of necessity indicate that the morbid phenomena under differentiate between the effects of the trauma of the consideration are due to this foodstuff. Just as a operation and those of the anesthetic. Morphin, owing syphilitic subject with a positive Wassermann reaction to its power to reduce the poignancy of centripetal may develop a skin affection which is unrelated to his impulses, has been regarded as a valuable adjuvant to systemic infection, so a patient with a positive food local anesthesia. The committee on anesthesia4 of the anaphylactic reaction may develop a cutaneous affec¬ American Medical Association, reporting in 1912, rec¬ tion due to other factors than his diet. ommended the routine administration of morphin pre¬ 7. Further studies in anaphylactic food reactions ceding the induction of general anesthesia, recognizing may shed considerable illumination on the etiology of at the same time that the imposition of one powerful certain diseases of the skin. depressant of the medullary centers, namely, morphin, 8. Hundreds and perhaps thousands of patients must on another, namely ether, might have disadvantages for be studied before any general deductions can be drawn which its antishock action could not compensate. The as to the relation between particular skin diseases and following observations are presented for study in con¬ food poisoning. nection with the preceding statements. 4037 Girard Avenue. While the recognition of shock is based on the pres¬ ence of a group of signs and symptoms no one of which in itself is diagnostic, there are several easily deter¬ mined under certain be THE RELATION OF MORPHIN TO POST- signs which, conditions, may assumed to be quite suggestive. Of these, the pulse OPERATIVE COMPLICATIONS rate appears to be the only one which is observed as AND IMMUNITY a part of the postoperative routine in the Presbyterian and this was chosen as the FRANKLIN Hospital, sign, therefore, BENJAMIN DAVIS, Ph.D., M.D. shock indicator for the present The Nicholas Senn Fellow in Surgery, Rush Medical College study. following standard was : A rate on return CHICAGO arbitrary adopted pulse from the operating room of 100 or more per minute Because of their knowledge of the depressing influ- was assumed to indicate some degree of shock ; a pulse ence of morphin on general metabolism, many surgeons rate of 99 or less was assumed to be negative for have been inclined to blame its use for a long list of shock. Cases were taken at random, the only condition disorders appearing in the course of and following on being that they must not show evidences of shock pre¬ operations, especially operations done under general ceding the operation. Morphin, when administered, anesthesia. With the object of testing the reasonable- was given in conjunction with atropin. Study of tables ness of this idea, a study was made of the records of constructed in part according to this standard and in 469 patients operated on in the Presbyterian Hospital part showing the number of patients requiring active and of the immunity curves (opsonic and lytic) of a measures to combat postoperative shock suggests that series of morphinized animals. Particular attention morphin, in ordinary doses, may exert a slight influence was directed to the possible relationship of morphin to against the induction of shock by operative procedures. postoperative shock, postoperative ileus (paralytic), The figures are as follows : Of 89 patients under¬ postoperative acute dilatation of the stomach, post- going radical amputations of the breast, 20 were given operative retention of urine, and immunity. morphin one hour before operation; of these 11, or have unable to Physiologists been explain adequately 55 per cent., were returned to bed with a pulse rate of the mechanism of shock.1 Among clinicians, surgical 100 or more. Sixty-nine patients did not receive mor¬ shock is usually defined as a condition of depression phin before operation, and of these 48 per cent, were or mental following painful injury strong emotion, the returned with a pulse rate of 100 or more. Of the 20 a weakness symptoms varying from slight feeling of morphinized patients, none required active measures accompanied by nausea, and perhaps a temporary loss to combat shock, while one out of 72 nonmorphinized of to of all the vital consciousness, complete paralysis patients did. In 126 laparotomies, 25 patients were processes resulting in speedy death.2 According to given preoperative morphin and 101 were not. Of the and in with the current theo¬ this definition, conformity morphinized patients, 68 per cent, were returned to bed ries of the cause of shock,3 sensory stimulation, sym¬ with a pulse rate of 100 or more, while but 50 per cent. bolized by the