Without considerable experience along this line no one can reasonably expect to be entirely successful either in his first or his first half dozen cases. But I submit that, in all fairness, failure on this score is properly chargeable to the operator-not to the method.

Perhaps the portion of my subject relating to anoci-association in practice may be best presented by a few words with reference to the results which have been accomplished by its use. Its clinical value has been emphatically attested by such well known surgeons as La Place, Bloodgood, Cabot, Carr, Terry, Harris, and a host of others. No less an authority than Sir Berkley Moynihan has said that Crile's work is the greatest thing in surgery since the work of Lister-a view which I heartily endorse. My personal experience with the method now embraces more than two hundred cases covering a wide range of different conditions and operations. Let me briefly mention just one: A young woman, aged 34, had been suffering for some months from the effects of hyperthyroidism, presenting all the familiar symptoms of this condition. In addition she was having excessive and increasingly severe hemorrhages at each menstrual period due to the presence of a large submucous fibroid. The operative work consisted of ligation of the superior thyroid vessels and hysterectomy at the same sitting. She suffered no ill effects of any kind-had no postoperative pain and was able to leave the hospital in 12 days. It will readily be admitted that a severer test of any method than that presented by such a combination would be difficult to conceive.

If I were asked to specify the most important single advantage of the method, I should say it lies in the fact that it compels gentleness of manipulation in every stage of the work. Nitrous oxid anesthesia maintained within

safe limits is never as deep and deathlike as that of ether and undue traction and trauma are much more apt to be resented by muscular contraction and rigidity. Rapidity in operating is, of course, desirable, provided it does not necessitate the sacrifice of thoroughness and a proper respect for the tissues. The surgeon who is too busy to concede the many advantages of gentleness in his work will naturally have little patience and less success with the method.

An excellent review of Crile's recent book in the California State Journal for October contains the following pertinent observations: "It (anoci-association) is an established surgical principle and a highly beneficent procedure. In the hands of some it fails to carry conviction. But this only denotes the quality of the technic employed. Used in its fullest application and given the advantages of time, dextrous surgery, and understanding, it speaks for itself in terms of freedom from shock, comfortable postoperative patients, and a low mortality . . For one who believes that in surgery there is a psychic factor, that a gentle hand is desirable, and that there should be a minimum of trauma it is highly suggestive and of a definite aid."

Whatever views one may hold as to the theories upon which the method is based, there would seem to be no just reason for doubting or discrediting its practical benefits. These any competent and conscientious surgeon may verify for himself. Upon this ground anoci-association makes its appeal. If our first aim in the practice of our high calling is in every possible way to promote the best interests of our patients, the subject has a very real and vital claim upon our consideration. Story Building.

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the nervous system is blasted by some sudden emotion or physical injury that, striking through it at the heart, leaves no opportunity for treatment. We are but too familiar with the pallor and restlessness, the cold skin, drawn features, quick, embarrassed pulse, shallow respiration, loss of muscular tone-extending from the blood vessels to the sphincters-lethargy deepening into unconsciousness or death itself, that will at times follow the grave operations in the abdominal cavity. But the staggering blows on the central nervous system that reach it through afferent nerves and affect the circulation, directly through the heart and indirectly by way of increased peripheral resistance, an impaired vaso-motor mechanism, venous stasis and lowered blood pressure these are not the only significant or alarming symptoms of shock, any more than the, for us, unavailable microscopic evidence of fatigue in cerebral, liver and supra-renal cells. shall have to remind you that shock, like haemorrhage, is in greater or lesser degree the constant companion of the surgeon; that it is always present, always harmful and, in the small or the grave surgical procedure, to be recognized, like haemorrhage, as a thing to be minimized or prevented. We must, in short, not be content to ignore those degrees of surgical shock that fall short of grave and alarming depressions of vitality.

I

The most brilliant experimental work on shock prior to that of Crile, was done by Professor Sherrington of the University of Liverpool. It would be worth your while to disinter the record from Vol. LIV of the Proceedings of the Royal Society. It is entitled, "On Changes in the Blood Consequent upon Inflammation of an Acute Local Character." Some years ago, I was engaged on animal experiments in a research on septic peritonitis and a means of lessening its incidence and mortality. I then repeated some of Dr. Sherring

ton's experiments, as far as they bore on my work and within the limits of my ability, and those experiments are certainly impressive. It is a well known fact that the fundamental phenomenon of inflammation is the abnormal exudation of intravascular fluid. Dr. Sherrington told us how to estimate this, and shortly, his experiments show that this is to be directly estimated by the degree of drying or inspissation of the blood, seen in a rise in its specific gravity. The experiments usually consisted in, 1. Immersion of one or more extremities in water at a temperature of 52°C. for five minutes; 2. The application for the same length of time of sponges steeped in .6% aqueous saline solution to a knuckle of intestine brought to a small incision in the linea alba, the gut being carefully replaced and the wound closed, and the whole operation being conducted under strict antiseptic precautions; 3. Mechanical trauma by the ligation of a knuckle of intestine. In my own experiments, I got similar results from the mere abdominal incision, with or without the sponging of intestines with warm, normal saline solution; or from the intraabdominal injection of 5% normal saline solution at the body temperature. The blood was examined at least once before operation by the drop method, and was usually taken from the pinna of the ear. Amongst other results, it

was increased and the lymph clotted well.

