ON THE Jiunnnl fbtllw awUti iWfviftwus IN RELATION TO STRICTURES OF LARGE CALIBRE. BY ROBERT F. WEIR, M.O., LECTURER ON GENITO-URINARY DISEASES IN THE COLLEGE OF PHYSICIANS AND SURGEONS SURGEON TO THE ROOSEVELT HOSPITAL, ETC. {REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, APRIL, 1876.] NEW YORK: D. APPLETON & COMPANY, 54 9 & 551 BROADWAY. 1876. THE POPULAR SCIENCE MONTHLY. CONDUCTED BY E. Ei. YOUMAISTS, This periodical was started (in 1872) to promote the diffusion of valuable scientific knowledge, in a readable and attractive form, among all classes of the community, and has thus far met a want supplied by no other magazine in the United States. Seven volumes have now appeared, which are filled with instructive and interesting articles ana nr>- straofs of articles, original, selected, translated, and illustrated, from the pens of the leading scientific men of different countries. Accounts of important scientific discoveries, the application of science to the prac- tical arts, and the latest views put forth concerning natural phenomena, have been given by savants of the highest authority. Prominent attention has been also devoted to those various sciences which help to a better understanding of the nature of man, to the bearings of science upon the questions of society and government, to scientific education, and to the conflicts which spring from the progressive nature of scien- tific knowledge. Tiie Popular Science Monthly has long since ceased to be an experiment. It has passed into a circulation far beyond the most sanguine hopes at first entertained, and the cordial and intelligent approval which it has everywhere met, shows that its close and instructive discussions have been well appreciated by the reading portion of the American people. It has not been its policy to make boastful promises of great things to be done in the future, but rather to appeal to what it has already accomplished as giving i t a claim upon popular patronage. But no pains will be spared to improve it and make it still more worthy of liberal support, and still more a necessity to the cultivated classes of the country. The following quotations illustrate the way it has been habitually spoken of by the press: “ This is a highly-auspicious beginning of a use- ful and much-needed enterprise in the way of pub- lication, for which the public owe a special debt of obligation to Messrs. D. Appleton & Co.”—Boston Gazette. “ This new magazine, in our estimation, has more merit thau the whole brood which have preceded it.”—Oswego Press. “ In our opinion, the right idea has been happily hit in the plan of this new monthly.”—Buffalo Courier. “ This is one of the very best periodicals of its kind published in the world. Its corps of contribu- tors comprise, many of the ablest minds known to science and literature. It is doing a great and noble work in popularizing science, promoting the growth of reason, and leveling the battlements of old su- perstitions reared in the childhood of our race be- fore it was capable of reasoning.”—The A merican Medical Journal, St. Louis, Mo. “This magazine is worth its weight in gold, for its service in educating the people.”— The American Journal of Education, St. Louis, Mo. “ That there is a place for The Popular Science Monthly, no one can doubt who has watched the steady increase of interest in scientific investigation manifested in this country, not only by a select class, but by the entire community.”—New York Times. “ We think it is not too much to say that this is the best first number of any magazine ever pub- lished in America.”—New York World. “A journal which promises to be of eminent value to the cause of popular education in this country.”—New York Tribune. “It is, beyond comparison, the best attempt at journalism of the kind ever made in this country.” —Home Journal. “ It is just what is wanted by the curious and progressive mind of this country, and ought to be widely circulated.”—New York Evening Post. “ It is the first successful attempt in this country to popularize science in the pages of a monthly.”— N. Y. School Journal. “The Monthly has more than fulfilled all the promises which the publishers made in the pro- spectus of publication.”—Niagara Falls Gazette. • The Popular Science Monthly is published in a large octavo, handsomely printed on clear type, and, when the subjects admit, fully illustrated. Each number contains 128 pages. Terms: $5 per Annum, or Fifty Cents per Number. Postage free to all Subscribers in the United States, from January 1, 1875. A new volome of the Popular Science begins with the numbers for May and November each year. Subscriptions may commence from any date. Back numbers supplied. Now Ready, Vols. I., II., III., IV., V., VI., and VII., of The Popular Science Monthly, embracing the Numbers from 1 to 42 (May, 1872, to October, 1875). 7 vols., 8vo. Cloth, $3.50 per vol. Half Morocco, $6.50 per vol. For Sale, Rinding Cases for Vols. I., II., III., IV., V., VI., and VII., of The Popular Science Month ly. These covers are prepared expressly for binding the volumes of Thu Popular Science Monthly as they appear, and will be sent to Subscribers on receipt of price. Any binder can attach the covers at a trifling expense. Price, 50 cents each. Address AGENTS WANTED. D. APPLETON 8p CO., Publishers, 549 & 551 Broadway, New York. ON THE NORMAL URETHRA AND ITS CONSTRICTIONS IN RELATION TO STRICTURES OF LARGE CALIBRE, BY ROBERT FL/W EIR, M.D., LECTURER ON GENITO-URINARX DISEASES IN THE COLLEGE OF PHXSICIANS AND SURGEONS, SURGEON TO THE ROOSEVELT HOSPITAL, ETC. IRE PRINTED FROM THE NEW YORK MEDICAL JOURNAL, APRIL, 1876.] NEW YOKE: D. APPLETON & COMPANY, 549 & 55 1 BROADWAY. 