Shock, Acute Dilatation of The Stomach

Disturbances of the Heart
by Oliver T. Osborne, M.D.

(Page 20 of 20)

If the collapse is not acute and there is gradual profound prostration, or if the patient is improved but still in a serious condition of shock, too energetic measures must not be used; neither should too many drugs be administered, or drugs in too large doses. Absolute quiet and the administration of liquid nourishment in but small amounts at a time are essential.

The hypodermic administration of epinephrin solutions, 1:10,000, or solutions of pituitary extract, 1:10,000, should be considered; they are often valuable.

If the shock occurs in ether or chloroform anesthesia, the vasopressor stimulating effect of inhalations of carbon dioxid gas may be considered, as advised by Henderson."

If the shock is due to hemorrhage and the hemorrhage has ceased, a transfusion of physiologic saline solution is generally indicated. Transfusion of blood under the same conditions is still better. Rarely is transfusion indicated in shock from other causes; it often adds to the difficulty rather than improves it. Occasionally if shock is decided to be due to a toxemia, the toxin may be diluted by the withdrawal of a small amount of blood and the transfusion of an equal amount of saline solution.

Acute Dilatation of The Stomach

This condition is not well understood, nor is its frequence known, but not a few instances of shock are due to dilatation of this organ. The shock to the heart may be a reflex one through the pneumogastric nerves.

It perhaps not infrequently occurs after abdominal operations and is more or less serious, the symptoms being persistent vomiting, upper abdominal distention and collapse. The vomiting is of bloody or coffee-ground material.

Sometimes the ordinary treatment of the collapse and washing out the stomach save the patient; at other times the patient with this series of symptoms dies in spite of all treatment.

It has been shown that acute dilatation of the stomach may occur in pneumonia, and may be one of the causes of cardiac collapse in pneumonia.

When the condition is diagnosed, the treatment would be that of shock plus abdominal bandage and washing out the stomach with warm solutions, if the patient is not too collapsed, or at any rate the frequent administration of hot water in small quantities.

Sometimes when the stomach is dilated the pylorus becomes insufficient, and bile regurgitates into the stomach, and is a cause of the profound nausea and vomiting arid the subsequent collapse. In these cases

114. Henderson: Am. Jour. Physiol., February and April, 1909. not infrequently small doses of dilute hydrochloric acid seem to aid the pylorus to maintain its normal contraction, the regurgitation of bile does not take place, and the stomach may soon acquire a more normal muscle tone. Not infrequently when a stomach is in this kind of trouble and all the foods are rejected, and yet the patient seriously needs nourishment, a warm, thin cereal, as oatmeal or gruel or something similar, may be retained. Such patients, as has been repeatedly stated, need starch as soon as possible, lest an acidosis develop.

In these vomiting and collapse cases the hypodermic administration of morphin and atropin will not only stop the vomiting, at least temporarily, but will also give necessary rest. The dose of morphin need not be large, and the atropin may prevent nausea from the drug.

Anesthesia in Heart Disease

While no physician likes to give an anesthetic to a patient who has valvular disease of the heart, and no surgeon cares to operate on such a patient unless operation is absolutely necessary, still in valvular disease with good compensation the prognosis of either ether or chloroform narcosis is good.

When there are evidences of chronic myocarditis or a history of broken compensation and the borderline of compensation and dilatation is very narrow, or when there is arteriosclerosis, the danger from an anesthetic and an operation is much greater; it may be serious, in fact, and the decision must be made whether or not the operation is absolutely necessary. Under any circumstances it is understood that the anesthetist must be an expert, as there can be no carelessness and nothing but the best of judgment in causing anesthesia when there is cardiac defect.

The anesthetic to select is a subject for careful decision, as one cannot assert which anesthetic is the best.

While chloroform seems occasionally to cause a fatty degeneration of the heart, or if given too rapidly at first may cause sudden death, especially in cardiac weakness, ether has its disadvantages, owing to the increased tension (especially if there is likely to be much valvular or cerebral excitement), and the greater amount of ether that must be given, with the attendant danger to the kidneys, which may have been disturbed from the cardiac conditions. Generally, however, the better method is perhaps to administer first chloroform to the point of producing sleep and then to change to ether, the first mild chloroform narcosis preventing the ether from causing acute stimulation, and ether being better for the operation, as it is more of a stimulant. Some anesthetists believe that it is better to administer morphin, with perhaps atropin hypodermically before the anesthesia, and then to use ether. Nitrous oxid gas would be contraindicated as tending to increase arterial pressure, and therefore endanger a damaged heart; it is a serious danger to damaged blood vessels.