Surgery Robbed Of Terrors By Dr. Crile's Discovery.

New York Times 100 years ago today, August 3, 1913:
Cleveland Surgeon Announces That the Era of the Shockless Operation Has Arrived — Mortality Rate Only Eight-Tenths of One Per Cent in 1,000 Cases Where This Process Was Used.    WHEREVER few or many surgeons have assembled in this country in the last few years to discuss the problems of their profession, either formally or informally, some one has been present, as likely as not, ready to back his assertions or start a fresh topic of conversation by saying: "Now, Crile of Cleveland says—" And so "Crile of Cleveland" has come to be known as one of the most distinguished surgeons in the world.
    In a general way, the entire medical profession knows that Dr. George W. Crile, Professor of Clinical Surgery in Western Reserve University, is an authority on "shock." The expression "in a general way" is used because the vast majority of physicians to-day are too busy attending to their work to read very thoroughly the medical publications, just as the most of them are too busy to attend the various meetings of medical societies, city, county, State, national, and international, that are held during each year.
    "Shock" is something tangible to the physician, and he meets it as the result of many untoward circumstances. He is called to a patient bowed down with grief who has suffered a mental "shock;" a patient dies from "shock" following grave injury, and again, another patient dies from "shock " following an operation. It is no affront to the medical profession to say that a majority of its members do not know what "shock" does to their patients that kills them.

A Master of Surgical Technique.
    Dr. Crile of Cleveland, on the other hand, has made a life study of "shock" and has discovered just exactly what it does to its victim. If a patient recovers from the effects of shock his brain cells have been impaired; if he dies these cells have been destroyed. Crile's work in experimental surgery to attain this knowledge ranks with any that has ever been accomplished in the history of the profession.
    This laboratory worker, who has been known for years as a master of surgical technique, was not content with the attainment of knowledge relative to the effects of shock.
    He sought the ideal of every effort in medicine and surgery — prevention.
    The prevention of operative shock is the most practical application of this particular principle of prevention, so he devoted himself to that. He has attained his object, and all the success that a research worker could hope for has crowned his labors. This means not only a lessening of suffering, but life-saving as well, and on a very large scale. Surgical operations in many areas of the body have been robbed of their terrors.
    Crile is only 49 years old now, but as long as sixteen years ago he issued a volume on "Surgical Shock." He has followed up this line of investigation ever since. He has also received the credit that is due to his labors both in this country and abroad, and there is none to cast doubt on the value of his contributions to the cause of humanity.
    Ten days ago Prof. Sir Berkeley Moynihan, the well-known surgeon, speaking at the meeting of the British Medical Association at Brighton, referred in warm terms to the debt that surgery owed to Crile for the new process of anaesthesia he has established, by which the area to be operated on is shut off entirely from the brain for as long a time as necessary, and absolutely without injury to the delicate cerebral structures. Doubtless Sir Berkeley had first been reading Dr. Crile's comprehensive article on "The Kinetic Theory of Shock and Its Prevention Through Anoci-Association (Shock-less Operation,) " published in The Lancet of London on July 5 last. Prof. Moynihan, in the course of his remarks, pointed out that surgeons were apt to delude themselves with the idea that because the patients are unconscious no damage to nerve fibres was possible, which, he said, was a great mistake. Under the new process, barriers were placed on all the nerve centres, completely isolating the field of operation. Sir Berkeley outlined Dr. Crile's theory and the practical results obtained.
    The Cleveland surgeon's most recent contributions to medical literature on this subject are the article in The Lancet, already referred to, and an article published in the June issue of The Interstate Medical Journal, entitled "The Kinetic Theory of Surgical Shock and Anoci-Association." This article is based on both of them.

Crile Tells of His Theory.
    Before proceeding to give an outline of Dr. Crile's theory and his method of anaesthesia we will quote the result of its practice, for, as he justly remarks, "no theory is worth more than its yield in practice, and the only test of laboratory findings is the crucible of the clinic." Here is what he has to say:
    "The proof of a surgical principle is found in the clinical results of its employment. In our adoption of this principle at the Lakeside Hospital we have found that there is no longer need of a post-operative recovery room; that the work of the nurse has been greatly minimized; that the clinical aspect, both in and out of the operating room, has been altered.
