SHOCK 303 



The symptoms may appear suddenly at the front or they may develop in men whr. 

 have comported themselves in an apparently normal manner until removed to the rear, 

 when they pass into a condition more or less simulating that of shock. Severe con- 

 ditions may also result to soldiers from injuries which in normal individuals would 

 not in themselves be sufficient to produce surgical shock. The characteristic symptoms 

 in such cases are frequently different from those of other forms of shock, and, as 

 has been shown by Elliot-Smith25 and T. H. Pear, 2 ^ the condition must be treated from 

 the neurologic or psychopathic point of view. 



Sometimes however a profound condition of shock which yields to no treatment sets 

 in without any degree of injury that would adequately account for it. 38 



7. Surgical Shock. It is this variety that is usually referred to when one speaks 

 of shock. It may be caused either by severe mechanical injury to a healthy person 

 or by extensive manipulation and rough handling on the operating table. It is a com- 

 mon sequela to war injuries and industrial accidents, especially where the destruction 

 of muscular tissue has been extensive. However produced, the symptoms of surgi- 

 cal shock are very much the same. The patient is restless and keenly alert mentally. 

 He complains of great thirst but if given water almost immediately vomits it. His 

 skin is a peculiar grey color and the lips and gums are more or less cyanotic; the skin 

 feels cold and is moist with sweat; the reflexes are greatly diminished, and it is 

 usually only after applying a very painful stimulus that any movement of defense is 

 elicited or resentment is shown on the part of the patient. The postural reflexes are 

 also abolished, so that if a limb is lifted it falls back limp and toneless. The pulse at 

 the wrist is very rapid, thin and almost imperceptible, and the arterial blood pressure 

 is usually abnormally low. The respirations are frequent and shallow. The rectal tem- 

 perature is 1 C. or more below normal. The pupils are dilated and react slowly to 

 light. The symptoms are thus not unlike those of cholera. 



In shock observed in the trenches and clearing stations it came to be 

 recognized that there are two stages, primary and secondary. The con- 

 dition described in the preceding paragraph is that of secondary shock. 

 The primary shock comes on immediately the wound is received or 

 shortly after, when the patient sees his wound or realizes the gravity 

 of his condition. It may be analogous to the effect caused by the re- 

 ceipt of bad news, fright, etc. By free administration of fluids and by 

 keeping the body warm this primary shock is likely to be recovered 

 from ; but if the patient be left untreated it is apt to pass on to second- 

 ary shock, the factors producing which are several. 



Although the above classification is convenient for descriptive pur- 

 poses it must be remembered that the clinical condition of shock is 

 usually due to the combined action of several causes, e.g., hemorrhage, 

 toxins, and anesthetics. Any one cause may be insufficient but if two 

 act together the effect will be greater than the sum of the two acting 

 separately, and this is particularly the case if they be allowed to act for 

 a long time. Since cold is a factor in the causation of shock, it is most 

 important to keep the patient warm from the moment at which the onset 

 of shock is feared. 



