may be dispensed with, and the patient may commence a course of tonics with gymnastic exercises, sponging, &c., as spoken of at p. 299. Violent exercise should not be indulged in for the first few days after the operation, but a moderate walk need not be interdicted. In from four to ten days the patient may take a little claret, and subsequently resume his usual mode of life, observing, however, abstinence from tobacco or strong coffee.

Relapses. The result of my experience proves that relapses of the local affection after cauterization do not often take place, nor is a second operation required; still every now and then cases like the following occur:-In 1853 I cauterized Mr. for spermatorrhoea; in August, 1854, he returned, telling me that after the last operation emissions had almost ceased, and his health improved, when within six weeks he paid attention to, and was the accepted lover of, a young lady. The marriage was to be delayed till Christmas. Lately the emissions had recurred with redoubled frequency, and he was falling into his former condition. Hearing that he would not see his intended for four months, I told him the emissions would probably cease, and if not, to take the ordinary precautions-baths, exercise (gymnastic), attention to diet and drink-and come to me a fortnight before his marriage, when I would repeat the operation.

The few cases followed by relapses are those in which men are engaged, but cannot marry from pecuniary circumstances; we meet with relapses likewise among some who will not or cannot take regular gymnastic exercise.

Beneficial effects of the operation.-The advantages of injecting a solution of nitrate of silver are so manifold, that I now never employ any other plan, and yet I have occasionally to treat some of the most obstinate forms that others have failed in curing. The operation as here described has never been attended with any unpleasant results, and I have never been called up, or been subsequently sent for, in consequence of the alarm of the patient. If the surgeon takes the precautions I have above spoken of, I have no reason to think that any untoward symptoms can

arise.

I am told that, in some of the books on spermatorrhoea so largely advertised in the papers, the operation is inveighed against in no measured terms. The only reply I wish to make is, that in my hands I find it most efficient and effectual, and my patients only regret that it had not been proposed to them earlier. As a result of cauterization, the patient succeeds in obtaining a control over the will which he never had before. The morbid irritability of the canal disappears, the emissions cease, and the health improves. The caustic appears to modify the local condition of the veru-montanum, and the effect is permanent if supported by other treatment. In this mode of operating the liquid comes in contact with every part of the canal, and does not leave untouched those depressions which escape the solid caustic, when used in Lallemand's instrument. We also have every reason to believe that by this plan the fluid enters the follicles, which are so frequently the seat of the disease, and thus tends to the cure of the complaint.

The success which has attended this mode of operating has induced me to lay aside Lallemand's instrument, which, when I commenced practice, more than thirty years ago, I used to employ. I have altered and improved the instrument I recommended on page 291 so much, that I now consider it perfect, both on the score of simplicity, usefulness, and impossibility of getting out of order.

As, however, in a work like this my readers may be desirous of comparing the one instrument with the other, I subjoin a woodcut of the catheter used by the Montpellier Professor; and I propose giving a précis of the mode of employing it, taken from his latest published edition.

ab

LALLEMAND'S PORTE

CAUSTIQUE.

Lallemand's plan.-A catheter should be passed in order to empty the bladder, and to judge of the length of the urethra. This, the Professor recommends, should

be done by stretching the urethra, and, as the catheter is withdrawn, watching the moment when the water ceases to pass. Having thus discovered the length of the canal, if the finger be placed on the instrument at the point just beyond the glans penis, the exact depth to which the porte caustique should be subsequently introduced may be accurately ascertained. On the instrument which goes under Lallemand's name, there are means for measuring this distance which can be fixed by the slide seen in the woodcut.

enema.

