CONSTITUTIONAL EFFECTS OF INJURIES
SYNCOPE--SHOCK--COLLAPSE--FAT EMBOLISM--TRAUMATIC ASPHYXIA--DELIRIUM
IN SURGICAL PATIENTS: _Delirium in general_; _Delirium tremens_;
_Traumatic delirium_.
SYNCOPE, SHOCK, AND COLLAPSE
Syncope, shock, and collapse are clinical conditions which, although
depending on different causes, bear a superficial resemblance to one
another.
#Syncope or Fainting.#--Syncope is the result of a suddenly produced
anæmia of the brain from temporary weakening or arrest of the heart's
action. In surgical practice, this condition is usually observed in
nervous persons who have been subjected to pain, as in the reduction of
a dislocation or the incision of a whitlow; or in those who have rapidly
lost a considerable quantity of blood. It may also follow the sudden
withdrawal of fluid from a large cavity, as in tapping an abdomen for
ascites, or withdrawing fluid from the pleural cavity. Syncope sometimes
occurs also during the administration of a general anæsthetic,
especially if there is a tendency to sickness and the patient is not
completely under. During an operation the onset of syncope is often
recognised by the cessation of oozing from the divided vessels before
the general symptoms become manifest.
_Clinical Features._--When a person is about to faint he feels giddy,
has surging sounds in his ears, and haziness of vision; he yawns,
becomes pale and sick, and a free flow of saliva takes place into the
mouth. The pupils dilate; the pulse becomes small and almost
imperceptible; the respirations shallow and hurried; consciousness
gradually fades away, and he falls in a heap on the floor.
Sometimes vomiting ensues before the patient completely loses
consciousness, and the muscular exertion entailed may ward off the
actual faint. This is frequently seen in threatened syncopal attacks
during chloroform administration.
Recovery begins in a few seconds, the patient sighing or gasping, or, it
may be, vomiting; the strength of the pulse gradually increases, and
consciousness slowly returns. In some cases, however, syncope is fatal.
_Treatment._--The head should at once be lowered--in imitation of
nature's method--to encourage the flow of blood to the brain, the
patient, if necessary, being held up by the heels. All tight clothing,
especially round the neck or chest, must be loosened. The heart may be
stimulated reflexly by dashing cold water over the face or chest, or by
rubbing the face vigorously with a rough towel. The application of
volatile substances, such as ammonia or smelling-salts, to the nose; the
administration by the mouth of sal-volatile, whisky or brandy, and the
intra-muscular injection of ether, are the most speedily efficacious
remedies. In severe cases the application of hot cloths over the heart,
or of the faradic current over the line of the phrenic nerve, just above
the clavicle, may be called for.
#Surgical Shock.#--The condition known as surgical shock may be looked
upon as a state of profound exhaustion of the mechanism that exists in
the body for the transformation of energy. This mechanism consists of
(1) the _brain_, which, through certain special centres, regulates all
vital activity; (2) the _adrenal glands_, the secretion of
which--adrenalin--acting as a stimulant of the sympathetic system, so
controls the tone of the blood vessels as to maintain efficient
oxidation of the tissues; and (3) _the liver_, which stores and delivers
glycogen as it is required by the muscles, and in addition, deals with
the by-products of metabolism.
Crile and his co-workers have shown that in surgical shock histological
changes occur in the cells of the brain, the adrenals, and the liver,
and that these are identical, whatever be the cause that leads to the
exhaustion of the energy-transforming mechanism. These changes vary in
degree, and range from slight alterations in the structure of the
protoplasm to complete disorganisation of the cell elements.
The influences which contribute to bring about this form of exhaustion
that we call shock are varied, and include such emotional states as
fear, anxiety, or worry, physical injury and toxic infection, and the
effects of these factors are augmented by anything that tends to lower
the vitality, such as loss of blood, exposure, insufficient food, loss
of sleep or antecedent illness.
Any one or any combination of these influences may cause shock, but the
most potent, and the one which most concerns the surgeon, is physical
injury, _e.g._, a severe accident or an operation (_traumatic shock_).
This is usually associated with some emotional disturbance, such as fear
or anxiety (_emotional shock_), or with hæmorrhage; and may be followed
by septic infection (_toxic shock_).
The exaggerated afferent impulses reaching the brain as a result of
trauma, inhibit the action of the nuclei in the region of the fourth
ventricle and cerebellum which maintain the muscular tone, with the
result that the muscular tone is diminished and there is a marked fall
in the arterial blood pressure. The capillaries dilate--the blood
stagnating in them and giving off its oxygen and transuding its fluid
elements into the tissues--with the result that an insufficient quantity
of oxygenated blood reaches the heart to enable it to maintain an
efficient circulation. As the sarco-lactic acid liberated in the muscles
is not oxygenated a condition of acidosis ensues.