1876. ON THE NORMAL URETHRA AND ITS CON- STRICTIONS, IN RELATION TO STRICT- URES OF LARGE CALIBRE.1 The questions to which this discussion lias now narrowed itself seem to me to be comprised under two heads : 1. What is the size of the normal urethra; and, 2. What are its nor- mal constrictions ? Before presenting to you the views I have been led to entertain on these points, I beg to recall to mind briefly the present status of the discussion. From the remarks made at the meeting of the Society a month ago, it was evi- dent, on the one hand, that the urethra in the dead subject could be distended to the diameter of ten to twelve millimetres in the middle of the spongy portion, and in the bulb from fourteen to twenty millimetres. These measurements corre- spond very nearly with those of casts I had similarly made in 1870 to illustrate some lectures on this subject, and whieh I shall presently exhibit to you, with others. And it is proper to remark here, in order to give due weight to such observa- tions as have been made, that, according to Sir Henry Thomp- son, the method ot determining the extensibility of the urethra by injections of wax and fusible metal is one of the best. In 1 Read before tlie New York County Medical Society, February 29th, 1876, in the discussion on “Gleet and its Relations to Stricture of the Urethra,” inaugurated by Dr. H. U. Sands, January 24, 1876. 4 addition to the figures just given, those obtained by Reybard1 by his registering dilator are also presented in the accompany- ing table. TABLE I. Fossa Navicu- laris. Middle of Spongy Portion. •Bulb. Mem- branous Portion. Prostatic Portion. Reybard (1853 > 11 mm. 14* “ 14 “ 14* “ 13 “ 14* “ 15* mm. 10 11* “ 11* “ 12* “ 11* “ 13 “ 18* + mm. 14 10* 14 “ 20 17 “ 18 18* + mm. 18X + ram. " *• 2 “ “3 14 « 4 “ “ 5 2 Weir (1870) 16 mm. 18 mm. 19 mm. 18* mm. 20 Diameters of the Urethra obtained by To complete this part of the subject it is only neces- sary to add that, in respect to the membranous portion, Civiale found that it was, contrary to the ideas of many, even at the present time, capable of being distended to a diameter of nineteen millimetres, while from the researches of Teevan and Doibeau we have been put in possession of the important fact that the prostatic part of the urethra can be dilated with- out rupture to the diameter of eighteen and three-quarters to twenty millimetres. The practical bearing of these data upon the operation of median lithotomy is evident to you all. But, on the other hand, it was not only shown by Dr. Otis in the painless passage before you of a sound, of the size of No. 40f, into the bladder of a living patient, but also by the revela- tions cf the urethrometer, admitted by all of us as an instru- ment of value in urethral explorations, that the urethra could be dilated in the living subject to a size much beyond what surgeons had been accustomed to. In addition to this, the statement was again brought to your notice that the size of the urethra corresponded to the circumference of the penis, 1 “ Retr6cissements du Canal de l’Urethre,” 1853, p. 12. 2 This cast was recently made by Dr. Sands, and is marked A' in the woodcut. The irregularities resulting from the extreme distention are ad- mirably shown, as well as the dilatability of the membranous portion. The urethra of the subject was unfortunately not examined microscopically, but to close inspection showed no abnormalities. 5 and varied, in a number of cases, at most only a couple of millimetres beyond this fixed ratio. In respect to both these points, I, in common with those interested in this subject, have for some time past critically observed, both in my own practice and in that of others, in order to test the accuracy of these statements; but, while finding by the urethrometer, or by the bougie a boule, or by the sound after enlarging the meatus, that the canal was of the larger dimensions stated, yet many exceptions to the given ratio were met with. It was in those cases where incisions were resorted to by the dilating urethrotome that I first learned to distrust the rule. The blade of the instrument would frequently be carried four to six millimetres beyond the indicated size, and the stricture, even after it had been divided according to the rule, found not to equal the urethra in front of it. To escape this confusion, a suggestion in operating was carried out, of cutting the band so long as any obstruction was felt by the bougie a boule. How- ever, it was soon ascertained that, after the first incision was made, a bulbous bougie of a sufficiently large size could always be made to catch at the upper angle of the wound. Since then, whenever it has been determined to incise a stricture up to the full size of the canal, the calibre of the urethra is pre- viously ascertained by the introduction of the urethrometer. This, however, is somewhat of a digression, but it explains the steps in my loss of faith. The table presented, marked II., shows the results of recent examinations of urethrae that were made, with the co- operation of my colleague Dr. Erskine Mason, and of Drs. Wallace and Heinmiiller, Knight and Rice, of the Bellevue and Roosevelt Hospital house-staffs. The upper figures were derived from patients who claimed never to have had any urethral discharge. The lower portion of the table comprises a few whose history in this respect was unreliable or else who acknowledged that they had had gonorrhoea. I give these cases, not only because they were examined with great care and gentleness, resulting from a considerable experience with the instrument, but also for the reason that these examina- tions were tested by other instruments of like nature, whose construction carried out more fully the principle of the bougie r; a boule, in having a shoulder, than the urethrometer of Dr Otis, which resembles more the ball-probe of Bell. Moreover, as several of these patients had been submitted a short time previously to an exploration, resorted to by Dr. Otis, their satisfactory statement as to the equality of the test, in respect to pain, etc-., was of importance. TABLE II. Size ot1 the Urethka rtf Healthy LiyisO Anti-ts, dum- ber. Age- ! Circum- ference of Penis. Meatus. Bulb, etc. Ratio, 1 30 3 in. No. 19 No. 44 + (the utmost capacity of the instrument used) for % in. ; then 37 for y in. ; then 31 for y in. ; then 26, which save 2 jumps or hitches in next in.; then 27 to fossa navic., which took 32 2 25 3% “ “ 24 No. 44 + for 1% in. ; then 38 for ya in. ; then 33 for y in., with a decided jump; then 28 for y in., with jump thence to fos. nav., which took 30 3 42 3% “ “ 15 No. 44 + for y in. ; then 32y for y in. ; then 25 to fos. nav., which took 30 