Contents

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SECTION I

GENERAL SURGERY

CHAPTER VII

WOUND SHOCK ^a

Wound shock occurs as a consequence of physical injury-the rupture, shredding, tearing, or crushing of large amounts of tissue. It is characterized by low venous pressure; low or falling arterial pressure; rapid thready pulse: diminished blood volume; normal or increased erythrocyte count and hemoglobin percentage in peripheral blood; leucocytosis; increased blood nitrogen; reduced blood alkali and lowered metabolism; subnormal temperature; cold skin, moist with sweat; pallid or grayish or slightly cyanotic appearance; thirst; shallow and rapid respiration: of ten vomiting and restlessness; and anxiety, changing gradually to mental dullness and lessened sensitivity. These features may appear at once or as soon after the reception of the wound as observations can be made, or they may develop only after several hours. The former type is called primary, the latter secondary, wound shock.

The factors concerned in the development of shock may be divided into those that initiate the condition and those that sustain it after it has once been developed.

INITIATING FACTORS

The onset of early or primary shock is most reasonably accounted for as a consequence of some disturbance of the nervous system. A review of shock theories has shown that it is impossible to eliminate, as a consequence of wounds, a reflex relaxation of blood vessels similar to that which occurs in fainting. Indeed, fainting is not infrequently seen after the reception of relatively slight wounds in warfare. Vincent I observed cases of this character, but the only instance which he described in detail is that of a man wounded in the abdomen who, through manifesting the syndrome of shock a few minutes after being hit, had a rise of blood pressure from 60 to 90 mm. Hg. within 45 minutes thereafter. It is possible, therefore, that an effect similar in character to fainting or syncope may be produced by a wound and that it may persist for a longer period than the usual fainting spell.

For an explanation of the onset of delayed or secondary shock the theories which have been most commonly advocated in the past, such as inhibition, reduction of the carbon dioxide content of the blood (acapnia), fat embolism, and an exhaustion of nerve centers or certain glands, have all been shown to be inadequate. Their chief and common defect is that they fail to account for the occurrence both in clinical and experimental shock of a diminution of blood

^a This chapter is based largely on the writer's experience in cooperation with British investigators at a casualty clearing station at Bethune during the summer of 1917, and in London during three months of the winter of 1917-18, and thereafter on the work of a group in the Laboratory of Surgical Research of the American Expeditionary Forces, at Dijon, France, during eight months of 1918. The members of the group had opportunity to observe shock cases in forward areas, both during the summer and in the fall of that year. The experimental and clinical observations in France and England were supported by laboratory investigations conducted simultaneously in the United States.

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volume and either a local or general concentration of blood corpuscles. A group of theories which do take these facts into consideration, namely, theories which postulate a primary vasoconstriction with a consequent capillary congestion, are defective in that they do not suggest how a vasoconstriction would occur capable of bringing about a reduction of blood volume. The theory of secondary shock which has the strongest support, both in clinical observations and in laboratory experiments, is that of a toxic factor, arising from damaged and dying tissue and operating to cause an increased permeability of the capillary walls and a consequent reduction of blood volume by escape of plasma into the lymph spaces. Thus the concentration of the corpuscles is also readily explained. It is recognized that after a sufficient time infection may occur and be of such character in itself as to induce a persistent low blood pressure. According to this theory there might be no essential difference between the effects of toxins given off by damaged tissue and of toxins resulting from activity of bacteria.

Emphasis should be laid on the fact that toxic agents are usually not working alone to bring about the shock state. Complicating the wounds there is usually some loss of blood. Under battle conditions, especially, there may be cold and exposure. Likewise there may be prolonged lack of food and water. Sweating is a regular accompaniment. of severe trauma. All these factors are known to be capable of playing a role in producing a more or less permanent fall of pressure; such a loss, when combined with injury, may bring about promptly the signs of wound shock. Similarly, after a serious wound, with loss of blood, shock may not be present, but then ether or chloroform anesthesia and operation may quickly induce a calamitously low blood pressure. It is because the state of shock may be the result of a group of circumstances that improvement often follows when one easily controllable factor (e. g., cold) is eliminated.

SUSTAINING FACTORS

When a low blood pressure is developing in consequence of the action of initiating factors a critical level is reached at about 70 mm. Hg. Below this level the delivery of oxygen to the tissues becomes inadequate, the blood alkali begins to be reduced (i. e., "acidosis" appears), and the rate of chemical change within the organism becomes slower. There is a diminished heat production. so that the body temperature gradually falls below normal.

When there are defective circulation and insufficient oxygen supply tissues are damaged. Most sensitive to oxygen want are the nervous tissues. In addition to injury to these delicate structures there is likely to be a relaxation of the walls of capillaries and perhaps also injury to the capillary endothelium. These disturbances in elements which are essential to the maintenance of an efficient circulation continue the state of shock which has been originated by other factors, and they may also still further reduce the already low arterial pressure.

EARLY TREATMENT

In the following suggestions for the treatment of the wounded who are suffering from shock or who, because of their wounds, may pass into a state of shock, the facts above mentioned will be applied. It is necessary to keep in

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mind at the outset that the early use of simple measures is of prime importance. Such measures will be described in relation to the conditions that have to be met in the course of treatment.

HEMORRHAGE

It is well known that bleeding may sensitize the organism to factors which are likely to induce shock, and furthermore that men who have been severely wounded and are in an unstable condition therefrom may be reduced to shock by relatively slight hemorrhage. Moreover, in association with serious wounds there is likely to he a considerable loss of blood and consequently urgent need that no more be lost. All these considerations strongly emphasize the importance of employing measures which will prevent a further bleeding that maybe of critical importance to the life of the individual.

The readiest method of checking hemorrhage when a limb has been wounded is by means of a tourniquet, and there is usually strong temptation to apply it. promptly. As mentioned above, however, there is good evidence of a toxic factor in shock. Part of the evidence for the existence of this factor was obtained in cases of a long exclusion of the circulation from a part of the body--especially a wounded part. When the blood flow was restored in the anemic region in these instances shock was promptly produced. Cases of this character illustrate a definite danger which may arise if a tourniquet is used to control hemorrhage and consideration is not given to the length of time it has been in place. The evils of thoughtless and indiscriminate use of the tourniquet became so prominent during the war that in certain parts of the British Army this method of hemostasis was definitely discouraged. Medical officers then found that in most cases the flow of blood could be stanched by applying compression to the wound itself. The advice of Wallace and Fraser, ² who had a vast experience with shock cases during the war, is as follows:

Bleeding is to be arrested by pressure upon or ligature of the bleeding point itself and not by constriction of the limb above or by tying the artery on the proximal side of the injury. The systematic use of the elastic tourniquet should be limited, and its use, apart from during an operation, should be restricted to those cases in which a limb is completely smashed or blown away, or as a temporary measure while a patient is being carried to a regimental aid post. If the medical officer finds that a tourniquet has already been applied it is his duty to remove it at once and to examine the limb so as to ascertain whether there is actually hemorrhage, and, if so, to take measures for its arrest.

A rule which is generally applicable is that the tourniquet should be avoided altogether if possible, and that if one is absolutely required it should be placed as far from the trunk as conditions permit and removed as soon as vessels are tied or snapped. If it must be left long in position a note should le attached to it stating when it was applied.

The suggestion has been offered that it a limb has been so badly mangled that it can not be saved a tourniquet should be set close above the trauma and left in place until after amputation. The amputation should be performed proximal to the tourniquet. Thus the body is protected against toxic material which is present in the torn and smashed tissues and is likely to be absorbed.

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LOSS OF BODY HEAT

The well-established association between the incidence of shock and loss of body heat emphasizes the urgency of taking every precaution to conserve the store of heat which the body has and to give back to the body the heat that may have been lost. In accordance with this observed relationship the following principles of treatment should be applied.

When a wounded man is being examined he should be subjected to as little exposure of the body as possible; only one part should be exposed at a time and it should be promptly covered again. These precautions are especially necessary in cold weather. As soon as possible the patient should be surrounded with blankets. Whether he is lying on the ground or on a, stretcher, more blankets, if available, are needed under the body than over. The reason for this is that the blanket protects against heat loss by the air which it holds enmeshed in its fibers. The weight of the body lessens the air space in the fabric and consequently reduces the amount of protection. Under military conditions it is necessary to reduce the number of blankets to a minimum. By using the

FIG. 105.- Method of folding three blankets to provide four layers beneath and four above the patient. The outer ends of blankets 1 and 2 are folded over the two layers of blanket 3, already in place above the patient

method illustrated in Figure 105, three blankets may be male to provide four layers above and four below the patient. Of course the feet should be wrapped in warm covers.

