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of the passage of the urine through the abnormal channel, thus favor ing cicatrization, while at the same time the stricture is being dilated. But when free incisions have been made, a ready outlet for the urine is afforded, it rapidly loses its unhealthy character, and its passage through the wound hinders cicatrization but little if at all. The very early introduction of the catheter is sometimes impossible, at best not easily effected; the presence of the catheter, if left in, is irritating, and adds to the unhealthy condition of the urethra and bladder. Its use is not necessary, for the tightness of the stricture is in a measure relieved by the free exit allowed the urine through the rupture, and the treatment of the stricture either by dilatation or otherwise, though very important, is for the time being of little moment in comparison with the relief of the peculiar and dangerous symptoms consequent upon infiltration. Even in cases of urethral laceration from external injury, where perineal section has been performed not only with a view to the relief of the immediate symptoms, but still more the prevention of a traumatic stricture, and where it is desired to preserve as perfectly as may be the normal calibre of the urethra, the use of the catheter is not demanded until after the separation of the sloughs. As respects the necessity and propriety of perineal section, there exists a decided difference of opinion. Where the infiltration has taken place in consequence of external injury which has not produced a wound of the integument, a free perineal incision not involving the urethra, with a judicious after-use of the catheter, will in many cases be all that is required. But when the urethral wall has to a considerable extent been lacerated and contused, the free laying open of the urethra will go far towards preventing a subsequent closure either complete or nearly so of that part of the canal included within the contused area, and it is this closure that is the special danger to be apprehended in this sort of injury. But when the infiltration is a consequence of stricture, is it advisable to so make the perineal incision as that the strictured portion of the urethra shall be laid open, or shall the incisions be made with reference only to the giving exit to the extravasated fluid, deferring until a later day direct treatment of the stricture? With reference to this subject Amussat says:
“ It is usually advised not to injure the urethra. However, when there exists a large depot from infiltration, is it not better to freely open the canal at that point which is the seat of stricture? If we adopt the measures insisted upon by writers, when the urinary depot has been opened, as the urine can not pass out by any direct channel, and as the stricture still remains, a second infiltration is to
be feared, and the difficulty of carrying a catheter into the bladder remains al. ways the same. On the contrary, if, after opening up the depot, the original obstruction be cut through (which may done by carrying a catheter down to the stricture and letting its point serve to indicate the point from which the incision shall be made), we may at once introduce the catheter into the bladder, and thus hasten very much the cicatrization of the wound, and prevent any new infiltration."
If the stricture is permeable and a catheter or staff can be carried through it to serve as a guide in the incising of the strictured and ruptured portion of the urethra, perineal urethrotomy is not an operation of any very great difficulty; but if the case is one in which a catheter can be carried into the bladder at the time when the perineal incisions are made, it is one in which the evil consequences of the infiltration can be as fully prevented by proper incisions not involving the urethra, as by urethrotomy, and one in which a fair trial should be made of dilatation in the treatment of the stricture. If the stricture is not permea ble, the laying open of the urethra without the aid of a guide other than the point of a catheter, that resting upon the external face of the stricture shall serve, as Amussat says, as the “point of departure" for the incision, such operation, as Bichat said of it, “is one always difficult and often impracticable." In the words of Colles :
“When you can not introduce the catheter, you are directed to cut down through the perineum and urethra on the point of the catheter, to find out the impervious part of the urethra, to cut through it, and pass on the instrument to the bladder by the inferior opening. Now the great difficulty is to find this opening, or to find the urethra at all. I assure you one of the most expert surgeons in the kingdom was an hour and half cutting here and there, looking for the urethra, and was at last obliged to put the patient to bed without finding it. The great difficulty is to find the urethra.”
But whether the opening of the urethra is difficult or easy, if the operation is necessary and the neglect of its performance will materially leggen the chances of recovery in cases of urinary infiltration, it should be performed, or at least attempted. But if as has been repeatedly shown, free incisions through the swollen and infiltrated subcutaneous areolar tissue are sufficient to arrest the infiltration and give exit to the urine, and if, after such incisions, the strictured portion of the urethra dilates in a few hours or days to such an extent as to pass a number 2, 3 or 4 catheter, it is not, as a rule, advisable to perform external perineal urethrotomy because there has been a rupture of the urethra and extravasation of urine. The operation diminishes
to a certain extent the patient's chances of recovery, and under the most favorable circumstances death is to be feared.
I had hoped to have been able to present to the Academy some statistics of the mortality of the accident under consideration; but the figures obtained as yet are too small to warrant any satisfactory statement as to the comparative per centage of deaths and recoveries.
VENTILATION AND VENTILATORS.
WILSON HOBBS, M. D., CARTHAGE,
Read before the Union Medical Society, at Knightstown, Indiana, at their November session; referred to the Committee on Publication, and by them presented to
the Western Journal of Medicine.