4 36 3X “ “ 23 No. 33 for 1 in. ; then 29 to meatus, making 2 jumps at depth of 2 in 5 45 3 “ “ 26 No. 44 + for 2 in. ; then 37 to meatus (Weir’s measurement). No. 44 for 1% in. ; then 43 for % in. ; then 36 to meatus (Mason’s measure- ment)—< + 6 28 3y “ “ 23 No. 43 for 1 in. ; then 40 for % in. ; then 33 to fos. nav., which took 35 — 7 21 3% “ “ 26 No. 45 for 1 in. ; then 37 to meatus—fos. nav. not tested + 8 33 3 X “ “ 20 No. 44 + for % in. ; then 4iy for 1 in.; then 40 for % in. ; then 34 to meatus—fos. nav. not tested 9 19 3% “ “ 28 No. 38 + for 1 y in. ; then 36y for 1 in. ; then 34 for y in. ; then 32 for 1% in. to meatus ; with 3 jumps 10 32 3 “ No. 44 + for ly in. ; then 42 for 34 in. ; then 39 to meatus Supplementary Cases. + 11 27 3X'n. No. 23 50 mm. for % in. ; then 40 for 1 in. ; then 35 for 1 in.; then 30 to meatus, with 1 jump..., - 12 42 3)4 “ “ 26 45 mm. for % it). ; then 43 for y in. ; then 40 for % ; then 35 to meatus .... 13 35 3X “ “ 21 No. for ly in. ; then 37 for 1% in.; then 34 for \y in. ; then 25 to meatus 14 35 3« “ “ 21 No. 39 for ly in.; then 37y to meatus + 15 13 2 # “ “ 28 No. 30 from periiiaeum to meatus, with a hitch at 2 in. from meatus v + ? Average of spongy portion in ten healthy urethrae, No. 32.1. From this table the variation in the size of the urethra is seen to he quite marked. In only three out of the fifteen does the ratio hold good. Observe, also, in the boy’s case the dis- proportion ; but upon this it is not proper to lay too much 7 stress, as the rule may be considered to apply chiefly to adults.1 It must be remembered, too, in justice, that the registration of circular urethral instruments is by the numbers of the French scale. Such is the custom, I learn, among all the instrument makers of this city, save in one instance. Hence Ho. 30 (and the more for the larger numbers), which has a diameter of ten millimetres, has, by multiplying this by the correct multiple of 3.146 (roughly 3-|), a circumference of 31 -f- millimetres. As Dr. Otis’s ratio is given in millimetres, this should be borne in mind, and while it may diminish the disproportion in the figures below, yet it necessarily increases those above the supposed ratio. But, as I saw these large sizes of the urethra demon- strated to me, I asked myself, as you have probably asked, "Why did previous explorers, who knew of this dilatability of the canal, apparently ignore it and advise the restoration of a damaged urethra only to a certain inferior calibre ? That they did so appreciate it a few short quotations will show. Ducamp,3 in 1827, said, in inference to the dimensions of the casts of Sir Everard Home: “We can obtain a radical cure of stricture in the urethra only by restoring it to its natu- ral calibre. How, if we compare the dimensions of bougies or catheters with those of the canal, we shall see that this result has never been attained, for the largest catheters in use, Ho. 12, are but three lines in diameter (i. e., Ho. 19 Fr.),” He also invented the bellied bougie, in order to dilate the canal without doing continued violence to the meatus. Yet he afterward limited his dilatation, etc., to four lines in diame- ter3 (i. e., 25 Fr.). Again, Civiale, whom I quote with especial reverence, for 1 The possible variation in the measurement of the penis itself has not been referred to. This is well shown in a case narrated subsequently in the discussion by Dr. E. L. Keyes, where the different external circum- stances, such as cold and warmth, and internal conditions, as a full or empty bladder, without any evidences of erection, gave a circumference which varied on different days from three and five-eighths inches to four and one-eighth inches. 3 Translation by Herbert, Kew York, 1S27. p. 4. 3 Page 120. 8 We must recollect we have in him the experience of a man who had treated fifteen hundred cases of stone, and that, too, in times when debris was often drawn through the urethra in the jaws of the lithotrite, a procedure surely calculated to dis- cover the capacity of the canal—Civiale 1 says that, “ whatever may be the variations among authors as to the diameter of the urethra, it is clearly demonstrated that the canal is larger than is generally believed.” Yet he restricted dilatation, etc., to a diameter of eight millimetres2 (No. 24), coupled, how- ever, with the sage advice to continue the treatment until the gleety discharge ceased. Richet,9 another eminent French surgeon, gives from 30 to 38 as the measurement of the distended urethra in adults, but he, too, advises that instruments not larger than seven or eight millimetres in diameter (Nos. 21 to 24), should be used. And finally, Reybard4 with his knowledge of fifteen and a third millimetres (No. 46), being the diameter of the spongy por- tion, states that eight and a third to nine millimetres (Nos. 25 to 27) mark the natural diameter of the canal. Upon what was such a determination founded by these distinguished observers ? Upon probably twTo points: 1st. The inefficiency of the thorough division of strictures by Rey- bard’s extensive internal incisions, and the failure of external urethrotomy, to effect a maintenance of the calibre of the canal; and, 2d. That these diameters represented to them the size which the ordinary performance of the function of the canal demanded. It is not amiss, therefore, that, a moment or two should be spent on the consideration of this latter point, inasmuch as thus far only the anatomical distention, so to speak, on the living and dead subject, has been entertained. Let us take up the question of calibre in respect to its physiological aspect. The facts germane to this point have been principally elicited by casts obtained by causing some solidifiable substance to gen- tly How through the urethra in such a manner as to simulate the natural discharge of urine. Some authorities, as Ricliet, in 1 “Mai. d’Org. genit.-uritlaires,” p. 34, edition 1858. 2 Page 33. 3 “ Anatom. Medico-Cliirnrgicale,” p. 739. 4 Rcybard, “ Retrecissements de l’Urethre,” 1853. 