—These vary to a considerable extent according as the patient is or is not under a general anesthetic. The description of types and symptoms includes an expressionless face, pallor of the skin and mucous membranes, with corresponding coldness of the same, i. e., reduction of surface circulation and heat; dilated pupils, reacting slowly to light; irregularity of the heart’s action, with a weak, irregular, thready, or almost imperceptible pulse; irregular respiration, i. e., irregular both in rate and depth; mental inactivity and apathy; loss of voluntary muscle movement; impairment of superficial sensibility; reduction of body temperature; and nausea or actual vomiting. These at least constitute the symptoms and form the apathetic or torpid type of shock.
In the so-called erethistic type (Travers) the patients are restless and excited, uncontrollable, with irregular pulse and breathing, often with dilated pupils.
In a third type, described by Travers as the delayed, the symptoms are as above detailed, but do not appear until some hours after the cause which has produced them, which may be a concealed (internal) hemorrhage. The delayed type is also seen in those who escape serious accident with a minimum of physical harm.
As shock becomes more pronounced, mental depression deepens into coma, or mental excitement subsides into it; the surface becomes colder and bathed with perspiration, and death follows. These symptoms are those generally noted, whether following injury to the head and denoting so-called concussion of the brain, loss of blood, wound of the abdomen with injury to the viscera, blows upon the testicles, gunshot wounds or other accidents which are causes of shock. They follow also after perforation of the bowel, as in typhoid fever or appendicitis; depression following the receipt of bad news, or fright, etc.; in other words, the physical condition is practically the same no matter what the exciting cause.
Diagnosis.
—Shock is mainly to be diagnosticated from fat embolism; concealed hemorrhage as well as pulmonary edema and suppression of urine are to be suspected. It is unquestionable that many patients have died of fat embolism in whom the actual cause of death has not been ascertained, yet has been ascribed to shock. (See [Fat Embolism], [Chapter II].)
Treatment.
—The treatment of shock consists essentially in measures directed toward raising the lowered blood pressure. At the outset reaction should not be established too quickly, lest it be succeeded by overaction, with attendant disasters in the shape of secondary hemorrhage, etc. Patients should not be expected to swallow nor act as they would under other circumstances. They should not drink strong liquors, for the irritating fluid may escape into the larynx and induce coughing, which might prove fatal. The same is true of inhalations of strong volatile stimulants, like ammonia. These measures, therefore, should all be resorted to with great care and discretion. Warm, stimulating drinks, if they can be swallowed, are useful; and whisky, brandy, etc., should be given dilute and warm rather than strong and cold. External heat is advisable, and can be supplied by immersing the patient in a bath-tub of warm water, care being taken to keep the face out of the water. When this is not at hand, bottles and other receptacles for warm water may be used, but with caution, since too much heat has been the cause of serious burns.
Numerous drugs have been recommended in the treatment of shock. There are but two or three which are worthy of confidence. Crile, of Cleveland, subjected a large number of animals to tests in regard to the effect of various drugs in influencing blood pressure. He found, for example, that alcohol apparently produces more depression, and in deep shock is dangerous. Nitroglycerin and amyl nitrite seem to increase shock and lower pressure. Digitalis may produce a temporary rise in pressure, but in considerable doses impairs or arrests respiration, and it seemed to him that cases of severe shock treated with it did not live as long as the control animals. Strychnine has been one of the main reliances in these conditions. Crile found that if enough were given to cause increased excitability of the spinal cord it raised the blood pressure, while small doses had little or no effect. Pressure was raised by doses large enough to produce convulsions; repeated smaller doses had little effect, tending rather to increase shock.
These were the experimental results in the treatment of shock, and are to be distinguished from what may be done with the same drugs in the way of fortification and preparation as against shock. Thus strychnine always exalts susceptibility of the cord of the medulla and digitalis may temporarily supplement its use; together they may help to sustain pressure or to fortify as against depressing agencies. They are like whip or spur to a jaded horse.