The Abdominal and Pelvic Brain
Byron Robinson, M. D.
[By Lucy Waite, A. B., M. D., Head Surgeon of Mary Thompson Hospital
for Women and Children.]
Shock in its widest significance covers the whole
of medicine. From the slightest physical traumatism or the lightest
mental depression to the most profound impressions on the vasomotor centers
causing instantaneous death, the difference is only one of degree, the
phenomena being the same. It would therefore be impossible in one
short chapter to follow out the subjects in all its various ramifications
in the field of medicine and surgery and it must suffice to treat it in
a comprehensive manner as an affection primarily of the nervous system
with the secondary involvement of the vascular system as a whole.
While it is only during the last fifty years that
any scientific experiment,.; have been made with a view toward discovering
the pathology of shock, as early as 1826, Travers, in his work on Constitutional
Irritation, gave an exact description of the phenomena of shock.
The first treatise on the subject I have been able to find was published
in 1868, by Edwin Morris, F. R. C. S. In this he states that the first
mention of shock in medical literature was in 1819, in the works of F.
Hennen and Guthrie, writing on military surgery. Morris considered
death from shock due to functional disturbance of the brain, the heart
being affected only secondarily. He places no emphasis on the part
played by the sympathetic system and mentions this only once incidentally
as the par vagum and says it connects the spinal cord, brain and heart.
lie treats of shock under two headings, surgical and shock from mental
causes. He gives the classical symptoms and concludes that shock
is due to paralysis of the nervous system destroying the normal function
of the brain and withdrawing the nervous stimulus from the heart.
He confuses shock and concussion of the brain, but warns against confusing
this condition with extravasation in injuries to the brain.
I have given a brief synopsis of his brochure because,
being written in a comprehensive manner and as late as 1868, we may assume
that it contains all that was known on the subject up to that date.
Previous to this mention was made of the subject in Cooper's "Medical Dictionary"
in 1838 and in Copeland's "Dictionary" in 1858. In Cooper's "Surgical
Dictionary," published in 1859, however, there is no mention of shock.
One of the most interesting landmarks in the history
of the literature on shock is Davey's work published in 1858. Under
the heading of "Syncope" he gives a long dissertation on the phenomena
of shock, although this word is used only once, and he foreshadows both
the present theory of the pathology and the latest treatment as demonstrated
by the experiments of Dr. Geo. C. Crile and others in his observations
on collapse after labor and the too rapid escape of the ascitic fluid in
paracentesis abdominis. "I am, however, confident," he says, "that
the bona fide explanation of the fact is to be sought for in loss of the
long-accustomed adaptation or relationship between the containing and contained
parts of the abdomen, whereby the ganglionic nervous system is at its very
center more or less paralyzed."
He says he has no doubt that the many cases of sudden
death attributed to cerebral hemorrhage, disease of the heart, air embolism,
etc., are in reality caused by "syncope," as he terms it, and that the
cause is to be found in the fact that "the ganglionic nervous system has
been drawn on so largely by the cerebro-spinal and muscular systems that
there is nothing remaining for the thoracic and abdominal viscera-no stimulus
left for the vital organs." Mr. Paget, writing in 1862, gives the phenomena
and treatment. Later Brown-Sequard and Savory (1870) made the valuable
discovery of the pathology of shock. Brown-Sequard announced as the
result of his work the theory of anaemia of the cerebral centers due to
a more or less persistent contraction of the capillaries through the vasomotor
center. The experiments of Goltz on frogs was the most important
work done in this direction until the last few years. With Brown-Sequard
and Savory, he held to the theory of cardiac paralysis. He showed
that through the inhibitory influence exerted upon the splanchnics, the
abdominal vessels were suddenly dilated. In Quain's "Medical Dictionary"
(1884) is a statement of the status of the subject of shock at that date
and concludes: "For the present we may thus accept as the most plausible
interpretation of the symptoms of shock a sudden dilatation of the abdominal
vessels, attributable to an inhibitory influence exerted upon the splanchnics,
through the medium of a special reflex center." Not much has been added
to this explanation of the real pathology of shock, but valuable experiments
have been made in recent years in the line of pathology, and some working
toward a more rational treatment by Geo. C. Crile, Robert Dawbarn,
Harvey Cushing, Eugene Boise, Guy C. Kennam'an, John H. Packard and others
of our own profession. In the extensive surgical encyclopedia edited
by Dupley and Reclus in 1890, "Traite de Chirurgie, " is the statement
that it is only during the last twenty years that shock has been studied
in France and that the French, in acknowledging the origin of the researches
in this subject, often use the English orthography, although having a legitimate
word in their own language, "choc." A differential diagnosis is made between
shock and syncope and the article concludes by saying that in fact we know
nothing of the pathological anatomy of shock or of its pathogenesis.