9 addition to injections, have endeavored to arrive at the same result, by slitting open the previously-nndisturbed urethra, and measuring the width of the canal without any traction being made upon its edges. The former method approximates so much more nearly Nature’s performance of this function, that I have been led to adopt it for the. purpose of determining—1st. The size of the urethra in ordinary forcible urination, representing the aver- age physiological distention ; and, 2d. The size of the urethra in obstructed urination, representing the extreme of physio- logical distention. Inasmuch as the details employed by Hi diet and II ey bard are not given, I have resorted to the following means to arrive at a solution of this question : Experiment I.—From a series of trials, in which some friends cooperated, it was found that urine could be projected in adults varying from thirty to forty years in age, and with meatuses from Nos. 22 to 26, a distance three and a half to four feet when the penis was held horizontally and the bladder distended with several hours’ accumulation of urine. Forcible and steady expulsive efforts of the abdominal walls were em- ployed on these occasions. A penis with a meatus of No. 21 was then obtained from the cadaver of a man of twenty-six, and water forced through it by attaching it to the faucet of the wash-basin, which was turned on until the distance acquired by the jet reached four feet, when the urethra was pinched simultaneously, by an assistant, at the meatus and membranous portion, and the imprisoned fluid collected in a graduated measure. This was repeated twice for correctness. The contained fluid was in each instance the same, viz., three drachms. This amount, with three-quarters of a drachm in addition, as an allowance for the fluid retained in the nozzle of the syringe and connecting tubing, in all three drachms and three-quarters, of a preparation of Chinese gela- tine and glycerine, liquid at a moderate heat, was forced into the urethra to the same points. In a few minutes sufficient hardening occurred to allow of the cast being withdrawn, as it was exceedingly smooth and slippery. A second cast was made, but it unfortunately became dam- 10 A', Forcible distention of a healthy urethra in the cadaver ; A, Urethra less strongly dis- tended; 3, Distention of the urethra in full, free urination ; O, Forcible distention of the urethra in the living subject. 11 aged ; its measurements corresponded, however, with the first one, showing, of course, only by this, the accuracy in manipu- lation. The diameters of this cast, from which those marked B were made, are as follows: At the fossa navicularis, 8 millimetres, “ “ erul of the fossa navicularis, 8 “ “ one and a half inch from the meatus, 8£ “ “ the bulb, 14 “ which correspond, it will be seen, quite closely with the diameters accorded to the natural canal by previous ob- servers. The cast also shows a number of transverse irregu- larities, best appreciated in gently drawing the linger along its moistened surface. It does not, however (nor was this to be expected), show at two and a half or at three and a quarter inches any trace of the strictures detected at these points by Nos. 29 and 30 bougie a boule/ We have now, I think, a fair representation of what is in- dicated by the natural distention of the urethra. So, in order to appreciate the dilatability of the canal under the influence of the full power of the bladder and accessory parts, the fol- lowing procedure was devised: Experiment II.—Urine was voided after several hours’ re- tention, and after the flow had become fully established it was directed into a mercurial gauge, with an assistant to mark the height to which the mercury ascended. This was tried several different times; the expulsive force being exercised up to the point of causing painful distention of the urethral canal. A mixture of plaster of Paris was then forced in to a urethra (of a penis three and a half inches in circumference, and with a meatus of No. 23), which wras attached to the gauge until a similar pressure wras marked by the column of mercury. It was allowed to harden under this pressure, and the urethra then laid open, the cast removed and measured. The diame- ters thus obtained were : 1 See Case No. III., post. 12 At the fossa navicularis, lly millimetres. “ “ end of fossa "avicnlaris, 11 “ “ one and a half inch from meatus, 11 “ “ the bulb, 14 “ This cast is marked 67, and shows to a still more striking degree the transverse ridges observed in the preceding smaller one, as well as those of Sir Everard Home and Dr. Sands. Now, these dimensions, with those obtained by the lire- thrometer, and by solidifiable injections, give us, in recapitu- lation, the diameter of the middle of the spongy portion of the canal in Normal micturition, as to 9 mm., or 26 to mm. in circumference (Weir, Key- bard, etc.). Extreme of physiological distention, as 11 mm., or 84 mm. in circumfer- ence (Weir). Anatomical distention on living, a circumference of 32 mm. (Weir), 31.81 Otis (part of- canal not stated). Anatomical distention on dead, a circumference of 32 to 36 mm., (Sands); 48 mm. (Keybard). From such data it can be easily understood why those who recognize the rarity of a cure of stricture, from experience in this disease, and from analogies of contractions elsewhere, arrest their endeavors at the point of the natural physiological cali- bre of the urethra. But those who are yet hopeful of a radi- cal cure, or even only of a tardy return of the disease, carry their incisions or dilatations up to or beyond the point of thirty- two millimetres, the average point of the anatomical disten- tion in the living subject. I confess to be one of those who prefer in gleet to distend the canal up to a large size by sounds, since reading a synopsis of an article of M. Allaire’s,1 published in 1865. From this author I learned to carry the dilatation of strictures causing gleet up to beyond the then- called normal calibre, by dividing the meatus. These dilata- tions were brought up by me frequently to No. 32, and some- times beyond, in the belief not only that the recognized Strict- 1 “ Recueil des Me moires Medioales et Ohirurgioales Militaires,” De- cember, 1865. 