When I was in the habit of employing Lallemand's porte caustique, I did not find it necessary to pass a catheter, as I usually enjoined a patient not to drink on the day I propose applying the instrument, and requested him to empty the bladder immediately before its introduction. It is a good precaution, moreover, to previously relieve the bowels by castor oil, or by means of an The porte caustique must be prepared in the following manner:- "Fuse some broken pieces of nitrate of silver in a watch-glass held over a spirit-lamp by means of a pair of forceps, taking care to apply the heat at first at some distance, otherwise an explosion may take place; when fused, the caustic should be poured into the little cup (see woodcut), allowed to dry, and the projecting portions removed by a file; the canula must then be returned into the closed instrument, which, after being oiled, may be passed down into the bladder, the patient being in bed or lying on a sofa; a surgeon at all in the habit of passing instruments is able to distinguish when the instrument enters that viscus. The diseased part is at once known to the patient (so Lallemand states) by the instrument causing some pain. This once ascertained, the surgeon will withdraw the outer canula to the extent of half an inch, and at the same time give a rotatory motion to the inner canula containing the caustic. By this means the diseased surface is slightly cauterized, eschars are not necessarily formed, nor are any passed in the urine, and the internal canula, being drawn within the external one, cauterization is confined to the morbid structures only. Rest in the horizontal position must be enjoined, and the patient desired not to make water for some hours. If pain comes on, a good dose of lauda

num, or an enema with opium may be prescribed. For the few following days there is some pain in making water. The discharge increases, and is mixed with a little blood; but by attention to diet and rest, together with moderate doses of copaiba or cubeb capsules, these symptoms abate, and with them the emissions, although in some cases the cauterization may induce one or two escapes of semen during the following nights. Sexual intercourse must be strictly prohibited, and any cause which may originally have produced spermatorrhoea must be studiously avoided. In some cases it may be necessary to have recourse to a second or third application of the caustic; but at least ten days should elapse between each cauterization, and any accidents. which may arise must be treated on general principles.

In the annexed woodcut the instrument is nearly straight, but experience taught me that such instruments cannot readily reach the bladder, and I formerly employed instruments with a considerable curve, which facilitated the passage of the catheter. The cup is usually made too deep; this causes the surgeon to use not only a large proportion of caustic, but requires great care in removing the salt when it has been used. After performing the operation, I usually withdraw the canula, and soak both it and the part holding the caustic in water, or with a pointed instrument remove the nitrate of silver.

Lallemand does not assert that his plan of cauterization will be always successful. "It has succeeded," he says, "in cases where atony and debility were the prominent symptoms; less rarely when accompanied with nervous symptoms, and a strong hereditary tendency." (Vol. iii, p. 392.) Again, he says, "Twothirds of the cases of spermatorrhoea would be beyond the resources of our art, were it not for the assistance we derive from this powerful medication." (Vol. iii, p. 406.)

In twenty years, during which he was daily in the habit of using the instrument, he asserts (p. 401) that he never saw any ill consequences arise from the treatment, and I can fully bear out this statement, as far as my own experience is concerned.

Treatment after Cauterization.-As soon as the effects of cauterization have subsided, the surgeon should take steps to

improve the general health. All the remedial measures (which others may have tried in vain before the cauterization) to build up the health of the patient may now be employed with the greatest advantage. Among the foremost of tonic agents stands the sponging-bath, of which we have already spoken (p. 37).

In addition to the employment of the sponging-bath, a patient should take regular exercise short of fatigue-as boating, fencing, rackets, quoits, riding, boxing, and gymnastics generally. To ensure regularity in London, I usually recommend a convalescent to place himself under the tuition of one of those persons who superintend gymnasia, and who are usually very attentive. If my patients cannot stay in London, I devise some scheme for exercise which they may be able to carry out at their own homes. Thus

One may be able to cleave wood, another to grind corn in a mill, another may prefer skittles or bowls. Quoits is an excellent athletic exercise; a cart-rope attached to a bough of a tree, or beam in a barn or shed, will serve as an extempore gymnasium. If no other means of obtaining muscular exertion be possible, I recommend dumb bells or the Indian clubs. In one or other of these ways muscular exertion may be regularly employed. Excessive walking I find objectionable, as if carried to any extent it will produce determination of the blood to the sexual organs and subsequent emissions; the same objection may be urged against riding on horseback. The effect of exercise in diverting the activity of the circulation from the genital organs into other channels was known to the ancients, who, with their very numerous gymnasia, could not fail to remark the continence of the athletæ. It is likewise a well-known fact that those who are obliged to undergo great physical exertion are remarkable for their abstinence from sexual indulgence. The moderns who are training are well aware that sexual indulgence wholly unfits them for great feats of strength; and the captain of a boat strictly forbids his crew anything of the sort just previous to a match. Some trainers have gone so far as to assure me that they can discover by a man's style of pulling, whether he has committed such a breach of discipline over night, and have not