The entire bibliography on shock is so meager that it may be interesting
from an historical stand point. In addition to those already maintained,
the field is practically covered by the following:
Gross, "System of Survey" (1864).
Erichsen, "The Railway and Other Injuries to the
Nervous System" (1866).
Verneuil, "de la mort prompte apres certaines blessures
ou operations" (1869).
Savory, "Collapse," "Holmes System of Surgery" (1870).
Fisher, "In Volkman Samml, klin. Vortr.
Demarquay, "In comptes rendus de l'Academie des
Renard, "Arch; Gen. de med. " (1872).
Blum, "Du choc traumatique Arch. gen de med, " (1876).
Le Dentu, "Bull de la Soc. de chir." (1877).
Vincent, "Des causes de la mort prompte apres les
grands trauma tismes accidentels et chirurgicaux Thesis" (1878).
Piechaud, "Que doit on entendre par 1'expression
de choc traumatique" (1880)
Jondan Furneaux, on "Shock after Surgical Operations
and Injuries," "British Medical Journal" (1880).
Raffer, "La Spermantate" (1882).
Torrier, "choc traumatique Elements de path. chir.
George Friedlander, "arch. fur klin. chirurg.
Dennis, "System of Surgery" (1895).
Mummery, Second Hunterian lecture, "New York Medical
Journal" of April 15, 1905.
From clinical observation of the phenomena of shock,
a rather arbitrary division of the aetiology has been made, viz.: Predisposing
and exciting causes. To establish this as a scientific classification
much more must be known regarding susceptibility to shock. Infants
are said to be almost immune, while youth is considered the period of the
highest susceptibility. Immunity is therefore before the age when
the cerebrospinal and sympathetic systems assume their reciprocal positions
in the nervous system, susceptibility from the time when the untrained
cerebrospinal system assumes more established control over the sympathetic
until the element of mental influence comes in as a factor. To counterbalance
this extreme susceptibility of youth comes in the fact that at this time
the resisting powers are greater and many cases are recorded by different
authors of recovering from the most profound shock in the young which must
certainly have proved fatal in the old. It would almost seem that
the proposition could be laid down that the power to withstand and overcome
shock is in inverse ratio to the susceptibility. Dr. Kiernan says
that the insane are not susceptible to the influences which produce shock
in the sane, and in fact the effects may be directly contrary - a wide
field for study and speculation. Certain peoples are said to be practically
immune and others to be little affected. Dr. John H. Packard writes
interestingly on this subject. He says that Hindoos bear injuries
and operations impassively; that Negroes are not easily affected and that
Americans are especially susceptible to the influences of shock.
It has been observed that injuries inflicted while the subject is under
the influence of intoxicating liquors rarely produce severe shock.
If all these clinical observations can be substantiated it would point
very strongly to a large mental element in every case of shock, either
directly or indirectly. When all is said, however, the real factor
in each constitution which speaks for or against susceptibility, the vital
force, will after all no doubt remain the unknown quantity. As regards
the varying degrees of susceptibility in the different organs of the body,
the most vascular tissues and those most highly supplied by the sympathetic
nerve have been found to be most easily affected.