13 tire, in the old interpretation of that term, was thereby more thoroughly stretched, but also, when the gleet was not of such origin, that the pressure exerted by the extra large sound upon both the inucons membrane and the musculature 1 of the prostate was of a most beneficial nature. And it is with satis- faction that I find the present anatomical consideration of the subject justifies this practice. In respect to the treatment of gleet from strictures of large calibre by incisions, the risks from haemorrhage, urinary fever, abscess, and the more or less permanent curvature of the penis, which is sometimes sufficient to prevent coitus, have always seemed to me to be too great to be lightly resorted to, and especially do I feel more convinced on this point since some observations, begun in 1873, and recently resumed, have fur- nished stronger reasons tor this adverse conviction. The consideration of these observations is, in reality, that of the second question, What are the normal constrictions of the male urethra, or, rather, of its spongy portion ? In operating, in 1873, upon a bov of thirteen years (with a penis of two and a half inches in circumference) for trau- matic subpubic stricture, I found that, after completing the required external perineal urethrotomy, I could pass a Iso. 30 bougie d boule very readily from the perineal wound to the meatus; which latter was large enough to admit Ho. 28. The urethra readily received this large instrument, save at a point two inches from the meatus, where an arrest or hitch, decided in character, was experienced both in going and in coming. A subsequent inquiry revealed no history of injury at this point. Some time after this, the same operation was performed upon a man of thirty, at the Roosevelt Hospital, for traumatic stricture. This patient had never had any venereal dis- ease. On passing a Ho. 30 bougie d boule from the wound to the meatus it hitched decidedly at the penoscrotal junction, ‘It is to this pressure that I attribute the relief afforded to those uri- nary difficulties and pains which radiate from the prostate as a centre. The analogous benefit derived from stretching the bladder end of the fe- male urethra supports this view. (See Boston Medical and Surgical Jour- nal., January 27, 187G.) 14 both in going upward and in returning. The patient died four days afterward from septicaemia, and the urethra was secured for examination. The pathologist of the hospital, Dr. Dela- field, reported that the urethra was normal, and that no evi- dence of any stricture was to be found by the microscopical examination. !No other opportunity in the living subject has been afforded me of similarly investigating this point, but during the past few weeks I have examined still further in the cadaver whether these constrictions were anatomical or pathological in their character. If the latter, they were to be truly called strictures, as Sir Henry Thompson 1 defines a stricture to be an “ abnormal organic contraction of some portion of the urethral canal.” I regret, however, to state that, owing to the recent great demand for penes, the number of examinations made in con- nection with this point has been quite limited. I have, however, examined five urethras, and in each have found the so-called strictures of large calibre. In detail, the cases are as follows : No. I.—From a man about thirty-five years of age, whose penis measured two and a half inches in circumference.8 The meatus, which admitted No. 23, was incised to receive No. 40, which was arrested at a depth of two inches, at which point a No. 35 passed with a jump, and was markedly caught in its withdrawal. A No. 32 was also arrested, in entering and re- turning, at a depth of three and a half inches. These were detected by Otis’s urethrometer. To test the value of Richard- son’s explorer (Fig. 2), it was introduced, and three other strictures recognized adjacent to the one at three and a half inches, and of the same size (i. e., 32): five strictures were therefore recognized. The examination was repeated by Dr. Heineman, the assistant pathologist of the hospital, who, how- ever, only detected four strictures. The urethra was then laid 3 Thompson “ On Stricture,” third American edition, p. 63. 2 No special importance is attached to this measurement, as consider- able traction had been made upon it prior to the record being taken, and also from the fact that the post-mortem shrinkage was found to vary con- siderably. 15 open and carefully inspected. Its surface was smooth, and indicated neither to sight nor touch anything abnormal. The F.Q.OTTO&SONS.N.Y. F.G.orro&soNS.N.r, ngj. Fig. 2. Dr. Weir’s TJrethrometer.—The rings on the shaft (see Fig. 2) locate the points of arrest, and permit subsequent accurate measurement. B. Winns Richardson’s TJrethrometer. Dublin Medical Journal, November, 1873. —Both of these instruments have been painlessly distended to their extreme limit in the bulbous portion of the ure- thra. The numbers indicate millimetres, not sizes. strictured portions were subsequently examined by Dr. Dela- field, and his report was, that “ the urethra examined micro- 16 scopically by him did not differ in appearance from corre- sponding portions of other healthy adult urethras.” No. II.—From a man of unknown age, penis three and a half inches, meatus twenty-three. By my dilating urethrome- ter(Fig. 1) raised to thirty-five millimetres, a decided hitch was felt in going and in returning, at three and a half inches. This was corroborated by a bougie d boule introduced from the membranous urethra. The canal was then inspected, and appeared and felt normal. Dr. Satterthwaite, the pathologist of St. Luke’s Hospital, kindly made the microscopical exami- nation for me, and, in his words, found that “ the mucous membrane was apparently unchanged in character, nor was there any marked change in the corpus spongiosum.1 No. III.