We have almost never had a case of true surgical shock. We have done our operating in a very warm room, with a temperature as high as 85 degree. I have almost had it 90 degree, and while it is uncomfortable to the operator, and very uncomfortable to those looking on, it is decidedly beneficial for the patient. In the case of No. 1 in the original paper, while it is distinctly said that there was comparatively little haemorrhage, I believe that the collapse was due to the haemorrhage. I don’t see how an operation can be made without considerable haemorrhage if the patient is susceptible to fainting.
In Cases 2 and 3 I have no doubt the septic condition of the system, and the changes the operator made in the anaesthetic, caused the trouble. I want to say one word in regard to the suggestion in the paper that the operation should be made as rapidly as possible. Perhaps I wouldn’t agree with Dr. Packard, for he operates very rapidly. I do not and cannot. I take a great deal of time for my operations. I believe if you are careful with your anaesthetics, and don’t give too much, and keep your patient just over the line and no further, you will have no trouble to keep him under the influence of ether. In regard to the administration of coffee, I hope you won’t use it. I have no argument in its favor, and I wouldn’t use it.
W.F. KNOLL., M.D.: This subject of shock after operation or injury is a very importance one to any surgeon who has done work a great while in public hospitals or railways. When such a complication arises in the course of an operation, it always goes far in the mind of our surgeons, and they have tried to find out its causes and what shock is. And after careful investigation of the subject, and from pathological observation, I have concluded that a shock is a sudden suspension of nerve forces. Now, shock is produce in one patient very easily and in another not so easily. I have seen it caused from dilatation of the return.
I have seen shock from pulling a tooth. I have seen shock from a man simply washing out his ear. I have seen a patient upon whom I have amputated three limbs of the body, not affected a particle by shock. I have seen a patient at the age of 90 upon whom I have made an operation where there was scarcely any variation in the pulse. You never can say when a patient is going to have shock; it depends altogether upon the nervous organization of the patient, and taking that as a basis, what is the term “shock?” Take your patient as you find him. What do you see? You find a slow or a rapid pulse. You see that respiration is superficial. You have general relaxation and sometimes a discharge of urine.
There is complete relaxation, the nervous system has been so profoundly affected that you have momentary paralysis. What do want to get at is to preserve the temperature of the body. Heat is no important thing; it is one of the main things. And in the second place, you want give a medicine which in a certain measure will restore the operation of the brain and the nerve centres, and the best thing is Strychnine. We have received from the hospitals some profound results from hypodermic injections of 1/120 grain of Strychnine. I believe in something that will have a stimulating effect also upon the circulation and upon the brain, and for that I believe Camphor is the best remedy. I believe it is a very good thing to place the head below the rest of the body.
I believe hypodermic injection of some stimulant, especially brandy, and the flushing of the bowels with warm water with whiskey in it, is a very good thing. If you can find out the peculiarities of the patient, you can very often prevent shock. If you have a patient that is of a very highly nervous organization, by preparing the mind you can stop a great many complications that may follow operation.
Now, the treatment that we have used with so much success can be summed up in this way: First, prepare your patients for the operation mentally and every other way; assure them they are going through their operation nicely; don’t have a great struggle with them under anaesthetics. In the second place, if shock takes place, keep up the temperature of the body at once. In the third place, use some hypodermic injection like Strychnine; in the next place, give something that will stimulate the heart’s action.
S.B. PARSONS, M.D.: Perhaps I am laboring under a wrong impression but it strikes me that Dr. Macdonald’s paper referred to shocks from accidents, more particularly than shocks from operative measures; therefore shocks from operative measures are not to be discussed at this time. There is one point that has absolutely been overlooked in the paper and discussion-one that has not been touched upon, yet one that has a more direct effect upon the patient than all the other matters that have been spoken of, and that is reflex action. We all know that sudden excitement of the sensory nerves will disturb the heart’s action and may arrest its movement.
If the patient is undergoing the operation and has only been partially anaesthetized when the operation began, or when he is partially under it and it has been continued for some little time, then the sensory nervous will reflex painfully and affect the heart’s action, and its inhibitory movement. That is why we see sudden collapse during operation. There energy is so far below par that they are not able to stand both the shock and the anaesthetic without great stimulation. The heart is the thing to be looked after, not the warmth of the body; it is the heart. You have your collapse coming on suddenly; it is the action of the reflex movement upon the heart. That is all I have to say.
THE CHAIRMAN: If there is none other Dr. Macdonald will have an opportunity of saying anything he may desire in closing in the discussion.
DR. MACDONALD. Mr. Chairman, Members of the Congress: I will keep you just a moment. Something was said about Camphor. I don’t want to be misunderstood as to the use of Camphor or any other internal remedy, or as excluding stimulation. I believe hypodermic stimulation of importance. Something has been said with reference to chloroform as a heart stimulant in cases of shock. My experience has been very different; where I have used chloroform and the heart has become dangerously depressed I immediately use ether as a heart stimulant. I think that ether is a better heart stimulant than chloroform. I say I had some cases that collapsed.
I want to say that all these cases were anaesthetized. You have been warned against the use of coffee. I admit in Boston there is a well-known way of using coffee, which is much better than putting it into the rectum. My experience is, as far as aesthetic matters go, it is better not to give it in that way. This is a matter of human life, and I don’t think of small matters like that. I am looking after the patient and human life. One of the cases I reported was aid to have been influenced by septicemia.
It was charged by Dr. Boothby with having caused the collapse; that it was probably due to septicemia, and that it was a dangerous operation. Let me say that it was a case of either performing the operation or losing the patient. So I felt that the operation was justifiable. But I don’t want to be knocked down by the chairman, because he has an old grudge against me, and I will stop now.
DR. BIGGAR: What objection is there to preparing the patient and anticipating the shock by giving a small quantity of whiskey or a hypodermic injection in proper quantities in the proper time?.
DR. MACDONALD: I don’t know of any objection to it. In my paper I spoke of the use of medication before operation. It seemed to me so common and so ordinary that it didn’t require any comment at all. I use coffee, strychnine and brandy; in many cases I deem it advisable to use stimulants of alcoholic nature. .
DR.NIELSON, of Michigan: What shall we do with that large and growing class of people who object to alcoholic stimulants in any shape or form.
DR. MACDONALD: From my acquaintance with the member of the Congress I think we should have to go outside of it to find them.
