ball, or any other ball, carries off a limb, or does other fatal injury, pain is not produced, but the vital shock is extreme, the general depression, or vital sinking, often passing rapidly to dissolution.

those who have had, or may have, a more extensive experience of the phenomena to which these remarks apply.*

5. Shock produces effects of various grades of severity, according to the health, or the states 3. Pain of itself rarely occasions, although it of depression or of excitement the individual may accompany shock, and, when it does, it may be in at the time of sustaining it. Thus a generally tends to diminish shock, and to de- person of a powerful constitution is much less velop reaction. Pain and shock are often asso- affected by it than a delicate, nervous, or melciated in injuries and surgical operations; but ancholic individual. A state of excitement, anthe former is an endowment tending to the pro- ger, passion, &c., to a certain extent, countertection of life, to the counteraction of the effects acts its effects, while fear, grief, or any of the of shock, and to the development of a salutary depressing passions, increase its effects. Even vital reaction. The severest or most prolonged pre-existing disorder, or structural change, renpain does not occasion vital shock, but it causes ders these effects more dangerous or severe, vital exhaustion, sometimes even sleep. This especially organic change of the structure, or was proved by the tortures of the rack in for- of the cavities or valves of the heart. These mer times, and by the history of the most painful are important circumstances as respects peraffections. When pain attends severe injuries sons for whom severe operations may be reand operations, the patient sinking more or less quired, and should be kept in recollection when speedily, the result should be imputed to the such operations are about to be determined on. influence of the shock on the constitution, and While the severity of shock is thus influenced not to the pain, which is merely unavailing in by constitution, temperament, states of mind, counteracting the fatal result. This view of and existing disorder or actual organic disease, the subject, I am aware, is very different from the phenomena constituting shock are also mod. what is generally taken; but a more intimate ified, by these circumstances, in a more or less consideration of the phenomena than has hith-remarkable manner. The intensity, as well as erto been entertained will show its truth. The importance of this topic is remarkably heightened, at the present day, by the circumstance of anesthetics being so generally employed during operations, and even during parturition; for, if the view I now take be just, the shock to the constitution, or vital influence, by severe operations, or by a severe labour, will be increased by annihilating the preservative influence of pain; and the immediate as well as the more remote effects of shock will be thereby more or less increased.

the modifications of the phenomena of shock, is very remarkably influenced, or even in great measure occasioned, by the state or amount of alarm produced in the mind of the sufferer by the injury causing the shock; this is the more remarkable in severe wounds and other injuries.

6. From these considerations, it will be readily inferred that the symptoms or phenomena of shock will vary more or less in different cases, according as one or several of these modifying causes are in operation; and that, while certain of them may be wanting in some instances, the whole may be differently grouped, or may appear in varied succession, in most cases

7. I. PHENOMENA OF SHOCK-The symptoms of shock vary with the severity or intensity, and nature of the cause, and the state or constitution of the recipient. The causes of shock are chiefly, 1st. Contusions, bruises, blows, and concussions; and these vary in their effects, according to their situation upon or near vital or

4. In the article POISONS, I have shown the effects produced by the inhalation of chloroform and ether (615, 616). It may be useful to view these effects in connexion with those produced by dangerous or fatal injuries, and to contrast them as far as they admit of contrast. It will be seen, by observing the progressive effects of chloroform, that it paralyzes sensibility, and subsequently, as its influence extends to the medulla oblongata, it more or less paralyzes the respiratory functions, and ultimately the heart * [We believe that anesthetics not only annul pain, but itself, if its inhalation be continued sufficiently also prevent the shock which the system would otherwise sustain during a severe surgical operation. They produce long to produce this effect; the functions of such an impression on the nervous centres, or so modify the brain, of the medulla oblongata, and of the their functions, that causes which in a normal condition ganglial system, being successively extinguish-excite pain, or rapidly exhaust nervous energy, produce ed. The effects of fatal shock are similar as comparatively no effect. This may partly be owing to their influence on the mind, removing all fear and mental respects the sinking and extinction of the func-alarm; but it is not wholly due to this cause. In order tions of these several organs, but they present a different order of procession, as will be more fully shown hereafter, the ganglial and cerebrospinal functions being successively affected. Now, as the effects produced by the inhalation of chloroform are depressing as well as anæsthetic, and as shock is also depressing, although in a somewhat different manner, must it not be reasonable to infer that the shock will be more severe and dangerous, cæteris paribus, during the influence or effects of chloroform, than when the frame is unaffected by this agent, and when pain exerts its influence, and develops a salutary vital resistance? In this matter the ascertainment of truth is my object. I reason from my own observation, as far as it has extended, and I leave this part of my subject to