—From a patient aged twenty-six; cause of death, phthisis: The penis in the denuded state in which it was received measured two and a half inches in circumference. The meatus admitted No. 24. A bougie d boule, size No. 30, was introduced from the membranous urethra, and showed, by its arrest in going and returning, a narrowing at three and a quarter inches from the meatus, and this bougie was again halted at a distance of two and a quarter inches from the meatus by a constriction, through which only a No. 29 could pass, and then with a jump. The urethra was examined by Dr. M. D. Mann, lecturer on clinical microscopy, in the College of Physicians and Surgeons, who reported the mu- cous membrane and its epithelium unchanged, and that the subconnective tissue was of uniform thickness. Cast B was from this specimen. No. IV.—From a man of unknown age and history ; penis three and three-quarters inches, meatus seventeen. This was incised to-day to admit 35, which was arrested at one and a half inches; 33 was then introduced to a depth of three inches, and caught going and returning at that point. The urethra was opened, and is submitted to your inspection. At 1 As a somewhat rare pathological change, though, from the normal character of the corpus spongiosum and the urethra, not bearing on the present point, there was found in the right corpus cavernosum a mass ot fibrous structure, nearly replacing its erectile tissue. This extended over a distance of about three centimetres. 17 the site of the hitch indicated by the pin, the mucous mem- brane was apparently more movable than elsewhere, and there were seen two whitish depressions nearly on the same plane but not encircling the urethra. After the lapse of a short time the lines became quite indistinct. Mv observation was corroborated by Drs. G. A. Peters and M. J). Mann. The urethra will be submitted to microscopical investiga- tion. No. Y.—Also examined to-day and presented as the fresh- est specimen, from a man aged forty-five, who had had gonor- rhoea and chancre; penis three and three-quarters inches, meatus twenty-three. No. 29 caught at two and three-quar- ters inches. Half an inch farther in, another hitch was felt by Richardson’s and Weir’s urethrometer raised to thirty-one millimetres. No. 28 passed with perfect ease. On opening the urethra, two partially transverse lines, slightly depressed, and of a uniform color with the adjacent part of the urethra, were found; at six and a half inches a stricture admitting No, 19 was met with.1 In all there were six examinations, five in the dead and one in the living subject, made of constrictions varying in size from No. 29 to 35, four of which presented under the microscope no evidence of any pathological changes. But, as it may be objected that a minute pathological alteration may in the lapse of time so closely approximate the normal condition as to be indistinguishable by the microscope, it was considered desirable to have, if possible, some additional cor- roboration of these unexpected results. This end was attained by the examination of the urethra of a boy, about three years of age, whose youth presumably insured freedom from inflam- matory attacks. In this child, whose penis measured one and a half inch in circumference, I obtained a similar result. The meatus was enlarged to admit a No. 14 botigie a boule, which was arrested at the penoscrotal angle, both ways, and a No. 16 in its turn arrested markedly once between this point and the meatus. This wras verified by Dr. Ileineman, who has, I 1 Since the above was written Dr. Mann has made a microscopical ex- amination of the strictures of large calibre, and reports that nothing ab- normal was to be seen at the points where Nos. 29 and 31 caught. 18 desire to acknowledge liere, materially assisted me in these researches. That this child’s urethra was not unduly distended is de- termined by the circumstance that in two living children, each aged four years, a No. 16 was passed by Dr. Beckwith at the Nursery and Child’s Hospital, through an undivided meatus to the bulb without inconvenience. Are these constrictions anatomical, or were they produced by the instruments used ? From their equally ready detection by the spindle-shaped instrument of Otis as wxell as by the bougie d bottle,1 and the other more irregularly-shaped instru- ments, and also from their locality remaining unchanged in the repeated explorations resorted to, 1 was inclined to the former view. But in the last two specimens the depressions noticed pointed strongly to a duplicature of the mucous mem- brane, as a cause of the hitching. The microscope did not aid in the solution of this point. As to the frequency with which these constrictions, if such they are, are to be found, and as to their influence in interfer- ing with micturition I cannot, of course, from such limited data say: but from the smoothness generally observed in the opened urethrae, and from the fact that in the casts B and C, made from urethrae Nos. II. and III., no trace of any extra constric- tion is to be seen at the points where the detecting instru- ments were caught, the inference wrould be, that they would not interfere with micturition, nor cause any stagnation of urine. Also, if they are normal constrictions, statistics based upon their non-return after division must of necessity not apply to the question of a radical cure of stricture ; and whether they be considered constrictions or duplicatures of the mucous mem- brane, it must be admitted that our heretofore relied-upon methods of exploration are not sufficiently trustworthy for us to distinguish between normal and abnormal narrowings of the urethra, certainly from No. 29 upward. An amendment to the statement of Dr. Otis is therefore demanded, for he says, “ Complete freedom from stricture can only be demonstrated 1 The bougies d loule used had metal stems, with metallic or hard-rubber bulbs. 