What Is Shock?

Generations of doctors have talked about "shock," but they have never agreed on what they mean by it. Trying to be more precise, some have distinguished different types such as those caused by fright and cold, and a special kind of "wound shock." Others have gone on to such refinements as primary and secondary wound shock. All this, say two British physicians, is not good enough: wound shock must be even more carefully classified if the patient is to get the right treatment--and the wrong treatment may cost the patient his life.

Drs. Ronald T. Grant and E. Basil Reeve found themselves caught in this confusion early in World War II, when they treated 120 victims of bombings and accidents in England. They went on to Italy and treated 190 more (both soldiers and civilians). They soon dropped the word shock from their vocabulary, because they found it not a help but a hindrance. From the varied conditions formerly lumped as shock, Grant and Reeve sorted out six kinds of circulatory upset, and their symptoms.

"Tip Up the Bed." What goes on in a patient suffering from "shock"? Dr. Grant admits frankly: "That's the point--we don't know." Trying to find the answer, he is working on rabbits in a cramped laboratory at London's ancient (1721) Guy's Hospital. Sometimes a patient who has merely been jarred by bad news or a fright shows about the same "shock" symptoms as one who has been injured.

"Tip up one end of the bed," says Dr. Grant briskly, "and in five minutes they feel better if there's no injury. Once, during the war, they brought in an old dame. They thought she was going to die. Her pulse was down around 50, and blood pressure about the same, and they called it 'severe shock.' I tipped up her bed [lowering her head] and turned round to get ready for a transfusion. When I turned back a few moments later, she was all right. And when I examined her, her injury was nothing--only a crushed toe."

Stories about a fatal kind of "battle shock" with no visible injury have caused further medical confusion. "There was a great haroosh in World War I about men showing all these symptoms but with no injury," he says, "so we looked for such cases in World War II. We never found one. Perhaps later examination showed that the man had had a brain concussion, or died from carbon monoxide produced by the bomb. So-called 'pure shock' may exist, but I haven't seen it. To me, so far, it's a bogy."

Don't Delay. The first thing to do for victims of "shock" and injury, Drs. Grant and Reeve found (as did U.S. Army medics, especially in Korea), was to see whether the patient had lost blood, and if so, how much. In some cases, even when the blood pressure was normal, there had been heavy blood loss. The actual volume of blood lost, say the doctors, should be computed (by a quick and simple dye method). Their motto: "If in doubt, transfuse."

It is, they say, "bad practice to delay transfusion." And a patient with a very large wound needs "much more than even a bold transfusion officer is inclined to give till he has learned for himself." The objective is to restore blood volume to at least 70% of normal and keep on going to 80% or more as a margin of safety.

Many a "shock" patient early in the war was harmed, not helped, by being kept too warm in an electric cradle and given drugs and rest, when he needed a transfusion and prompt operation. And it was wrong, the two researchers believe, to give fluids freely to patients with limb injuries : to avoid vomiting, they should get only sips of water even if they are "avidly thirsty."

There is still much to be learned about so-called shock, say Drs. Grant and Reeve. But only since World War I has there been detailed study of the subject, though it has been important since man started being clawed by saber-toothed tigers and rolling rocks down on his fellows.

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