LONDON, APRIL I945

POST-GRADUATE MEDICAL JOURNALTHE THERAPY OF SHOCK

SOME LESSONS FROM MILITARY SURGERY

By J. E. DUNPHY, Lt.-Col., M.C., Aus.(From the Surgical Service of the 5th General Hospital

APO 350, Etousa.)The state of peripheral circulatory failure,

referred to as "shock," is so frequentlv associatedwith the extensive injuries incurred during militaryoperations, it may properly be called a maladyof warfare. Not only is it encountered morefrequently, but its severity far exceeds that ordin-arily seen in civilian practice. It is thus possibleto draw from the experiences of military surgerymany points of practical value in the treatmentof shock.

Because the term "shock" has been used quiteloosely to indicate any form of peripheral circu-latory collapse, this discussion will be prefaced bya brief definition and classification. Shock isdefined as a "state of actual, or impending, peri-pheral circulatory failure due to a reduction of theeffective blood volume not primarily cardiac inorigin." This excludes from discussion all formsof peripheral circulatory collapse in which failureof the heart is the primary cause. Dependingupon the mechanisms involved, three types ofshock may be recognised: neurogenic, a state ofsudden loss of vasomotor tone with a redistribu-tion and pooling of blood in dependent portionsof the body; vasogenic, a consequence of directinjury to capillaries or small vessels; and hema-togenic, the result of a primary loss of fluid fromthe circulation.4 The term "decompensatedshock" is used to indicate the state of -advancedcollapse which follows a prolonged reduction of theeffective blood volume, irrespective of the originalcause or causes.

NEUROGENIC SHOCK

Neurogenic shock is a condition in which thetotal volume of blood is unaltered, but is ineffectivebecause of a loss of constrictor tone, with a redistri-bution and pooling of blood in the lower portionsof the body. It is manifested by pallor, sweating,a lowered blood pressure, and a slow pulse rate.It is usually a consequence of severe pain, fright,or other emotional disturbance, but may be asso-ciated with hematogenic shock. The syncopeobserved in blood donors is a familiar example.It is of interest that in severe hemorrhage thisneurogenic reaction is mediated by vasomotornerves, and occurs before the cardiac output isdecreased.2

An understanding of the characteristics ofneurogenic shock is of the greatest importancebecause, its occurrence in conjunction with theother forrms of shock, makes an accurate appraisalof the therapeutic needs of a patient more difficult.Thus, on the one hand, blood or plasma may beneedlessly given the patient who has fainted witha minor injury, and, on the other hand, recoveryfrom neurogenic shock may temporarily obscurethe fact that a concealed hemorrhage is actuallyprogressing.

VASOGENIC SHOCK

TRe term "vasogenic shock" is used to include anumber of factors such as infection, anaestheticagents, or hypothetical toxins which, althoughthe exact mechanism of their action is not known,are recognised as contributing to the circulatoryfailure of shock. Whether these agents cause aspecific capillary injury, or a generalised loss ofvascular tone associated with cellular necrosisthroughout the body, is not yet established. Thelatter possibility seems more likely since progres-sive hemo-concentration is not a feature ofsevere infection, unless there is associated dehy-dration.7 From the practical point of view theprecise mechanism is unimportant. It is import-ant, however, to realise that specific measures toprevent or treat infection are of more value thanmeasures taken to improve the circulatory failurewhich it produces.1, 7

HEMATOGENIC SHOCK

Hematogenic shock is a consequence of a loss offluid from the circulation. This may occur asblood, plasma, water and electrolvtes, or anycombination of these. It may be obvious, as inexternal bleeding or vomiting or, as is more oftenthe case, it may be concealed as in bleeding intoa body cavity or into tissue spaces. Irrespectiveof the type of fluid lost from the blood stream,two compensatory phenomena occur: the move-ment of available extra-cellular tissue fluid intothe circulation, and peripheral vasoconstriction.These compensatory mechanisms may be sufficientto maintain the blood pressure despite a continued'reduction of the blood volume, a fact of the greatestpractical importance to the clinician.

