102

- corresponding periods by rather more than half an inch. Thl

aggregate duration of bright sunshine during the 13 week;was 587 hours, exceeding the recorded amount in the sami

period of last year by 1641 hours, and the average amounin the corresponding period of recent years by 87 hoursit seems probable that the unfavourable effect on the publi(health of the unseasonably cold and trying weather ir

April, causing excessive mortality from diseases of thE

respiratory organs and increased fatality of measle:

and whooping-cough, was fully counterbalanced by thE

effect of the exceptionally fine weather and bright sunshinEduring May and the greater part of June. It does not,

however, appear that any considerable proportion of thE

marked reduction in the rate of urban mortality duringlast quarter can reasonably be attributed to unusuallyfavourable meteorological conditions. The mean annual

death-rate from the principal epidemic diseases in the 76towns during the quarter did not exceed 1’12 per 1000,against 1’45 and 1-58 in the corresponding periods of 1906a.nd 1907. The recorded deaths in these towns from measles,scarlet fever, diphtheria, whooping-cough, "fever," and

diarrhoea during last quarter were -from each disease

considerably below the mean number in recent correspond-ing periods. Infant mortality in these towns, which hadbeen equal to 108 and 110 per 1000 births registered inthe spring quarters of 1906 and 1907, declined to 100 per1000 in the quarter just ended. These facts seem to pointconclusively to continued improvement in the sanitary con-dition. of our large urban population. It is not without

interest to note that while the death-rate during last quarter<did not exceed 13- 8 per 1000 in the 76 English towns, it was<equal to 16’4 in the eight principal Scotch towns, and to no

less than 20 in the 22 Irish towns respecting which the

Registrar-General for Ireland reports weekly ; thus, com-

pared with the mean rate in the English towns the

arban death-rate showed last quarter an excess of

-18-8 per cent. in the Scotch towns and of 45’7 per cent.in the Irish towns. Having regard to the fact that the mean

population of both the Scotch and the Irish towns is consider-

ably smaller than that of the English towns, the markedexcess of urban mortality in Scotland and Ireland forciblysuggests the conclusion that improved sanitation has notmade the same progress in those parts of the United

Kingdom as in England and Wales. A comparison of the

mortality statistics of London, Edinburgh, and Dublin

points to the same conclusion. The death-rate among the

nearly 5,000,000 of persons residing within the County ofLomion during the 13 weeks ending on June 27th last didmot exceed 13’3 per 1000; whereas in Edinburgh, with

an estimated population of 350,524, the death-rate

was equal to 15’5, and in Dublin, with an esti-

mated population of 394,525, it was equal to 20-1 per1.000. Thus in equal numbers living, for each 100 deaths

registered last quarter in London 117 deaths occurred in

Edinburgh and 153 in Dublin. This startling excess of

recent urban mortality in Ireland, which cannot un- I

fortunately be regarded as exceptional in view of the

light thrown upon defective sanitary organisation by therecent Belfast report, urgently calls for exhaustive publicinquiry.

The Treatment of Shock.THERE are many problems in surgery in the solution of

which physiological experiment can be of the greatestservice. Empirically there has -grown up a mass of thera.

peutic measures designed to deal with complications that

may occur, and in regard to most of these it is difficult

indeed to say which are really of value. There is probablyno more common cause of death after operation nowadaysthan shock. Thanks to modern surgical methods sepsis haslost its former pre-eminence as a cause of death in caseswhere an operation has been performed, but in the preven.tion and treatment of shock little progress has been made

until recently. Every surgeon and every anaesthetist has

certain methods of treatment of shock, but many of themfail utterly when put to the test. The vital importance ofthe matter must be acknowledged by all, for it may be that

the very methods which we employ are increasing in place ofretarding the shock which we try to treat. Here is the office

of applied physiology ; by judicious experiment we can in-

vestigate the true value of our methods of treatment and

then our therapeusis will rest on a firm basis. In a

paper recently read before the London Hospital Medical

Society and published in’our columns (see p. 85) Mr. A. J.

WALTON showed conclusively the immense value of the

aid that physiological experiment can give to surgeryin the solution of these difficult problems.

All pathologists are now agreed that in shock there is amarked fall of blood pressure and that this fall is broughtabout partly by the weakening of the heart but chiefly by a

’

great dilatation of the vessels of the splanchnic area. Some

use the term collapse as synonymous with shock, but more

generally it is applied to the condition when the shock hashad added to it a marked loss of blood or a loss of fluid

from the vessels by transudation. The fall of blood

pressure is due to the trauma which acts by impulsesconveyed by the afferent nerves to the vaso-motor centres,and this is shown by various facts. The amount of shock

is directly proportional to the amount of injury to the

nerves of a region, and, further, the more specialised andthe more abundant the nerve-supply of a part the more

readily is shock produced when that part is subjectedto injury. Cutting a limb produces much less shock

than crushing a limb. When previously to the injurythe main afferent paths are cocainised the resultingfall of blood pressure and shock are of little importance,even when severe injury is employed. The most significantfact is that the amount of shock depends on the partinjured. In some parts, as the skin of the limbs, the firsteffect of an incision is to cause a rise of blood pressure, but

as the injury increases in severity the rise is replaced by afall. When the abdomen is opened the mere incision of thetissues of the abdominal wall and the exposure of the

contents of the abdomen are sufficient to produce a markedfall in the peripheral blood pressure with symptoms of

shock ; this fall can be at once checked by the application ofwarm saline solution to the peritoneal cavity. Experimentsshow that this fall of blood pressure resulting from injury isiue to paralysis of the vaso-constrictor centre. We have,iherefore, been enabled to obtain a very exact notion of the

103.

