he is not in the habit of leaving the elastic tube, on the first introduction, for more than half an hour or so in the bladder. Those who are acquainted with the difficulties which often beset the surgeon during the treatment of stricture must confess that the principle on which Mr. Wakley's instruments act is one of deep importance, and that great credit is due to him for the ingenious and perfect manner in which he has attained the desired object. Mr. Wakley has now treated a very great number of cases of stricture with his instruments, and he states that the results have been of the most gratifying description. That the guide-tube must greatly facilitate the introduction of dilating instruments, I have no doubt; but I am not quite so certain that the necessity of always keeping an instrument in the bladder may not occasionally give rise to unpleasant effects. It may now be useful to say a few words on the kind of cases to which the treatment by dilatation is more particularly applicable. Temporary dilatation is not only the oldest, but the best of all methods; it is likewise the one most generally employed; yet it were absurd, in my opinion, to assert that it should be applied indiscriminately in all cases and to every species of stricture. It is well suited for recent cases not accompanied by considerable change of structure, and also for those in which more rapid dilatation produces unfavourable symptoms. Many cases of old and hard stricture will also yield to the metallic sound, whereas the bougie produces little or no effect on them. Rapid dilatation may be attempted in cases where the stricture yields readily, or when it is a matter of great consequence to the patient to obtain a speedy cure. But although it is certain that rapid and effectual cures have been obtained by quickly increasing the size of the instruments employed, and by introducing them in quick succession, yet I cannot too strongly caution you on the necessity of prudence whenever this method is adopted, and of watching the case with the utmost care during the whole period of treatment. The urethra often resents these attempts to dilate it in a hasty manner, and a very slight increase in the size of the instrument may cause a reaction, which will continue with obstinacy until we cease the use of instruments altogether. This is seen every day in practice, and surgeons are well aware that any imprudent attempt at forcible dilatation may be followed by severe inflammation of the urethra, or perhaps retention of urine, with fever, nervous symptoms, and other disagreeable consequences. Permanent dilatation is a very efficient method in most cases of bad stricture, where the urethra is dense and resisting, or the canal rendered tortuous by chronic inflammation. It should also be preferred in those anomalous cases where the contact of an instrument with the neck of the bladder produces on each occasion severe shiverings and nervous disturbance of a serious character. On the other hand, there are undoubtedly cases which will not yield to any form of dilatation, but are rather aggravated by it; there are some in which dilatation is plainly contra-indicated; there are some in which no rational hope can exist of our being able to relieve, much less cure the disease by bougies or sounds. I have, however, fully considered these points in a former lecture, and shall now conclude with some remarks on the advantages and disadvantages of dilatation. Although this method of treatment has stood the test of time— and this is a strong presumption in its favour-many objections have been advanced against it. In the first place it has been objected that there are strictures through which a bougie cannot be passed. This is perfectly true; I cannot concur in the opinion that no such thing as an impermeable stricture exists; still I believe that with caution and perseverance an instrument can almost always be passed. There are, however, strictures which cannot be overcome without the certainty of making a false passage; here dilatation should not be employed, and such cases necessarily limit its field of application. To dilatation it is also objected that the surgeon can never be sure of being able to re-introduce any instrument after it has been once withdrawn. This is also true, but the disadvantage has been remedied by the excellent instruments of Mr. Thomas Wakley, of which I have already spoken. Dilatation sometimes produces inflammatory and nervous accidents of a disagreeable nature. This cannot be denied; but I maintain that it is much less likely to excite such disorders than any other mode of treatment, and that the objection holds good against rapid, not against gradual and methodic dilatation of the urethra. The treatment by dilatation is inapplicable to cases of old, callous, or very contractile stricture. This I admit, and would reserve such cases for other modes of treatment. The process is a long and tedious one, and the necessity of confinement or repose is a great inconvenience. Temporary dilatation unquestionably is a slow process; but if it be slow it is safe, and probably as sure as any other method. Unless the case be a severe one, no great repose is necessary, for every surgeon in extensive practice knows that the great majority of his cases of stricture are in persons who follow their usual avocations. Finally, it has been urged that the cure by dilatation is only palliative; the contraction has been removed for a time; it soon returns. This objection, I fear, will equally apply to any other method which may be employed. After the cure of stricture, whether by bougies, caustics, or incisions, a certain tendency to contraction often remains, and it will always be prudent to continue from time to time the occasional use of an instrument long after the disease has been apparently cured. This is an imperfection attached to every method hitherto adopted, and I cannot perceive that it affects dilatation more than any other. The advantages of dilatation, if we admit its efficacy, are obvious. It is safe, painless, and easily managed, being under the control of the operator, and capable of being suspended at any given moment, should unfavourable symptoms set in. By temporary dilatation we avoid the danger of making false passages, or producing retention of urineaccidents which so often follow the use of caustics, or permanent dilatation. The vital contractility of the urethra is better restored by this method than by any other, and it possesses the great advantage of enabling us to ascertain step by step the progress which is being made towards a cure.-Lancet, Dec. 24, 1853, p. 593. 120.-NATURE AND TREATMENT OF SPERMATORRHEA. By JOHN L. MILTON, Esq. Spermatorrhoea admits of a very natural division into—1. Night Discharges; 2. Day and Night Discharges; and 3. Imperfect Secretion of Semen. 1. Night Discharges.-These constitute the mildest form of the complaint, and are, as is well known, a common result of seminal plethora; they seldom require much treatment, unless in excess, or when complicated with gleet, stricture, or discharges in the day-time. 2. Night and Day Discharges-a more advanced grade, and in their worst form often bordering on the third clas.. The urethra is then red and highly irritable, and the health severely impaired; but happily for the patient both varieties are for the most part easily curable. 3. Imperfect Secretion of Semen-the most severe of all, and necessarily accompanied by temporary impotence. Instead of properly eliminated, healthy, consistent semen, a thin, rank fluid, unaccompanied by almost any signs of erection of the penis, is thrown off under the influence of the slightest excitement. Intense irritability of the urethra, and a marked dread of examination, usually complicate this form. There is a variety of the disease which is generally considered as spermatorrhoea, and with which most surgeons are familiar: I mean the discharge after stool of large quantities of glairy, tenacious fluid, supposed to be the contents of the seminal vesicles. Now, I very much doubt if this be an evacuation of semen: great part of it, I suspect, comes from the prostate; and in my work on Gonorrhoea (p. |