that shock should be felt, the functions of the nervous system must be in a normal state, or the seminal powers active. If a limb, for example, be amputated, or an extensive burn be inflicted during deep intoxication, from any cause, no shock will be experienced, any more than pain. We lately had an opportunity of observing this in a man who had both feet burned off during a state of intoxication. There were no apparent symptoms of shock whatever. So, also, the statistics of capital operations, both in European and American hospitals, show that the average mortality from shock, occasioned by such operations, has been greatly diminished since the introduction of anaesthetics into surgical practice. Their pre-eminent value consists, indeed, in their preventing shock. If they have this effect, and that they do is sufficiently proved by facts of daily occurrence, even granting that the effects of chloroform are temporarily depressing, the danger of a fatal result is not enhanced, but greatly diminished by its use. Pain, within certain limits, may be conservative; vital force, and co-operates with shock in inducing a fatal beyond these it rapidly exhausts nervous energy and the result.]

treatment of shock, with the particular cause of it, it is still more important, especially as regards the treatment, to mark the particular form and modification requiring our aid.

important organs, as when they are seated over or near the epigastrium, the cranium or neck, the joints, the spine, &c. 2d. Gun-shot wounds, by which large nerves, blood-vessels, or important viscera, or joints, or large bones, are more or less injured. 3d. Penetrating or incised wounds, or surgical operations, implicating these or other parts. 4th. Simple or compound fractures, dislocations, lacerations, or lacerated injuries of all kinds; and, 5th. Mental alarm or terror, or shocks from the sudden or unexpected intelligence of losses of near relations, of friends, of wealth, of honour, or of worldly consideration, or intense fear or dread of some calamity. In many of the preceding classes of causes of shock, mental alarm or dread the mental shock-greatly increases the effects of the physical shock upon the vital ity of the frame, and especially on the manifestations of life in the nervous system; so that, in estimating the amount of the latter, care should be taken not to overlook the exist-nance, terminating, more or less rapidly, in loss ence and intensity of the former of the mental alarm or shock.

10. (a) The simple or more vital states of shock may be so slight as to pass off in a few hours, or so severe as to terminate fatally in a few minutes, according to the intensity of the cause. This effect may be altogether independent of any hæmorrhage, and may result from a variety of causes. A violent blow or contusion over or near the epigastric centre may so paralyze the heart as to produce more or less sinking, not only of the action of this organ, but of all the vital functions; the symptoms being chiefly feebleness, slowness, or irregularity of the pulse; coldness and pallor of the face, general surface, and extremities; a distressing feeling of sinking and anxiety; slow or irregular respiration; sometimes cold perspiration, with general tremour; and a sunken or collapsed state of the counte

of pulse at the extremities and in the carotids, and in extinction of sensation, of the heart's action, and of respiration. In some cases, especially when the injury is less intense, or when a large joint is very severely injured or crushed, these symptoms may not be so intense, may be of longer duration, and be attended by others, as vomiting, singultus, or by restlessness, by feelings of alarm and anxiety at the epigastrium; and, according to the nature and severity of the cause, relatively to the state of the sufferer, these symptoms may lapse into fatal sinking, or be followed by imperfect efforts at reaction, or by delirium, or by reaction, terminating ultimately either in coma and death, or in recovery, according to the constitution of the patient and the treatment adopted.