19 bv the easy passage of a bulbous sound of a size fully equal to the normal calibre of the urethra.”1 The bougie d boule has not been free from the censure of others, for B. Wills Richardson, in the Dublin Medical Jour- nal for November, 1873, says: “ I believe it to be a deceptive urethral explorer. If, for instance, after having been passed into the healthy urethra to the bladder, it is then gradually withdrawn, the bulb will frequently follow the stem by a series of jumps or jerks, and may thereby lead to the supposition of the presence of a stricture where none exists.” Thompson3 also speaks slightingly of the instrument. I should, in concluding this portion of my subject, regret to be understood, from the preceding remarks, as denying the existence of veritable strictures of large calibre ; for the patho- logical changes to which the almost continually-closed urethra is subjected in inflammation, it is well known, can vary from the slightest impairment of the elasticity of its walls, to the severest degree of stenosis. Our mode of detection of such strictures is, however, I am compelled to say, as yet imperfect. If your patience will permit, I should like to direct your attention, for a few moments, to the normal size of the mea- tus urinarius, about which some confusion has recently been shown by the views entertained by Dr. Otis. The narrowing of the meatus urinarius is classed by this author as a stricture in these terms : “ In point of fact, besides varying congenitally more than any other orifice of the body, it is more often strictured from disease than any other portion of the body; ” and in his work on “ Gleet,” etc. (“ Ameri- can Clinical Lectures,” No. x., p. 8), he quotes Henle (erro- neously it has been shown) to support his view that the mea- tus should equal the fossa navicularis in size. To aid in settling the question of the normal size of the meatus, I have to present the record of one hundred and twen- ty-flve measurements of that orifice in adults. They range from No. 12 to No. 37. Of those below 20 there were, however, but ten ; of those above 30 there were but eight. Between 20 and 30 there were one hundred and nine, or 87 1 “Radical Cure of Stricture,” p. 10. 3 Lancet, December 11, 1875. 20 per cent., or, if the numbers were extended, one at each end of the scale, that is, between Nos. 19 and 31 inclusive, there were one hundred and fourteen cases, or 91 per cent.; of these, of No. 19 there were four; 20, three; 21, nine; 22, twelve; 23, thirteen ; 24, eleven ; 25, thirteen ; 26, fifteen ; 27, eight; 28, ten ; 29, six ; 30, seven ; 31, three. Most of these cases, it wdll be observed, occurred between the Nos. 21 to 28, i. e., ninety- one in all, or 73 per cent. This would indicate the l'ange as the normal limit. These data agree very nearly with those given by Civiale, Reybard, Thompson, Henle, Rollet, Phillips, and Yoillemier, these authorities making the diameter of the mea- tus to vary from six to ten millimetres, Nos. 18 to 30. The casts of Dr. Sands and the Table II. also show that a normal disproportion exists between the meatus and the fossa navicularis. This latter point is also, as would have been supposed, more sensitive to pressure. In eight of the thirty-eight cases where the urethra was also explored, there was found, within one-quarter to one-half an inch from the meatus, a narrowing which was from one to six millimetres smaller than the meatus itself, and in one case this ran from 30 to 21, nine numbers. This anatomical pe- culiarity is spoken of by Thompson and others as a congenital contraction, and as of rare occurrence. May it not act, within moderate limits, as the vena contracta known to physicists, and so expedite micturition ? When the meatus is narrower than the normal standard, it has been known to originate and perpetuate a cystitis by impairing the relation between the expulsive power and the freedom of escape of the urine. Furneaux Jordan (Surgi- cal Inquiries, 1873, and recently in Lancet for January 29, 1876) gave several such cases occurring from congenitally small openings, to wit, •“ a line or tivo in length,” and states that there is no result of stricture that he had not seen follow a small meatus, except retention, extravasation of urine, uri- nary abscess, and perhaps renal disease. In concluding these remarks, I beg to recapitulate briefly ; 1. That the spongy portion of the urethra is the smallest (except the meatus) and least dilatable portion of the canal. 2k That normal constrictions (or obstructions) are to be 21 met with in this portion of the canal as small certainly as No. 29, and that the means at present resorted to are insuffi- cient for the differentiation of such from strictures of large calibre. 3. That the healthy urethra in this portion can generally be readily and safely dilated up to an average size of 32 millimetres. 4. That the normal size of the meatus is from No. 21 to 28. 5. That the urethral canal is, in the excellent words of Jarjavay,1 “narrow at the meatus, dilated in the gland, and very slightly narrowed at the termination of the fossa navi- cularis ; then it forms a cylinder nearly uniform to the prepu- bian angle, where a coarctation is often found. It enlarges then to the bulb,” etc. It is unnecessary to add this anatomist’s description of the deeper portions of the canal, as it is beyond the reach of the present discussion. 1 “Recherches Anatomiquea sur l’Urethre,” 1856, p. 208, MEDICAL WORKS PUBLISHED BY D. APPLETON & CO. Anstie on Neuralgia. 1 vol., 12mo Cloth, $2 60 Martholoiv’s Treatise on Therapeutics (In press.) Marker on Puerperal Diseases. 1 vol Cloth, 5 00 Marker on Sea-Sickness. 1 vol., 16mo “ 75 Barnes’s Obstetric Operations. 1 vol., 8vo “ 4 60 Bellevue and Charity Hospital Meports. 1 vol., 8vo “ 4 00 Mennet’s Winter and Spring on the Mediterranean. 1 vol., 12mo “ 3 60 Mennet on the Treatment of Pulmonary Consumption. 1 vol., 8vo “ 1 60 Billroth’s General Surgical Pathology and Therapeutics. 1 vol., 8vo... “ 6 00 Sheep, 6 00 Mastian on the Common Norms of Paralysis from Mrain Diseases.... 1 75 Bulkley’s (M. D.) Acne; its Pathology, etc (In press.) Combe on the Management of Infancy. 1 vol., 12mo Cloth, 1 50 Carpenter’s Mental Physiology 3 00 Chauveau’s Comparative Anatomy of the Domesticated Animals. Ed- ited by George Fleming, F. R. G. S.. M. A. I. 1 vol., 8vo, with 450 Illustrations “ 6 00 Davis’s (Henry G.) Conservative Surgery “ 3 00 Dickson on Medicine in Relation to the Mind “ 3 60 Elliot’s Obstetric Clinic. 1 vol., 8vo “ 4 50 Mcker’s Convolutions of the Mrain 1 26 Plint’s Physiology. 5vols., 8vo Cloth, per vol., $4 50; Sheep, 6 00 Plint’s Manual on Urine. 1 vol., 12mo Cloth, 1 00 Plint’s Relations of Urea to Exercise. 1 vol., 8vo “ 2 00 Prey’s Histology and Histo- Chemistry of Man “ 6 00 Hoff matin’s Manual of Medicinal Chemicals “ 8 00 Holland’s (Sir Henry) Recollections of Past Life. 1 vol., 12mo “ 2 00 Howe on Emergencies. 