    "Last year the writer and his associate, Dr. W. E. Lower, performed 729 abdominal sections of every grade with a mortality rate of 1.7 per cent. In the Lakeside Hospital service, where all kinds of acute emergencies are met, and where most of the writer's private work is done, there were last year performed, by his associate and himself, operations on 2,672 patients with a mortality rate of 1.9 per cent. — a result never before approached in the Lakeside Hospital.
    "In the last 1,000 operations performed by Dr. Lower and the writer — these operations including every risk of a general surgical practice — the mortality rate has been 0.8 per cent."
    "When a barefoot boy steps on a sharp stone," says Dr. Crile, "there is an immediate discharge of nervous energy in his effort to escape from the wounding stone. This is not a voluntary act. It is not due to his own personal experience, but is due to the experience of his progenitors during the vast periods of time required for the evolution of the species to which he belongs — i. e., his phylogeny, (ancestral history.)
    "The wounding stone made an impression upon the nerve receptors in the foot similar to the innumerable injuries which gave origin to this nerve mechanism itself during the boy's vast phylogenetlc or ancestral experience. The stone supplied the phylogenetlc association, and the appropriate discharge of nervous energy automatically followed.
    "If the stone be only lightly applied there is a discharge of nervous energy from the sensation of tickling, but if the sole of the foot is repeatedly bruised or crushed by the stone shock may be produced. The body has had implanted within it other similar mechanisms of ancestral or phylogenetic origin, the purpose of which is the discharge of energy for the good of the individual.
    "According to my kinetic (kinetic means relating to motion or muscular movements) theory of shock, it is one of these mechanisms — the motor mechanism in particular — which, through its phylogenetic association with injury of the individual, is responsible for the discharge of energy represented by shock. According to this theory, the essential lesions of shock are in the brain cells, and are caused by the conversion of potential energy in the brain cells into kinetic energy at the expense of certain chemical compounds stored in the cells."
    The author refers to these common instances of shock:
    "Throughout medical and surgical history we find physicians and surgeons constantly baffled in their efforts to combat the condition which most often follows psychic or physical stress — the condition called shock. The aged man dies suddenly on hearing of the death of an idolized son; the Marathon runner is overcome; the banker emerges a physical wreck after a season of financial panic; the patient succumbs after a major operation which in itself should not cause death; and in each case we say 'he suffers' or 'he died from shock.'"
    The surgeon then describes his researches. He says:
    "We approached our goal by the aid of many sign-posts. First, we knew that the vasomotor (vasomotor means causing dilatation or constriction of the blood vessels) system may recover its balance a few hours after the physical or psychic injury has been inflicted, while the ultimate restoration to health of all the bodily functions after shock may require weeks, months, or often years.
    "Secondly, our researches and experimental studies soon convinced us of a primary and most far-reaching fact — namely, that the animals most capable of being shocked are those whose self-preservation is dependent upon some form of motor activity — the same animals are those in whom the presence of bodily danger is capable of producing the phenomenon of fear.
    "And here it may be noted that the final result of intense fear is the same as that of physical exhaustion or that following psychic strain. In such animals the motor activity is excited by the adequate stimulation of the nerve receptors, both of the contact ceptors in the skin and the distance ceptors — the special senses. Since the distance ceptors are as active as the contact ceptors in their warning of dangers to be avoided, we must assume that the stimulation of the former is as potent as is the stimulation of the latter. "As pain is produced by those causes only whose evil effects maybe mitigated or overcome by this or that form of muscular activity, so in surgical operations it is known that shock follows only operations upon those parts of the body which in our phylogenetic history have been subjected to injury by the dangers of environment. For example, injury of the brain or of the lungs, parts normally well protected and little liable to injury from enemies, is not followed by the characteristic shock phenomena.
    "As injury of the heart, the brain, and the lungs led to immediate fatal results, there was no opportunity for the evolution of a protective motor mechanism. These parts, of necessity, were placed under special structural protection. We are forced, therefore, in this study to bear constantly in mind that the motor activity of the present, with all its accompanying manifestations of increased motion, fear and exhaustion, is the resultant of the continual adaptation to environment in our phylogenetic forbears.

