Where it is possible the mucous membrane of and the skin is closed, except for a point at the the roof of the canal should not be destroyed and lower angle through which the catheter is brought the ends of the urethra will thus be prevented out. When the closure of the wound is complete, from retracting excessively. In the worst cases, ¿he patient is placed in a horizontal position, the where the urethra has been practically destroyed, catheter is adjusted at the proper point and is transverse division may be necessary. In many then fastened in position by a suture in the skin. of the inflammatory strictures, however, it is After-treatment. The important points in the possible to leave this strip on the roof which does after-treatment are— the care of the anterior not in any way interfere with the free mobilization urethra and the retention of the catheter until the of the anterior segment. For convenience of wound is completely healed. The care of the description, the steps of the operation will be anterior urethra has been described above, and given in order. the essential thing is that the urethra should be (1) With the patient in the lithotomy position a kept entirely clean with some solution which will free median incision is made down to the urethra, not produce undue irritation, and by some method dividing the structures of the bulb in the median which will not traumatize the suture. It has line and turning them aside. It is important that seemed to us that injection with a small syringe is this incision should be carried well backward so preferable to irrigation, either with a catheter or that the membranous urethra can be exposed. with a reservoir and nozzle. (2) The stricture is then divided by a longi- The catheter should be left in position for from tudinal incision upon a guide, if one has been ten to fourteen days. In one case we removed it passed; without a guide, if its insertion has been at the end of a week and slight leakage occurred impossible. The whole incision should be about at the point of suture. In more recent cases it has one and one-half inches in length. The condition been retained for two weeks and no leakage has at the point of stricture is then examined. All taken place. The perineal boutonnière closes, as excess of scar tissue should be removed", the whole a rule, in two or three days after withdrawal of strictured portion excised if necessary, and the catheter. No instrument should be passed hemostasis obtained. (Fig. 2.) through the stricture until complete healing has (3) The anterior segment of the urethra is then taken place, which will be during the third week. freely mobilized by separating the corpus spongi- Cases to which the operation is suited. —• Resec- osum from its attachments until it can be joined tion is applicable to all strictures of the bulbo- to the posterior segment without tension. Upon membranous portion of the urethra not amenable this part of the operation particular stress is laid. to gradual dilatation and not complicated by- (4) Suture. If it is necessary to completely infiltration of urine or fistulœ. It is thus ap- divide the urethra, suturing should be begun upon plicable to a considerable group of cases, both of the roof, the sutures being passed from without traumatic and inflammatory origin. inward, including all the structures of the corpus Since healing practically by first intention is spongiosum and the urethra. We have generally essential, it cannot safely be employed while the used number zero chromicized catgut and a fine inflammatory process is active or in some cases of full-curved needle. Where it has been found pos- traumatic rupture of the urethra with extensive sible to leave the roof of the canal intact, suturing tissue destruction. It may more properly be is begun at the sides in such a way that the longi- used in the less severe cases of traumatic rupture tudinal incision in the urethra is brought together in which the superior wall is still intact, tissue transversely, somewhat after the method of a destruction is not great, and which are seen before pyloroplasty. (Figs. 3 and 4.) After about one infiltration of urine has begun. third of the circumference of the canal has been To the more severe traumatic ruptures of the sutured, a No. 28 sound is passed into the urethra urethra and for inflammatory strictures compli- and the suture is completed about this so as to cated by infiltration of urine or fistulœ, the oper- be sure that the canal is given full caliber. As the ation of fistulization as described by Pasteau and dilated urethra behind the stricture generally Iselin is better suited. yields more readily than the anterior segment, the We have done the operation of resection more line of suture will be found at the end of the or less as above outlined in twelve cases during the operation to occupy a position further forward last eighteen months. In none of them has the than the original stricture. The last suture closing time elapsed been sufficient to warrant any con- the wound unites the two extremities of the longi- clusions as to the ultimate result, and they will not, tudinal incision in the urethra, and by lengthening therefore, be reported now. this incision the caliber can be increased to any reasonable extent. (5) The suture having been completed, the A NEW TREATMENT FOR ABDOMINAL SUR- urethra is opened upon the sound at a point as far GICAL SHOCK.* behind the stricture as possible. This opening BY JOHN R. HOPKINS, M.B., DENVER, COLO., should be small, just sufficient to admit a No. 12 Surgeon to St. Anthony's Hospital. (English) soft rubber catheter, which is passed to As the problem of the cause of shock now the bladder and left in position. (Fig. 5.) stands, there are many contradictory theories.1 (6) The wound is then sutured in layers, bring- It is best for me to state at the beginning of this ing together the muscular structures of the bulb paper that the case that I will report later, to- as accurately as possible with interrupted sutures, *Read before the Colorado State Medical Society, Sept. 15, 1909. The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at THE UNIVERSITY OF IOWA on September 15, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. gether with my investigations, have proven to my once to correct the situation; the heart beats satisfaction that in surgical shock the peripheral faster and peripheral vessels dilate; thus more vessels are contracted and the vessels in the blood is gotten to the surface to radiate and splanchnic area are dilated. And the vasomotor evaporate heat. nerve mechanism is not paralyzed, but is injured This treatment which I advocate is especially sufficiently to lose its reason or function instead suitable for shock during the few hours or days of acting in its long-accustomed extremely intelli- following an abdominal operation, when the pa- gent and prompt manner in distributing the right tient is not under an anesthetic, although it is amount of blood to the right places at the right probably beneficial when the patient is anes- times, which is essential to life. There is not thetized, but not to so great a degree. It is as nearly enough blood in the body to fill all the follows: blood vessels at once if they were all dilated. Take out two skin sutures as near the umbilicus Goltz, in his famous experiment, showed that if as the wound will permit, then pry apart the con- a frog be suspended in the upright position and tinuous sutures in the fascia and peritoneum. its heart exposed, a blow upon the abdomen has You can now see if hemorrhage is present. This a twofold action: (1) It stops the heart reflexly procedure is not difficult nor very painful, because through the vagus; but, after this effect has passed when patients are in shock they are more or less off, (2) the heart beats again, but is empty and insensible to the causes of ordinary pain. See sends on no blood into the vessels, because the that a nurse has ready very hot and cold normal blow has caused dilation of the abdominal vessels salt solution, reservoir with four feet of rubber and all the blood becomes stored up in them, so tubing, together with a glass tube or cánula six that none reaches the heart. to eight inches long. Both rubber and glass tubes Besides the chief vasomotor center in the me- should have a diameter of one third to one half dulla, there are subsidary centers in the spinal inch. Have a quart of saline solution at tempera- cord, and Goltz 2 and Ewald have shown that the ture of 1'12° F. in reservoir, which should hang ganglionic chain of the sympathetic can assume three feet higher than abdomen. Now have wound the function of the vasomotor centers. held open so that you can see omentum or intes- When the centers or nervous trunks of the tines; also see that the tube and the cánula are vasomotor nerves are irritated, the vessels now full of the hot solution; then insert the long contract.3 cánula beneath the omentum, if possible push- Section of the splanchnic nerves causes an ing it upward so that your glass tube penetrates immediate and sharp fall of blood pressure.4 The to the posterior peritoneum up behind the trans- intestinal arteries, veins and portal vein are verse mesocolon to the neighborhood of the pos- dilated and overfilled with blood.