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JANUARY, 1894 
SURGICAL SHOCK. 
BY CHARLES P. NOBLE, M.D., 
f PHILADELPHIA, 
Surgeon-in-Chief of the Kensington Hospital for Women . Surgical Shock.1 
BY CHARLES P. NOBLE, M.D., 
PHILADELPHIA, 
Surgeon-in-Chicf of the Kensington Hospital for Women. 
It is proposed in this communication 
to briefly consider the nature of sur- 
gical shock, and then to take up its 
treatment in detail. Shock is a con- 
dition of the body which is character- 
ized by feebleness and rapidity of 
action of the heart, by the shallow- 
ness and frequency of respiration, by 
the lowering of the temperature of 
the body, and by the lessened activity 
of most of its functions. Intellection, 
digestion, and the secretion of urine 
all are more or less in abeyance. It 
is probable, also, that the processes 
of assimilation and metabolism are 
profoundly interfered with. Perspira- 
tion is usually free, the body being 
covered with a cold, clammy sweat. 
This, however, is due not to the in- 
creased activity of the sweat glands, 
but rather to an arrest of the activity 
of their cells, so that they simply act 
as strainers for the watery part of the 
blood to pass through them. 
There can be no question that 
vitality is at a low ebb when shock 
exists, but there is some difference of 
opinion as to the real physiology or 
pathology involved. It is generally 
accepted that shock is a manifesta- 
tion of paresis of the nervous system, 
its symptoms being due to lessened 
and irregular innervation. The ques- 
tion as to whether the cerebro-spinal 
or the sympathetic system is most in- 
volved is in dispute, and we do not 
propose at this time to attempt the 
elucidation of the question. As a mat- 
ter of fact, injury of the body in any 
of its parts can bring about shock. 
Injuries to certain parts of the body 
are especially liable to produce shock. 
These parts are the testicle and ure- 
thra, in the male, the ovary (in a 
lessened degree) in the female, and 
the abdominal viscera. Examples of 
shock from injury to these structures 
are common, and familiar to every 
one of experience. The familiar ex- 
periment of temporarily arresting the 
heart’s action of the frog by a blow 
upon the abdomen is a striking illus- 
tration. Leaving aside the disputed 
points at issue, we wish to consider 
certain facts because of their very 
practical bearing upon the therapeu- 
tics of surgical shock. Among the 
most important symptoms of shock is 
1 Read before the Obstetrical Society of Philadel- 
phia, December 7, 1893. 2 
CHARLES P. NOBLE. 
the lessened force and greater fer- 
quency of the heart’s beat. The ac- 
tivity of the respiratory centre, also, 
is much lessened. The superficial 
blood-vessels are contracted, so that 
the surface of the body i£ pale and 
even blanched. The temperature of 
the body is lowered below the nor- 
mal. These facts are indisputable, 
and a recognition of the existence of 
these conditions forms the basis for 
rational therapeutics. Heat must be 
restored to the body; the heart and 
respiratory centres must be stimu- 
lated to do their work ; and the super- 
ficial blood-vessels must be dilated, 
so that the circulation may be equal- 
ized by affording a channel for the 
blood which has been retained in the 
great veins of the abdomen. The 
practice which I have followed for 
some years to accomplish these re- 
sults will now be given. 
Treatment of Shock.—The most 
important point in the treatment of 
shock is its prevention. Much can 
be done by prudent management, 
either to avoid shock or to lessen 
its degree. In selecting the date for 
operation, a time should be chosen 
when the patient is in good condition. 
Almost always this is possible. It is 
only in emergency cases, and in pa- 
tients who are suffering from a disease 
whose progress is steadily and rap- 
idly downward, that preparatory treat- 
ment will not put them in better con- 
dition. All patients requiring opera- 
tion should receive careful study, and 
every therapeutic indication should 
be met before operation. Especially 
should the condition of the emunc- 
tories be looked after. The bowels, 
skin and kidneys should be put in 
good condition by the use of baths, 
purgatives (especially broken doses 
of calomel and salines), and the abun- 
dant ingestion of water. The morale 
of the patient should not be neglected, 
as much can be done, by stimulating 
the courage of the timid and allaying 
the fears of the despondent, to make 
the patient look forward to the opera- 
tion with courage and without dread. 