In the present light of our knowledge we may consider
as predisposing causes all conditions which impair the nutrition of the
nervous system and consequently the circulation; exhausting diseases, prolonged
physical pain or mental strain, insomnia, melancholia, in fact, everything
which reduces vital force. Mummery says in his second Hunterian lecture
that in elderly patients a very high blood pressure is generally observed,
largely accounted for by arteriosclerosis, and that in such patients a
relatively slight fall in blood pressure may produce shock. It is
as a predisposing cause that hemorrhage plays its proper role through the
secondary physiological phenomena of anaemia which leaves the ganglia to
be bathed with impoverished blood and as a surgical condition to be handled
surgically should be sharply differentiated from shock proper. The
exciting causes of shock may be more satisfactorily considered under the
classification of traumatic and mental. Direct traumatism of the
tissues may result from accidental injuries or from trauma during the course
of surgical procedures. Many writers treat this last condition under
a separate classification as surgical shock. It seems true that this
subject can be treated scientifically only as a subdivision of the general
classification of traumatism, which is either accidental or surgical.
The confusion has arisen by considering hemorrhage as an exciting cause
of shock instead of giving it its proper classification as a surgical complication
and secondly by the involvement of the anaesthesia in the aetiology.
All surgical writers agree that the frequency of shock has greatly lessened
since the general use of anaesthesia and this fact speaks loudly against
operating under partial or local anesthesia, as a routine practice.
I have seen patients profoundly influenced by an excessive quantity of
the anesthetic, either on account of the manner in which it was administered
or the length of time the patient has been held under its influence, with
no symptoms of shock whatever, and I cannot think the effects of long anaesthesia,
serious as they are, can legitimately be considered as factors in the production
of shock. The whole story of a depressed nervous system following
a prolonged anaesthesia is told in the added traumatism caused by the repeated
and unnecessary handling of the tissues and the exposure to atmospheric
influences tissues normally protected by the coverings of fascia and skin.
During extensive experimentations in intestinal operations on dogs, Dr.
Byron Robinson demonstrated that the shock following these procedures was
in direct proportion to the amount of manipulation or traction in the abdominal
viscera and duration of exposure; that is, the amount of trauma inflicted
upon the sympathetic nerve. Sudden blows, especially in the region
of the solar plexus, burns and scalds involving large areas, all manner
of traumatic injuries, especially those producing extensive crushing of
tissues, are the principal exciting causes in shock from accidental traumatism.
It has been observed that burns involving a large area, causing extensive
nerve periphery trauma, cause more profound symptoms - than deeper burns
covering a small area. Irritation in one organ may produce nerve
storms in a distant one. The introduction of the sound in the uterus
or the catheter in the male urethra may produce faintness, nausea or even
vomiting. Dr. Nicholas Senn demonstrated a rare case in his clinic
which well illustrates the principle of reflex nervous irritation.
The patient came into the hospital with a history of anurea for sixty hours.
The right kidney was enormously distended, the left apparently normal.
A diagnosis was made of right ureteral calculus, which was removed.
During the period of convalescence both kidneys secreted an equal amount
of urine, proving conclusively that the suppression of urine from the left
kidney was caused by the reflex irritation produced by the disturbance
in the right. The size and extent of the renal ganglia and their
nearness to the solar plexus give to the kidneys an especially strong sympathetic
connection. From the first observations made in the subject to the
present day, all writers have recognized the mental element in Etiology
of the phenomena of shock. Davey, 1858, cites in detail many cases
and says the part played by the mind in the production of "syncope" is
not sufficiently appreciated. Clinical observation has established
the fact that a profound mental impression may cause all the nervous phenomena
following a blow over the solar plexus. Sad news, fright, violent
emotions may be followed by the same vasomotor paralysis with all its accompanying
nervous manifestations; and when this is said, all has been. said regarding
our knowledge of the influence of the mind in the production of the phenomena
of the shock.
