185
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.
186
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
187
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.
188
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-
189
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.
190
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
191
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.
192
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
193
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
194
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
195
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
196
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
197
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
198
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.
199
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
200
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
201
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
202
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
203
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.
204
TRANSFUSION EQUIPMENT FOR A HOSPITAL
A. APPARATUS
CHART
205
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.
206
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.
207
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
208
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.
209
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
210
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
211
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.
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