All these matters should be attended 
to prior to the day of operation. The 
temperature of the room in which the 
operation is done should be high, 
from 750 to 850 F. In such a room 
the loss of heat from the patient by 
radiation is much less than when 
the operation is done in a cool room. 
Loss of heat from the patient can be 
lessened also by the manner in which 
she is dressed. It is best that she be 
well wrapped in blankets, and that as 
little of the skin surface be exposed 
to the air as the necessities of the 
particular operation permit. For the 
same reason the use of wet towels or 
gauze about the patient is to be dep- 
recated. Evaporation from such wet 
materials chills the patient. Much 
can be done also by the proper admin- 
istration of the anaesthetic. Patients 
should not be drowned in ether. 
Enough only should be given to main- 
tain anaesthesia, unless to meet a cer- 
tain indication, absolute relaxation is 
required. The prevention of haemor- 
rhage, and the avoidance of rough 
handling of the patient, especially of 
the abdominal viscera, are matters of 
the greatest importance in preventing 
shock. The careful surgeon gives 
due attention to each and all of these 
matters of detail, and no one so much 
appreciates their importance as he 
who has to deal constantly with grave 
operations. This applies especially 
to the abdominal surgeon, because, in 
many cases, when he begins an opera- SURGICAL SHOCK. 
3 
tion the life of the patient depends 
upon its completion. He cannot do 
a part of it and postpone the rest to 
another day. In many of the long, 
tedious operations which he is called 
upon to do, involving multiple vis- 
ceral adhesions, the very life of the 
patient itself depends upon attention 
to every detail to prevent shock, so 
that he may have time to complete 
the operation secundum artem. 
The active treatment of shock con- 
sists in supplying heat to the body 
which has been lost, in stimulating 
the heart to better work, in counter- 
acting nervous depression and in 
overcomingirregular action, especially 
on the part of the vaso-motor nervous 
system, until reaction shall occur and 
the vitality of the patient can be sus- 
tained by alimentation. In describing 
the treatment of shock I shall simply 
give an account of my own practice 
in the treatment of this condition. 
If during the operation the patient 
begins to suffer from shock and there 
is reason to expect that this will in- 
crease, especially when the operation 
is not yet completed, I begin at once 
actively to treat it. One-fifteenth of 
a grain of sulphate of strychnia and 
one-fiftieth of digitalin is given hypo- 
dermically, and the dose of strychnia 
is repeated every fifteen minutes 
until some improvement is manifested 
in the pulse, until a fifth of a grain is 
given. If improvement does not 
manifest itself promptly, and espe- 
cially if shock be profound or if the 
patient has been markedly prostrated 
before the operation, a hundredth 
of a grain of atropia sulphate and 
two or three minims of a i per cent, 
aqueous solution of nitroglycerine are 
given hypodermically. In still other 
cases from three to six grains of 
citrate of caffein are administered in 
addition. During this time hot-water 
bottles have been put about the 
patient, and if the .operation is an 
abdominal section, at times warm 
water is poured into the peritoneal 
cavity. I have also employed hot 
beef-tea enemas, but, as a rule, an 
enema is not given, because it inter- 
feres with the completion of the 
operation, which is just as important 
as any one detail in the treatment of 
shock, if not more so. In fact, it is of 
the highest importance to complete 
the operation as rapidly as is con- 
sistent with safe work. The same is 
true of the after-dressing of the 
patient, who should be put to bed as 
promptly as is feasible. 
