Treatment.—Absolute rest and quiet in the recumbent position, the external application of heat (taking care that the water-bottles or bags used be not too hot, lest they burn the patient) around the trunk and extremities, are the first meas ures to be resorted to. Senn recommends the inhalation of nitrite of amyl, and the administration of stimulants, such as alcohol, camphor, coffee, and tea. Of alcoholic stimulants, hot red wine, rum, and brandy-punch deserve the prefer ence. If spirits are used, an ounce should be given every fifteen to thirty minutes until reaction is established. Copious rectal enemata of hot normal salt solu tion are always valuable in the treatment of pronounced shock. Subcutaneous or intravenous infusion of the same solution is also of value. Opium is contra-indi cated in the treatment of uncomplicated shock. Subcutaneous injections of ster ilized camphorated oil is deemed by Senn a valuable cardiac stimulant. 3 or 4 hypodermic syringefuls being adminis tered every fifteen minutes until reaction sets in. Electrical stimulation of the phrenic nerves and artificial respiration are indicated. In shock the absorption of all drugs administered by the stomach or rectum. or even injected into the tis sues, is always slow: hence, care is neces sary to against an accumulative action during the recovery of the patient.
The treatment of shock following operation may be summed up as follows: 1. Prophylaxis before and during the operation. 2. The patient is to he wrapped in a warm blanket and hot water bottles cr hot bricks and a ha air apparatus applied. 3. The head and shoulders are to be lowered. 4. Sina pisms to the are of value. 5. If shock is severe. hypodermoclysis should he performed: if alarming. saline transfusion. 6. An enema of 6 ounces of strong. hot coffee is to be given. 7. Massage of the abdomen and an ab dominal compress are of service. S. The limbs should he elevated with cotton wool and bandaged. 9. Hypodermic in jections of liquor ammonite aromaticus in "drachm doses should be admin istered every fifteen minutes. and atro pine sulphate. ' grain. every half-hour. until reaction sets in. Thomas Leidy Rhoades {Then Gaz.. Oct. 15. '97 .
A valuable solution for intravenous in fusions in shock is that recommended by Ringer. as follows:— R Calcium chloride. Potassium chloride. 1 :main. Sodium chloride. 90 grains.
Water. 1 quart.—M.
Careful asepsis of the arm, apparatus. and solution is insisted upon; also the exclusion of all air from the tube be fore introducing the cannula. The solu tion should be free from solid particles.
A probe-pointed cannula should always he used. If these points are carefully ob served. there is little danger in the pro c-eeding.
The temperature of the solution should be about 100' F.; hotter solutions are of greater value as a stimulant; an ini tial temperature of 10S* to 110° F. is well borne. The fluid is cooled from one to two degrees by entering the cannula. The amount of the solution to he in jected at one time varies with the rapid ity of the injection and with the quality and tension of the pulse: 1 quart. re peated when necessary, is generally bet ter than a large amount given at one time. The infusions are of most value in shock accompanied by hmmorrhag.e; the nearer the symptoms approach thc of pure shock, other things being equal. the less effective is the infusion. D. F. Jones Boston Med. and Surg. Jour., Feb. 1. '99...
Among the preventive measures of shock greatest reliance can be placed upon free use of intravenous. hot. saline infusion, injected while the patient is still upon the operating-table. Whenever pc ssible. the solution should be intro duced into the median basilic vein, but occasionally a vein iu the operating wound trio answer the purpcse. cr, if necessary, the solution may he intro duced into the common femoral artery with the aid of an hypodermic needle at tached to a fountain-syringe. Next in
order of efficiency to intravenous saline infusions are those introduced into the rectum. Hypodermoclysis is the slowest cf all the methods: a heaping teaspoon ful of common salt to the litre or quart: plain warm water, devoid of sodium chIcride should never be used intravas cularly, as it may prove fatal by pro ducing a rapid disintegration of the red disks. The proper temperature for the solution is about 150' F. At least 1 litre. and sometimes even 2 or 3 litres. may be injected. providing the precau tion is taken to introduce the solu tion slowly. The time occupied in in the fluid should never be less than ten minutes per litre. The employ ment of intravenous before or at the beginning of the operation is not considered good practice, since, by in creasing the blood-pressure, it encour ages freer haemorrhage. Robert H. M. haw barn (Boston Med. and Surg. Jour., Feb. 22, '90).
Patients are personally prepared for grave operations by administering 2 ounces of whisky by the stomach or rec tum an hour before the time of operat ing, and by injecting grain of strych nine hypodermically a few minutes be fore anesthetizing the patient. These measures are of great value in lessening the danger from anesthetics and the shock of the operation. It is also im portant to prevent loss of heat and favor peripheral circulation by enveloping the body and limbs during the operation. In the treatment of traumatic shock, copious enemas of hot, normal salt solu tion should never be neglected. In the treatment of pronounced cases subcuta neous or intravenous infusion of the same solution is followed by most encouraging results. The absorption of all drugs is always slow; hence it is necessary to guard against cumulative action. The therapeutic value of strychnine in the treatment of shock is doubtful. Conte jeans explains this by the fact that in animals in the state of shock the spinal cord is aneemie and not supplied by suffi cient blood to convey the remedy to this centre of innervation. N. Senn (St. Louis Courier of Med., July, '99).
In combating shock rapid hypodermo elysis may easily be practiced by means of four hypodermic needles adjusted to the ends of rubber tubes, which tubes unite and lead to a reservoir containing the salt solution. The needles are in serted under the skin at various points, the liquid being conducted by the press ure obtained by raising or lowering the receptacle. An apparatus with four needles is usually capable of introducing three quarts of solution into the tissues in half an hour. E. O'N. Kane (Jour. Amer. Med. Assoc., Mar. 3, 1900).
Adrenalin will raise the blood-pressure in normal animals in every degree of shock, with the medulla cocainized or in the decapitated animal. It is rapidly oxidized by the solid tissue and by the blood. Its effect is fleeting; it must therefore be given continuously. By this means the circulation of a tated animal was maintained ten and a half hours. G. W. Crile (Medical News, Nov. 29, 1902).
Adrenalin found to be more efficient in raising vascular pressure than either strychnine, digitalin. or normal saline solution; hence it was much better than these so-called stimulants, especially in eases in which the respiratory centres were not paralyzed. Adrenalin is indi cated in vasomotor collapse following cocaine or chloroform poisoning, and shock after operation. When used, it should he given subcutaneously, and the site of the injection should be slowly and deeply massaged until the adrenalin shows its characteristic effect on the pulse. Too great dilution is not advis able, as absorption is slower and the ef fect is less energetic. M. S. Miles and W. Muhlbert (Cleveland Med. Jour., Dee., 1902).