word "pain," appears to be the trigger of the exhibited a similar the The nonmorphinized patients which sets off shock sequences. argument fol¬ rate. Of a total of 283 cor¬ laparotomies, preoperative lows, therefore, admitting for the moment the was administered in 94 cases ; 2 of these of the that the morphin rectness preceding assumption, ques¬ patients required active antishock treatment after oper¬ the of shock becomes a of tion of prevention question ation. Of the 189 laparotomies in which no preopera¬ the of the to the nerve interruption centripetal paths tive morphin was given, 5 required active measures to centers, or a modification of those centers such that combat shock after the operation. The following are irritated to a the they not dangerous degree by were included among the : gas- Local anesthesia blocks the operations laparotomies pain impulses. centripetal trostomy, 5 cases ; anterior gastro-enterostomy, 8 ; pos¬ paths, and, when practicable, appears to be the best terior 24; in gastro-enterostomy, exploratory (carcinoma known preventive of shock surgical operations. Gen¬ of the stomach), 25; pylorectomy, 14; acute appendi¬ eral anesthesia the nerve centers but depresses appears citis, 8 ; cholecystostomy, 22 ; cholecystectomy, 7 ; to be somewhat less effective than local anesthesia in pelvic operations with appendectomy, 114; miscellane¬ off it is often difficult to warding shock, although ous intra-abdominal operations, 19 ; appendectomies From the Departments of Surgery of Rush Medical College and (chronic), 21; chronic intestinal obstruction (carci¬ of the Presbyterian Hospital. noma and adhesions), 2; colostomy (carcinoma), 6; 1. Bevan, A. D.: The Choice and Technic of the Anesthetic, The intestinal 8. Journal A. M. A., Oct. 23, 1915, p. 1418. resection, 2. Brewer: Text Book of Surgery, 1909, p. 106. 3. Henderson: Proc. Soc. Exper. Biol. and Med., 1909-1910, vii, 41. 4. Report of Committee on Anesthesia, The Journal A. M. Crile: Ibid., p. 87. June 15, 1912, p. 1908. Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/08/2015 The evidence is conflicting, and the balance in favor secretion ; later the pressure of the gastric tumor on of the conclusion drawn is very meager, so meager the movable small intestines, forcing them downward, that possibly a Scotch verdict might be given with and producing thereby tension on the root of the justice. More weight has been attached to the figures mesentery, which in turn compresses the third portion showing the number of patients requiring active mea¬ of the duodenum against the spine and causes more or sures to combat shock than to those dealing with the less occlusion. Kinking of the duodenum from pro¬ pulse rate because it was felt that the addition of lapse of the distended stomach may also be a factor of atropin to the morphin might have influenced the car¬ importance. The primary dilatation of the stomach diac mechanism of the morphinized patients inde¬ is probably caused by a muscular paresis from toxemia pendent of shock, and because the former figures are due to acute or chronic disease, or from surgical opera¬ absolute, while the latter are based on a standard which tion or shock. The exciting cause may be an indiscre¬ is open to criticism. tion in diet, or the ingestion of food or water too soon Because of its effectiveness in retarding gastro¬ after operation, before the stomach wall has had time intestinal peristalsis, morphin has been considered one to regain its muscular tone." 12 The rôle played by of the contributing causes of postoperative constipa¬ morphin in relation to this condition may be a very tion and gas pains. Morphin produces constipation, minor one indeed, but its tendency to induce nausea first, by occasionally causing a spastic-contraction of and vomiting in certain individuals nausea always the pylorus, thus delaying the passage of food from the retarding gastric motility6—and its demonstrated— ability stomach into the duodenum as much as four or five to delay gastric evacuation into the bowel, suggest that hours.5 According to the observations of Dr. B. W. its use, postoperatively, may be associated with some Sippy,6 nausea from any cause retards gastric peri¬ danger. The fact that acute dilatation of the stomach stalsis. As morphin may cause nausea and vomiting in occurs under conditions similar to those under which men and in dogs, this, rather than pyloric spasm, may intestinal atony develops justifies the application of the be responsible for the delayed emptying of the stomach statements made concerning the latter to the gastric noted above. Secondly, morphin produces a consid¬ syndrone. erable diminution in the rate and force of intestinal In consideration of the conditions outlined