If the patient already is cold or is likely to lose heat despite blanketing his body may be heated by means of hot-water bottles. If there are insufficient bottles in the medical supplies for the purpose the ordinary canteens may be used instead. Great care should be exercised to avoid a degree of heat which might cause burns. The bottles are more effectively employed if both sides instead of one are brought into contact with the body. Further, the physical fact should be remembered that heat passes faster from a warm to a cold object than to a lukewarm object. and, finally, heat is distributed throughout the body by the circulating blood. In accordance with these considerations one hot-water bottle should be laid on the abdomen, and the hands, which are likely to be cold, placed over it. The second bottle should be placed between the feet, which also are likely to be cold. If more bottles are available they should be placed between the thighs or pushed toward the axilla between the arm and chest on either side. By such distribution the heat passes chiefly to the body rather than in large part to the layer of air in the surrounding blankets; further-

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more, it warms the parts which are most likely to be or to become chilled when the circulation is poor.

Another highly effective mode of contributing heat to the body is by means of hot drinks. There are, however, limitations to the use. of this method, for in case of wounds of the alimentary tract the taking of fluid would be likely to wash material into the peritoneal cavity, and, besides, fluid taken by mouth is sometimes not retained by the severely wounded. If the gastrointestinal canal has not been opened by injury and if the swallowed fluid is not vomited a hot drink is by far the best method of warming. All of the heat in it above the temperature of the body passes to the body itself. Moreover, the fluid helps to restore a reduced blood volume. It also satisfies the distressing thirst which is so constantly complained of by the wounded. The hot drink may be given in forms which are relished, such as hot tea or coffee. Under military conditions these drinks may be provided at advanced stations and may be given repeatedly, when they are tolerated, in the course of the journey to a permanent hospital.

Preliminary dressing of wounds should be done, if possible, in a warm place. In military activities this is a rare possibility, but provision should be made in advanced dressing stations for keeping the patient warm during the first care of his wounds. An arrangement which has proved simple and satisfactory in military service is that of providing in these stations a rectangular support. the length and width of a stretcher and about 3 feet high, which is surrounded by blankets and heated by a lamp or oil stove placed on the floor. Over this warm chamber stretchers may be set and patients thus kept warm during the examination of their wounds. If the layer of warm air which is ordinarily retained in garments is replaced by moisture the loss of heat through this better conductor may be rapid. During the preliminary dressing outer clothing which is wet should be removed and replaced by more blankets. If the patient can be kept warm, however, this need not be done.

During the World War an important improvement in the care of the wounded, especially in cold weather, was made when devices for warming the motor ambulances were installed. Some accidents occurred from escape of gases into the car when the exhaust was used to supply the heat. Cars may be heated, however, by hot water from the radiator.

When, on arrival at the hospital, the patient has a low temperature and cold skin his clothing should be promptly removed or cut away (with care not to lose more heat) and he should be put in a warm bed. A highly effective means of warming the patient while in bed is to set over him fracture frames which are covered with blankets and then to introduce heat into the covered space. If electricity is available a permanent arrangement for this purpose may be made by wiring six or eight electric lights so that they project inward from the frame. Another device which may be used in the absence of electricity is that of leading from near the floor to the space under the fracture frames an elbowed stovepipe and using as a source of heat a lamp or alcohol burner set on the floor under the lower end of the pipe. It is advisable to pass the pipe through a wooden board shaped like the end of the frame so as to avoid danger of burning the bedclothes.

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Great care should be exercised not to overdo the heating. A shocked man is suffering from reduced blood volume and should not be made to lose unnecessarily more fluid from his body by sweating.

The clinical improvement seen when a wounded man, cold and shocked, is merely put to bed and warmed is often astonishing. The pulse, absent at the wrist, may return in good volume, and within an hour, as the patient becomes warm, the blood pressure may rise to a satisfactory level.

PAIN AND RESTLESSNESS

Experimental tests have shown that the agitation of a broken bone in damaged tissue results in a sharp fall of blood pressure-an effect which may be accounted for by further trauma and by the liberation of more toxic material. Experience during the years of the war proved to British surgeons that the use of the Thomas splint in bringing in the wounded did more, perhaps, than any other agent to reduce the incidence of shock. The lesson of these facts is that when, in a serious injury, a bone is broken, it should be carefully splinted before moving the patient. This precaution is especially important in fracture of the femur, with the possibility of damage to the large muscle masses which surround the bony fragments. The benefits of splinting arise both from lessening the occasion for pain and from minimizing further destruction of the soft parts by movement of the broken fragments.

When the transporting of a severely wounded or shocked man is likely to last for a considerable period and to involve a good deal of agitation and jarring, as is the case in military operations, his chances, unless infection is developing rapidly, are improved by stopping occasionally and giving him opportunity to be warmed, rested, and supplied with fluid. Opportunities of this character usually are offered in warfare at the battalion aid post and the dressing station before the hospital is reached. Commonly an ambulance service is eager to make a record for rapid transportation of the wounded. This attitude should be tempered by the judgment of the surgeons, who should not permit the seriously wounded to be rushed to the next station before showing the improvement which arises from warmth and rest.

Concerning the use of morphia, there have been differences of opinion. It has been given hypodermically even in as large a dose as 1 grain to badly wounded men. Crile and Lower: ³advocated giving the drug to the point at which the respiration sinks to at least 12 per minute. On the other hand, Marshall ⁴ who had a very large experience in anesthetizing shocked men, testified that the severely wounded, deeply under the influence of morphine, make an unsatisfactory recovery after operation. The object to be sought in giving Morphine is to blunt the feeling of pain and to lessen anxiety, especially during a rough and dangerous carry, and to reduce or abolish the restlessness which is wasting the patient's energy and making a great demand on his defective circulation. As experiments have proved, after morphine the blood pressure may he lowered further without producing acidosis than is possible otherwise, an observation which suggests that morphine lessens metabolism at a time when the oxygen, needed for the maintenance of chemical changes

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in the tells, is likely to be insufficient. The drug should be given, therefore, until the patient is comfortable and quiet. In some cases one-fourth grain may be sufficient, in others one-half grain may be needed. The dose should be repeated if necessary.

LOW BLOOD PRESSURE

If simple measures such as warmth and rest do not result within an hour in producing a rise of systolic pressure to at least 80 mm. Hg., other means should be used to raise it. Evidence of extensive hemorrhage associated with a very low blood pressure would warrant radical interference as soon as the patient is warm. The decisively harmful effects of prolonged insufficient volume flow of blood, which have been previously emphasized, should always be kept in mind.

To rationalize the treatment of low pressure, the facts already developed should be applied. It should be remembered that the blood is serviceable to the tissues only as it flows through the capillary region, and that the prime cause of the low pressure in shock is a diminished volume of blood in circulation: furthermore, that apparently the stagnant blood is not in the arteries nor in the veins, but is concentrated in capillary areas. With these considera- tions in mind we may regard critically the proposals which have been made for improving the circulation.

POSTURE

For many years in civil hospitals shock cases have been treated by raising the foot of the bed so as to permit gravity to aid the return of blood from the large veins of the abdomen to the heart. There is some evidence that in normal individuals the blood pressure in the head-down position may be increased approximately 15 mm. over the figure for the supine position. Henderson and Haggard ⁵ questioned earlier results because in the cases studied by them the change from the flat to the inverted position was accompanied by no marked effect upon either systolic or diastolic pressure. The pressures rose about as often as they fell, due probably to the slowing of the heart beat which accompanied the inversion of the body. Even in normal men, therefore, it is questionable whether a greater height of pressure is developed in the arteries when a head-down position is taken. At B thune observations were made on the effects of raising the foot of the bed in cases of shock, but no benefit was noted as a result of the procedure. On the other hand, it proved to be rather disturbing to the patient. The failure of any benefit from tilting the bed is made rational by the facts which already have been presented. The method was based on the assumption that the stagnant blood was in the large veins of the abdomen. For gravity to be effective the blood would have to be chiefly in the vena cava, for there is no evidence that the blood of the portal vein can be made to pass through the liver capillaries by, gravity drainage. All the evidence, both clinical and experimental, proves that the stagnant blood is not in the large veins. Consequently, the attempt to improve the circulation by postural change is naturally futile.