THE TREATMENT OF SHOCK.

essential nature of shock: it is a decrease in blood pressure,which is caused by dilatation of the splanchnic area.

resulting from multiple afferent impulses ; these afferent

impulses may cause a temporary action of the vaso-con-

strictor centre, but the centre is soon paralysed and the

peripheral vessels dilate. A further complication maybe present-a decrease in the total amount of the

fluid constituents of the blood, and this materiallyincreases the difficulties of the circulation. These ex-

perimental results have been obtained from animals,but all observations show that the conditions are the

same in man. In an excision of the breast with much

traction on the brachial plexus the blood pressure has beenobserved to fall from 135 to 60 millimetres of mercury. The

chief factors which determine the amount of shock are of

importance. As the length of the operation increases, thefall of blood pressure increases also ; and it is clear that, sofar as is consistent with efficiency, the operation should be

as brief as possible, especially in the old, in the ill-fed, andin the debilitated. The organ involved is of the greatestmoment in determining the amount of shock, and when theabdomen or brain is involved the fall of blood pressure is verygreat. Ansesthetics have much influence and their action is

two-fold. Inasmuch as they produce unconsciousness, theyblock the afferent impulses and thus have a very definiteeffect in diminishing shock. It must not, however, be for-

gotten that an ansesthetic may in itself have a toxic action

on the vaso-constrictor centres. With ether there is no fall

but a steady rise of blood pressure throughout the wholecourse of the operation, and this is not due to any stimulant

action of the drug. If any fall occurs it is due to the opera-tion itself. On the other hand, the administration of

chloroform is accompanied by a steady fall of blood pressurefrom the very beginning of the operation to the end. This

fact is of very great importance. Spinal anaesthesia has beenshown not to cause per se the slightest fall in blood pressure,and even in old and exhausted patients operations may be

performed under spinal anaesthesia with remarkably little

shock.

All this is the theory of shock in operations ; how canwe apply it in practice ? 7 We must start from the prepara-tion of the patient for operation. Drastic purgation mustnot be employed, for it has a very definite effect in loweringblood pressure, and prolonged fasting previously to an opera-tion is equally or even more harmful. Whenever possibleether should be preferred to chloroform, or if ether be,

contra-indicated spinal anaesthesia should, from the point otview of prevention of shock, be employed when possible.CRILE devised a "pneumatic suit" in which the patientis enveloped and pressure is maintained on the surface;this certainly tends to diminish shock but we are.

- not aware that it has been much employed. Cocaine

has been injected into the main nerve trunks previously tolarge amputations, and the fall of blood pressure has been

greatly reduced; the method seems to be worthy of a trial,in suitable cases. The maintenance of the bodily heat is

,also of importance, though it has not been shown that lossof temperature is a definite causative factor. All these

methods of treatment are preventive ; but what can be donewhen shock has already appeared ? 7 If there is one remedy

which is trusted more than any other for the treatment of

shock it is strychnine, yet all surgeons will acknowledge thatit seems to fail in all the cases in which it is most needed.

In health strychnine will raise the blood pressure bystimulating the vasomotor centre, but in shock the adminis-tration of this drug will only serve to exhaust still more

rapidly the damaged centre, so that if shock is presentstrychnine is not only useless but positively dangerous.Other stimulants are equally valueless, and with ether andbrandy the fall of blood pressure is even more marked, forthese drugs cause a dilatation of the peripheral vessels.

Cardiac stimulants will affect only one factor concerned inthe maintenance of blood pressure, and increased action of the

heart cannot compensate for any marked relaxation of the

peripheral resistance. Suprarenal extract has a very evi-dent effect in contracting the peripheral capillaries and so

raising the blood pressure, but its effect is transient ; andMr. WALTON is of opinion that the best method of ad

ministering it is by continuous rectal injection in saline lsolu-tion, one drachm of solution of suprarenal extract to a, pint of &pound;

the saline solution-that is to say, 1 in 160,000 ; the tempera-ture of the liquid should be between 108&deg; and 112&deg; F.

and it should be allowed to flow in at the rate of one pintan hour. Ergot, too, is valuable and its effects last

longer. The injection of saline solution into the veins

or subcutaneous tissue is of very definite value but it

can easily be overdone, and Mr. WALTON considers that

the maximum amount that may be given intravenouslyis three pints and by continuous rectal injection not

more than from five to eight pints. Raising the foot

of the bed 18 inches or two feet tilts the blood from

the splanchnic area towards the brain but it would

hardly be suitable in a case of localised septic peritonitis.The main doctrine of the paper may be summarised bysaying that stimulants of all kinds, but especially strychnineand brandy, must be avoided both before and during an

operation ; they can have no effect in diminishing shockand they may easily increase it. These facts should be

laid to heart by surgeons and anxsthetists, for they rest ona very sure basis of fact. Almost equally important was thesecond part of the paper in which the author dealt withthe rare condition which has been called "peritonism,"where all the signs of intestinal obstruction are present butno mechanical obstruction exists. The occurrence of such

a condition has been denied but cases of it undoubtedly dooccur and they are caused by a paralysis of the bowel. We

have not space to follow Mr. WALTON through his dis-

cussion of the etiology and treatment of this serious con-

dition but we may draw attention to his recommendation of

eserine salicylate which acts directly on the intestinal

muscular tissue and not on the exhausted intestinal nerve

plexus; it has proved of value in several cases; a dose ofone-hundredth of a grain appears to be suitable and six

doses may be given. It is curious that in health eserine

has hardly any effect on the intestine but it is probablethat it can only act when the local centres are

paralysed. Mr. WALTON’S paper should be read byall who have to deal with shock; it can hardly fail

to prove useful in the treatment of this most serious

condition.