University of Virginia Library

Recapitulation

The following are the principal points presented: In operations under inhalation anesthesia the nerve impulses from the trauma reach every part of the brain—the cerebrum that is apparently anesthetized as well as the medulla that is known to remain awake—the proof being the physiologic exhaustion of and the pathologic change in the nerve-cells. Under ether anesthesia the damage to the nerve-cells is at least four times greater than under nitrous oxid. Inhalation anesthesia is, therefore, but a veneer—a mask that "covers the deep suffering of the patient." The cause of the exhaustion of the brain is the discharge of nervous energy in a futile effort to energize the paralyzed muscles in an attempt to escape from the injury just as if no anesthetic had been

given. The exhaustion is, therefore, of the same nature as that from overexertion, but if the nerve-paths connecting the field of operation and the brain be blocked, then there is no discharge of nervous energy from the trauma, and consequently there is no exhaustion, however severe or prolonged the operation may be.

Fear is a factor in many injuries and operations. The phenomena of fear probably are exhibited only by animals whose natural defense is nerve-muscular. The skunk, the porcupine, the turtle, have little or no fear. Fear is born of the innumerable injuries which have been inflicted in the course of evolution. Fear, like trauma, may cause physiologic exhaustion of and morphologic changes in the brain-cells. The representation of injury, which is fear, being elicited by phylogenetic association, may be prevented by the exclusion of the noci-association or by the administration of drugs like morphin and scopolamin, which so impair the associational function of the brain-cells that immunity to fear is established. Animals whose natural defense is in muscular exertion, among which is man, may have their dischargeable nervous energy exhausted by fear alone, or by trauma alone, but most effectively by the combination of both. What is the mechanism of this discharge of energy? It is the adequate stimulation of the nociceptors and the physiologic response for the purpose of self-preservation. According to Sherrington, the nervous system responds in action as a whole and to but one stimulus at a time. The integration of the individual as a whole occurs not alone in injury and fear, but also, though not so markedly, as a result of other phylogenetic associations, such as those of the chase and procreation. When adequate stimuli are repeated with such rapidity that the new stimulus is received

before the effect of the previous one has worn off, a higher maximum effect is produced than is possible under a single stimulus, however powerful.

Sexual receptors are implanted in the body by natural selection, and the adequate stimuli excite the nerve-muscular reactions of conjugation in a manner analogous to the action of the adequate stimuli of the nociceptors. The specific response of either the sexual receptors or the nociceptors is at the expense of the total amount of nervous energy available at the moment. Likewise in daily labor, which, in the language of evolution, is the chase, nervous energy is expended. Under the dominance of fear or injury, however, the integration is most nearly absolute and probably every expenditure of nervous energy which is not required for efforts toward self-preservation is arrested; hence fear and injury drain the cup of energy to the dregs. This is the potential difference between fear and desire, between injury and conjugation.

What is the practical application of this? In operative surgery there is introduced a new principle, which removes from surgery much of the immediate risk from its trauma by establishing anoci-association; it places certain of the phenomena of fear on a physical basis; it explains to us the physical basis for the impairment of the entire individual under worry or misfortune; it makes evident the physical results of the daily noci-associations experienced by the individual as a social unit. On the other hand, it explains the power of therapeutic suggestion and of other influences which serve for the time to change the noci-integration; it shows the physical basis for the difference between hope and despair; it explains some of the phenomena of Graves' disease, of sexual neurasthenia, possibly of hay-fever and of

the common cold. The principle is probably equally applicable to the acute infections, in each of which chemical noci-association gives rise to many of the phenomena of the disease and it explains their cure by natural immunity and by vaccines. This hypothesis should teach us to view our patients as a whole; and especially should it teach the surgeon gentleness. It should teach us that there is something more in surgery than mechanics, and something more in medicine than physical diagnosis and drugs.