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VASOCONSTRICTOR DRUGS

For many years it has been the practice to attempt to improve the circulation in shock through the administration of adrenalin or pituitrin. Adrenalin constricts the arterioles in so far as they are effectively innervated by the sympathetic. Pituitrin acts by constriction of smooth muscle of the arterioles everywhere and has a more lasting effect than adrenalin. No doubt the arterial pressure may be temporarily raised by the intravenous exhibition of these drugs. The rise of pressure, however, results from increase of resistance in the tips of the arterial tree: in consequence, the blood accumulates more and more in the arteries because of the difficulty of exit. This accumulation will lead temporarily to a better flow through the heart muscle and the cerebral vessels when adrenalin is used, because in the presence of a high arterial pressure the arterioles of these regions are not constricted. The effect, however, is very temporary. When pituitrin is used there may be contraction of the smooth muscle of the cerebral as well as the cardiac vessels. However, the increased arterial pressure, when either of these drugs is employed, gives a wholly spurious impression of the state of the circulation. Damming the blood in the arterial portion of the circulatory system when the organism is suffering primarily from a diminished quantity of blood, obviously does not improve the volume flow in the capillaries; in other words, the desideratum is not merely a higher arterial pressure in the treatment of shock but a higher pressure which provides an increased nutritive flow through the capillaries all over the body. This improvement can be obtained when, as in shock, a diminished volume flow is the cause of the low pressure, only by increase of the volume flow. It can not be accomplished by medication. In the British and American armies the use of stimulant drugs, such as strychnine, and also vasoconstrictor drugs, such as piruitrin and adrenalin, practically disappeared during the course of the war.

A drug which has been advocated for shock cases, especially by French surgeons, is camphorated oil injected slowly into the circulation itself. The argument for this drug is that it promptly improves the action of the heart and thus permits time to be gained for the use of other measures. Here, again, we may apply critically the evidence obtained in clinical and experimental observations. It has shown that the heart is not primarily affected in shock. Unless the low pressure has persisted for a long time the action of the heart promptly becomes normal as soon as a sufficient volume flow of blood is present for it to act upon.

FORCED ABSORPTION OF FLUIDS

Experiments by Gesell ⁶ proved that a relatively small loss of blood greatly reduces the volume flow through peripheral organs. The converse also is true; when the circulation is failing from a low content of the vessels slight increase of blood volume will greatly increase the peripheral flow. This fact is the basis for treating low blood pressure by increasing the circulating fluid even though solutions incapable of conveying oxygen or carbon dioxide are employed for that purpose. As Gesell has pointed out, the nutrient flow may be increased several hundred per cent by injecting an inert solution-an increase

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out of all proportion to the dilution of the blood produced by the added fluid. According to Rous and Wilson,⁷ about 75 percent of the total hemoglobin may safely be removed provided the bulk of circulating fluid is maintained.

The simplest means of increasing a reduced blood volume, it the condition of the patient is not urgent, is by giving fluids by mouth. Unfortunately, vomiting is likely to occur when shock is well developed. In that event, and in case the patient's condition will permit, the rectal route may be used. Robertson and Bock⁸ proved that in case of reduced blood volume, fluid administered in large amounts by way of the alimentary tract is to a high degree retained in the circulation. By direct tests they showed that when patients who had suffered hemorrhage were treated by forcing fluid through the intestinal wall into the circulation the blood volume could be much increased. They gave water by mouth as rapidly as the patient would take it, and normal salt solution by rectum; after well marked hemorrhage 250 c.c. of normal salt solution could thus be given every half hour. By these procedures in one instance they increased the blood volume nearly 1,400 c.c. in 24 hours. As the volume became restored to near the normal the urine output became almost as large as the water intake. These observations on cases of hemorrhage are an indication of what may be done through simple measures in nonurgent cases of shock where there is a similar lack of circulating blood. The remarkable feature of the results of Robertson and Bock is the increased volume of fluid held in the blood vessels when water or salt solution enters the body by natural channels, which is very different from the effects of direct injection.

INJECTION OF SALT SOLUTIONS

All the evidence, clinical and experimental, indicates that the intravenous injection of warm normal salt or Ringer's solution has only a temporary effect. The injected fluid promptly passes from the capillaries into the tissue spaces and within a brief period the pressure is as low as before, if not lower.

Favorable results have been claimed for normal salt solution given subcutaneously, but not on the basis of critical observation. Both in human cases and in experimental animals with low blood pressure and sluggish blood flow, salt solution injected under the skin has been found post-mortem spread through the fascia in the region of injection. At Dijon, Robertson carefully followed the hemoglobin percentage after subcutaneous injection of salt solution in a shocked animal and found no dilution of the blood such as would appear if the solution entered or were retained in the vascular system.

Early in 1917 the injection of hypertonic salt solution was suggested as a way of withdrawing fluid from the tissues and increasing the blood volume by an "internal transfusion." Experience proved, however, that though the pressure could thus be raised the effect was transitory. No doubt the higher osniotic pressure of a concentrated solution does for a time attract water into the blood stream, but since the capillary wall is freely permeable to salts they are soon equally distributed and then nothing prevents a rapid infiltration of the injected fluid outwards into perivascular spaces.

Because of the strikingly favorable immediate results obtained by injecting sodium bicarbonate in shock cases which were characterized by marked

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acidosis and " air hunger," Wright, ⁹ and later Cannon, Fraser, and Cowell, ¹⁰ suggested that such solutions be employed to raise the blood pressure and simultaneously to increase the low alkali reserve. Clinical experience proved, however, that usually by the time such extreme conditions have developed sensitive structures in the body have been so much injured that the beneficial effects are not likely to be permanent; and experimental analysis led to the conclusion that the reduced alkali reserve is the consequence of a low blood pressure and that it is probably not an important secondary factor in augmenting shock. Since "acidosis" in shock indicates a deficient delivery of oxygen to active tissues, the rational move is not to treat the effects, but the cause, i. e., to provide for a better supply of oxygen by early and permanent improvement of the circulation. As the foregoing paragraphs show, salt solutions alone are incapable of achieving this result.

GUM-SALT SOLUTION

Salt solutions fail to produce a permanent rise of blood pressure because they lack a colloidal material which, like the protein of the blood plasma, will not pass through the capillary walls and which, by its osmotic pressure, prevents water from passing through. Various colloids have been suggested to compensate for this lack, among them being boiled starch, agar, dextrin, gelatin, and gum acacia. Bayliss¹¹ carefully analyzed the properties of these substances and found that gum acacia alone is free from serious objections and capable of replacing blood plasma. A solution of 6 to 7 percent of it in 0.9 percent sodium chloride has the same viscosity as whole blood and the same osmotic pressure as blood plasma. It is chemically inert; it does not cause thrombosis or promote clotting; it can be sterilized without chemical or physical alteration; and it does not induce anaphylactic reactions when repeatedly injected. Only the purest pearls are to be used. They should be placed in tap water or freshly distilled water and allowed to swell for a clay. They may then be dissolved quickly over a water bath. The solution must be filtered finally through paper of coarse texture. Bayliss showed experimentally that "gum-salt " solution will restore permanently a low blood pressure produced by removal of 40 percent of the estimated blood volume. Meek and Gasser¹² reported injecting gum until it was 10 percent of the blood without ill effects. And Drummond and Taylor,¹³after an experience with it in 38 cases, and McNee,¹⁴ after an experience in more than 100 cases, declared it harmless for man.

Though reports highly favorable to the use of gum-salt solution have been made, strong opinions have been expressed against its use. Mixter ¹⁵cited two cases in which death, in his opinion, was caused or hastened by gum-salt injection, and Lee,¹⁶ though reporting an excellent result from its use, mentioned two cases of collapse. The writer has earnestly endeavored to obtain reliable data showing under what conditions the solution is useless or harmful. In October, 1918, at his suggestion. Maj. O. H. Robertson visited the forward hospitals in the American area and systematically collected observations and opinions from a large number of resuscitation teams. Along with laudatory

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statements there were some that were indifferent and others condemnatory. According to Robertson's ¹⁷ analysis, the unsatisfactory results occurred incases of long-lasting shock (15 to 20 hours), cases treated before being warmed, cases of very severe hemorrhage, and cases of gas bacillus infection. These conclusions coincide with those of Ohler,¹⁸ who had large experience as a resuscitation officer.