DECOMPENSATED SHOCK

Decompensated shock is advanced or late shock.Practically speaking, it is the result of untreatedhematogenic shock, and is often complicated bysepsis, anesthetic agents, exposure to cold, andvariable neurogenic factors. Decompensated

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from

112 POST-GRADUATE MEDICAL JOURNAL . April, I945

shock' is characterised by low arterial pressure,diminished cardiac output, low blood volume, adecrease in the total circulating plasma protein,acidosis, and anoxia. If untreated, decompen-sated shock becomes irreversible in the sense thatan adequate restoration of the blood volume hasno effect upon the circulatory collapse. Thenature of this "irreversible state" is not known.It has been thought that either as a consequenceof "toxins" absorbed from the area of injury orprolonged anoxia, a generalised permeability ofcapillaries develops. That this may occur in theterminal stages seems likely, but there is increasingevidence to indicate that before the capillariesare injured a generalised "cellular" death occurs,particularly in highly specialised cells in the Bver,adrenals, kidneys, and gastro-intestinal tract.Apparently the heart itself is affected for, even ift-he blood volume is restored to normal and thevenous pressure raised by rapid infusions, thecirculation fails to improve.An example may serve to clarify precisely what

is meant by each of these types of shock: a mansustains a perforating gunshot wound of thebuttock and abdominal cavity. He falls to theground, experiences moderate pain, realises hehas been badly wounded, fears he may die, andpasses into a state of collapse. If examined atthis time he will be pale, sweating, and will havea low blood pressure. However, his cardiacoutput and blood volume if determined wouldprove to be normal. This is neurogenic shock.The man is picked up, and some two hours laterarrives at an Aid Station. He has received a largedose of morphine, his pain is relieved, and hisworst fear-that of dying neglected on the battle-field-has been proven groundless. He smokes acigarette and begins to feel more cheerful. Atthis time he will no longer be sweating, and as aconsequence of compensatory vasoconstriction hisblood pressure will be normal, or even a littleabove normal, and his pulse rate may not exceedIOO. Yet, by now he has lost I,OOO c.c. of blood-most of it "concealed"-and he shows evidenceof early peritonitis. This man is now in hemato-genic shock. Before he is transported to theField Hospital, replacement therapy with bloodor plasma should be instituted.

Let us assume that no therapy is given. Theman is transported another five miles to the rear,he is given another dose of morphine because of arecurrence of his pain, and he is exposed to coldand is badly shaken up in transport. Some sixhours after injury he arrives at a Field Hospital.Examination will again show him to be in obviouscollapse; he is pale, his face and extremities are cold,and his pulse is weak and thready. Despite con-tinued vasoconstriction as evidenced by cold, white

extremities, the blood pressure will now be low.If determined, the blood volume would be fourfdreduced by as much as half its original total. Thisis decompensated shock. If treated promptly byadequate replacement of the lost fluid, and ifthe therapy is continued throughout the necessaryoperative procedures, this patient may yet recover.However, if further delay ensues and peritonealor retroperitoneal infection becomes established,or if therapy is inadequate and a generalanaesthetic is given, there will develop a state ofcirculatory collapse which will no longer respondto the infusion of blood or plasma. Even thoughthe blood volume is restored to normal the bloodpressure will remain low and the extremities coldand nearly pulseless. This is an "irreversiblestate."

DIAGNOSIS AND TREATMENT

It has been emphasised repeatedly that the mostimportant evidence of shock is obtained from anevaluation of the clinical findings.5, 6, 8, 10 Thisview has been confirmed by recent experiences inthe campaign in Normandy. The inexperiencedmedical officer is lost when first confronted witheven a single patient in profound collapse. Where-as an orderly and logical appraisal of each case,using clinical findings as the principal criteria fordiagnosis and treatment, allows an experiencedofficer, with one or two enlisted men as assistants,to care for an entireward full of patients in shock.The following "standard operating procedure" forthe reception and management of the patient incirculatory collapse was established for this unitover two years ago. Although certain aspects ofit may appear exceedingly elementary, it is pre-sented here in detail as a guide for those who havehad little or no experience with this problem.When confronted with a patient in circulatory

collapse the first, and most important, thing to dois to determine as nearly as possible under theexisting circumstances the exact nature of theinjuries. Usually sufficient history to provide thebackground for an immediate examination can beobtained in a word or two, such as "Jeep accident,"or from a glance at the "Emergency MedicalTag," such as "Shell wound of chest and abdomen."A preliminary examination is made as follows:

i. Determine the state of consciousness of thepatient and ascertain whether or not he hasany recollection of the accident-thus, in asecond, including or excluding a cerebralinjury.

2. Inspect and palpate the skull swiftly, butgently, for laceration, contusion, or depres-sion; note the colour of the ears and lips forpallor or cyanosis.