MR. PRESIDENT— My paper for to-day may be considered as doubtfully coming within the constitutional provision which requires each member, at each meeting, to report a case or read an essay of his own writing upon a medical subject. What I shall say upon the topic selected relates more especially to the sciences of natural philosophy and chemistry--but I shall attempt to apply this knowledge, not to the cure of disease, but to-its prevention, by the removal of some fruitful causes of disease and death.
It is as much the duty of the intelligent physician to inforın himself upon sanitary and hygienic questions, by which he may be able to give advice for public as well as private use in relation to the preservation of health, as to arm and equip himself for battles at the bed-side, and he is a lame workman in the beneficent mission of the science of medicine who is not well informed upon such subjects.
Our thinking men are just now saying and writing much upon the varying and changing types of disease and the corresponding changes in plans of medication; and I have often thought if we would carefully study the changes in the habits of our people, which advancing civilization is producing, we should find more satisfactory solution and remedy for these differences of type than elsewhere.
The necessity of pure air for respiration need not be considered here; nor need we stop to discuss the question whether poisons sufficient to produce disease may be introduced into the blood by the respiratory organs: these are established theorems.
In the primitive states of society, when the people spend most or all their time in the open air, or in wide and airy tents or huts, there is little need of disquisitions upon ventilation and pure air—their supply comes direct and uncontaminated from the broad ocean above and around, with nothing to confine its circulation or obstruct the supply; but when, according to the custom of modern, civilized and enlightened nations, we shut ourselves up in close rooms, we have great need to study the conditions of health as they relate to this subject.
Age after age we are becoming more effeminate. Our fathers and mothers lived in log cabins with puncheon floors, loose board ceiling and wide-jam fire-places, with walls through which light and air were never forbidden to enter; in the cities and “better-to-do" localities they had large rooms and open chimneys, which furnished an ample supply of air and kept it constantly in motion, thus preventing the accumulation and concentration of atmospheric poisons.
Small rooms in residences, and close and ill-ventilated ones for assemblies, are modern inventions, as are also stoves and hot-air fur
Year after year we are becoming more timorous of the cold, and closer and closer we are shutting ourselves in. The open fireplace, that good old life preserver, which seeks every nook and corner and crevice for a fresh breath, and failing there gives the alarm by a cloud of smoke, which compels the inmates to open a door or raise a window, is now fast passing away, and we are warming ourselves by hot stoves, steam pipes, furnaces and other devices, which allow the air in our rooms to become corrupted, and which provide rro sufficient remedy. In rooms heated by stoves, no systematic method of ventilation is usually arranged, the doors and the windows sliding each way being generally considered ample means to change the air-but their proper use for such purpose is so often neglected, that danger and injury to the inmates are not always escaped. For the ventilation of rooms heated by hot-air furnaces and steam pipes, flues are usually provided, but they are not always so arranged as best to accomplish the purpose intended. I have sometimes seen the ventilating register placed near the ceiling-sometimes near the floor-sometimes at intermediate points—sometimes two in each flue, one near the floor and the other at the ceiling. Each of these methods has its advocates. There is at least one right way to arrange this apparatus, and there may
be many wrong ones. It is the purpose of this paper to discuss the scientific principles involved in the question, and determine, if possible, which is the correct method.
Where furnaces are used for heating purposes, a current of cold air is made to pass into a chamber where it surrounds the heater, and its temperature is raised to such point as is desired. It is thence conducted by pipes or flues to the apartment which is to be warmed, and there admitted by a register, which is so arranged as to regulate the size of the current. This register should always be placed at the floor of the room, and, by reason of a well known law, the hot air will immediately rise from it to the ceiling. The apartment being before full of air, this current can not long continue unless a way of exit is opened. This is done by means of flues in the wall, leading to the roof, which are also furnished with registers to regulate the outward current. The hot air thus admitted will warm the room in either of two ways--by mixing with and imparting its caloric to the cold air by radiation and convection, or by rising above, displacing and replacing the cold air, if the flues are so arranged as to allow it to do so.
The specific gravity of the warm air being less than that of the cold, it will rise to the ceiling, while the heavier cold air will always be found below it. The two will not mix nor come together except as they are forced by currents or by agitation.
Now if the ventilating register be placed near the ceiling, the warm air will pass out of the room, leaving the heavier cold air below but slowly affected in its temperature. The current would be from the lower register to the ceiling, thence to the ventilating register: and were it not for counter-currents and the agitation which these currents would produce in the body of the air in the room, with the slight amount of caloric radiated, the furnace might be kept hot the whole of a cold day without making the room comfortable.
The draft in the ventilating flue, with the registers thus arranged, would be a very strong one, as there would a continuous column of heated air from the cellar to the roof.
If, however, we place the ventilating register at the floor, the heated air will make its way to the ceiling as before; but finding no means of escape, it becomes imprisoned there, pressing upon the cold air below, which immediately seeks exit through the ventilating register. As the currents continue, the heated air gradually fills the room from above downward, and the cold air near the floor is all carried out through the flues to make place for it. Thus the room is quickly heated, the warm air driving out and replacing the cold.
Until the room is thoroughly heated, the draft in the flues, with the ventilating register thus arranged, will be much weaker than in