In both the British and American Armies gum-salt solution, when used early in cases of shock and moderate hemorrhage, had excellent effects which brought forth enthusiastic commendation from good clinical observers. These results were comparable with those obtained under experimental conditions on lower animals. But during September and October, 1918, when the wounded were brought in after prolonged exposure to cold and wet, the favorable action of the solution, that had been noted in July and August when the weather was warm and the transportation prompt, were no longer observed. American medical officers reported that they tried it then and obtained no benefits from it. Under the hard conditions of the autumn, however, it was found that blood transfusion also was often quite as ineffective as the artificial fluid in restoring the circulation. British experience was summarized in a statement issued after a conference of British surgeons (including Maj. Gen. Sir Anthony Bowlby, Maj. Gen. Sir Cuthbert Wallace, Col. S. L. Cummins. Col. T. R. Elliot, Maj. J. W. McNee, Maj. Geoffrey Marshall, and Capt. N. M. Keith) held in November, 1918. They agreed that when made from pure pearls of acacia and introduced warm and at a slow rate, gum-salt solution had no seriously harmful effects; that it has a valuable place in resuscitation: but that in order to have beneficial action it must be given early.

The writer occasionally has seen "chills" follow its use in cases near death from shock, but a similar reaction occurs, at times, after the intravenous injection of blood or normal salt solution. In this connection the recent discovery of Stokes and Busman¹⁹ is important. They found that just such reactions as have been ascribed to gum-salt-chills, sweating, and subsequent prostration-are due to a toxic agent present in rubber tubing used for intravenous injection. This factor should be ruled out before evil action is attributed to the gum-salt solution itself. De Kruif ²⁰ subjected gum-salt solution to very thorough tests as to its toxicity, with negative results. All the experimental testimony indicates that the properly prepared solution is innocuous.

Various reports mentioned above emphasize the importance of early treatment of low blood pressure. Reasons for this have already been mentioned in relation to the damage done to nerve cells when long subjected to oxygen lack. In addition there is likely to be, as a consequence of defective blood supply, and of the action of toxic agents, an increasing permeability of the capillaries. Keith²¹ reported two cases in which 1,000 c.c. of gum-salt solution were injected, but without beneficial effect. In one case determination of the blood volume before and one hour after the injection (shortly before death) showed that the addition of 1,000 c.c. had increased the blood volume only 200 c.c. In the other case gum-salt solution was given after the blood had concentrated so that the hemoglobin percentage had risen from 104 to 120. The injection

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caused no improvement, and at autopsy the lungs and subcutaneous tissues were edematous. Similar instances have been reported to the writer by resuscitation officers in the American Army. The conclusion drawn by Keith was that in the late stages of shock the capillaries may become so damaged that they are no longer capable of retaining fluid, even though it be a colloidal solution. These observations and the interference from them fit closely the conception that in shock the reduction of blood volume is due to escape of plasma, because of increased capillary permeability.

HYPERTONIC GUM ACACIA AND GLUCOSE

Erlanger and Gasser ²² produced shock experimentally by a standard procedure-holding the arterial pressure down to 40 mm. Hg. for two and a quarter hours. They then treated the animals by giving 20 percent gum in per cent glucose. The virtues of this hypertonic solution they believed to be (a) the drawing of fluid from the tissues into the blood stream and thus the increasing of blood volume; (b) the maintenance of the increased volume through some property of the gum acacia; (c) the dilatation of the arterioles through a specific action of the hypertonic glucose: (d) the increase of the energy and food supply of the heart; and (e) the augmentation of metabolism. When animals subjected to standard shock-producing trauma were left untreated (23 cases) 48 percent died within 48 hours. When they were treated (21 cases) by injecting intravenously the hypertonic solution at the rate of 5 c.c. per kilogram per hour only 24 percent died within 48 hours.

There is some question whether in this particular feature results obtained on the shocked dog can justifiably be transferred directly to man. For example, the dog does not absolutely lose fluid from the body by sweating as man (toes; it is probably present in the tissues or lymph spaces. On the other hand, in wounded men, according to Robertson and Bock,⁸ blood volume is made up very slowly; often after five or six days these cases have less than two-thirds of the normal. The indications seem to point, therefore, to the need of adding fluid to the body rather than attempting to withdraw fluid from tissues which may themselves be lacking it. Erlanger and Gasser have tested the method of Robertson and Bock, however, on shock-like states in main (12 cases), and they found that the solution was not only innocuous but produced results "strongly suggestive, to say the least, of beneficial action." ²² The only ill effects which they observed occurred under experimental conditions when the hypertonic gum solution was run rapidly into the veins of dogs almost moribund: then the heart became irregular and stopped as though it had passed into fibrillation. After an experience with over 200 animals they state: "If there is any one thing we are convinced of, it is that gum acacia when given slowly is entirely innocuous. ²²

Full knowledge of the merits and limitations of gun-salt solution under clinical conditions may be regarded as not yet attained--except in late shock when it has proved useless. After severe, induced hemorrhage and in experimental shock caused by muscle injury, gum-salt solution has been shown to be capable of raising and maintaining a normal blood pressure. Its service

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under these circumstances lies in speeding the circulation and thus inducing a greater use of the red corpuscles for the delivery of oxygen to the needy tissues. At best, however, it is a substitute for blood.

TRANSFUSION OF BLOOD

The transfusion of compatible blood in cases of persistently low arterial pressure has been proved beyond question to be highly valuable by experience during the war. Blood can permanently raise arterial pressure, as gum-salt solution can; but in addition it contributes to the recipient a large increase of oxygen-carriers-the red corpuscles. Theoretically, however, in pure shock, when plasma has escaped and corpuscles are crowded in capillaries, gum-salt solution should be quite as good as blood, if not preferable to it; and even after hemorrhage. when not severe, it should serve well. In a series of carefully observed cases, Keith ²¹ found that the results of intravenous injection of gum-salt solution and whole blood were practically identical. He concluded that probably in some cases of shock blood transfusion would give better results than the solution, but such cases did not come under his observations. On the other hand, Robertson and Bock ⁸ and Lee²³ declare that when the hemorrhage factor is large in the production of circulatory deficiency blood is highly preferable to any indifferent fluid. Ohler ¹⁸ is of the same opinion, and the cites cases in which, after gum-salt solution had failed to sustain arterial pressure, transfusion of blood was successful. That this was not due merely to an additive effect of introducing more fluid is indicated by the gradual fall of pressure to the former low level in these cases after the gum-salt injections and the satisfactory rise after transfusion. It seems probable that what Pike and Coombs²⁴ suggested regarding nerve cells is true generally throughout the body-that "injured cells require a better blood supply for their restoration than uninjured cells do for mere maintenance." At least, in the experience of many men who had great opportunities for observation during the war, blood transfusion was found to be the most effective means of dealing with cases of continued low blood pressure, whether due to hemorrhage or shock.

There is the same urgency for using blood early, before serious damage has been done, as there is for using any substitute for blood. Keith ²¹reported cases of failure of blood transfusion in which there was evidence of escape of fluid, just as there was in his failures with gum-salt solution. In one instance 880 c.c. of whole blood increased the recipient's blood volume only 150 c.c. At autopsy in this and in another similar instance edema of the lungs and more than normally moist tissues were found. To be effective, therefore, blood must be introduced before a low nutrient flow has caused irreparable injury.

As the methods of matching blood, the technique of transfer, and the absence of harm to donors become better known, blood transfusion seems certain to become the method of choice for restoring a low blood volume. In hospitals the personnel may be classified in blood groups for emergency purposes. And in military service it is desirable that the lightly wounded and the gassed cases be sent near the shock wards, so that blood may be obtained promptly for those who are in sore need of it

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METHOD EMPLOYED IN THE AMERICAN EXPEDITIONARY FORCES ^b
 
In March, 1918, a committee representing the laboratory and surgical services of the United States Army adopted transfusion with citrated blood as the method for combating shock and hemorrhage in the hospitals of the American Expeditionary Forces. The reasons for this choice were simplicity of equipment and technique, convenience to donor and recipient, and excellence of results. The chief precaution to be regarded is the quick delivery of the blood through clean tubes into the citrate solution, so that changes in the blood in the direction of coagulation may be arrested as soon as possible.
 
The only apparatus required for this method is a liter bottle provided with two rubber stoppers having two perforations, appropriate glass and rubber tubing, and two transfusion needles. (See figs. 106 and 107.) The largest size needle is used for bleeding, the small size for giving the blood. The rubber tube B should be short and of large bore to assure a rapid flow and lessen the chance of coagulation. A convenient suction and pressure pump may be made from an ordinary Davidson syringe. Suction or pressure can be made by reversing the ends. The bottle E and the stoppers and tubing are wrapped in a towel and sterilized in an autoclave. Prepared in this Sway, the apparatus may be kept sterile and ready for immediate use. If an autoclave is not available the apparatus should be sterilized by boiling in previously boiled or in distilled water.

