sions. Recognizing the facts that the canal varies in its capacity for distention in its different divisions, and that no two urethræ are alike in regard to their normal calibre, no limit was placed upon the size of the bougies employed in the subsequent treatment, as each case had to be managed upon its individual merits. Hence, there are certain disadvantages in this method, which depend upon the normal anatomy of the urethra. Not only, in the vast majority of cases, does the meatus require to be enlarged, as a preliminary measure—and I have only met with two examples in which the size of that orifice corresponded with the size of the passage behind it— but violence is liable to be inflicted upon the sound portions of the canal, which correspond to its actual normal contractions at the end of the navicular fossa and at the bulbo-membranous junction, and occasionally to one present about an inch in advance of the latter locality, or possibly others in the spongy portion, as demonstrated by Dr. Weir, of New York.

To place the subject in a clearer light, let it be assumed that a stricture is seated in the middle of the spongy portion, which latter equals 32 mm. in circumference, while the meatus measures 24 mm. To act efficiently upon the coarctation, an instrument 32 mm. in circumference must be passed; but to do this, the orifice will have to be divided to the extent of producing, in many instances, a deformity. In addition to this operation, which is not only painful, but is inconvenient to the patient on account of the hemorrhage which attends the subsequent passage of the bougie, with a view to keep the lips of the incision separated during the healing process, an instrument of the size specified is liable to sever not only the natural contractions at the end of the navicular fossa and at the commencement of the membranous portion, if it be carried so far back, but also to produce one or more tears in the ante-bulbous urethra. In the event of the stricture being seated in the bulb, the meatus will have to be cut still more freely, while the danger of tearing sound tissue will be greatly increased.

From these considerations, which are not theoretical, but are based upon actual observations, I have arrived at the conclusion that enlargement of the meatus is uncalled for when the relation between its size and that of the spongy urethra is normal. Hence, I have been trying for some months past, to devise an instrument with which, after divulsion or internal incision, the severed parts could alone be stretched during the healing process, without detriment to the remainder of the urethra, and I have finally succeeded, with the assistance of Messrs. Geo. Tiemann & Co., in perfecting the dilator shown in Fig. 3. It consists of a No. 16 steel sound,

the terminal two-thirds of which are split into two halves to form the blades. These are united at the vesical extremity, where they are carefully bevelled, and can be separated laterally, so as to form a spindle-shaped body, by a flattened cone attached to a rod, which is acted upon by a wheel at the proximal end of the handle, the

Fig. 3.

G. TIEMANN & CO

extent to which the blades can be parted being indicated by a register, marked in millimetres, attached to the handle.

In using the instrument, the blades are expanded sufficiently to traverse the meatus without overstretching it, when its centre is made to correspond with the divided stricture, and the wheel is slowly turned until the register indicates that the desired degree of distension has been reached. By reversing the wheel, the blades are approximated and the dilator withdrawn.

In the event of the meatus being congenitally contracted, or smaller, from any cause, than it ought to be, it should be enlarged only to the extent of being 8 mm. less in circumference than the spongy portion of the urethra. By preserving these normal relations,' which are obviously intended to increase the projectile force of the seminal fluid and the stream of urine, the natural functions of the urethra will be preserved, extensive cutting will be avoided, and the patient be spared suffering and discomfort.

As the sides of the expanding cone of the dilator protrude through narrow ovoidal openings in the blades, the instrument may be used as an explorer to define the anterior face of a stricture, when it may be employed for ordinary dilatation, by gradually and progressively expanding the blades; or it may be utilized as a divulsor, by rapidly

1 I believe that the meatus and spongy urethra in front of the bulb bear almost constant relative proportions to each other, so that the former really constitutes a gauge for the latter. Weir's estimates, based upon 114 measurements, show that the average meatus is 24.91 mm. in circumference, while the average spongy urethra averages 32 mm. Otis, from 100 observations, fixes them, respectively, at 24.72 mm. and 32.95 mm., while I have found them, in 83 trials, to be 24 mm. and 32 mm.

turning the wheel. I have recently resorted to it on two occasions for forcible rupture, and found that it answered every purpose.

With regard to the ultimate results of the operation as practised in the way that I have described, my experience is, as yet, too limited to speak authoritatively.

Within the past month I have twice used the dilator, instead of conical steel bougies, after internal incision, and I have every reason to be satisfied with its action.