8. Now, although these several classes of injury, with their frequent attendant, mental alarm or shock, may be supposed to produce varied effects, yet such is not always the case; for so much may be owing to the severity, as well as the nature of the cause, relatively to the state and constitution of the sufferer, that the phenomena consequent upon the one class may hardly vary from those following the others. So much, however, is often observed to depend upon the viscera and parts injured, and upon | the loss of blood, and the amount of that loss, as well as upon the intensity of mental alarm, as to render it necessary to connect the shock and its intensity with the nature and severity of the cause or causes which produced it. For, 11. (b) With more or less of the above symp. according to the cause, (1st) the shock may be toms, others may supervene, or may be present altogether and simply a vital one, as when it from the first, more especially when a limb is is produced by a violent blow on the epigastri- carried away by a cannon-ball, or when it is um, occasioning concussion of the solar gan- lacerated extensively, or near to the trunk of glion; (2d) or it may be associated with various the body, or when large blood-vessels or nerves nervous phenomena, as when a large nerve, or are lacerated, or large joints are crushed. In joint, or limb, is lacerated or severely injured, these circumstances, as well as in others, esand the patient thereby greatly alarmed; (3d) pecially in nervous and irritable temperaments, or it may be complicated with, or rather char- various nervous symptoms, especially mental acterized by, comatose sinking, as when the alarm and restlessness; irregularity of the contusion, concussion, or blow effects the inti-heart's action and of respiration; a terrified, as mate organization and circulation of the brain; well as a sunk state of the countenance; de(4th) or it may be so associated with the sink-lirium, terror, and incoherence; a general treing, consequent upon losses of blood, as not mour and coldness; a remarkable and peculiar to be distinguished from this cause, especially tremour or quivering of the injured limb, with when the injury is such as occasions both shock a cold, wet, pallid, or leaden state of the surand hæmorrhage; or (5th) the alarm or shock face of the limb, or parts adjoining, are more or may be entirely a mental one, or that consist-less remarkable, and seldom terminate in a saling entirely of the sudden effects of extremely depressing emotions on the action of the heart, or of the sudden and unexpected intelligence of distressing losses or events, whereby the nervous system is more or less shocked, the mental manifestations disturbed, and the functions of the heart and vital organs depressed and otherwise disordered.

9. It will thus be perceived that the injuries or causes occasioning shock may be divided into five classes, and that the effects they produce may present five modified forms; but, although either of these may result from either class of causes, and although it is necessary to connect our observation of the phenomena, and our

utary reaction, unless in a few cases which admit of surgical interference by amputation, &c. When severe injuries are inflicted upon any part of the abdominal cavity, a state of stupor or apathy, yellowness of the surface of the body, collapsed features, and fatal sinking, as already described (§ 10), either appear from the first, or supervene upon the symptoms just enumerated. In most of these severe injuries, and especially those produced by fire-arms, the amount of pain is very small compared with the intensity of the shock; and even where the shock is the greatest, the pain may be the least, or may even be entirely absent. Indeed, in many cases, the pain precedes the occurrence

of reaction, and even favours the development | ror, or even delirium, sometimes, in females, of this salutary effort of nature.

12. Although surgeons have neglected to treat specifically of shock-a state which particularly concerns them, as respects both the period and the prudence of operating, and the effects of operations-the subject has been briefly adverted to by many, and especially by LARREY, GUTHRIE, COPLAND HUTCHISON, DUPUYTREN, and HENNEN. It falls not within the scope of this work to notice the remarks they have offered respecting it; but what they have advanced, which is extremely little, will be readily found in the works of these celebrated surgeons.

with hysterical convulsions, prolonged faintness or catalepsy. In this form of shock, the strength of mind, the nervous energy, or force of character of the sufferer, modifies remarkably the amount or intensity, as well as the particular form or state, of the physical effect; for the same intensity of cause, which might make but slight impression on a person thus mentally constituted, or on one physically robust, might produce a very dangerous effect on a delicate, nervous, and susceptible individual; this effect being, moreover, often attended by faintness, convulsions, incoherence, &c. Mental shock is more especially depressing and dangerous to persons who are the subject of organic diseases of the heart or brain-of the former particularly-death often immediately following it.