FIG. 106. - Transfusion apparatus. A, Transfusion needle B, rubber tube; C, glass tube; D, rubber stopper, E, bottle of liter capacity; F, glass tube; G, rubber tube; H, glass tube for suction, with cotton in bulb

The needles are sterilized by boiling just before the transfusion. If they are being repeatedly used they may be sterlized in boiling liquid petrolatum or albalone and left standing in the oil until needed. The needle is the most important part of the apparatus and requires careful attention. Before each bleeding it should be well sharpened. The chief consideration in the sharpening is to produce a fine spear point with a bayonet edge. This is best done by grinding first on the bevel--which should be moderately short--and then on the back of each edge at the point. If the point is well protected when not in use sharpening will require only a few moments. Before boiling, the needle should be slipped into a short length of rubber tubing. The needle must be kept scrupulously clean. After each bleeding it should be washed out at once, all fragments of fibrin or clot removed from the base, and small pieces of cotton soaked in oil thrust through the lumen with the stilette. The whole needle should be well oiled before being put away.

^b The present description is taken largely from "A Report upon the Transfusion of Blood for the Recently Injured in the United States Army," published by the Medical Division of the American Red Cross Society in France 4, Place de la Concorde, Paris, May ,1918.

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 Before the blood is collected a tube of sodium citrate is broken off at thefile mark, the opened end flamed, and the contents poured into the bottle E.Normal saline solution (0.9 o/o) is then added up to 100 c.c., (i. e., to the top ofthe figure). When the bottle is filled to 700 c.c. the citrate present is 0.6 percent. The apparatus (see fig. 107) is then assembled so that the rubber stopperfits snugly into the mouth of the bottle. Great care should be taken to keep allthe open parts sterile.

 Bleeding.- The donor's arm is now extended at a right angle to the body. A tourniquet is applied to the arm high up-the cuff of a blood-pressure apparatus folded to half its width makes an excellent tourniquet with the pressurekept at 50-60 mm. of Hg. Choose a suitable vein in the bend of the elbow,remembering that the needle is best inserted toward the hand. It is importantto have as large a vein as possible. Opening and closing the fist and flickingthe skin over the veins cause them to dilate considerably. The tourniquet isthen released. The skin over the vein is scrubbed with soap and water and thesterilization completed with alcohol. At the point selected for venepuncture a small quantity of novocaine or cocaine is injected intra cutaneously. A very slight nick is then made through the skin with the point of a scalpel. The tourniquet is tightened and the means above described are again employed todilate the vein. Do not touch the point of puncture. The bottle is placed on a stand close to the patient's arm in such a position that there will be no kinking of the tube B when the needle is in the vein. After drying the skin opening with a piece of sterile gauze the needle is inserted for a short distance beneath the skin; then by raising the base slightly it is pushed into the vein. It is essential to keep the needle immobile. The operator should hold it throughout the bleeding, steadying his hand against the donor's arm. With the free hand the bottle is given a rotary motion every few seconds in order to insure thorough mixing of the blood with the citrate, which is very important. A moderate degree of suction is maintained either by means of the tube H, which is held in the operator's mouth, or more conveniently by using the adapted syringe pump. The donor continues to open and close his hand slowly, making a firm fist each time, care being taken that he does not move his arm.
 
The citrated blood does not coagulate and consequently its introduction into the recipient need not be hurried. Under ordinary conditions the blood will be used immediately, but when occasion requires it may be kept for several hours before introduction. If in the course of drawing the blood clotting occurs and the blood ceases to flow, release the tourniquet, withdraw the needle, and obtain the blood through use of entirely fresh apparatus (needle, rubber, and glass tubing), which should be at hand, sterilized for such an emergency. It is usually better to take the other arm.

Six hundred c.c. of blood is the limit to be removed, for a donor may lose this amount without distress. If more blood is required a second donor must be taken. The same donor must not be used twice within a single week.
   
The bottle of blood should be placed in a receptacle containing water at about body temperature, where it should be kept during the transfusion.

Transfusion.-The introduction of the blood into the recipient is accomplished by removing the first stopper D (fig. 106) with its connections and putting

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the stopper N (fig. 107) with its connections snugly into the mouth of the bottle. Air pressure is increased by blowing through the tube Q, and blood begins to rise in the tube M, which forms one limb of the siphon K, L, M (fig. 107). The tube K is held high as the blood passes into the rubber tube L, and then is gradually lowered. When K is completely filled a pinch cock closes the rubber tube L close to the glass tube K.

A bandage or tourniquet is placed about the arm of the recipient sufficiently tight to give the maximum venous pressure. Remember that the arterial pressure of the recipient is low; the arterial flow must continue if the veins are to be made prominent. The needle I with the short rubber tube J attached is then introduced, in the direction of venous stream, into the vein of the recipient. As the blood begins to flow through the needle and tube the assistant quickly removes the bandage while the operator immediately connects the rubber tube J with the glass tube K, the precaution being observed to have both tubes filled with blood. The bottle is then raised to the full height allowed by the rubber tube L, the pinchcock is opened, and the blood enters the recipient by gravity. The time allowed for the introduction of 600 c.c. of blood should not be less than 10 to 15 minutes. Any symptoms of distress should indicate a checking of the

FIG. 107.- Transfusion apparatus. J, Rubber tube; K, glass flow. Such symptoms, which are usu- tube; L. rubber tube; M, glass tube; N, rubber stopper; O, glass tube; P. rubber tube; Q, glass tube for exerting compression (cotton in bulb) flow. Such symptoms, which are usually nothing more than a feeling of fullness and slight respiration difficulty are ordinarily transient. At the completion of the transfusion a small amount of blood will remain in the bottle below the level of the glass tube M.

If more convenient, the bulb of it Davidson syringe or of a blood-pressure apparatus may be connected with tube P (fig. 107), and the blood forced in by air pressure.

If the veins of the recipient are very small or collapsed an incision may be made and a canula introduced into the vein.

After use the apparatus must be cleansed with cold water immediately. If not being frequently used the needles should thereupon be dried by running first alcohol and then ether through them, after which they should be stored in test tubes with a cotton plug in the bottom and the mouth of the tube. The needles must be kept sharpened.

Selection of donors.-There exist in the plasma of animals certain bodies which will agglutinate or agglutinate and hemolyse the red blood cells of other individuals who are members of the same species. The transfusion of such incompatible blood may be fatal to the recipient. Among human beings it is definitely

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known that all individuals fall into one of four groups. Knowledge of these groups has proved of practical value in blood transfusion. Hemolysis does not take place between individuals belonging to the same blood group, and practically never takes place between certain definite combinations of different groups. Having determined the blood group, it is possible to select a donor whose blood is compatible, as regards hemolysis, with the blood of the recipient.

The classification of these groups is as follows:

Group I. Serum agglutinates no corpuscles. Corpuscles agglutinated by sera of Groups II, III, and IV.
Group II. Serum agglutinates corpuscles of Groups I and III. Corpuscles agglutinated by sera of Groups III and IV.
Group III. Serum agglutinates corpuscles of Groups I and II. Corpuscles agglutinates by sera of Groups II and IV.
Group IV. Serum agglutinates corpuscles of Groups 1, II, and III. Corpuscles are not agglutinated by any serum.
   
The incidence of the four groups is approximately:
Group I, 5 percent; Group II, 40 percent; Group III, 10 percent; Group IV, 45 percent.

The following table shows the relation of the four blood groups with respect to agglutination of corpuscles:

CHART
 
In order to determine the group of an individual, it is sufficient to test his corpuscles against known sera of Groups II and III. This is readily accomplished by a macroscopic test, which in addition to the two known sera requires only a glass slide, a needle, and two small glass rods. Citrated sera for this test are furnished by the Central Medical Department Laboratory. These sera remain active indefinitely, as a rule, but they should be tested occasionally against blood of known groups to prove that they are active and ready for emergency.

The test is performed as follows:

By means of the stopper in the bottle place a drop of Group II serum on the left half of the glass slide (slide need not be sterile, but should be clean and dry) and a drop of Group III serum on the right half of the slide.