Limitations of Anaesthetics.
    "As already indicated, we have long known that chloroform and ether anaesthesia, while they prevent the conscious appreciation of pain, do not prevent other afferent traumatic impulses (impulses that travel from the seat of injury to the brain) from affecting the vasomotor, the cardiac, and the respiratory centres. In the very course of the operation itself the effect upon these centres is manifested by increased pulse and respiration, and by the rigidity of muscular structures. These vasomotor and respiratory manifestations are found also in conscious persons threatened by physical injury. The only difference between the unconscious traumatized person and the conscious is that the former is deprived of the power of muscular action and does not see the threatened attack.
    "It is a physical law that no energy can be lost, and every adequate stimulus must, therefore, receive its adequate response. In an unconscious patient and in a conscious person alike the stimuli which are too powerful to be adequately met by defensive and offensive action, or slight stimuli repeated with too great frequency, must meet their response at the expense of damage to some part of the bodily mechanism.

Where Does "Shock" Act?
    "Where then shall we look for the part which is exhausted under the strain of too great stimulation? Since we find that those animals which suffer most from shock are those with the most highly developed power of associative memory, we should expect to find the greatest ultimate damage in the centre of the mechanism for this faculty. In such animals, therefore, the nerve cells of the cortex (external layer of gray matter of the brain) must have borne the damage. This damage may be sufficient to break down the cells at once and we have a general exhaustion; or the cells may have become so overcharged that slight additional stimuli will be sufficient to overbalance them and we see the postoperative drain of 'nervous symptoms.'
    "Our researches proved this reasoning. The cells in the cortex of animals exhausted by fright or by prolonged physical trauma (injury) showed like changes, and these morphological changes varied from slight alterations in the cell contents to complete deterioration.
    "As a result of this reasoning and of these researches, the writer formulated what he calls his 'kinetic theory of surgical shock.' This theory assumes (1) that the environment of the past (phylogeny) through adaptation predetermines the environmental reactions of the present; (2) that in each individual at a given time there is a limited amount of potential energy stored in each brain cell, that is, that the cell contents under stimulation are capable of a certain amount of chemical change, which will produce a relative amount of action — kinetic energy; (3) that the motor activity following each stimulus — traumatic or psychic — diminished in some degree the amount of potential energy in the brain cells, that is, by some chemical change of the cell contents a certain amount of kinetic energy is produced; (4) that when the motor activity resulting from the change of the potential energy in the brain cell to kinetic energy takes the form of obvious work performed, the phenomena expressing the depletion of the vital force are termed physical exhaustion; (5) that traumatic stimuli of sufficient number and intensity lead inevitably to exhaustion and death; (6) that when the expenditure of energy caused by emotional stimuli cannot take its normal course and produce motor activity, the condition reacts upon the cell itself.
    "The stimulation is thus automatically increased, and the resultant expenditure of potential energy is proportionately active. The final condition in either of the last two instances is designated shock.
    "If our kinetic theory is correct — namely, if fear and trauma produce like effects upon brain cells, then, since unconsciousness of threatened danger would assuredly prevent fear, why does not unconsciousness of the trauma inflicted in an operation, prevent damage to the brain cells? That is, why is not the administration of an inhalation anesthetic a sufficient preventive of shock?
    "In the case of fear of a threatened danger, distance ceptors (receiving agents) alone are concerned; in the amount of which case of actual physical trauma, contact ceptors come into play, and their path to the brain is not interrupted by the inhalation anesthetic. The patient is unconscious of the injury inflicted; but the brain cells reached by the nerve impulses from the seat of damage register the injury in cell changes.
    "That the whole brain is not asleep is made evident often in the course of the operation itself by a marked increase in respiratory action and by an alteration in the blood pressure. In fact, in serious operations one may see every grade of response to the injury, from the slightest changes in the respiration to a vigorous defensive struggle. As to the purpose of these sub-conscious movements there can be no doubt — they are efforts to escape from injury.
