Some may understand the must violent injuries and yet retain their consciousness, while others faint on slight exhibitions of pain, or the sight of blood, or even the thought of injuries; and the effect upon the circulation, even to the almost complete cessation of the pulse; the pallor; the cold, clammy sweat; and the entire unconsciousness, are familiar to us all. The symptoms, except in degree, are quite similar to those of shock, and it is difficult to determine beforehand the patient most liable to be affected by it. As a rule we except it more in those of a highly nervous, active, or sanguine temperament, while those of a plethoric or sluggish condition are more exempt. Yet even this does not always hold true. .
Under my care a strong, highly plethoric man, who felt most fully able to go through the operation without ether, finally thought it best to take it for opening a palmar abscess, took the ether very favorably with little or no struggling, and after the operation had been performed, and he had partially rallied from the ether, suddenly went into collapse from which it was quite difficult to resuscitate him.
On the other hand, we have all met most nervous and excitable men and women who have gone through the severest and most long continued operation without any symptoms of shock or collapse. That the mind may affect the patient unfavorably I believe to be quite certain, and in looking over my notes I find several cases in which the patient had previously exhibited great dread of an operation feeling quite certain that she would not recover, in which although in no case fatal collapse occurred, yet it required during the operation and afterwards, careful watchfulness the first apparent symptoms.
In cases, then, of persons subject to easy syncope, I think it of great importance form the first to see that as far as possible their systems are in good condition physically, that they should have previously quiet rest, good food, and cheerful surroundings; that however much their friends, or the family may be informed of the possible dangers, the patient should only look to the most hopeful and encouraging prospects.
I fully approve of the use of Camphor as a stimulant, as suggested by Dr. McDonald, yet the most rapid and successful measure I have ever adopted has been the hypodermic injection of the finest quality of brandy. The motion of the patient, friction, and encouraging words on the first appearance of consciousness, will do much to speedily restore the patient.
L. H. WILLARD, M.D.: We have all listened to Dr. Macdonald’s paper on “Surgical Shock” with interest and attention both because the subject is of great importance and because of its able presentation. The subject is of especial interest as the opinions of surgeons differ widely not only as to treatment but as to the proper time to operate after an accident involving serious shock. I wish to discuss briefly this latter phase of the subject. Before doing so, however, let me present in a few words our method of treating shock at the Pittsburgh Homoeopathic Hospital, a method which is not new in any essential particular, but which has rendered excellent results.
Our hospital, being in the vicinity of many mills and manufactories, and having a railroad patronage, we are familiar with all varieties of shock from the slightest nervous depression or exaltation to the most profound collapse. A case of serious injury being received is at once taken to the operating-room, if the injury requires operative treatment, and the surgeons of the staff being sent for. vigorous restorative measures are begun and kept continuously.
These consist of, briefly:.
1. Control of haemorrhage, by tourniquet or ligature.
2. Heat-hot water bags, etc.
3. Stimulation-by means of brandy, Digitalis, or the alkaloid hypodermic injection, Sparteine, Strychnine, Atropine. But especially have we found efficacious a mixture of brandy, ether and spirits of Camphor, equal parts, which administered by hypodermic injection, seems to have a salutary effect on the circulation in the state of collapse incidental to profound shock.
If there has been loss of blood we use hot water by mouth or rectum, and other ordinary means, such as bandaging the limbs, depressing the head and shoulders, etc.-Rectal injections of warm water seem to have been especially beneficial in many cases even where there was no appreciable loss of blood, having apparently a stimulating effect on the circulation and promoting the freer action of the kidneys which are especially prone to be affected.
The addition of a little salt facilitates absorption by raising the specific gravity more nearly to that of the blood. Our custom is to inject 4-8 ounces every 1-3 hours depending upon the necessities of the case. If the sphincters are lax a smaller quantity is used. Many cases of serious and seemingly fatal shock have been saved, I believe, by this means more than by any other. As instances in point I might cite two or three recent cases of crushed limbs requiring double amputation, one case of leg and thigh amputation having been brought ten miles to the hospital on the guard of an engine after a delay of two or three hours from the time of the accident.
In this instance amputation was performed at once and restorative measures were kept up for many hours after. The state of a patient’s vitality is indicated, of course, by the condition of the pulse and respiration, and by the temperature. Operative measures, if not of immediate necessity, are delayed only long enough for the pulse, respiration and temperature to indicate a beginning reaction-not until full reaction has taken place. And it is in this particular but I wish to hazard an opinion at variance with generally accepted belief.
When I have a patient suffering from shock caused by an accident, the first thing necessary, it seems to me, is to relieve the depression, sustain his strength, and perform any operation that may be necessary as soon as possible and as quickly as can be done. This we know is the generally accepted belief of a great many surgeons, who give as reasons for such procedure that an operation, when the vitality is so low, would surely be fatal. No one who has waited patiently for his patient to recover fully from shock can help but feel that this waiting should be avoided.
It is certain that the older surgeons, in times before anaesthesia was known, were right in laying down these rules in regard to shock, for in those times and under such conditions it would have been fatal to operate when the vitality of their patients was so low, thus intensifying the shock. But now, when we have anaesthetics to deaden the pain and even to improve the heart action (as it seems to do at times), and Camphor and other remedies to assist in stimulating the circulation, I cannot think it necessary to wait until full reaction has taken place before operating.
By so doing we nearly always produce a second shock, which may throw the patient into a condition beyond any help we may be able to render. In a given accident-a patient with crushed arms or legs, for example-tourniquets are applied to the part to prevent haemorrhage; and they not only control the haemorrhage, but they also cut off the entire circulation of the part.
The nerves are pressed upon, and, in fact, the limb below the tourniquet is for the time being practically dead, and remains so until after the operation. Now it seems to me that the mere fact of an amputation when the patient is in a condition of shock, can do little harm to a part virtually dead. Mangled tissues are generally cut off and splintered bones removed. It is but little more to take away the entire crushed mass, sawing off the bone, and completing the necessary dressings, thus ending at once the pain and irritation caused by a mangled limb.
We are now speaking of crushed limbs and of operations done in the quickest possible manner, cure being taken, of course, to insure complete antisepsis, and the pulse and respiration being sustained by all necessary means. There are at times cases requiring long and tedious operative interference where it would be advisable to wait until the patient’s condition shall better enable him to withstand such a trial of his vitality.
Many cases, such as abdominal injuries, with protrusion or laceration of any of the viscera, require immediate surgical attention. Such cases do not seem to be markedly affected either by the use of an aesthetic or by the operation itself, so that even in cases not requiting immediate attention it is my custom to operate at once if the pulse shows any sign of returning vitality, rather than submit the patient to the risk of a second shock.
And in this line let me say that I believe the anaesthetic, especially chloroform, to have rather a stimulating than a depressing effect on the circulation in such instances.
THE CHAIRMAN: The subject is now open for general discussion. .
DR. BOOTHBY: Mr. President, it seems to me that it has not been made clear to us just what is considered surgical shock. We must distinguish between surgical shock and the shock from an injury, as has been spoken about in the last one of these discussions. In regard to surgical shocks proper, we have to distinguish between a true shock and the case that Dr. Talbot referred to. My opinion is that a surgical shock is a very rare occurrence. In the first place, I believe that a great cause of surgical shock is having the room too full, or the patient entirely denuded over a large portion of the body, and that the chill that comes from that is the cause of a great deal of the shock. I speak from my own experience and form the experience of my brothers, Packard and Emerson.