Puncture the ear or finger of the individual to be tested, and transfer in turn to each of the sera about one-third of a drop of blood, on the end of the glass rod, mixing the blood intimately with the serum. Avoid mixing too much blood with the serum; it will prevent a clear result. Take care to transfer the blood before coagulation has commenced. Avoid mixing the two

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sera; a separate glass rod or opposite end of a rod must be used for each transfer. Agitation of the slide accelerates the appearance of an agglutination.

Within a few seconds after mixing the blood and sera one may see a brick-dust-like appearance in one or both sera, or one may see only a homogeneous suspension of the cells in one or both sera. If the distinction between the

FIG. 108.- Graphic illustration of macroscopic agglutination test

"brick-dust" and the homogeneous appearance should not be quite clear, tip the slide toward the vertical; a thin layer of blood will be left in the upper limits of the drop in which the difference, if present, will be evident. The brick-dust-like appearance denotes agglutination. Occasionally there is atendency to rouleaux formation, which may be confusing. Rouleaux formation appears more slowly than agglutination, and, contrary to agglutination, is

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dissipated if the rouleaux are broken up by stirring the serum. In the rareinstances in which the agglutination is questionable, the donor should notbe used.

Groups are indicated as follows:
When agglutination occurs in both sera the individual belongs to Group I.
When agglutination occurs only in III serum the individual belongs to Group II.
 When agglutination occurs in either serum the individual belongs to Group IV.
 
Except in cases where the risk of delay is greater than the risk of hemolysis, the compatibility of the blood of donor and recipient should be determined before transfusion. It is not necessary that the donor belong to the same group as the recipient. The only practical consideration is that the recipient does not agglutinate the red corpuscles of the donor. From the above table it is seen that the red cells of Group IV are not agglutinated by the serum of Group I recipients can take donors of any group, since the serum of Group I agglutinates the cells of no other group. Recipients of the other groups can take donors of their own group of Group IV only.
 
No person should be used for a donor who has, or has had, syphilis, malaria, trench fever, or who has recently recovered from other infectious diseases.

Lightly gassed patients, i.e., patients whose color is normal or nearly normal, may be used as donors if properly grouped and free from transmittable disease.

Patients with scabies may be used as a source of blood for transfusion if they are otherwise satisfactory.

In general, convalescent patients who are nonfebrile and in good physical condition constitute the class from which donors may be selected.

No reward is to be offered a donor; his consent must be obtained without urging or compulsion.

A list of donors, with their group, age, ward, and bed, must be posted in the operation room and in the resuscitation ward. When necessity arises, a donor is thus immediately obtainable. To avoid a possibility of error this list should provide every means for proper identification. For absolute assurance, small perforated metal tags should be provided, marked to indicate the group to which the man belongs. This tag must be attached to the man by "the individual making the test at the time the grouping is determined.

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TRANSFUSION EQUIPMENT FOR A HOSPITAL

A. APPARATUS

CHART

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CHART
 
Precautions to be observed in intravenous injections. - Whether blood or an indifferent fluid is injected, careful attention should be given to the mode of procedure. The possibility of further loss of blood, as the pressure is raised, should be eliminated. The fluid should be introduced slowly and with little pressure. Zunz and Govaerts ²⁵showed that blood transfusion after hemorrhage is effective in restoring normal blood pressure when 40 to 75 minutes are taken to replace about half the blood volume. But if this amount is introduced in 5to 10 minutes a marked fall results which may last for hours. And they noted that the deeper and more lasting the circulatory failure before the transfusion the more slowly must the blood be injected in order to avoid a subsequent drop of pressure.

The fluid should be given warmed to body temperature, or, better, slightly above, in order to enter the body warm after passing through the connecting tubes.

If any harmful or unfavorable effects are noticed as the fluid is entering the blood stream, the flow should be checked at once. The amount injected usually need not be great; 500 or 750 c.c. may be given at first, and later 500 c.c. more if circumstances seem to require it. This probably will not restore the blood volume to normal, for, as Keith ²¹ and Robertson and Bock ⁸ showed, the volume is often reduced as much as 2,000 c.c. or more. Therefore, though an intravenous injection may raise the pressure satisfactorily, other and simpler means of increasing the circulating fluid should be continued-such as fluid by mouth and rectum.

On the basis of their Béthune experience in 1917, Cannon, Fraser and Hooper ²⁶ called attention to the unfavorable prognosis attending continued concentration of the peripheral blood, and to the disappearance or "dilution"of the blood as recovery occurs. Both Keith ²¹ and Lee ²³emphasized the significance of these blood changes, and suggested repeated hemoglobin determi-nations in order to learn whether " dilution " is occurring and whether the patient, therefore, is on the course toward improvement and recovery.

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OPERATION
 
Operation on a man who has been greatly injured, or who is in shock, or who has been in shock for a considerable period and has to some degree recovered, is likely to be hazardous because blood pressure barely sustained, or already low, or only recently restored, may be reduced seriously by operative procedures. A number of conditions contribute to this danger, some of which can be avoided.

ANESTHESIA
 
The fall of blood pressure during or after operation in shock is probably due chiefly to ether or chloroform anesthesia. Sharply contrasted with the effects of these general anesthetics in shock cases is the action of nitrous oxide and oxygen or "gas-oxygen." During his extensive experience as an anesthetist in a casualty clearing station in Flanders, Marshall ⁴ found in a large series of very severe cases that gas-oxygen anesthesia was followed by no increase of shock whatever. And Bazett,²⁷ who likewise had abundant opportunities to make careful observations, has testified: "One can only say that with nitrous oxide and oxygen anesthesia there is rarely any sign of shock observed. The clinical contrast between cases anesthetized with nitrous oxide and oxygen and those receiving other general anesthetics is enormously in favor of the former." In this connection Dale's observation ²⁸ on the relation of ether and gas-oxygen to histamine shock are highly pertinent. He found 10 mg. of histamine per kilogram necessary to produce shock in the unanesthetized animal, whereas under ether 1 to 2 mg. were sufficient. But under gas-oxygen shock would be induced only by giving the dosage required in the unanesthetized state, i. e.,10 mg. Ether and the toxic agent cooperated to bring on the low pressure; with gas-oxygen anesthesia the cooperation was lacking. Bazett ²⁷ noted that after ether or chloroform there was a concentration of the blood, amounting at times to 20 percent. With rapid operation under gas-oxygen, however, very slight and only temporary concentration was seen.

Gas-oxygen should be given with great care and by experts in its use. Cattell ²⁹noted that high ratios of nitrous oxide to oxygen are quite as harmful as ether. A ratio of three parts nitrous oxide to one of oxygen caused no fall of blood pressure whatever. Gwathmey and Yates ³⁰ found in their work on chest cases in battle areas that with a preoperative use of morphine, deep analgesia could be induced and maintained without increasing the ratio above three to one; Gwathmey ³¹ stated that, with proper preliminary medication, complete relaxation of the patient for prolonged periods is easily maintained under gas-oxygen anesthesia. American and British experience during the war led to strong affirmation that in shock cases gas-oxygen is undoubtedly the anesthetic of choice, and this conclusion was accepted by the Interallied Surgical Congress at Paris in 1917.³²

Whatever the general anesthetic employed, there should be avoidance of deep anesthesia and cyanosis. With the blood volume reduced and the nutrient flow inadequate or bordering on inadequacy, the organism is in danger from oxygen want. Shutting down the oxygen supply is certain to do harm. As Marshall ³³ remarked, cyanosis during operation causes a shocked man to lose ground which may be extremely hard to recover.

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An alternative to general anesthesia, particularly in operations on the lower extremities, is spinal anesthesia. There is the possibility that through the blocking of tonic vasoconstrictor impulses in the spinal nerves a fall of blood pressure may result. Indeed, according to Quenu,³⁴ this is to be expected. The suggestion has been made that under such circumstances the pressure may be maintained by slow and continuous infusion of a weak solution of adrenalin. Theoretically this is an appropriate mode of procedure, but it is questionable whether there is a special advantage in its use.