13. (c) Injuries may be received directly or indirectly by the brain or spinal marrow, so as to produce a form of shock, which has been generally termed concussion of the brain, or of the spinal chord, as either may be affected. In 16. II. The DIAGNOSIS and PROGNOSIS of such cases, with more or less shock to vitality SHOCK require but little remark.-A. Of the or to the frame, there is a special shock sus- former it may be observed, that it is often diffitained by these nervous centres, the minute or cult to determine whether or no a fatal result ultimate organization and circulation of these be owing to the immediate physical shock and parts being so changed or affected as to in- mental alarm which an injury or operation prostantly arrest all the functions they perform. duces, or to the consecutive effects on the frame, With the phenomena of shock, as manifested either by interrupting some important or vital in its more simple form (§ 10), unconscious fæ-function, or by contaminating the blood. True cal and urinary evacuations, sometimes with or simple shock is always instantly manifested vomitings, are also present. When the injury on the cause producing it; it is generally atthus implicates the brain, or upper portion of tended by nearly all the symptoms already enuthe spinal chord, the annihilation of the func-merated, by more or less mental alarm, and by tions of those parts especially distinguishes the case, although the marked and often rapid sinking of the heart's action, or the paralysis of the respiratory muscles, farther characterizes it, either of these being the more immediate cause of dissolution.

a sensation of sinking and anxiety referred to the epigastrium and præcordia, sometimes with vomitings, characterized by slight or even no effort, or with unconscious or involuntary evacuations, and a universal failure of all the vital functions. In some of the most severe cases of physical shock, instead of mental alarm, there is either delirium, or stupor, or apathy.

17. B. The Prognosis depends entirely upon the nature of the cause or injury, and the intensity of the effect indicated by the symptoms. Great slowness or weakness of the pulse; or great frequency, with feebleness or irregularity; marked coldness, pallor or leaden hue of the surface; tremour, cold perspirations, vom

14. (d) Cases often occur in which the shock is heightened by, or complicated with, either internal, or concealed, or open hæmorrhage. In these the symptoms of simple shock (10) are more or less manifest, with great pallor of the surface, often with coldness and tremour, sometimes with succussions, or shudderings, or vomitings, passing into deliquium, or fatal sinking, especially when attempting to sit up. The action of the heart then ceases, and with it res-itings, singultus; irregularity of the respiration.; piration; the cerebral functions either being but slightly disturbed, unless shortly before death, or ceasing in a way not to be distinguished from the accession of sleep, excepting in the rapid failure of the pulse and respiration. In the less severe cases of this kind, reaction may supervene, and recovery take place, when the nature of the injury causing the shock and hæmorrhage, and the consequences of both, admit of this issue.

15. (e) The fifth form of shock depends more or less on mental causes of an intensely depressing nature. The physical effect may be entirely owing to the mental cause, or partly owing to this cause, or to alarm or dread of dissolution in connexion with a physical cause, as in cases of gun-shot or other wounds, severe injuries, operations, &c. In these latter cases, the causes are both physical and mental; and the phenomena present a mixed character, more or less of mental alarm or of nervous phenomena, such as are above noticed (§ 11), being associated with physical depression-the symptoms of either the first or the second of these forms predominating with fright, anxiety, or most manifest alarm and distress, or of absolute ter

continual restlessness; a sensation of sinking or of impending dissolution; delirium, apathy, or stupor; involuntary evacuations; a jaundiced appearance of the surface; rapid failure of the pulse, &c., are all very dangerous, and often fatal symptoms. When the phenomena are less severe, and when the means employed are successful in bringing about a salutary reaction, or even in diminishing the severity of those now mentioned, then hopes of a recovery may be entertained. But so much depends upon the nature and peculiarities of the case, upon the patient's feelings and opinions as to the issue, which should always be duly considered, and upon the progress and contingencies of the after-treatment, especially for complicated injuries, as hardly to admit of definite laws of prognosis being assigned.