The more highly the injured part is endowed with sensory nerves the more
marked is the shock; a crush of the hand, for example, is attended with
a more intense degree of shock than a correspondingly severe crush of
the foot; and injuries of such specially innervated parts as the testis,
the urethra, the face, or the spinal cord, are associated with severe
degrees, as are also those of parts innervated from the sympathetic
system, such as the abdominal or thoracic viscera. It is to be borne in
mind that a state of general anæsthesia does not prevent injurious
impulses reaching the brain and causing shock during an operation. If
the main nerves of the part are "blocked" by injection of a local
anæsthetic, however, the central nervous system is protected from these
impulses.
While the aged frequently manifest but few signs of shock, they have a
correspondingly feeble power of recovery; and while many young children
suffer little, even after severe operations, others with much less cause
succumb to shock.
When the injured person's mind is absorbed with other matters than his
own condition,--as, for example, during the heat of a battle or in the
excitement of a railway accident or a conflagration,--even severe
injuries may be unattended by pain or shock at the time, although when
the period of excitement is over, the severity of the shock is all the
greater. The same thing is observed in persons injured while under the
influence of alcohol.
_Clinical Features._--The patient is in a state of prostration. He is
roused from his condition of indifference with difficulty, but answers
questions intelligently, if only in a whisper. The face is pale, beads
of sweat stand out on the brow, the features are drawn, the eyes
sunken, and the cheeks hollow. The lips and ears are pallid; the skin of
the body of a greyish colour, cold, and clammy. The pulse is rapid,
fluttering, and often all but imperceptible at the wrist; the
respiration is irregular, shallow, and sighing; and the temperature may
fall to 96° F. or even lower. The mouth is parched, and the patient
complains of thirst. There is little sensibility to pain.
Except in very severe cases, shock tends towards recovery within a few
hours, the _reaction_, as it is called, being often ushered in by
vomiting. The colour improves; the pulse becomes full and bounding; the
respiration deeper and more regular; the temperature rises to 100° F. or
higher; and the patient begins to take notice of his surroundings. The
condition of neurasthenia which sometimes follows an operation may be
associated with the degenerative changes in nerve cells described by
Crile.
In certain cases the symptoms of traumatic shock blend with those
resulting from toxin absorption, and it is difficult to estimate the
relative importance of the two factors in the causation of the
condition. The conditions formerly known as "delayed shock" and
"prostration with excitement" are now generally recognised to be due to
toxæmia.
_Question of Operating during Shock._--Most authorities agree that
operations should only be undertaken during profound shock when they are
imperatively demanded for the arrest of hæmorrhage, the prevention of
infection of serous cavities, or for the relief of pain which is
producing or intensifying the condition.
_Prevention of Operation Shock._--In the preparation of a patient for
operation, drastic purgation and prolonged fasting must be avoided, and
about half an hour before a severe operation a pint of saline solution
should be slowly introduced into the rectum; this is repeated, if
necessary, during the operation, and at its conclusion. The
operating-room must be warm--not less than 70° F.--and the patient
should be wrapped in cotton wool and blankets, and surrounded by
hot-bottles. All lotions used must be warm (100° F.); and the operation
should be completed as speedily and as bloodlessly as possible. The
element of fear may to some extent be eliminated by the preliminary
administration of such drugs as scopolamin or morphin, and with a view
to preventing the passage of exciting afferent impulses, Crile advocates
"blocking" of the nerves by the injection of a 1 per cent. solution of
novocaine into their substance on the proximal side of the field of
operation. To prevent after-pain in abdominal wounds he recommends
injecting the edges with quinine and urea hydrochlorate before suturing,
the resulting anæsthesia lasting for twenty-four to forty-eight hours.
To these preventive measures the term _anoci-association_ has been
applied. In selecting an anæsthetic, it may be borne in mind that
chloroform lowers the blood pressure more than ether does, and that with
spinal anæsthesia there is no lowering of the blood pressure.
_Treatment._--A patient suffering from shock should be placed in the
recumbent position, with the foot of the bed raised to facilitate the
return circulation in the large veins, and so to increase the flow of
blood to the brain. His bed should be placed near a large fire, and the
patient himself surrounded by cotton wool and blankets and hot-bottles.