I omit other changes described, contenting myself with the quotation that the circulating blood becomes inspissated in the sense that it loses some of its plasma, while the chromocytes do not escape, or at least, not in direct proportion to the loss of the plasma. And this loss of plasma, or apoplasmia of the blood, is not, as we might have supposed, equalized by increased entrance of lymph into the circulation via the thoracic duct, etc., a fallacy that has hitherto led us to undervalue the importance of irritative exudation. Nor is the phenomenon one of lost time between the escape of fluid from the circulation and its return thereto. This is indicated by the continuance of the apoplasmia for so long a period as sixty hours after operation; the specific gravity of the blood being heightened, while that of the serum (plasma) remained unaltered.

Now the possibility of apoplasmia lasting four or five days, as it will, after a carefully conducted and, as we should consider it, simple abdominal operation, is to be borne in mind by the practical surgeon. It must be considered as gravely as the more obvious and urgently realized question of haemorrhage, and means taken to prevent it. I have not satisfied myself that the exuded plasma gets into the peritoneum entirely or largely, as I have never seen enough there to account for the manifest loss; and we know that when the urine is lessened in quantity for nearly the whole period of this apoplasmia it continues practically unaltered. What happens, then, is, that considerable exudation into the tissues takes place and much fluid is lost to the circulation at a time when the vaso-motor mechanism is badly affected. Peripheral resistance from the plus friction of altered blood adds to the circulatory crisis. It would have been interesting, had there been time,

to discuss some changes in the leucocytes that accompany these other conditions, as they probably have important effects on bactericidal properties of the peritoneum. But the picture of the rise of 4, 6 or 8 degrees in the specific gravity of the blood should be present to the surgeon who is contemplating only Crile's exhausted cells. We may accept or deny Crile's theory in whole or in part, but it is impossible to deny its great value as a working hypothesis in practice.

But as regards the production of shock, it was Crile who drew attention to the importance of the time element on the vaso-motor mechanism during operative exposure of the peritoneum. Here we have rapid engorgement with blood, the dilatation of the splanchnic area, removing large quantities of blood from the general circulation-for indeed a man may readily bleed to death into his splanchnic veins without losing a drop of blood from his vessels; add to this the loss from severed vessels during operation, and the constant factor of exuded plasma to which I have drawn your attention, and we arrive at an enormous effect on the circulation; a circulatory crisis, that may dangerously deplete heart and brain. The vaso-motor nerves and ganglis amongst which the abdominal surgeon is working control much larger venous areas than are to be found, e. g., in the extremities; here the circulation may be described as leaving the rivers and channels in which it is usually confined and overflowing into the great "dead" lakes of the splanchic region. The effect of this on cerebral cells, which, as Crile points out, show a more rapid onset of exhaustion under impairment of the circulation, may be imagined. It may not be impertinent here to recall other causes of increased shock peculiar to our work, which run with defective means of meeting it. Patients already exhausted with bleeding from fibroid and malignant uterine growths and the

septic poisoning that sometimes accompanies them; hearts that are hypertrophied or damaged by large uterine tumours and pregnancy; kidneys unequal to the strain of pregnancy or handicapped by pressure of pelvic growths on the ureters; patients who are exhausted by the effort to establish some sort of immunity against the pus collections they harbour which, though a protection perhaps against operative sepsis, does not protect them against other forms of shock. These examples, and others will immediately rise to your minds, indicate some of our difficulties the physical and circulatory strain involved in these patients that would tax the resistance of a healthy individual; and to them we add peculiar dangers, such as the prolonged exposure, drying and manipulation of the peritoneum, and certain subacute infections that are assumed to be shock but are really masked sepsis. Such patients do not need the addition of operative haemorrhage to make shock a grave possibility for them and a possibility to be dreaded even in the minor degrees which Sherrington's work enables us to estimate.

In 1901 we were starving our patients before and after operation, in accordance with the advice of Lawson Tait. In that year, I read a paper before the British Medical Association in which I argued that this treatment might easily become harmful, and that we should supply them with more fluid by mouth, rectum and peritoneum, since a sustained blood pressure was more likely to promote absorption of exudations (especially into the pelvis, where they had great potentialities of sepsis) than the treatment then popular of starving our operative cases in order to promote absorption by thirsty tissues. A good blood pressure will empty the splanchnic area better than a lowered one, and shock, as we know, lowers blood pressure. Friction and a plus peripheral resistance are also eased by

giving the blood cells a more spacious circulatory medium in which to move, and the work of the heart is so much lessened.

Crile's theory of shock interests us mostly in the way of suggestions for prevention. Like Groeningen long ago, he recognizes that surgical shock is due to a long series of influences acting before, during and after operation. All of these must be taken into account by the surgeon who aims at a higher success than that which merely sends the patient home alive. The kinetic theory is, shortly, the conservation of energy; shock may be roughly represented by a train of gunpowder lying between the explosive central cell and the torch of traumatism at the periphery of afferent nerves. In the paper to which I have already referred, I remarked that I had been struck by the absence of shock in abdominal operations done under a local anaesthetic like B Eucaine in human beings, though in my operations on cats or rabbits this did not prevent apoplasmia of the blood that was observed under general anaesthesia. In Crile's observations, as I understand him, there is a general exhaustion of cerebral (and other) cells, and the area is not limited to the bulb, nor, I suppose, to the motor areas involved in any resistance of the animal to injurious attacks. We cannot know whether a man whose intellect restrained defensive movements would show exhaustion of other or additional groups of cells, but we do know that without any anaesthetic he would be more profoundly shocked than with. Certainly his moral control would cause fatigue in cells of the higher cerebral centres.

But however we may theorize, Crile's practice is of the greatest value; nothing that we know of can so reduce shock, and on his lines, or some modification of them, we shall probably eventually work. He would give the surgeon who is about to shock his patient, the same advice that Mr. Punch