18. Many of the injuries which occasion severe shock involve the questions, 1st, as to the propriety of amputating a limb, or shattered or torn stump; and, 2d, as to the period at which this operation should be performed. The first of these questions has been satisfactorily considered by surgical writers; but the second has been long a subject of discussion, many writers

of experience taking different views of the mat- tioned; and I have generally preferred to warm ter. The differences of opinion, as well as of baths, as being more efficacious, more immedisuccess, as regards the period, after these in- ate, and attended with less trouble and fatigue, juries, at which the operation should be per- or exertion, on the part of the patient, the apformed, have arisen from the want of due at-plication of flannels, wrung as dry as possible tention to the existence or non-existence of out of very warm water, then freely sprinkled the more marked phenomena of shock at the with spirits of turpentine, and instantly applitime of performing the operation, and from re-ed over the epigastrium and whole abdomen, course having been too frequently had to it before these phenomena had subsided, or before the frame had recovered itself, either partially or more fully, from the shock it had experienced before vital reaction had commenced; for, if a few hours be not allowed for this purpose before the operation be attempted, the performance of it so rapidly upon the receipt of the injury may convert a state of shock, admitting of vital reaction, into a state of fatal sinking; or, if the vital energies continue to sink more and more, during the few hours thus allowed for them to rally, notwithstanding a recourse to rational means to this end, an operation will only add to the patient's suffering, and accelerate the fatal issue.

salutary reaction, or increased or inflammatory action of the nervous centres, or their membranes, the shock, whether mental or physical, degenerates into a low, incoherent, or mutter

along the spine, when it is the special seat of shock, or even around the cranium, when the concussion implicates the brain, and an enema may be administered containing asafoetida, with a moderate quantity of camphor. But a re-ing delirium, passing more or less rapidly into course to these or other means should depend much upon the states of the pulse, and of the sensorium, at the time.

24. The external or local means must be left to the judgment of the medical attendant. Cold applications ought not to be made to the seat of injury, as long as coldness of the surface, collapse of the features, and failure of the pulse exist. They will not only aggravate these symptoms, but also increase the anxiety, sinking, and pain at the epigastrium, and the general restlessness and distress. Warm fomentations, with a decoction of poppy-heads, especially if much pain be experienced, or warm embrocations containing some preparation of opium, will generally afford some relief.

coma (§ 27). In these circumstances recovery rarely takes place; but, nevertheless, a strenuous recourse to the restorative means already mentioned, such as frequent doses of camphor or ammonia, terebinthinate epithems on the scalp and epigastrium, stimulating enemata, &c., should not be neglected. (See arts. DelirIUM and COMA.)

a treatment suitable to its several states. I have treated

BIBLIOG. AND REFER.-I am not acquainted with any work or treatise on vital or nervous Shock, and but few writers notice it incidentally, far less describe it, or advise of Shock in this work, because I consider it a most important and dangerous affection, implicating more or less the whole vital and animal functions, and hence coming within that of the surgeon. When we consider that, of strictly within the province of the physician, as well as the numerous accidents and wounds which cause death, the greater proportion produce this effect by the severity and suddenness of the shock to the vitality of the frame, rather than by any interruption to the functions of the injured part, the interest of this subject will appear in its true light. The principal works in which it is incidentally mentioned are the following: Larrey, Mém. de Chirurg. Gun-shot Wounds of the Extremities, 3d ed., 8vo. LonMilitaire, 4 tomes, 8vo. Paris, 1812-1817.-G. Guthrie, On don, 1827; and on Wounds and Injuries of the Abdomen and Pelvis, 8vo. London, 1847.-J. Hennen, Principles of Military Surgery, 2d ed., 8vo. Edin., 1820.-4. Copland Hutchison, Practical Observations in Surgery, 2d ed., 8vo, 1826; and Observations on the Period for Amputating in Gun-shot Wounds, 8vo. London, 1817.-Dupuytren, Leçons Orales de Chirurg. Clin., t. ii., art. 7; t. iv., art. 7, et 14.-S. Cooper, Surgical Dictionary, 7th ed., 8vo. Lond., 1838, p. 650.