    "The resulting exhaustion after a prolonged operation is the same as that following too prolonged muscular exertion or too great psychic strain. In our experiments upon animals we found, by examination of the brain cells after trauma inflicted under an inhalation anesthetic, that the morphological changes were the same as those seen after physical exertion or after fright. So in shock from injury, in exhaustion from overwork, in exhaustion from fear, and in collapse after a prolonged surgical operation, the impairment of function is the same — in each case morphological changes in the brain cells are produced, and in each a certain length of time is required to effect recovery.
    "Since the change of the potential energy of the brain cells into kinetic energy is due to the chemical alteration produced by oxidation of the cell contents, we should then search for the general anesthetic which would present the most interference to the use of oxygen by the brain cells. Testing this point experimentally, we found that the cell changes were approximately three times as great under ether anesthesia as under nitrous oxide anesthesia; that the fall in blood-pressure was, on the average, two and a half times less under nitrous oxide than under ether; and, finally, that the general condition was correspondingly better after the use of nitrous oxide than after ether. In the course of operations upon the human body this same protective effect of nitrous oxide has been repeatedly observed. It would seem, therefore, that nitrous oxide should be the anesthetic of choice.

Experiments on a "Spinal Dog."
    "But nitrous oxide, although to some extent it protects the brain cells by interfering with their chemical change, does not prevent damage by the traumatic impulses from the seat of injury. How can this danger be averted? Experiments upon a 'spinal dog' pointed the way to this final achievement of the shockless operation. A spinal dog is one whose spinal cord has been divided at the level of the first dorsal segment. Such a dog, if kept in good condition for two months or more, will show a recovery of the spinal reflexes, such as the 'scratch reflex.' Obviously, in such an animal the hind extremities and the abdominal viscera have no direct nerve connection with the brain.
    "We experimented upon a 'spinal dog' and found that a continuous severe trauma of the abdominal viscera and the hind extremities extending over four hours was accompanied by but slight change either in the circulation or the respiration, and microscopical examination of the brain cells showed no morphological alteration. Judging from a large number of experiments on normal dogs under ether, such an amount of trauma would have caused not only a complete physiological exhaustion of the brain, but also morphological alterations of all the brain cells and the physical destruction of many. We must, therefore, conclude that although ether anaesthesia, or any inhalation anaesthesia, produces unconsciousness, it is in reality only a veneer, as it protects none of the brain cells against exhaustion from the trauma of surgical operations.
    "These experiments showed us conclusively that if the connection between the brain and the traumatized part could be broken, the brain cells would be protected from damage, and we found that this could be accomplished by a thorough infiltration of the tissues to be traumatized with a local anaesthetic.
    "By the use of a non-oxidizing general anaesthetic — nitrous oxide, and of a local anaesthetic — novocaine, we achieved the thorough protection of the brain cells from danger during the course of the operation itself.
    "But we have postulated already that psychic strain may be as active as actual trauma in producing shock. How, then, may we extend our technique to cover the preoperative dread of the approaching ordeal, especially in such cases as goitre patients, in whom the psychic factor is most dominant?
    "To accomplish this end our search was for a drug or drugs which would produce quiet and solace, and so conserve the output of energy, while at the same time they would cause no brain-cell changes. Morphia and scopolamine filled this need. Morphia and scopolamine in physiological doses present psychic shock. Under the influence of morphia no one is brave, no one is a coward; one is indifferent to danger. This negative state induced by morphia and scopolamine is due to their action in depressing the associational power of thebrain, in limiting or obliterating associational memory.
    "By the technique thus far developed, we have protected the brain cells from preoperative psychic strain and from damage in the course of the operation itself. If we can now find a procedure which will diminish or eliminate post-operative suffering, the protective cycle will be complete. By our continued experimentation we found that this end could be secured by an infiltration of the parts surrounding the line of suture with quinine and urea hydrochloride. This block between the operative field and the brain lasts for hours, sometimes for days, so that when the effects have worn off the patient is well on the road to recovery.