As the result of some experimentation and much speculation
two theories regarding the pathology of shock have been evolved, viz.:
Vasomotor paresis and cardiac paralysis. Almost all of the modern
investigators hold to the theory of vasomotor paresis. The nervous
impression is conveyed to the medulla by the afferent nerves, causing vasomotor
paralysis and dilatation. There is a more or less rapid fall in blood
pressure. The vessels lose their normal tonicity which is necessary
to the rapid transition of the blood, the first effect is contraction in
the caliber of the capillaries, followed quickly by dilatation, with at
first increase in rapidity of the blood current, but in proportion as the
dilatation increases the rapidity decreases and may proceed to a complete
stasis. The right side of the heart becomes engorged and does not
empty at each contraction, accumulating largely in the relaxed veins, leaving
the arteries partially emptied; the patient bleeds into his own veins.
The blood is normal into the abdominal vessels. Cerebral anaemia
results as a natural consequence and a slowing of the activity of all the
different viscera dependent for the fulfillment of their physiological
functions upon a perfect blood supply. The influence on the heart
together with all other viscera is therefore secondary to the paralysis
of the vasomotor system through the great reorganizing center, the solar
plexus, the abdominal brain. The phenomena of shock are therefore
the result of a reflex inhibition affecting all the functions of the nervous
system, causing a lowering of the general blood pressure, checking normal
metabolism, arresting the exchanges between blood and tissues; the venous
blood becomes red, temperature lowers in consequence of the lowered blood
pressure, respiration slows and we have a picture of systematic asphyxia.
The entire mechanism of life is deranged, the balance of power is destroyed
and each organ is in an independent control of its own functions for the
time being and consequently only as long and as thoroughly as its limited
reserve force will allow. Brown-Sequard, Goltz and Savory advanced
the theory of cardiac paralysis. They gave as the conclusion of all their
experiments that shock was caused by a violent impression on some portion
of the nervous system acting at once through a nerve center upon the heart
and destroying its action. No reliable findings have been found at
autopsy. Parascandola claims to have found certain changes in the
spinal cord after profound shock affecting the cell body, prolongations
nucleus and nucleolus, constituting chromatolysis, fragmentation, nuclear
It must be admitted that the pathology of shock
after all remains very indefinite and unsatisfactory, the x, as Dr. Senn
has called it in the surgical formula. It is therefore very difficult
to give a comprehensive definition of this ignis fatuus in the domain of
pathology. Based in reality more on the phenomena than upon the pathology,
according to our present light we must consider it as primarily a disturbance
of the great sympathetic nervous system afflicting secondarily the entire
vascular system, a more or less profound impression on the sympathetic
nerve producing a vasomotor paresis with a consequent dilatation of the
right side of the heart and the large vessels, especially the abdominal,
and in consequence lowering the general blood pressure and deranging through
the solar plexus all the automatic visceral ganglia, and consequently destroying
their functional activity. rhythm, absorption and secretion.
The phenomena of shock manifest themselves through
the tripod of vital forces, the nervous, circulatory and respiratory systems,
and principally in those organs most highly supplied by the sympathetic
system. The rhythm of the viscera is disturbed, secretions are diminished,
causing an intense thirst, the cry of the tissues for fluids; there is
a general trophic disturbance; the heart action and the respirations are
increased, the temperature is subnormal, the face is pale, the lips are
blue, the pupils dilated; there is nausea, vomiting and restlessness, more
or less pronounced according to the degree of shock, until the stage of
collapse, when the reflexes are lost. A cold, clammy sweat appears
on the entire surface of the body, and the extremities are cold.
Shallow respirations, with frequent sighing, yawning, hiccoughs are often
added to the clinical picture.
In the most profound shock, where the cerebrospinal
system is involved, this picture may be changed by the substitution for
the phenomena caused by a hyperirritation of the sympathetic system as
nausea, vomiting and restlessness, those manifestations resulting from
a secondary depression of the cerebrospinal system causing a loss of reflexes,
as involuntary urination and bowel movements; delirium and even stupor
may appear. The cold sweat, rapid, irregular pulse, subnormal temperature
here persist in a more profound degree, some observers having noted a fall
in temperature of 6o F. During the War of the Commune observations
were taken in regard to the temperature after injuries. The average
temperature varied from 96.5o to 97.5o, the lowest
registering at 93.5o. The fall was greater after shell wounds
and the curious fact was noted that there was a uniform lower temperature
among the insurgents than among the regular troops.