25. The injury, especially those produced by gun-shots, severe compound fractures, lacerations, &c., may require the removal of the limb. In this case, if the phenomena of shock produced by the injury be severe, this operation should not be performed until the constitution shows indications of rallying, either by the efforts of nature-owing to the vital resistance in less severe cases or by the means above recommended. A few hours should be allowed for this purpose · often not more than two or three seldom more than eight or ten hours; for if, at the termination of this longer time, reaction has not commenced, and more especially if the vital depression has increased, the additional shock produced by the operation may rapidly terminate life. It will be better, therefore, to persevere somewhat longer in the use of the means advised for rallying the powers of life, and to increase the doses of these means, al- 1. I. FUNCTIONAL ALTERATIONS.-The skin, or ways with due reference to the previous hab-integumental sack or covering of the body, disits of the patient, than to attempt an operation which will be of no avail.

26. As soon as indications of vital restoration or of vascular reaction appear, the means resorted to for attaining this end should be relinquished; and gentle diaphoretics be given with the view of equalizing the circulation and removing internal congestions, which are apt to occur during the vital depression caused by the shock. If the reaction be such as is attended by heat and dryness of skin, full or strong pulse, thirst, &c., cooling diaphoretics, purgatives, and even blood-letting, especially if the previous loss of blood has been inconsiderable, should be prescribed; and these should be aided by such local means, in cases of severe injury, as their nature may require.

27. The reaction following mental shocks, especially in nervous, susceptible, and delicate persons and females, is apt to be followed by delirium or fever, sometimes by phrenitis and inflammation of the brain or its membranes, on either of which coma is liable to supervene, and similar consequences may follow concussions of the brain or spinal marrow; in such circumstances, the treatment recommended for these diseases, under their respective heads, should be adopted. (See articles BRAIN and its MEMBRANES, INFLAMMATIONS of; also DELIRIUM, CoMA, &c.)

28. In some instances, instead of either a

SKIN. SYNON.- Integuments; Integumental
Sac, or envelope of the frame; Cutis, Corium,
Derma; die Haut, das Fell, Germ. Peau, Fr.
CLASSIF-GENERAL AND SPECIAL PATHOL-
OGY-SYMPTOMATOLOGY.

charges more important functions than have commonly been imputed to it. I long ago, and more recently in various parts of this work, endeavoured to prove that the skin performs offices of a very high order in the economy; that through it effete and excrementitious matters are carried out of the blood, and that in this respect, as a depurating organ, it aids the functions of the kidneys, of the large bowels, and of the lungs; an impairment of the functions of either of these being often attended by a vicarious increase of its actions. It is thus an eliminating organ, contributing to the depuration of the blood, generally to an extent more or less intimately related to the amount of function performed by the other emunctories. That the skin performs a vital action, consisting of an insensible and a sensible exhalation, the amount of either depending much upon the state of the atmosphere, is generally admitted. Increased transpiration may proceed from a variety of causes, and so may diminished transpiration; and either, in its more manifest states, is an important indication of disorder. The insensible perspiration may become sensible, owing only to a mild, warm, or humid state of the air; while the perspiration may not only be insensible, but this state of it may be much increased, by more or less evaporation of the fluid in the skin by great dryness of the air.

2. A. When the halitus, or transpiration of