The bed should have been warmed 
by having hot-water bottles in it 
while the operation was in progress, 
and in all cases in which shock is a 
marked feature, the sheets should be 
removed and the patient placed be- 
tween warm, dry blankets. At this 
stage the use of whiskey by enema is 
of service, and at times it is proper to 
use whiskey during the operation, 
especially if shock is not another 
name for too much ether. The use 
of whiskey or alcohol in any shape is 
not good treatment for an overdose of 
ether. The best way to employ 
whiskey, as a rule, is to give it by 
enema with hot beef-tea, about two 
ounces of whiskey and six ounces of 
beef-tea. Dry friction with the hand 
or with a dry cloth, especially to the 
extremities if they are covered with 
clammy perspiration, will do much to 
bring about reaction, and also will 
lessen radiation from the surface by 
preventing evaporation of the per- 
spiration. Morphia in small doses, 
one-eighth of a grain or less, is also 4 
CHARLES P. NOBLE. 
useful as a heart stimulant and as an 
anodyne, if, when the patient becomes 
conscious, there is marked pain. The 
morphia not only acts as a stimulant 
itself, but prevents depression which 
would result from severe suffering. 
So much for the immediate treatment 
of shock. Under ordinary circum- 
stances, when the shock is marked 
and yet not so profound as to be 
alarming, within half an hour strych- 
nia can be pushed to a fifth of a grain, 
atropia to a fiftieth, caffein to five 
grains or more, and digitalin to a 
twenty-fifth of a grain, or what is 
really better, tincture of digitalis to 
half a drachm, with the fiftieth of a 
grain of nitroglycerine. 
If the crisis passes and yet the 
patient remains in a markedly de- 
pressed state, the question of treat- 
ment for the ensuing twenty-four or 
forty-eight hours comes up. The use 
of external heat should be continued 
until the temperature of the body 
becomes normal, and even longer 
should the patient complain of chilli- 
ness. But the sheet-anchors of safety 
are strychnia, digitalis and whiskey. 
In a marked case it is my habit to 
give ihe following order: To give 
hypodermically sulphate of strychnia, 
one-thirtieth of a grain one hour; 
tincture of digitalis, fifteen drops, 
with the one-fiftieth of a grain of 
nitroglycerine, the next hour; three 
grains of citrate of caffein the third 
hour; and an enema of whiskey, two 
ounces, and beef-tea, six ounces, the 
fourth hour. This order I have had 
carried out many times for twenty- 
four, forty-eight and even seventy- 
two hours. In the worst of cases, for 
its temporary effect, cocaine has been 
employed in addition to the above, 
also small doses of morphia if much 
pain and especially if great restless- 
ness were present. It is my experi- 
ence that most patients will take a 
fifth of a grain of strychnia in twenty- 
four hours without manifesting symp- 
toms of strychnism. I have not em- 
ployed the heroic doses of strychnia 
described by some writers, such as 
half a grain within two hours, but in 
a desperate case, watching it carefully, 
I should not hesitate to give repeated 
doses of one-fifteenth of a grain every 
half-hour for a short time until some 
symptoms of irritation appeared. We 
certainly have no more reliable exciter 
of the nervous and muscular systems 
than strychnia, nor any drug which is 
more capable of maintaining its effect. 
Digitalis is also a very reliable drug 
in the treatment of shock. It is capa- 
ble of whipping up the heart to in- 
creased work, especially for a few 
days and until a sustained effect can 
be secured by alimentation. This is 
exactly what is required in the treat- 
ment of shock. Digitalis has, how- 
ever, one effect which is undesirable. 
It causes a contraction of the arte- 
rioles, and thus increases arterial 
pressure, so that, while it whips up 
the heart to do increased work, it 
also hinders the heart through the 
increase in arterial pressure; hence, 
it is wise, in the treatment of shock, 
to combine digitalis with nitrogly- 
cerine, which overcomes this bad 
effect of digitalis. The combination 
is much more effective than either 
drug alone. Caffein is a pure heart 
stimulant, and can be administered 
freely without evil consequences. 
Alcohol used judiciously and in not 
too large quantities, is one of our 
most important remedies. In shock 
following abdominal operations, it is 
best administered by enema combined SURGICAL SHOCK. 
5 
with beef-tea, which is itself a stimu- 
lant. Later in the case champagne 
by the mouth is often of service, but 
it fills only a partial indication and is 
not to be compared in value with 
whiskey when this can be ingested 
and retained. 