Authenticated cases have been reported where jaundice,
deafness and arrest of lacteal and menstrual secretions have followed profound
shock. Many efforts have been made to classify the nervous symptoms
of shock, but all are unsatisfactory for the reason that one state runs
so insensibly into another that it is impossible to measure the degree,
except by the rate of recovery, and here again come in the unsolved problems
of susceptibility and resistance and we simply travel in a circle and soon
find ourselves at the starting place again. The only classification
which is any aid in diagnosis and prognosis is a differentiation between
the state implicating only the functional activity of the sympathetic system
and that in which the cerebrospinal is also involved and even here the
symptoms run so imperceptibly into each other that classification is elusive;
even in collapse consciousness may be retained until death.
The intensity of physical shock is influenced by
four principal considerations: the extent of the injury, that is, the number
of nerve peripheries involved; the nearness of the traumatism to the solar
plexus; the character of the injury, the more crushing or bruising of the
nerves the greater being the nervous impression; and the severity of the
pain produced. It is therefore from the standpoint of intensity rather
than by means of a scientific classification that we must study the phenomena
The diagnosis of shock is simply the recognition
of the clinical phenomena as here we have no pathological findings to aid
us. The clinical manifestations of this nerve storm are however so
pronounced that practically the only difficulty lies in differentiating
this condition from syncope caused by severe hemorrhage, with which there
is danger of confounding it. When syncope co-exists with shock it is often
extremely difficult to establish the presence of internal hemorrhage as
a complication. In one condition the blood leaves the peripheries
and congests the abdominal vessels, in the other the large and small vessels
are equally deprived of the usual volume of blood. In nervous shock
certain tissues only lose their blood supply, while there is no diminution
in the quantity of blood. In the one the primary violence is to the
nervous system, in the other the circulatory system is attacked directly.
Syncope causing always a cerebral anaemia is practically identical with
the last manifestations of overwhelming shock, or collapse. As a
recognition of the presence of hemorrhage is often of the utmost importance,
sometimes meaning even the saving of a life, we should never rest content
with a diagnosis of shock until we have excluded the possibility of hemorrhage
by every means in our power. If the patient is seen immediately after
the injury, or in surgical cases where internal hemorrhage may arise, the
most reliable source for establishing a differential diagnosis is by observation
of the pulse and temperature. Both conditions, to be sure, produce
a rapid pulse with normal or subnormal temperature, but there is a decided
difference in the course of the pulse and temperature which with careful
observation one can not fail to recognize. In internal hemorrhage
there is a gradually rising pulse, more or less rapid according to the
rapidity of the bleeding, with a gradual lowering of temperature, the golden
rule in abdominal surgery establishing the presence of internal hemorrhage
laid down by Mr. Lawson Tait over twenty years ago. In shock proper,
however, we have the maximum rapidity of pulse and depression of temperature
at the time of infliction of the trauma and co-existent with all other
clinical manifestations, as the rapid shallow breathing, cold sweat, and
To illustrate: A patient is taken from the operating
table with a ten,perature of 99o-100o, rectal, pulse
90-100. In a half hour the pulse is 110-120, the temperature is found
to be 98o; in another fifteen minutes to half an hour the pulse
has risen to 180-140 and the temperature is falling towards 97o
and the diagnosis of internal hemorrhage is practically established.
This rising of the pulse with a corresponding depression of temperature
may be extremely gradual and extend over hours and even days in cases of
slow bleeding, sometimes a mere oozing, as where an hematoma or an hematocele
is forming and before the period of infection or localized peritonitis,
and here of course the diagnosis is more obscure, but fortunately less
urgent. If, however, the patient is taken from the table with a pulse
of 120-140 or upwards, rectal temperatures 980-970,
respirations 80-40, and even if these conditions persist for several hours,
we have no reason to fear internal hemorrhage, and if after the first half
hour of the patient's rest in bed the pulse and respiration slow ever so
little and the temperature rise even a fraction of a degree we may know
that we have to deal with a case of recovering shock. The surgical
nurse should be taught to make this differential diagnosis through a clinical
study of pulse and temperature and respiration, as it is to her that we
must look for the accurate observation and a prompt report of a condition
in which minutes count in the saving of a life.
