It must not be forgotten that indiscriminate resort to intravenous infusion may do great harm. It is a minor procedure which requires skill. When the lungs are congested from the irritating effect of ether, and the right heart is embarrassed, a too sudden flushing with saline solution may further embarrass it or even check its activity. So with a patient in the Trendelenburg posture, the intestines are crowded up against the diaphragm and its natural downward play impeded, though the brain is better supplied with blood in this than in any other position.
Much may be done in the way of prevention when shock can be foreseen. This includes the general fortification of the patient by overcoming any auto-intoxication which may have been previously noticed, by improving elimination, and by stimulating the heart’s action with strychnine, digitalis, cactus, etc. Atropine is especially a stimulant to the respiratory centres.
Once the operation is begun, and remembering that the depressing influences which tend to reduce blood pressure are transmitted through the afferent nerves, we may take advantage of Crile’s suggestions and temporarily paralyze them, by exposing them and injecting directly into the nerve trunks two or three drops of 1 per cent. cocaine solution. This should be done before division of the main trunks and at a point above the line of section. It is possible during an amputation, by taking a little extra time and pains, to “block off,” as it is called, the nerves in this way and prevent their conveying any depressing sensation. At other times, as in operations on the mouth, and especially the larynx, cocaine solution may be used locally, as by the spray, and the same effect produced. Cocaine seems to be a protoplasmatic poison which inhibits nerve action.
In the description of the treatment of shock there has been little reference made to the result of loss of blood as such. In cases where this has already occurred, or cannot be prevented, it should be atoned for by the infusion of saline solution, either by intravenous introduction or by hypodermoclysis, i. e., its injection into the loose connective tissues in various parts of the body. While a special apparatus has been devised for this purpose, a sterile fountain syringe with an ordinary aspirator needle will be found to be sufficient for nearly all purposes.
The erethistic, or extremely restless type of shock, may be profitably treated by small doses of morphine given subcutaneously.
The question of immediate operation or delay should be carefully considered. Shock is often alleviated by prompt removal of mutilated limbs or parts whose fragments, while still connected with the trunk, seem rather to perpetuate the condition, especially if the principal nerve trunks are cocainized. In serious cases intravenous infusion should be practised.
After commencing with the anesthetic, while scrubbing and cleansing the field of operation it is advisable to scrub an arm where it may be necessary to expose a vein, or the skin at several points, where a needle may be entered, so that there may be no delay for this purpose should infusion or hypodermoclysis be suddenly required.
CHAPTER XIX.
ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS; TRANSFUSION; CATHETERIZATION; SKIN GRAFTING; BANDAGING.
Abstraction of blood, usually of venous blood, known as venesection, was a practice frequently indulged in years ago. At one time in the history of medicine it seemed to be the measure regarded as a panacea for all ills. The reaction from the period of excessive bloodletting came during the previous century, and was so strong that the practice was for a generation or so almost abandoned. The eminent surgeon S. D. Gross wrote a paper entitled “Bleeding as a Lost Art.” Bloodletting is an expedient of great value in a somewhat restricted class of cases, but is capable of affording such relief in certain emergencies that practitioners should be ready to resort to it at any moment when it may be required.
After removal of a certain amount of fluid blood pressure is naturally reduced and at the same time equalized, while when the right side of the heart is overburdened with its task it is thus made to beat more easily and regularly; thus indirectly there may be brought about a subsidence of violent heart effort, a reduction of the respiration rate, a lowering of temperature, and sometimes a diminution in the activity of morbid processes which may be beneficial, and even life-saving. Even after moderate bleeding, say a half-pint, the amount of urine is increased and the proportion of solids raised. More air is taken into the lungs, and oxygenation is thereby much improved.