TIME OF OPERATION

In 1917 Santy ³⁵ observed 340 cases of nontransportable wounded, in 79 of whom the time between the reception of the wound and the surgical treatment was known. The mortality in these wounded was as follows:

CHART
 
As the above figures show, the mortality was only 11 percent in the first three hours; it rose to 37 percent when there was a delay of between three and six hours (though infection was not marked until after six hours); it was 75 percent in the eighth to the tenth hour. Although during the first hour the cases were not in complete shock, they were in grave condition, anemic and cold. A review of Santy's full description of his cases reveals that in all there were wounds of similar severity. For example, the lesions in the group operated on in the first hour included (1) mashing and pulping of the arm and leg; (2) of the leg and knee and of the forearm (in a diabetic); (3) of the right thigh and left leg; (4) of the thigh in the lower third; (5) of the mid-thigh, with laceration of the muscle above; (6) of the leg above the right knee, with tearing away of the calf; (7) of the elbow, with wounds of the face, loss of an eye. and two large wounds of the thigh; (8) double shattering of the left arm and forearm; (9) destruction of the popliteal space with section of the artery; (10) laceration of the muscles of both thighs and the calf. Of these 10 cases 1 died. Amputation was performed in 7 cases; in 2 cases double amputation. Six of the 7 amputations resulted successfully. In the last group, operated upon after nine or ten hours, the lesions were: (1) Extensive laceration of both thighs; (2) smashing of the knee with muscular lesions; (3) crushing of the shoulder; (4) wounds of both thighs with section of the left femoral artery and vein; (5) shattering of the right knee; (6) multiple wounds of the thighs; (7) fracture of the right thigh and the left leg; (8) tearing away of the left arm; (9) muscular destruction of the right thigh; (10) smashing of the leg; (11) of

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both legs: (12) of the right thigh. Of these 12 cases, 9 died. There were 6 amputations with only 2 successes.

Santy's observations are sustained by Gatellier ³⁶, who treated 1:3 serious cases, without waiting, by limited excision of injured tissues or by amputation, and had no deaths.
           
The excellent results of prompt operation, performed on the severely wounded before the development of secondary shock, have been noted before this time. The great French military surgeon, Larrey ³⁷, who followed Napoleon's campaigns, laid down the dictum that crushing wounds of the extremities should be operated upon at once, for that treatment gives the only hope. The figures given by Santy point to action of some agency, which, as time passes, brings on the state of shock and seriously jeopardizes the chances of recovery. The bearing of these observations on the toxic origin of secondary shock is obvious. The crushed and lacerated tissues become not only a source of danger to the body from processes of death taking place in them but they are most favorable sites for infection. Therefore, for both reasons, early clearing away of destroyed tissue, or débridement, is a prophylaxis against shock and other damaging conditions. If secondary shock is existent when the patient, cold and depressed, is brought under surgical care, there is general agreement that simple measures, such as warmth, rest, and fluids, should be applied in an attempt to improve his state before operative interference is begun. If, however, there is continued hemorrhage accompanying and augmenting the shock, or if there is rapidly spreading infection (e. g., with gas bacilli), operation may be necessary before full recovery has occurred. And if the surgeon must begin his work thus, a protective transfusion of blood before the anesthetization, or while the wounds are being attended to, will keep the blood flow adequate during the most critical time.
           
The principle involved in the operative treatment of fully developed secondary shock is the same as that employed for prophylaxis against its development. As soon as possible there must be suppression of the trauma. This procedure is often the initial step in an extraordinary improvement in the patient's state. the Surgical Conference, in1917, Tuffier ³⁸declared that we have too long submitted to the doctrine that shock absolutely contraindicates operation. Experience proves that the exclusion of the focus of injury, by short and radical procedures, causes the symptoms of shock to disappear. And the conference concluded: "If true shock, without hemorrhage, is severe, if the patient is cold and pulse less, the shock itself must be treated first. It is the same if the operation to be done must be long and difficult. But extensive destruction of parts necessitating amputation indicates operative attack."

Quénu's advice is that in any case, long and complicated operation should be avoided; meticulous surgery is out of place; the principal lesion must be treated quickly and radically, and often less important wounds can be given only simple cleaning.

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PRECAUTIONS TO BE OBSERVED DURING OPERATIONS

The relation of cold to shock has been repeatedly emphasized. During operation every effort previously employed to prevent heat loss should be continued; needless exposure of the body should be avoided. The skin and protective coverings should not be allowed to remain wet, for both by evaporation and by more rapid conduction the escape of heat from the body thereby is promoted. Cavities and wounds should be washed out with warm solutions only. The operating room and the operating table should be warm even under the rudest circumstances simple arrangements can be made for these desirable conditions.

In the foregoing pages emphasis has been placed upon the sensitiveness of the badly injured and the shocked to hemorrhage. A small loss of blood, wholly without permanent effect under ordinary circumstances, may cause a calamitous fall of pressure. Special care should be exercised during operation on shock cases not to lose a drop more blood than actually must be lost.

Marshall ⁴ called attention to the fact that after larapotomy on a man who is or has been in shock, a turn of the body laterally causes a sharp drop in blood pressure. He urged that if the back as well as the abdomen has been wounded, it be dealt with before opening the abdomen. Binders or many-tailed bandages should be applied by lifting the body, not by turning it free from side to side.

Abdominal and thoracic viscera should not be exposed or pulled upon more than is absolutely required for the satisfactory performance of the operation. And all tissues should be handled with extreme gentleness.

TREATMENT OF PRIMARY SHOCK

The occurrence of primary shock of clearly nervous origin was so rare in the World War that almost no reference has been made to its treatment. It should be dealt with symptomatically-by rest and quiet, and, if the blood pressure remains below the critical level, by measures to increase the blood volume.

Primary shock due to mortal wounds or to excessive and sudden hemorrhage usually offers so little chance for treatment that nothing further need be said concerning it than that the principles developed in the foregoing pages should be applied when there is any hope of their being serviceable.

AFTER-CARE
 
It should be remembered always that the patient who has been in shock and resuscitated, and then operated upon, is in a precarious state. His nervous system has been disturbed not only by the original trauma, but also by the low nutrient flow of blood and by the surgical procedures incidental to operation. Rest is therefore essential, and should be secured, if possible, in sleep. Warmth should likewise be provided, but not to a degree which will induce sweating. It should be remembered that the blood volume has probably been reduced much more than the amount represented by the usual intravenous injection, and that the blood flow will not be normal until the volume is restored to the normal

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level. Fluids should be continued, therefore, by mouth or rectum until the urine output equals the water intake. Furthermore, the patient should be attentively watched for unfavorable developments, and if they arise should be promptly treated.

SHOCK TEAMS, THEIR TRAINING AND DUTIES

A contribution to military organization made during the World War by the American Army was that of giving special training to medical officers who were assigned to the care of serious cases of shock and hemorrhage.²⁸ During the months from May to November, 1918, medical officers were sent to Dijon weekly and there received instruction regarding the nature of shock, the theories of its onset, its clinical manifestations, the conditions favorable to its development, and the principles of treating it, as outlined in the foregoing pages. Also they were disciplined in methods of matching blood and in the procedure of blood transfusion. The methods of instruction consisted of demonstrations of blood pressure measurements, the development of shock in a lower animal, and lectures and practical exercises in which the men determined their own blood pressures and their own blood groupings., and practiced transfusions on anesthetized animals. From these classes medical officers were selected who went to hospitals in battle areas and took charge of the shock wards. Their service to the surgeons has been highly commended.

A number of valuable pertinent points resulting from this experience may be summarized as follows:

(1) So far as possible, medical officers of field and evacuation hospitals should receive such instruction as is mentioned above and be detailed to take charge of shock wards in times of activity. At Dijon men from base hospitals, A. E. F., were given instruction, because it was believed that they could be called forward into battle areas in time of need. This proved, however, to be almost impossible, because base hospitals were quite as busy as forward hos- pitals during military engagements. (2) For each shock ward there should be at least two resuscitation teams, each consisting of a medical officer, a nurse, and an orderly. (3) Hopeless, moribund cases should not be sent to the shock ward; provision should be made for a separate place for such cases. The presence of a number of dying men in a crowded shock ward takes the time of the teams and interferes with efficiency and morale. (4) In the transfer of the wounded away from the front line, provision should be made, in wards close to the shock cases, for caring for at least some of the minor cases, and for men who have been gassed. Withdrawing 500 to 750 c.c. of blood from a man who has been only slightly wounded does him no harm, and that amount taken from a man who has been gassed may be serviceable to him; the blood thus obtained may save the life of a comrade who is suffering from shock or severe hemorrhage. (5) Officers in charge of hospitals should understand that men badly wounded require special care and that medical officers who have been particularly trained to give that care should have, so far as possible, free rein in making proper arrangements.