We have little to guide us in forming a prognosis,
as here again the . unknown quantity, the vital force of the individual,
the power of resistance of the tissues to the nervous impression comes
in as the most important, factor in the equation. In general the
temperature. is the best guide here also. A persistence of 96o
below for several hours warrants an unfavorable prognosis while even a
slight rise from time to time may be taken as a happy omen.
The many and diverse theories regarding the treatment
of shock shows conclusively the chaotic state of the professional mind
regarding this condition. One writer is so confused in his interpretation
of the phenomena that he advised at the same time morphine, strychnia,
digitalis, nitroglycerine, whisky and citrate of caffeine. No one
has done more to bring order out of this chaos than Dr. Geo. C. Crile,
of Cleveland, by his experiments on dogs. He has practically demonstrated
not only the uselessness but the harmfulness of strychnia in shock and
that the rational treatment lies in raising the blood pressure. He lays
down the principle that the treatment must be sedative to the sympathetic
system and relaxing to the arterioles. To this end he advises compression
of the abdomen and extremities to prevent the accumulation of blood in
the large veins, with the administration of adrenalin given with salt solution.
Dr. Halsted advises morphine also normal salt. It is interesting
to note that Morris, as early as 186S, advised opium 1- 2 gr. every two
hours. Rest and heat, preferably moist, added to these remedial agents,
and we have certainly fulfilled the requirements for treatment in accordance
with all that is known of the pathology of shock, to quiet the nervous
system and relax the arterioles. The addition of strychnine, digitalis,
nitroglycerine and whisky is certainly irrational. The heart is already
overworked by nature's effort to repair the damage and strychnine may prove
to be what the whip is to the spirited horse at the end of the race, and
under its influence the heart may exhaust itself in a last effort.
When there has been hemorrhage as a complication the first indication is
most assuredly to restore the volume of blood, but it is certainly irrational
to increase the quantity of blood suddenly when the normal amount is present
in the vascular system and the difficulty lies in reality in properly caring
for the usual quantity. It would seem theoretically that increasing
the volume of blood rapidly under these conditions would only increase
the local congestion in the large blood vessels and make the ultimate restoration
of the normal blood pressure more difficult. Small quantities of
hot water per mouth or rectum sufficient to allay the thirst, or the slow,
continuous rectal irrigation, which introduces the fluid gradually and
as the tissues are prepared to appropriate it seems to me to be more rational
than intravenous infusion of a large quantity of fluid. Briefly stated,
the treatment in hemorrhage is to restore immediately the normal volume
of blood, in shock to restore the normal blood pressure. Dr. Robert
Dawbarn calls attention to the danger of using plain water in intravenous
infusion in hemorrhage and says that experiments on dogs have proven that
it will kill almost as quickly as prussic acid. He advises normal
salt solution at a temperature of 118o-120o F., one to two quarts, ten
minutes to be taken in introducing it. If the kidneys are not functionating
normally, the quantity must be lessened.
Some writers make a point on the value of force
of gravity and advise lowering of the head. Mummery says that the
ideal treatment of shock would be the raising of the external air pressure,
and thus substituting an artificial peripheral resistance for the lost
peripheral resistance caused by the exhaustion of the vasomotor centers,
but that as yet this method is not practical.
The administration of foods and drugs by the stomach
is distinctly counterindicated. The same principle holds good here
as in the case of the heart. The stomach is exhausted and oversensitive
and should not be irritated or stimulated to work until the period of exhaustion
has passed. Perhaps the principal factor in the therapeutics of shock
is rest, anatomic and physiologic rest. This of course forbids all
stimulants, alcoholic as well as stimulating drugs. Light and sound
should be excluded that the tired brain may share in the general calm with
which we seek to surround our patient.