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from

Airil. io94 BURNS 113

3. Inspect the chest, looking particularly for asucking wound; then compress the chestgently for evidence of fractured ribs. Auscul-tate the chest anteriorly, but do not do adetailed examination unless there are findingsindicating a tension pneumothorax or cardiactamponade which require urgent therapy.

4. Palpate the abdomen, merely to excludetenderness and spasm.

5. Gently compress the wings of the ilium andpalpate the symphysis pubis for evidence ofpelvic fractures.

6. Feel and gently move, or have the patiefitmove, all his extremities to exclude majorfractures.

7. Note the colour and temperature of thehands and feet.

8. Finally, gently turn the patient just enoughto slide a hand under the perineum, buttocksand back to exclude major wounds withcontinued and unrecognised hemorrhage.

While the surgeon is making this survey of theextent of the injuries, trained corpsmen should bepreparing a plasma infusion, taking and recordingon a graphic chart the pulse rate, respiration rate,blood pressure, and rectal temperature, andassisting in the judicious removal or cutting awayof clothing, as indicated by the surgeon. Thus, atthe conclusion of the examination everything is inreadiness for treatment. It is usually wise tobegin with an initial plasma infusion, at whichtime a sample of blood should be taken for deter-mination of the serum protein and hematocrit.Thus, within a matter of minutes the case isevaluated, treatment is started, and the basisestablished for continuous therapy as indicated bychanges in the chart or -laboratory data. Thefollowing case reports are examples

i. Truck Accident.-Patient semi-comatose; nodemonstrable injuries of chest, abdomen, orextremities. There is a small contusion ofthe scalp. BP 90/70; pulse IIo; respirationIo. Impression: Head injury; withhold in-fusions, proceed with detailed neurologicalexamination and appropriate therapy.

2. Patient Run Over by Half-track.-History ofshort period of unconsciousness. Complainsof severe abdominal pain; laboured respira-tion; chest negative. Cold, white extremities.Abdomen spastic and tender, especially in leftupper quadrant. BP 5o/o, pulse I40,respiration 24. Impression: Hematogenicshock due to abdominal injuries; possiblerupture of spleen with intraperitoneal haemor-rhage and probably retroperitoneal haemor-rhage. Start infusion at once-plan to give

at least I,000 c.c. of blood. Subsequent courseto be guided by response to infusion and resultof more detailed appraisal of the abdomen.The presence of uncontrolled haemorrhagewill make prompt surgery necessary. As theshock is being treated prepare for surgery.

3. Gunshot Wound ofArm.-Severe pain; patientpale, but extremities are warm. Examinationdiscloses no other injury. No evidence ofloss 'of blood from history or character ofwound. BP go/50, pulse go, respiration20. Impression: Neurogenic shock-withholdinfusion; give morphine and warm drinks.

4. Gunshot Wound of Chest.-Marked dyspnea;chest shows shift of mediastinum to oppositeside with tympany and absent breath soundsover the injured side; no other evidence ofinjury. BP 90/50, pulse I20, respiration 30.Impression: Tension pneumothorax. Insertflutter valve. Start infusion because someblood loss is inevitable. Watch carefully forsigns of intrapleural bleeding as evidenced byincreasing dullness over affected side. Keepin mind the fact that once the pneumothoraxis relieved the patient can bleed to death intohis pleural cavity without signs of respiratoryembarrassment.

5. Severe Burns of Trunk and Legs.-BP I40/60,pulse ioo, respiration 20. Despite apparentlvnormal circulation, begin plasma infusion atonce. Plan to give approximately 500 c.c. ofplasma for each ioper cent of body areaburned.As soon as possible, apply pressure dressingsto limit loss of plasma. Subsequent course tobe guided by response to therapy and resultof hematocrit and serum protein changes.

The type and amount of replacement fluidnecessary is determined by: (i) the nature of theinjury; (2) the response to therapy; and (3) thedata provided by determination of the hematocritand serum protein. In general, except for burnsand peritonitis uncomplicated by hemorrhage,whole blood will be required in every case. Plasmais no substitute for blood if the losses are large,and particularly if extensive surgery must be doneunder a general anesthetic. If an infusion isneeded at all, I,000 c.c. represents a minimalrequirement. If the injury is an extensive one,and particularly if the blood pressure is below70 mm. systolic, at least double this amount willbe required. The loss of blood, both externally andinto the tissues, in the explosive type of woundscaused by shell fragments and land mines. isappalling.