If he has lost much blood, the limbs should be wrapped in cotton wool
and firmly bandaged from below upwards, to conserve as much of the
circulating blood as possible in the trunk and head. If the shock is
moderate in degree, as soon as the patient has been put to bed, about a
pint of saline solution should be introduced into the rectum, and 10 to
15 minims of adrenalin chloride (1 in 1000) may with advantage be added
to the fluid. The injection should be repeated every two hours until the
circulation is sufficiently restored. In severe cases, especially when
associated with hæmorrhage, transfusion of whole blood from a compatible
donor, is the most efficient means (_Op. Surg._, p. 37). Cardiac
stimulants such as strychnin, digitalin, or strophanthin are
contra-indicated in shock, as they merely exhaust the already impaired
vaso-motor centre.
Artificial respiration may be useful in tiding a patient over the
critical period of shock, especially at the end of a severe operation.
Failing this, the introduction of saline solution at a temperature of
about 105° F. into a vein or into the subcutaneous tissue is useful
where much blood has been lost (p. 276). Two or three pints may be
injected into a vein, or smaller quantities under the skin.
Thirst is best met by giving small quantities of warm water by the
mouth, or by the introduction of saline solution into the rectum. Ice
only relieves thirst for a short time, and as it is liable to induce
flatulence should be avoided, especially in abdominal cases. Dryness of
the tongue may be relieved by swabbing the mouth with a mixture of
glycerine and lemon juice.
If severe pain calls for the use of morphin, 1/120th grain of atropin
should be added, or heroin alone may be given in doses of 1/24th to
1/12th grain.
#Collapse# is a clinical condition which comes on more insidiously than
shock, and which does not attain its maximum degree of severity for
several hours. It is met with in the course of severe illnesses,
especially such as are associated with the loss of large quantities of
fluid from the body--for example, by severe diarrhœa, notably in Asiatic
cholera; by persistent vomiting; or by profuse sweating, as in some
cases of heat-stroke. Severe degrees of collapse follow sudden and
profuse loss of blood.
Collapse often follows upon shock--for example, in intestinal
perforations, or after abdominal operations complicated by peritonitis,
especially if there is vomiting, as in cases of obstruction high up in
the intestine. The symptoms of collapse are aggravated if toxin
absorption is superadded to the loss of fluid.
The _clinical features_ of this condition are practically the same as
those of shock; and it is treated on the same lines.
FAT EMBOLISM.--After various injuries and operations, but
especially such as implicate the marrow of long bones--for example,
comminuted fractures, osteotomies, resections of joints, or the forcible
correction of deformities--fluid fat may enter the circulation in
variable quantity. In the vast majority of cases no ill effects follow,
but when the quantity is large or when the absorption is long continued
certain symptoms ensue, either immediately, or more frequently not for
two or three days. These are mostly referable to the lungs and brain.
In the lung the fat collects in the minute blood vessels and produces
venous congestion and œdema, and sometimes pneumonia. Dyspnœa, with
cyanosis, a persistent cough and frothy or blood-stained sputum, a
feeble pulse and low temperature, are the chief symptoms.
When the fat lodges in the capillaries of the brain, the pulse becomes
small, rapid, and irregular, delirium followed by coma ensues, and the
condition is usually rapidly fatal.
Fat is usually to be detected in the urine, even in mild cases.
The _treatment_ consists in tiding the patient over the acute stage of
his illness, until the fat is eliminated from the blood vessels.
TRAUMATIC ASPHYXIA OR TRAUMATIC CYANOSIS.--This term has been
applied to a condition which results when the thorax is so forcibly
compressed that respiration is mechanically arrested for several
minutes. It has occurred from being crushed in a struggling crowd, or
under a fall of masonry, and in machinery accidents. When the patient is
released, the face and the neck as low down as the level of the
clavicles present an intense coloration, varying from deep purple to
blue-black. The affected area is sharply defined, and on close
inspection the appearance is found to be due to the presence of
countless minute reddish-blue or black spots, with small areas or
streaks of normal skin between them. The punctate nature of the
coloration is best recognised towards the periphery of the affected
area--at the junction of the brow with the hairy scalp, and where the
dark patch meets the normal skin of the chest (Beach and Cobb). Pressure
over the skin does not cause the colour to disappear as in ordinary
cyanosis. It has been shown by Wright of Boston, that the coloration is
due to stasis from mechanical over-distension of the veins and
capillaries; actual extravasation into the tissues is exceptional. The
sharply defined distribution of the coloration is attributed to the
absence of functionating valves in the veins of the head and neck, so
that when the increased intra-thoracic pressure is transmitted to these
veins they become engorged. Under the conjunctivæ there are
extravasations of bright red blood; and sublingual hæmatoma has been
observed (Beatson).
