COLLAPSE AND SHOCK.
Collapse is generally due to loss of blood from hemorrhage or to profuse diarrhoea as in cholera, which reduces the vascular tension throughout the body. The treatment is obvious: the vessels must be filled by the intro duction into the system of Normal Saline Solution. In mild cases large saline enemata may suffice, but when the collapse has become established neither this nor hypodermic injection of the fluid is to be relied upon. The patient being placed in a bed, the feet should he raised and the head lowered, and a bandage having been applied to each lower extremity to press the blood out of the limb into the large vessels, intravenous injection of saline solution should he performed. The breathing being liable to fail, Artificial Respiration may be demanded. In the sudden collapse follow ing blows over the splanclmic area the paralysed vasomotor centres may be stimulated as in syncope, by the inhalation of strong Ammonia or Acetic Acid vapour, and later by Alcohol given by the mouth. The hypodermic injection of Strychnine is rationally indicated. The Japanese method of treatment consists in making a number of sharp blows over the seventh cervical vertebra till reaction occurs.
Shock is clue not to paralysis of the vasomotor centres, but to exhaustion of these, and hence strychnine or other stimulant is contra-indicated, but in mild cases of shock the condition of severe collapse may supervene as in a secondary hemorrhage following a prolonged surgical operation. Fortunately, however, the main indication is the same in both cases: the head and shoulders of the patient should be depressed, the limbs bandaged and Saline Solution given by the veins, hypodermically or by the rectum, the venous channel being selected in all severe cases. Artificial respiration should be kept up when the breathing shows signs of failure.
Adrenalin Solution is indicated in all cases of severe shock, and it should be introduced along with the saline; its action being exerted on the vessels independent of the influence of the vasomotor centre, the blood pressure is at once raised. 15 mins. adrenalin chloride solution should be
added to the intravenous saline injection. Ergot principles as Tvramine and Ernutin act in a similar manner. Morphia hypodermically is valu able; by diminishing or cutting off the centripetal stimuli it tends to reduce the extent of the shock.
The treatment of the profound condition of acid intoxication following chloroform anxsthesia is detailed under Acidosis.
Shell Shock will be referred to under its own Preventive treatment of surgical shock is of importance, and in prolonged operations Ether or A.C.E. mixture should he preferred to chloroform, and Nitrous Oxide used for shorter operations; warmth to the extremities should be maintained, and in abdominal operations the shortest exposure and handling of the peritoneum and especially douching with cold liquids must he guarded against. A hypodermic of Morphia combined with Strychnine or a small dose of Atropine should always be administered previous to operation. Crile injects Cocaine or Eucaine into the proximal end of the nerves about to be divided. Barker's method of artificial feeding by the preliminary hypodermic administration of 5 per cent. solution of Glucose is a valuable addition to the surgeon's armoury when prolonged operation is to be undertaken. Sterile glucose tubes are pro curable, the contents of which, when added tor pint of boiled water, make an isotonic solution.
In severe traumatic shock, operations, except in the case of uncon trollable hemorrhage or sepsis, should. when possible, he postponed till the symptoms have been relieved by the above-mentioned treatment i.e., rest in bed, saline by the veins with adrenalin, and morphia with either strychnine or atropine.