Attention is directed to the value of recordingthe pulse, respiration, and blood pressure on a

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from

114 POST-GRADUATE MEDICAI, JOURNAL April, i945

chart. It takes no longer to record it, and the-graphic chart attached to the bed or litter allowsone to appraise the status of the circulation at aglance. The first i,ooo c.c. of replacement fluidshould be given rapidly, that is, each 500 c.c.within I5-20 minutes. The response to thisinitial infusion is a good guide to the severitv of theshock. If the blood pressure promptly rises towell over I00 the shock is not severe, and immediatearrangements for surgery can be made. If theresponse is slow, either the degree of shock isextreme or there is continued bleeding. By thistime laboratory data should be available. If theinitial hematocrit is found to be low-and it issurprising how frequently readings of 25 or 30are obtained -the former alternative is likely,and a second i,ooo c.c. should be given rapidly. Ifthe initial hematocrit is not low, and especiallyif the nature of the injury makes continued uncon-trolled bleeding likely, it is wiser to continue withthe second i,ooo c.c. infusion more slowly, but tohasten preparation for surgery. In the presenceof uncontrolled hemorrhage one cannot expect theblood pressure to return to normal. As soon asestimated losses have been restored, the generalcondition of the patient improves as evidencedby a teturn of colour and blood flow to the ex-tremities, and the systolic pressure rises to go orI00, or higher, necessary operative proceduresshould be carried out, but at the same time trans-fusion must be continued. It is useless to transfuseand delay. It is folly to operate without continu-ing the transfusion. Amounts of 4,000 to 6,ooo c.c.of blood given simultaneously, through two ormore venipunctures, may be required. Indeed,there is no limit to the amount of blood which maybe given if it is necessary to maintain the circulationin the face of continued and temporarily uncon-trolled losses. The hypothetical danger of renaldamage or toxic reactions to massive blood trans-fusions is no contra-indication to their use whenthe alternative is death.The value of hemoglobin or hematocrit deter-

minations in acute hemorrhage has not beensufficiently appreciated. Particularly after earlyreplacement therapy with plasma, but, at times,even in untreated patients, enormous reductionsmay occur within a few hours of injury. Oftenthe degree of blood loss indicated by this laboratoryfinding is fully appreciated, but occasionally, andespecially in non-penetrating abdominal injurieswith concealed hemorrhage, very low values areobtained unexpectedly and furnish information ofconsiderable value. In crushing wounds, or badlylacerated explosive wounds, hemorrhage is asso-ciated with a loss of additional plasma, thusmaking changes in the hematocrit variable anddifficult to interpret. Moreover, the nutritionalstate and water balance of the patient at the timeof injury will also affect the change in the hema-tocrit. Some of the possible variations in thehematocrit are shown in the accompanying table(Fig. i).

In burns, peritonitis, dehydration, and followingprolonged surgery, varying degrees of hemo-concentration occur. In burns, particularly, thisrise in the hematocrit long precedes the fall inblood pressure. When the loss of plasma or fluidis severe and prolonged the following formulaemay be used as guides to the volume of replacementrequired.

i. First-aid Formula: One pint of plasma foreach io per cent of body area burned. (Har-kins) (Fig. 2.)

2. Plasma required equals (5 - Hb) X IOOO,

in which Hb is the hemoglobin observedafter the injury (Black).

3. For each point the maematocrit is elevatedabove the normal of 45, give IOO cc. ofplasma (Harkins).

It must be emphasised that these formulae onlyprovide an approximate estimate of the require-ment. Determination of the serum protein pro-

FIGURE I

Clinical State. Fluid Lost Stage of Shock Hematocrit or Hemoglobin

Clean wounds of major vessels, in- Blood -Early -Normal-lowjuries of spleen, liver, etc. -After dilution by plasma -Low

infusion

Burns Plasma -Early -HighCrush -After dilution by plasma -Normal

infusion

Crushing injuries with associated Blood and additional -Early -Normal--shighhemorrhage, extensive explosive plasma - After dilution by plasma -Low-normalwounds, compound fractures with infusionextensive tissue injury, etc.

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from

April, I945 BURNS 115

vides an additional basis for estimating the degreeof plasma loss. A high hematocrit associatedwith a normal, or slightly reduced, level of theserum protein is indicative of an enormous loss ofplasma. In simple dehydration the plasma proteinconcentration as well as the hematocrit is high.

FIGURE 2.