The management of the diet in the 
treatment of shock is also important. 
Immediately after an operation ac- 
companied by much shock, the stom- 
ach, as a rule, is not retentive; hence it 
is wise for a time in no case to admin- 
ister much aliment of any description 
by mouth. Some hot black coffee or 
hot beef-tea is as much as should be 
given. When the stomach becomes 
retentive, light, easily assimilable food 
should be employed, as beef-tea, broth, 
milk (preferably peptonized), egg- 
nog, punch, etc. • These foods should 
be administered in small quantities 
frequently repeated. The question 
of alimentation in the treatment of 
shock following abdominal operations 
offers certain peculiar difficulties. 
Under ordinary circumstances, when 
shock is not a special feature, it is the 
rule to administer no food to the pa- 
tient, who has had a coeliotomy, for 
from thirty-six to forty-eight hours 
after the operation. Then broths or 
beef-tea from two drachms to one 
ounce, or two drachms of milk with 
one of lime water, are given every 
half-hour, and if retained the quanti- 
ties are increased and the intervals 
lengthened, until about the fourth 
day after operation the patient is put 
upon liquid diet, the amount being 
regulated largely by the appetite. 
But in cases accompanied by marked 
shock, if the stomach proves reten- 
tive, it is wise to begin the adminis- 
tration of milk or beef-tea at the 
earliest feasible time, the quantity 
being increased as rapidly as in the 
judgment of the surgeon the patient 
is able to digest and to assimilate. 
In some critical cases lives will be 
saved by judicious alimentation, which 
would be lost were the usual rules, 
applicable in abdominal surgery, fol- 
lowed. 
It may be questioned whether the 
term shock should be applied to con- 
ditions which persist for one, two, 
three or more days. It is customary 
to consider that shock is of temporary 
duration, and that it ends either in 
the prompt death or in the recovery 
of the patient. But there are cases 
in which it is difficult to assign a 
name for the condition of patients, if 
it be not shock. I refer to those 
cases in which the patient exhibits 
marked shock after operation, and in 
which, although after a time the tem- 
perature of the body becomes normal 
and remains so, yet the patient’s 
vitality remains at a very low ebb, the 
pulse continues rapid, small and fee- 
ble. The cutaneous circulation is not 
restored, the surface of the body 
being cool and pale; and where no 
other symptoms are present, except 
those of pronounced asthenia. This 
condition must be called shock, or 
else inanition or asthenia following 
shock. The condition persists until 
it is relieved by alimentation, as the 
nerve and heart stimulants, strychnia, 
digitalis and even whiskey, are not 
curative. I have had patients to die 
in this condition as long as a week 
after operation, without having mani- 
fested other symptoms than those of 
pure asthenia, and in which the post- 
mortem examination showed no cause 
of death. On the other hand, I have 
seen patients recover from this con- 
dition, improvement becoming mani. 6 
CHARLES P. NOBLE. 
fested upon the third, fourth or fifth 
day, when it had appeared that death 
was imminent from failure of the heart 
and respiratory centres. It is in such 
cases that judicious alimentation is of 
the highest importance. 
In this class of cases the adminis- 
tration of oxygen gas by inhalation, 
is at times of service. All the vital 
functions are at such a low ebb, that 
any agent which is capable of improv- 
ing the processes of metabolism is of 
value. My experience with the use 
of oxygen for this purpose is limited 
to one case, which was one of marked 
shock following an operation for dou- 
ble pus-tubes, in a woman reduced to 
the last extremity by hectic. She 
went to bed with a pulse of 180, with 
cool and blue skin, and every other 
evidence of the profoundest shock. 
The pulse did not fall below 145 for 
three days, near the close of which 
period there was every indication of 
early death from pure asthenia. The 
plan of treatment already detailed 
was followed out in her case, and in 
addition oxygen gas was administered 
during one day. It seemed to be of 
great benefit; at all events, she passed 
out of the shadow of death and made 
a good recovery.