1 vol., 8vo “ 8 00 Howe on the Breath, and the Diseases which give it a Fetid Odor “ 1 00 Huxley on the Anatomy of Vertebrate! Animals. 1 vol “ 2 60 Huxley and Youmans’s Physiology and Hygiene. 1 vol., 12mo “ 1 75 Hammond’s Insanity in its Relations to Crime. 1 vol., 8vo “ 1 00 Hammond’s Diseases of the Nervotis System. 1 vol., 8vo....Cloth, $6 00; Sheep, 7 00 Hammond’s Clinical Lectures on Diseases of the Nervous System. 1vol., 8vo. 3 50 Hamilton’s (A. McL.) Flectro-Therapeutics. 1 vol., 8vo Cloth, 2 00 Johnston’s Chemistry of Common Life. 2 vols., l2ino..... “ 3 00 Letterman’s Recollections of the Army of the Potomac. 1 vol., 8vo “ 1 00 Lewes’s Physiology of Common Life. 2 vols., J2mo “ 8 00 Markoe on Diseases of the Bones. 1 vol., 8vo “ 4 60 Maudsley on the Mind. 1 vol., 8vo “ 3 50 Maudsley’s Body and Mind. 1 vol., 12mo “ 1 00 Maudsley on Responsibility in Mental Disease 1 50 Meyer’s Electricity. 1 vol., 8vo “ 4 50 Niemeyer’s Practical Medicine. 2 vols., 8vo Cloth, $9 00; Sheep, 11 00 Neftel on GaIvano-Therapeutics. 1 vol., 12mo Cloth, 1 50 Nightingale’s Notes on Nursing. 1 vol., 12mo “ 75 Neumann on Skin Diseases. 1 vol., 8vd “ 4 00 New York Medical Journal $4 00 per annum. Specimen copies, 25 Paget’s Clinical Lectures and, Essays. 1 vol., 8vo ..Cloth, 6 00 Peaslee on Ovarian Tumors. 1 vol., 8vo “ 5 00 Pereira’s Materia Medica and Therapeutics. 1 vol., 8vo....Cloth, $7 00; Sheep, 8 00 Richardson’s Diseases of Modern Life. 1 vol., 12mo Cloth, 2 00 Sayre’s Club-Foot,. 1 vol., 12mo “ 1 00 Sayre’s Orthopedic Surgery. With the Operations incident to Deformities. With numerous Illustrations (In press.) Schroeder on Obstetrics. 1 vol., 8vo Cloth, 3 60 Steiner’s Compendium of Children’s Diseases “ 3 60 Stroud’s Physical Cause of the Death of Christ. 1 vol.,12mo 2 00 Swett on Diseases of the Chest. 1 vol.. 8vo “ 3 50 Simpson’s (Sir Jas. Y.) Complete Works. Yol. I. Obstetrics and Gynae- cology. 8vo. Vol. II. Anaesthesia, Hospitalism, etc. 8vo. Yol. III. The Dis- eases of Women Per vol.. Cloth, $3 CO; Sheep, 4 00 Tilt’s Uterine Therapeutics. 1 vol., 8vo Cloth, 3 50 Van Muren on Diseases of the Rectum. 1 vol., 12mo 1 50 Van Muren A Keyes’s Genito-Urinary Diseases, with Syphilis. Cloth. $5; Sheep, 6 00 Vogel’s Diseases of Children 1 vol.. 8vo Cloth. $4.50; “ 5 50 Wells on Diseases of the Ovaries. 1 vol., 8vo Cloth, 5 00 Wagner’s Chemical Technology. 1 vol., 8vo 5 00 Walton’s Mineral Springs of the United States and Canada. With Anal- yses and Notes on the Prominent Spas of Europe “ 2 00 *** Any of these works will be mailed, post-free, to any part of the United States, on receipt of the price. A large and carefully-selected stock of Medical Works, American and Foreign, constantly on hand. Descriptive Catalogue forwarded on application. Physicians desiring to have their names inserted in our Medical Directory of the United States and ■Canada., will please send them, in full, with addresses. No charge. D. APPLETON & CO., Publishers, 549 &. 551 Broadway, New York. D. APPLETON & CO., 549 & 551 Broadway, New York, Have just published: Animal Parasites and Messmates. By P. J. Van Beneden. W ith 83 Illustra- tions. 1 vol., 12mo. Price, $1.50. Memoir and Correspondence of Caroline Herschel. By Mrs. John Hkrschel. Writh Portrait. 1 vol., 12mo. Price, $1.75. Dr. Hammond’s Treatise on Diseases of the Nervous System. Sixth edition. 1 vol., 8vo. Cloth, $6.00; sheep, $7.00. Great Expectations. By Charles Dickens. Household Edition. Price, in paper covers, 75 cents; cloth, $1.25. TllC Progress of Science. A Short History of Natural Science and the Prepress of Discovery, from the time of the Greeks to the Present Day, for Scholars and I oung Persons. By Arabella B. Buckley. 1 vol., 12mo. Cloth. Price, $2.00. A Hand-Book of Architectural Styles. Translated from ihe German by W. Oot- lett Sanders. 1 vol., 8vo. With 639 Illustrations. Price, $6.00. Kroeh’s First German Reader. Containing the Story of Cinderella. With Trans- lations and Vocabularies. 1 vol., 12mo. Price, 40 cents. Schulte’s Elementary German. 1 vol., 12mo. Price, $1.25. Coinin’ Thro’ the Rye. 1 vol., 8vo. Paper covers. Price, 75 cents. Diseases of Modern Life. By Dr. W. B. Richardson, F. R. S. 1 vol., l2mo. Cloth. Price, $2.00. Cox’s General History of Greece, from the Earliest Period to the Death of Alex- ander the Great. 1 vol., 12mo. Cloth, $2.50. Telegraphy. By Wm. II. Preece and J. Sivewright. Illustrated. Price, $1.50. Ml'S. Limber’s Raffle; or, a Church Fair and its Victims. A short story. 1 vol., 18mo. 50 cents. Cloth, 75 cents. The Cotton States in the Spring and Summer of 1875. By Charles Nordiioff. 1 vol., 8vo. Paper covers, 50 cents. Tile History of Creation j or, the Development of the Earth and its Inhabitants by the Action of Natural Causes. From the German of Ernst Haeckel. 2 vols., 8vo. Price, $5.00. The Nature of Light, with a General Account of Physical Optics. By Dr. Eugene Lommel. 1 vol., 12mo. Cloth. Price, >f2.00. The Emotions and the Will. By Alexander Bain, LL. D. Third edition. $5.00. Rational Method, following Nature Step by Step, to learn How to Read, Hear, Write, and Speak French. By Claude Marcel. 1 vol., 18mo. 50 cents. Air, and Its Relation to Life. Being, with some Additions, the Substance of a Course of Lectures. By W alter Noel Hartley. 1 vol., 12ino. Cloth. Price, $1.50. Darwin’s Movements and Habits of Climbing Plants, l vol., i2mo. Cloth. Price, $1.25. Geier-Wally. A Tale of the Tyrol. By Wilhelmine von Hillern. Cloth, red edges. Price, $1.25. French Children at Home. An Introduction to “ Comment on Parle h Paris,” or French as spoken at Paris. By Madame de Peyrac. 1 vol., 12mo. Price, 90 cents. Our Place Among Infinites. A Series of Essays, contrasting our Little Abode in Space and Time with the Infinites around us. By Richard A. Proctor. 1 vol., 12mo. Cloth. Price, $1.75. Currency and Banking. By Bonamy Price, Professor of Political Economy in the University of Oxford. 1 vol., 12mo. Cloth, $1.50. Poets and Novelists. A Series of Literary Studies. By George Barnett Smith. 1 vol., 12mo. Cloth. Price, $2.00. — Either of the above sent /ree by mail to any address, on receipt of the price.