Area Burned. Plasma Required(approximate)

Head .. .. .. .. .. 300 cc.

Upper Extremity:Arm and Forearm .. .. 300 C.C.Hand .. .. .. .. 100 C.C.

Total .. .. 400 C.c.

Trunk:Anterior surface .. .. IOOO C.C.Posterior surface .... goo C.C.

Total .. .. I900 C.C.

Lower Extremity:Thigh .. .. ;. .. 500 C.C.Leg .. .. .. .. 350 c.c.Foot I.. .. .. .. 50 C.C.

Total .. .. IOOO C.C.

In evaluating both the laboratory and clinicaldata there are no substitutes for acumen andcommon sense. It is of vital importance to deter-mine whether or not there is a cerebral injury,cardiac tamponade, tension pneumothorax, or anopen sucking wound of the chest, or severe infec-tion, for all of these require prompt, specifictherapy, and do not of themselves require massiveplasma or whole blood- transfusions. Indeed,they may be made worse by it. Furthermore, itcannot be emphasised too strongly that no singlesign, symptom, or laboratory determination is areliable guide to the state of the circulation.Characteristically, the pulse is rapid and weak,but rates of 9o-ioo are not uncommon even insevere hematogenic shock. The blood pressuremay be low because of neurogenic factors alone.It may be normal, or above normal, after-severeinjuries with marked loss of blood or plasma. Thelaboratory data may prove exceedingly accurateand valuable, or it may furnish information so outof keeping with the general picture that it has tobe disregarded.

GENERAL SUPPORTIVE MEASURES

Thus far the replacement therapy of hema-togenic shock has been the principal concern ofthis discussion. Although it constitutes the

essence of modem shock therapy, certain additionalsupportive measures require mention. The neces-sity for adequate splinting and immobilisation ofextensive soft tissue wounds, as well as of fractures,is well appreciated. Morphine must be used tocontrol pain, but overdosage should be carefullyavoided. Unless there is uncontrolled pain orexcessive restlessness, morphine may only depressthe respiratory centre and add to an alreadyexisting anoxia. To avoid delayed absorptionwith possible cumulative action it is best adminis-tered intravenously.The use of heated cradles and many hot-water

bottles wrapped in blankets has been' discardedas a specific form of therapy. It is actuallyharmful since it increases peripheral vasodilatationwhen the available blood volume is needed else-where. On the other hand, the use of blankets andheat to maintain normal body temperature is oftenessential.

It has been proposed by certain observers thatexposure to cold may be beneficial in shock.There is no sound clinical grounds for this. Recentexperiences in Northern France indicate thatpatients who have been exposed to severe coldrequire more replacement therapy, and react lessfavourably to transfusion, than patients who havebeen protected from exposure, but who haveessentially the same injuries. In the present stateof our knowledge, it is only common sense to tryto maintain normal body temperature.The use of the Trendelenburg position is a

debatable point. As an emergency procedure inhaematogenic shock until the blood volume canbe restored, and as a means of combating the lossof constrictor tone in neurogenic shock its useseems reasonable. Since it causes a certaindegree of respiratory and circulatory embarrass-ment, it should be discontinued as soon, as thecirculation is restored by transfusion.Oxygen should be used only when specifically

indicated by dyspnea, air hunger, or cyanosis.The anoxia of shock is primarily circulatory, andonce the circulation is restored oxygen is unneces-sary. Its routine use is cumbersome and ofteninterferes with, or delays, more vital forms oftherapy. It should be used whenever specificallyindicated, but not routinely. In neurogenic shockthe simple measures of the recumbent position,sedatives, and warm drinks appear to hastenrecovery. Failure of neurogenic shock to respondpromptly to these measures should stimulaterenewed search for signs of concealed haemorrhage,

THE CHOICE OF AN ANESTHETIC

It is axiomatic that surgery is never done untilshock is treated. Once the circulation has been

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from

116 POST-GRADUATE MEDICAL JOURNAL April, 1945restored by replacement therapy the choice of ananesthetic agent must be determined largely bythe extent of the surgery to be done. That ageneral anesthetic is a contributing factor in theproduction of an irreversible state is well estab-lished experimentally. For this reason localanaesthesia is the one of choice and should beused whenever possible. When local anaesthesiacannot be used, ether is the best all-round choice.In general, spinal and pentothal anaesthesiashould be avoided; at times they may be employedin exceptional circumstances by the highly-experienced anesthetist, provided the circulationhas been restored to normal by replacementtherapy.Attention is directed to the specific usefulness of

local anesthesia for amputation of badly injuredlimbs, especially when the circulation fails torespond after adequate replacement therapy. Ifadequate blood and plasma infusion have beengiven and the blood pressure remains low, it isevidence of an irreversible state. To delayfuither is to accept a fatality. On several occa-sions the writer, or his colleagues, has had occasionto advise immediate amputation under localanaesthesia while the replacement therapy iscontinued. Following removal of the damagedlimb a general improvement of the circulation hasfollowed, with eventual recovery.