The discoloration begins to fade within a few hours, and after the
second or third day it disappears, without showing any of the chromatic
changes which characterise a bruise. The sub-conjunctival ecchymosis,
however, persists for several weeks and disappears like other
extravasations. Apart from combating the shock, or dealing with
concomitant injuries, no treatment is called for.
DELIRIUM IN SURGICAL PATIENTS
Delirium is a temporary disturbance of mind which occurs in the course
of certain diseases, and sometimes after injuries or operations. It may
be associated with any of the acute pyogenic infections; with
erysipelas, especially when it affects the head or face; or with chronic
infective diseases of the urinary organs. In the various forms of
meningitis also, and in some cases of injury to the head, it is common;
and it is sometimes met with after severe hæmorrhage, and in cases of
poisoning by such drugs as iodoform, cocain, or alcohol. Delirium may
also, of course, be a symptom of insanity.
Often there is merely incoherent muttering regarding past incidents or
occupations, or about absent friends; or the condition may assume the
form of excitement, of dementia, or of melancholia; and the symptoms are
usually worst at night.
#Delirium Tremens# is seen in persons addicted to alcohol, who, as the
result of accident or operation, are suddenly compelled to lie in bed.
Although oftenest met with in habitual drunkards or chronic tipplers, it
is by no means uncommon in moderate drinkers, and has even been seen in
children.
_Clinical Features._--The delirium, which has been aptly described as
being of a "busy" character, usually manifests itself within a few days
of the patient being laid up. For two or three days he refuses food, is
depressed, suspicious, sleepless and restless, demanding to be allowed
up. Then he begins to mutter incoherently, to pull off the bedclothes,
and to attempt to get out of bed. There is general muscular tremor, most
marked in the tongue, the lips, and the hands. The patient imagines that
he sees all sorts of horrible beings around him, and is sometimes
greatly distressed because of rats, mice, beetles, or snakes, which he
fancies are crawling over him. The pulse is soft, rapid, and
compressible; the temperature is only moderately raised (100°–101° F.),
and as a rule there is profuse sweating. The digestion is markedly
impaired, and there is often vomiting. Patients in this condition are
peculiarly insensitive to pain, and may even walk about with a fractured
leg without apparent discomfort.
In most cases the symptoms begin to pass off in three or four days; the
patient sleeps, the hallucinations and tremors cease, and he gradually
recovers. In other cases the temperature rises, the pulse becomes rapid,
and death results from exhaustion.
The main indication in _treatment_ is to secure sleep, and this is done
by the administration of bromides, chloral, or paraldehyde, or of one or
other of the drugs of which sulphonal, trional, and veronal are
examples. Heroin in doses of from 1/24th to 1/12th grain is often of
service. Morphin must be used with great caution. In some cases hyoscin
(1/200 grain) injected hypodermically is found efficacious when all
other means have failed, but this drug must be used with great
discrimination. The patient must be encouraged to take plenty of easily
digested fluid food, supplemented, if necessary, by nutrient enemata and
saline infusions.
In the early stage a brisk mercurial purge is often of value. Alcohol
should be withheld, unless failing of the pulse strongly indicates its
use, and then it should be given along with the food.
A delirious patient must be constantly watched by a trained attendant or
other competent person, lest he get out of bed and do harm to himself or
others. Mechanical restraint is often necessary, but must be avoided if
possible, as it is apt to increase the excitement and exhaust the
patient. On account of the extreme restlessness, there is often great
difficulty in carrying out the proper treatment of the primary surgical
condition, and considerable modifications in splints and other
appliances are often rendered necessary.
A form of delirium, sometimes spoken of as #Traumatic Delirium#, may
follow on severe injuries or operations in persons of neurotic
temperament, or in those whose nervous system is exhausted by overwork.
It is met with apart from alcoholic intemperance. This form of delirium
seems to be specially prone to ensue on operations on the face, the
thyreoid gland, or the genito-urinary organs. The symptoms appear in
from two to five days after the operation, and take the form of
restlessness, sleeplessness, low incoherent muttering, and picking at
the bedclothes. It is not necessarily attended by fever or by muscular
tremors. The patient may show hysterical symptoms. This condition is
probably to be regarded as a form of insanity, as it is liable to merge
into mania or melancholia.
The _treatment_ is carried out on the same lines as that of delirium
tremens.