THANKS to anesthesia and antisepsis, pain and poison have been eliminated from operative surgery, and the most formidable complication now remaining for the surgeon to cope with, is shock. Its paramount importance, and the meagerness of the subject, make its further study eminently advisable. As here considered, the subject has nothing to do with “railroad spine” or “litigation symptoms,” but is no deal with the immediate constitutional phenomena produced by local traumatism, and will be used synonymously with collapse. It will not be understood by this that shock cannot be produced by psychic as well as traumatic influences.
The interdependence of the mind and body is shown by the influence of impressions that fall upon the retina from without. Let a patient who is to be operated gaze upon an elaborate array of instruments, and in some cases the effect is most pronounced. Through the mind the knees quake with terror, the hair stands on end, the brain reels, the heart beats tumultuously, the respiratory apparatus stammers and gasps, the perspiration oozes from every pore, the urine is voided or suppressed-in fact any of these organs may be transiently disturbed or even paralyzed.
These are familiar illustrations, but severe to show that psychical disturbances may act powerfully upon our physical being; and who can tell (and I ask it in all charity and kindness) how much this had to do with the death of Col. Sheperd?.
The above examples would seem to indicate that, turn and twist it how we will, we cannot escape from the fact that the mind is a power within our muscular being (Mueller), or that the psychical and physical are practically one, and that the normal status of our grosser structures is more or less dependent upon the mind as well as the heart or lungs. Although shock of this variety may be profound, it is not necessarily surgical, but the varieties which are the accompaniment of visible trauma, and especially if coincident or subsequent to surgical operation, are of special interest to us. Because the symptoms of shock are so familiar, they may wisely be omitted; but, on the other hand, its pathology is so obscure that it demands further study.
The most advanced work on surgery takes up surgical shock, and dismisses the subject of its pathology with the statement that it consists of paralysis of the vaso-motor system. Other works, devoting several pages to the pathology, add nothing to the above except what is conjectural. We know that peripherally the capillary resistance is diminished; so, too, is the motive power of the cardiac centres. If the vaso-motor supply be cut off from one part of the body, the vessels therein dilate, but in a few days recover their tone, although future contraction and expansion are dependent upon local stimuli.
The abdominal vessels may or may not be dilated. Further than this, everything at present lies beyond the range of human perception. We may say that in shock there is a disturbance of the molecular equilibrium, which can no longer liberate force, but this is of little satisfaction to the analytical mind. Autopsies teach us nothing of the pathology, no post-mortem traces ever having been discovered. The whispering of molecular vibrations, which constitute human agony, is lost in the roar of hurrying dissolution.
The clinical phenomena, however, corroborate the vaso-motor theory, and the consequent relaxed vascular system. It is borne out especially by the intense thirst and the incredible quantities of water that many of these patients drink during profound relapse.
CASE 1.-Removal of four and one-half inches of rectum for epithelioma. The operation was tedious but not very bloody, only two vessels being ligated. The operation was completed, and the patient, in the most profound collapse, was placed in bed. The pulse was but an occasional flicker, the respiration faint; features pinched and ghastly, pupils dilated. The ears and supra- sternal fossa were filled with cold sweat, and the body and limbs wet and cold. Hypodermic stimulation brought about little or no improvement, and as there was fortunately no vomiting, I decided to try simulating fluids by the stomach.
Brandy and hot water was administered, at first a few drops at a time, but it was soon given freely, when it was perceived that deglutition was unimpaired. Suffice it to say that during that night he drank nearly five quarts of the liquid, though much of the time too weak to do more than turn his eyes appealingly toward the glass. He rallied the next day, the temperature not running above normal. In such cases the desideratum seems to be to give the relaxed vascular system something to contract upon.
The proneness of intestinal lesions to produce shock is worthy of attention and so is the deception in its manifestations, especially during the period preceding dissolution. It is characterized by cessation of pain and sometimes vomiting, both of which may have been persistent, and the patient becomes perfectly easy and rational and the temperature may be normal. This is augur of collapse, which is precipitated by operation.
CASE II.-I was called hurriedly to the suburbs, and went prepared to operate for suspected intestinal obstruction. Found the patient able to sit up, feeling perfectly comfortable and having a normal temperature. The history as well as condition upon examination corroborated the tentative diagnosis, and after giving the family a most guarded prognosis the patient was hastily prepared for operation. The abdomen was quickly opened and a quantity of dark brownish fluid came to view, and instantly the patient was collapsed. The pulse was lost and the respiration consisted of an occasional gurgling in the throat.
Inversion and subcutaneous stimulation were quickly resorted to. A hasty examination of the abdomen revealed a twist in the small intestines lying in the left hypochondrium. Below this the gut was collapsed; above it, markedly distended and five or six feet of it black and gangrenous. Holding the intestines in with hot sponges, we placed her in a warm bed and surrounded her with artificial heat and continued the stimulation, the abdominal wall being sutured in the meantime.
She rallied slowly, only to die seven hours later, and another death was registered, hastened by operation, and yet preventable by earlier interference. Here life is unstable, and the slightest molestation is sufficient to destroy the equilibrium, but humanity prompts us to attempt to aid while yet the fingers of our surgical instincts are palpating the lean possibilities that lie beneath the abdominal wall.
Before going further, I wish to wring the neck of a moss- grown delusion. There has been much teaching to the effect that surgical shock is in proportion to the extent of the injury received. This is not true; the extent of the injury is no standard by which to estimate the intensity of the shock. It has been said that “shock is the measure of the ability of an individual to resist hurtful influences form without.” In a general way this is good, but it is far more likely that it is a measure of the power of resistance possessed by certain organs or structures.
CASE III. will illustrate my meaning. A female about forty, with a hydatid cyst of the liver as large as a coconut. Being incapacitated for household duties, she desired an operation. The abdomen was opened freely, but the cyst was non-removable (en mass) because firmly adherent in all directions save toward the line of incision. The intestines were pushed aside and a passage to the tumor maintained by a firm packing of Iodoform gauze. In spite of the rather free handling of the abdominal contents (because of a desire to extirpate if possible), there was little or no shock following the operation.
During the next few days her general condition improved, and when sufficient time had elapsed to allow the bowels to be walled off firmly the cyst was opened, and this simple procedure was followed by the most pronounced disturbance of all the vital functions. The pulse was a mere thread, and running one hundred and seventy-six to the minute, and vomiting was quite troublesome. It was evident that her life was greatly imperiled, and I was quite doubtful as to the issue.
A point of hot black coffee in the rectum and hypodermic injections of twenty minims of Digitalis tincture brought the pulse down in two hours to one hundred and twenty to the minute. She was then complaining of the strong taste of the coffee, and was tided over the danger of the hour.
CASE IV. is even more suggestive. Mrs. G., aet. 51, suffering from a large ovarian cyst. The abdomen was opened and the tumor, weighing fifty-five pounds, removed. There was no post-operative shock, and the laughed and joked with the return of consciousness. A few days later an enema of warm water was given by a competent nurse, and was promptly followed by profound shock.
It was a very good picture of Travers’s “prostration with excitement.” She tossed wildly, the respiration were quick and shallow, pulse lost in one wrist and flickering in the other, skin clammy and cold. She complained of nothing definite, but the face was expressive of indescribable anguish. Arsenicum 3x was administered, and, aided by sharp stimulation, she made a good recovery.