It is proper to state that Dr. Gouley has described an instrument which he has found advantageous, not only for overstretching the passage in cases of granular urethritis, but also for replacing conical steel bougies in the process of gradual dilatation, whereby he does away with division of the meatus.

In conclusion, I may be permitted to incorporate the substance of the preceding considerations in the following axioms:

1. The rational treatment of stricture of the urethra consists in restoring the natural expansibility, or calibre, of the affected portion of the canal.

2. Before any operation, having this end in view, is practised, the sensibility of the urethra should be obtunded, lest it resent the violence to which it is about to be subjected.

3. After the spasm and hyperæsthesia have been relieved, the calibre of that portion of the urethra in which the stricture is located should be estimated by the urethrometer, with the view of bringing the affected portion up to that standard.

4. Internal urethrotomy from behind forwards is the most effectual mode of accomplishing that object.

5. And finally-The meatus should not be interfered with, provided its circumference is eight millimetres less than that of the spongy urethra.

REPORT ON THE CARE OF THE INSANE.

BY JOHN CURWEN, M.D.,

OF HARRISBURG.

THE interest awakened in the care of the insane, and the attention given to that subject within the last few years by all classes of the community, has led many persons to express their views on the care and treatment of this class, whose ideas are of the most superficial character and whose knowledge is confined to the reading of a few books and the examination of a limited number of cases. These views, being founded on what they suppose to be the condition of the insane, and from their reasonings on these suppositions, are necessarily, from their very limited knowledge, of the very crudest character; and the eagerness and pertinacity with which they are advocated are graduated only by their self-esteem, their ignorance of the true character, habits, and modes of thought and action of the insane, their lack of acquaintance with what has been done and is still doing for this class, and their desire for distinction or to make out a case on a partial statement of facts.

Much has been thus written which would never have seen the light had the writers fully informed themselves of all the facts of the case, or have taken the time and labor to have examined what has been written by those who were thoroughly acquainted with the whole matter from long residence among and great familiarity with the insane of all classes and conditions.

But starting with the assumption that the more carefully a man has investigated and studied any subject the less qualified is he to express a reliable opinion on that subject, they have verified the old adage that a little knowledge is a dangerous thing, and, in their zeal to give practical effect to their teachings, have promulgated ideas and urged the adoption of plans which were discovered on trial more than a quarter of a century since to be impracticable, or being good in theory are vicious or injurious in practice. In order, therefore, to show that the doctrines of these self-constituted teachers are of a character to involve the treatment of the insane in a state

calculated to do them injury, and to bring upon the public authorities greater troubles and expenses than those which these gentlemen are so very anxious to avoid, it is proposed to state, in the plainest and briefest manner compatible with a clear understanding of the principles involved, what has been clearly and definitely settled by the long experience and careful, cautious observation of those who, having devoted their lives to the care of the insane, have neither friends to reward nor enemies to punish, but seek only the truth for the truth's sake, and because they believe it wrong that the public should be called upon to spend money for that which will only prove to be a delusion and a snare.

The Association of Medical Superintendents of American Institutions for the Insane, organized in 1844, has at different periods. adopted a series of propositions relating to the care of the insane, derived from the long experience and mature observation of its members; and these propositions have received the approval of those who have been engaged in the same course of duties in Great Britain, and, to use the words of an English superintendent, they have done much to shape the course of action of medical men connected with the specialty in that country. They have also been translated into French by one of the ablest alienists of France, and published in several of their journals.

To certain of these propositions, with explanatory remarks, it is proposed at this time to call attention, as giving the ablest and best digested opinions on the proper care of the insane.

"Every State should make ample and suitable provision for all its insane."

"Insane persons considered incurable and those supposed curable should not be provided for in separate establishments."

"The large States should be divided into geographical districts of such size that a hospital situated at or near the centre of the district will be practically accessible to all the people living within its boundaries, and available for their benefit in cases of mental disorder."

In the first series of propositions on the construction of hospitals for the insane, adopted by the Association in 1857, the number to be accommodated in any one hospital is thus expressed: "The highest number that can with propriety be treated in one building is two hundred and fifty, while two hundred is a preferable maximum."

Such continued to be the uniform practice and opinion of the members until, in 1866, this proposition was brought forward:-"The enlargement of a city, county, or State institution for the