The duties of resuscitation officers are as follows: (1) To provide heating arrangements in anticipation of shock cases. These arrangements should

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consist of hot-water bottles or canteens. means of getting hot water, and for applying hot air under fracture frames as described above. (2) To assure an adequate supply of transfusion equipment from the medical stores. (3) To arrange continually for an adequate number of donors, whose blood grouping must be determined. (4) To determine the blood grouping of all donors and recipients. (5) To be available for consultation with any of the hospital staff concerning transfusion. (6) To perform or direct personally all transfusions. (7) When possible, to obtain records of the clinical condition of the shocked men, in order to add information regarding the onset and the course of events in wound shock. (8) To perform such clinical work as the surgeon in charge may direct (this duty is mentioned with the proviso that no assignment will be made that removes the resuscitation officer from his important service in the shock ward).

Obviously, the shock team should cooperate closely with the surgical service. Resuscitation officers who have followed the progress of shock cases from the time of admission and who best know the limits of improvement in each case should give the surgeon their judgment of the optimum time for surgical intervention. Even apparently hopeless cases should be given the chance which surgery offers, though the percentage of recovery of such cases may be small.

REFERENCES

(1) Vincent, C.: Contribution a l'étude de l'état de shock promitif chez les blessés de guerre Comptes rend us des Séances de la Société de Biologie, Paris, 1918, lxxxi (meeting of October 19), 1886.
(2) Wallace, C., and Fraser, John: Surgery at a Casualty Clearing Station. Hemorrhage and Wounds of the Blood Vessels. A. and C. Black, Ltd., London, 1918, 241.
(3) Crile, Geo. W., and Lower, William E.: Anoci-association. W. B. Saunders Co., Philadelphia, 1914, 115.
(4) Marshall, Geoffrey: Anesthetics at a Casualty Clearing Station. Proceedings of the Royal Society of Medicine, Section of Anesthetics, London, 1917, x, No. 7, 28.
(5) Henderson, Y., and Haggard, H1. W.: The Circulation in Man in the Head-Down Position and a Method for Measuring the Venous Return to the Heart. Journal of Pharmacology and Experimental Therapeutics, Baltimore, 1918, xi, No. 3, 1 9.
(6) Gesell, Robert: Studies on the Submnaxillary Gland. IV. A Comparison of the Effects of Hemorrhage and Tissue-Abuse in Relation to Secondary Shock. The American Journal of Physiology, Baltimore, 1919, xlvii, No. 4, 468.
(7) Rous, P., and Wilson, Geo. W.: Fluid Substitutes for Transfusion after Hemorrhage. Journal of the American Medical Association, Chicago, 1918, lxx, No. 4, 219.
(8) Robertson, O. H., and Bock, A. Y.: Memorandum on Blood Volume after Hemorrhage. Special Report Series No. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, August 8, 1918, His Majesty's Stationery Office, London, 1919, 23.
(9) Wright, Sir A. E.: Conditions which Govern the Growth of the Bacillus of "Gas Gangrene" in Artificial Culture Media. The Lancet, London, 1917, January 6, i, l.
(10) Cannon, W. B., Fraser, John, and Cowell, E. M.: The Preventive Treatment of Wound Shock. Special Report Series No. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, December, 1917, His Majesty's Stationery Office, London, 1919, 125.
(11) Bayliss, W. M.: Intravenous Injection in Wound Shock. Longmans, Green and Co., London, 1918, 75.
(12) Meek, W. J., and Gasser, H. S.: The Effects of Injecting Acacia. The American Journal of Physiology, Baltimore, 1917-18, xlv, 548.
(13) Drummond, H., and Taylor, E. S.: The Use of Intravenous Injections of Gum Acacia in Surgical Shock. Special Report Series No. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, January, 1918, His Majesty's Stationery Office, London, 1919, 135.
(14) McNee, J. W., Sladden, A. F., and McCartucy, J. E.: Observations On Would Shock Especially with Regard to Damage of Muscle. Special Report Series No. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, His Majesty's Stationery Office, London, 1919, 33.
(15) Mixter, C. G.: Gum Salt Solution (Eleventh Session of the Research Society of the American Red Cross in France, November 22-23, 1918, Hotel Continental, Paris. War Medicine, Paris, 1919, ii, No. 7,1276.
(16) Lee, Roger I., Ibid., 1276.
(17) Robertson, O. H., Ibid., 1277.
(18) Ohler, W. R.: Treatment of Surgical Shock in the Zone of the Advance. American Journal of the Medical Sciences, Philadelphia, 1920, clix, No. 6, 843.
(19) Stokes, J. H., and Busman, G. J.: Tubing as a Cause of Reaction to Intravenous Injection, Especially Arsphenamin. Journal of the American Medical Association, Chicago 1920, lxxiv, No. 15, 1013.
(20) DeKruif, P. H.: Experimental Research on the Effects of Intravenous Injection of Gum-Salt Solutions.Annals of Surgery, Philadelphia, 1919, lxix, No. 3, 297.
(21) Keith, N. M.: Blood Volume Changes in Wound Shock and Primary Hemorrhage. Special Report Series No. 27. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, His Majesty's Stationery Office, London, 1919, 25.
(22) Erlanger, J., and Gasser, H. S.: Hypertonic Gum Acacia and Glucose in the Treatment of Secondary Traumatic Shock. Annals of Surgery, Philadelphia, 1919, xix, No. 4, 389.
(23) Lee, Roger I.: Field Observations on Blood Volume in Wound Hemorrhage and Shock, American Journal of the Medical Sciences, Philadelphia, 1919, clviii, No. 4, 570.
(24) Pike, F. H., and Coombs, Helen C.: The Relation of Low Blood Pressure to a Fatal Termination in Traumatic Shock. Journal of the American Medical Association, Chicago, 1917, 1xviii, No. 25,1892.
(25) Zunz, E., and Govaerts, P.: Recherches experimentales stir les effets de la transfusion dans les divers états de collapsus circulatoire. Bulletin de l'Académie royale de médecine de Belgique. Bruxelles, 1919, 4th s., xxix, No. 5, 796.
(26) Cannon, W. B.; Fraser, John and Hooper, A. N.: Some Alterations in the Distribution and Character of the Blood. Special Report Series No. 25. Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, December, 1917. His Majesty's Stationery Office, London, 1919, 72.
(27) Bazett, M. C.: The Value of Haemoglobin and Blood Pressure Observations in Surgical Cases. Special Report Series No. 25. Ibid., April, 1918, 29.
(28) Dale, H. H.: Conditions which are Conducive to the Production of Shock by Histamine. British Journal of Experimental Pathology, London, 1920-21, i, 103.
(29) Cattell, McKeen: Studies in Experimental Traumatic Shock. Archives of Surgery, Chicago, 1923, vi, No. 1, 41.
(30) Gwathmey, .J. T., Yates, J. L., Middleton, W. S., and Drane, Robert: Laboratory of Surgical Research, Central Medical Department. Laboratory, A. E. F. A. P. O. No. 721, France. Boston Medical and Surgical Journal, Boston, 1919, clxxx, No. 15, 410.
(31) Gwathmey, J. T.: Anesthesia Reviewed. New York Medical Journal, New York, 1916, civ, No. 19, 895.
(32) Conclusions On Traumatic Shock adopted by the Interallied Surgical Conference at its 6th Session, November 18-21, 191S. Archives de médicine et de pharmacie militaires, Paris, 1918, lxx, 705.
(33) Marshall, Geoffrey: Modification of Technique. Special Report Series No. 25, Reports of the Special Investigation Committee on Surgical Shock and Allied Conditions. British Medical Research Committee, December, 1917. His Majesty's Stationery Office, London, 1919, 155.
(34) Quénu, E.: De la toxémic traumatique à syndrome dépressif (shock traumatique) dans les blessures do guerre. Revue de Chirurgie, Paris, 1918, lvi, November, 339.
(35) Santy, P., Moulinier, and Marquis: Du shock traumatique dans les blessures de guerre De la distinction dans les états de shock chez les grands blessés, du shock nerveux hemorragique ou infectieux. II. Du rốle joué par l'hémorragie daus lapparition du shock traumatique. III. Analyses d'observations. Bulletins et mémoires de la Société de chirurgie de Paris, 1918, xliv, No. 5, 205.
(36) Gatellier,: Quelques considérations stur les plaies vasculaires. La Presse médicale, Paris, 1918, xxvi, 322.
(37) Larrey, J. D.: Mémoires de chirurgie militaire et campagnes. Tome i, J. Smith, Paris, 1812-1817, 70.
(38) Tuffier, T.: Shock Traumatique. Conférence Chirurgicale Interalliée, 2nd Session (14-19 May, 1917). Archives de médecine et de pharmacie militaires, Paris, 1917, lxviii, 123.