    "By these means there has been developed a new operative principle, for which we have coined a new word — 'anoci-associatin,' which means that by the use of this principle the action of the nociceptors (the nerve mechanism for the appreciation and transmission of painful stimuli) has been blocked. As we have indicated, and as the term implies, this principle finds its special application in operations on those parts of the body most liberally supplied with nociceptors, that is, those parts which in the course of evolution have been most frequently subjected to injury — the face, the throat, the hands and feet, the abdomen.
    "In operations on the deep parts of the back, behind the peritoneum, and on the brain, little shock is produced, even without the aid of this technique, since in our phylogenetic history these parts have been little exposed to injury.
    "To carry out the principle of anoci-association requires a careful and expensive technique. We have shown that the desired end cannot be obtained by the use of a single anaesthetic. The preoperative strain must be reduced by the hypodermic administration of morphia and scopolamine; an inhalation anaesthetic must he used to exclude the physical stimulation of the brain cells in the course of the operation, and the anaesthetic of choice should be nitrous oxide, which is unsafe in the hands of any but a skilled anaesthetist; a local anaesthetic must be used progressively in the course of the operation to protect the brain from local operative injury; and finally the post-operative effects must be eliminated by a local anaesthetic of lasting effect. "For the hospital this means increased expense; for the surgeon and the anaesthetist it means special training; for the individual patient it means the elimination of the dread of the operation and the prolonged after-results which have so often been sufficient to deter him from accepting the only means of rescue; and, finally, for the general public it means the satisfaction which comes from a decrease in the mortality and morbidity rate, since by these means morbid results and death from shock are eliminated. In view of the last two conclusions, certainly the first is to be disregarded. The expense must be borne, the surgeon and anaesthetist must be trained if the increased safety and comfort of the patient are to be gained.
    A detailed description of this technique in abdominal and goitre operations will be sufficient to indicate the universal application of the principle.
    "Anoci-association In Abdominal Operations.
    "1. Excluding infants, the aged, and patients with depressed vitality, we administer, as an average, 1-6 grain morphine and 1-150 grain scopolamine one hour before operation.
    "2. If local anaesthesia alone is employed, novocaine in 1-400 solution is used by local infiltration.
    "4. As soon as the patient is unconscious, first the skin and then the subcutaneous tissues are infiltrated with 1-400 novocaine. The novocaine is spread by immediate local pressure with the hand. Incision through this anaesthetized zone exposes the fascia which is novocainized, subjected to pressure, and then divided. In succession also the remaining muscles or posterior sheath and the peritoneum are infiltrated with novocaine, subjected to pressure, and divided within the blocked zone. If the blocking has been complete, then within the opened abdomen there will be no increased intra-abdominal pressure, no tendency to expulsion of the intestines, and no muscular rigidity.
    "5. The peritoneum is next everted and infiltrated with a one-half per cent. solution of quinine and urea hydrochloride, so that the line of proposed suture is completely surrounded. As before, momentary pressure serves to spread the anaesthtic. This infiltration of quinine and urea hydrochloride serves as a block which may last for several days. It prevents, or at least minimizes, the postoperative wound pain and gas pains, and by so much prevents or minimizes post-operative shock. Quinine and urea cause a certain amount of edema of tissue, which lasts for some time after the wound is healed.
    "6. With this technique the relaxed abdominal wall permits the easy and gentle exploration of the entire abdominal cavity. If there is no cancer in the field of operation, and if no acute infection is present, then the following regions may be blocked as completely and in the same manner as the abdominal wall — namely, the meso-appendix, the base of the gall bladder, the uterus, the broad and the round ligaments, the mesentery, and any part of the parietal peritoneum. Since operations on the stomach and intestines cause no pain if they are made without pulling on their attachments, in such operations no novocaine block is required.
    "In operations carried out in this manner the closure of the upper abdomen is as easy as the closure of the lower; all is done with ease in the perfect relaxation. What is the result? No matter how extensive the operation, no matter how weak the patient, no matter what part is involved, if anoci technique is perfectly carried out the pulse rate at the end of the operation is the same as at the beginning.
    "The post-operative rise of temperature, the acceleration of the pulse, the pain, the nausea, and the distension are minimized or wholly prevented."