Surgery in the patient who has been in severeshock is not for the dilettante or the beginner.Since the duration of the anesthesia is a con-tributing factor to an irreversible state, what is tobe done must be done expeditiously.

THE PROBLEM OF SHOCK

There can be no doubt that in the present warearly and adequate restoration of the blood volumeby massive blood and plasma infusion is enablingthousands of men to survive injuries which wouldhave proved fatal in the last war. There remains,however, a comparatively small, but significant,group of cases in which adequate replacementtherapy is without avail. In this group are veryextensive burns (8o-ioo per cent of the bodysurface), multiple explosive wounds with extensivedamage to muscle, and late decompensated shock,irrespective of original cause or causes, but especi-ally when complicated by sepsis (peritonitis,retroperitoneal cellulitis, etc.). Two factors whichcontribute to this irreversible state are the extentof the destruction of tissue and the time whichelapses between the injury and surgical measuresdesigned to correct the condition (for example, thedebridement of extensive muscle wounds or theamputation of badly mangled limbs). A thirdfactor which affects the response of the circulation

to replacement therapy is the age and generalcondition of the patient. An elderly, malnourishedindividual cannot withstand losses of blood orplasma which hardly affect a young, hardenedsoldier. Very extensive injuries (i.e. a burn ofgo per cent of the body area), even in well-condi-tioned individuals and even when treated promptly,will not respond to therapy. Less extensiveinjuries such as bomb wounds (land mine) of bothlegs, if treated by replacement therapy and amputa-tion or debridement, as indicated, do well. Ifdelay ensues, however, no favourable response toreplacement therapy occurs. A discussion of thecauses of this irreversible state is not within thescope of this paper. As suggested recently, it maybe a generalised cellular death in which the heartas well as other viscera is affected. Whether thisis a consequence of a specific toxin absorbed fromthe injured area, or of an altered metabolism of thecells because of anoxia, is unknown. From thepractical point of view, all that can be done at themoment is to prevent this state from developingby early and adequate replacement therapy,followed by prompt surgery. Surgery in explosivewounds involving muscle is as important in pre-venting shock as in preventing sepsis.

SUMMARY

Practical points in the diagnosis, treatment, andprevention of shock derived from experiences inmilitary surgery are presented.

BIBLIOGRAPHYI.AUB, J. C., New Eng. J. Med., 231, 7r, 1944.2. BARCROFT, H., EDHOLM, 0. G., McMICHAEL, J., and SHAR-

PEY-SCHAFER, E. P., Lancet, 1, 489, 1944.3. BLACK, D. A. K., Brit. Med. J., 2, 893, I930.4. BLALOCK, A., Surg. Gynec. and Olstet., 58, 55I, 1934.5. DUNPHY, J. E., New Eng. J. Med., 224,903, I941.6. DUNPHY, J. E., Brit. J. Surg., 32,66, 1944.7. EBERT, R. V., and STEAD, E. A., Jr., J. Clin. Invest., 20, 67I,

'94'.8. GRANT, R. T., and REEVE, E. B., Brit. Med. J., 2, 329, 1941.9. HARKINS, H. A., Surgery, 9, 232, 1941.

io. KEKWICK, A., MARRIOTT, H. L., MAYCOCK, W. d'A., andWHITBY, L. E. H., Lancet, 1, 99, I942.

FIRST AID TREATMENTOF BURNS

By ALFRED M. CLARK, M.C., M.A., Ch.M.(Surgeon to the Glasgow Royal Infirmary)

There is considerable confusion at the presenttime regarding the first-aid treatment of burns.Many of the methods, which have been recom-mended, are unsuitable and interfere with thesubsequent treatment. The first essential is toappreciate that every burn involving more than5 per cent of the body surface and burns of theface, hands, feet and eyes should be admitted at

copyright. on A

ugust 31, 2021 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.21.234.111 on 1 A

pril 1945. Dow

nloaded from