There was a suspicious flabbiness about this patient that I did not like, and on this account the operative work was conducted with all possible dispatch in order to avert shock. The significant fact, however, is that she could withstand a laparotomy but not a rectal injection.
The examples showing that the extent of the injury is not in proportion to the shock might easily be multiplied. Opening a digital abscess has produced death; a slight blow upon the testicle or epigastrium will result in alarming depression of all the vital forces. I have seen simple skin plantation for an ulcer of the leg followed by severe shock, from which the patient did not recover for forty-eight hours.
In one particular, shock has not been sufficiently dwelt upon, either by writers, teachers, or operators, and that is, that sudden cessation of life in an individual does not, of necessity, mean cessation of cellular life in the tissues. This is a legitimate conclusion, and is based upon investigations in physiological chemistry, corroborated by observations in natural history and by the experience of surgical clinicians. We may say that, grossly, the animal life is extinct, but histologically there is yet life and function in the tissues.
This is shown by the fact that muscle removed from an animal killed suddenly will for some time give off carbon dioxide, absorb oxygen, and respond to electric stimuli. Even after rigor mortis has occurred, tremblings, elongations, and contractions have been observed. After cross section of a tadpole the tail will not only live for some time, but will actually grow if allowed to remain in the water (Vulpian).
For more than twenty-four hours after removal from the animal the pancreas continues its fermentation, and the liver also produces sugar slowly after death. Surgeons know that ends of fingers severed and left upon the block have been sent for and made to live and grow upon their stumps, and that skin from recent corpses has been successfully grafted upon the living.
Now, if the cellular structures of the grosser muscles and glands thus continue their function, so must the histological elements of the heart muscle, or the respiratory apparatus or nervous system.
How often have we seen, upon the operating table, extinction of life which would be eternal were the surgeon to turn his back to the patient, and how often the operation resolves itself into a question, not of obtaining primary union, removing the tumor, or preventing a hernia, but of saving a human life.
The ghastly but tranquil features bedewed with tomby mist, the motionless thorax, the pulseless wrist-all these shape themselves into a picture with which almost every surgeon is familiar. In this case life is extinct, and from death to dust the pathway is straight, and all that lies between the patient and the grave is a death certificate.
The following I take from our hospital records:.
CASE V.-Patient 60 years of age and quite feeble. Heart, lungs and kidneys sound. Small, hard tumor in Douglas’s cul de sac, which cause much suffering. Prognosis very grave. Treatment: rapid abdominal section. The growth, an ovarian carcinoma, lifted, and a ligature passed through the broad ligament, when it was announced that both respiration and circulation had stopped.
The heart was still, and not the faintest sign of respiratory effort could be detected. The patient was inverted and artificial respiration resorted to, and was accompanied by hypodermic stimulation. For some time all effort seemed in vain, but slowly and faintly the pulse reappeared, and in about ten minutes she began to breathe and life was resumed. Actual time of operation a little over fifteen minutes.
There is no more tragic scene in human life than sudden collapse on the operating table. To know that one’s hand has shortened the life of a patient, even though doomed by some preexisting disease, is a horribly unwelcome sensation, but to know that resuscitation is possible, even when life seems extinct, robs operative surgery of much of its horror.
While we regret exceedingly that with our present knowledge we are unable to give the rationale of the phenomena of surgical shock, the great and absorbing question should be its prophylaxis, and I believe there is no other means by which so much can be accomplished in this direction as by rapid operating. Remember, that upon the operating table it is often impossible to differentiate traumatic shock from the toxic effects of our anaesthetics; that this period is usually characterized by subnormal temperature; that beyond a certain point every inhalation of the anaesthetic increases the depression; that, at best, operative insensibility means the establishment of a tendency toward death, and that the culmination of this tendency may occur during one single minute which is unnecessarily added to the time of operation.
This thought should underlie all our surgical procedures, but I am afraid we may justly be charged with more or less disregard of this principle. There is not enough attention devoted to the pre-operative arrangements, and consequently too much dilly-dallying during the operation. How often have I seen an hour and more consumed in a simple trachelorrhaphy which could easily be accomplished in twenty minutes, or even twelve of fifteen minutes, with competent assistants. This must not be regarded as a reproach to beginners, but to those who have been operating long enough to possess much better technique. I would not be understood as desiring to sacrifice methods (good methods) for rapidity, but that I plead for better methods in order that the operative period may be reduced and with it the tendency to shock.
The preparation of the patient for a state of invalidism, too, is all important, and this having been done it should be a part of our professional ritual to operate in the morning whenever possible. I am well aware that there are lesions that can neither wait for preparatory treatment nor the morning hours, but the fact that this is just the class most prone to shock but shows the importance of the above observations-when they can be carried out.
Tranquilizing the patient’s mind, the administration of medicine before operation and the maintenance of proper temperature during the operation are too familiar to bear comment.
Nineteen years ago it was taught that inflammation and suppuration were reduced to the minimum, and that they were the inevitable accompaniments of operative surgery. Let us hope that our present ideas may be as abruptly changed, and that shock may yet been spelled from the list of surgical complications. At present, however, it must be admitted that shock cannot be positively averted and that the best the surgeon can do is to equip himself for the comprehensive grasp of critical emergencies.
Collapse on the table has been sufficiently dwelt upon already. I might add that in two cases I fancied I obtained relief by Maas method of rapid and rhythmic compression of cardiac region, but I cannot speak with any degree of positiveness of this method. In one case I obtained an abrupt renewal of respiration by anal dilatation. It has failed me in many others.
In post-operative shock we can find a place for our Homoeopathic remedies, and while I never omit the general measures deemed necessary or at least essential, I have acquired an immense amount of faith in Camphora (low, of course). I would give more for this drug than for all the rest of our Materia Medica. Arsenic is good, and so is Veratrum alb., but often the vitality is so low that the stomach is inactive and we can obtain no results by this route.
In such cases a favorite resort with me is enemata of warm and strong black coffee; from a half pint to a quart, and repeated as fast as it is absorbed or till reaction is secured. Dr. Van Lennep has obtained good results from enemata of whiskey and Valerianate of ammonia-a teaspoonful of each.
After all, our main reliance is upon cardiac and respiratory stimulants, artificial respiration and artificial heat. Copious intra-venous or intra-cellular saline injections will always to remembered, especially if there has been much Haemorrhage.
The most manifest indications point, with imperative necessity, to tiding the patient over the perilous but brief period and our success in obviating the tendency to death will be in proportion to our ability to distinguish the direction from which death is threatening.
DISCUSSION.
I. T. TALBOT, M.D.: The subject of shock is one of great interest to every surgeon. First, because it may render a simple operation fatal, or in grave operations, suddenly turn the surgeon’s victory into defeat; and second, because he can never know beforehand the liability of the patient to shock, or the extent to which it may attain.
This paper of Dr. Macdonald’s suggests certain points of great importance to the surgeon, and among these the surgical character of the affection. We all appreciate the great difference in which different persons are affected by syncope or fainting.