The preventive treatment of shock lies almost entirely
in the domain of surgery. Here is indeed the ounce of prevention
worth a pound of cure. Paget in 1868 advised hypodermics of morphine
after operations before the patient is restored to consciousness to lessen
the shock caused by pain. Davey in 1858 recommended waiting in cases
of shock injuries not complicated with hemorrhage until some of the "Promethian
fire" had returned to the shocked tissues. Dr. Harvey Cushing and
Dr. Crile advise the cocainization of main nerve trunks thus "blocking"
the nerves proximal to the site of operation, in severe cases where shock
may be anticipated. Dr. Crile has invented a pneumatic rubber suit
with which he envelops the patient, which he claims assists greatly in
preserving the normal blood pressure. There is no doubt that much
can be done by the proper preparation of the patient before coming to the
operating table to prevent subsequent shock and the practice of some surgeons
of rushing nonemergency cases under the knife without any preparatory treatment
cannot be too strongly condemned. It is self-evident that the more
normal the condition of the system the greater will be the resistance of
shock. The indication, then, is to bring all organs as far as possible
to their highest function. This is especially important in the case
of the kidneys, bowels and skin, the great eliminatory organs; these must
actually secrete normally at the time of operation if we are to expect
normal conditions to follow. Free drainage by means of nature's own
remedy, water used liberally, internally and externally, for several days
previous to operation, will in ordinary cases be sufficient to put the
kidneys and skin in good condition. A free catharsis, making sure
that the entire intestinal tract is cleared, is of the utmost importance.
The liberal use of a normal salt solution as long before the operation
as possible not only aids in the systemic drainage but increases the volume
of the blood and promotes the rapid metabolism which is so important in
preserving the quality of the flood. The stomach should be absolutely
empty when the patient is brought to the operating table, as it is one
of the first viscera to manifest reflex irritation, and a persistent nausea
and vomiting keeps the patient in constant distress and the muscular system
in action, preventing the rest and relaxation so necessary to recovery.
Rapid operating, as rapid as is consistent with a proper
attention to detail, is unquestionably one of the greatest factors in the prevention
of surgical shock. The entire regime of the operating room should be conducive
to this end. Every detail, should be attended to as far as possible before
the patient is placed under the anaesthetic. Minutes wasted for any reason
while the patient is under abnormal conditions is an injustice to all concerned.
In abdominal surgery involving the peritoneal cavity there is little doubt that
shock is in almost direct proportion to the amount of handling and exposure
of the intestines. Mummery says that turning the intestines out of the
abdomen is always followed by a sudden and dangerous fall of blood pressure.
Methods of operating, therefore, in which these viscera are little or not at
ail exposed can certainly claim to be a factor in the preventive treatment of
shock. I have frequently seen patients put to bed after the removal of
large myomata (hysterectomy) per vaginam with no more symptoms of shock than
after a normal labor. The choice of anaesthetic in cases where shock is
apprehended is considered by sorpe of great importance.
Mummery says that ether anaesthesia almost always causes a rise in blood pressure,
while chloroform is usually accompanied by a fall in blood pressure, and believes
the chloroform-ether mixture to be the best anesthetic from the point of view
of subsequent shock. It would seem, however, that there are more important
points to be considered in the choice of an anaesthetic, as the organic condition
of the heart, kidneys and lungs, as we have more definite knowledge of the action
of ether and chloroform on these organs. The temperature of the operating
room is of great importance, and should be kept between 80o and 85o
F. Wetting and chilling of the body should be avoided, and heat applied
directly by means of a water cushion placed over the operating table assists
greatly in preserving the normal body temperature. The mental state in
which the patient comes to the operating table is no doubt an important factor.
Every effort should be made, therefore, to inspire the patient with confidence
in the success of the operation, that the demon of fear may be exercised from
the sick room, that the spirit of hope may hover around the last few conscious
breaths and be the first to greet the awakening mind struggling back to consciousness.