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War Surgery and Medicine


page 93


THIS condition had been studied extensively prior to the First World War, and much research had been undertaken in an endeavour to find explanations of the cause and nature of the phenomenon and the best methods for its relief.

It was realised that there were many diverse causative factors and that these were both psychic and traumatic. At one time a differentiation was made between shock which was unassociated with loss of blood or fluid and collapse which was held to be due primarily to loss of body fluids. This distinction proved unsatisfactory as there was so much overlap, and the final pathological condition seen in the two states proved to be more or less the same. However, stress was laid on the serious effects produced by loss of blood or body fluids, and in the wounded this was naturally of the greatest importance.

The utilisation of intravenous fluids was common prior to the war, saline and glucose solutions being especially employed. Blood transfusion had also been used in the treatment of blood diseases, as well as for the restoration of blood loss. It had been shown that stimulants of all kinds had but a temporary beneficial action, and later a definitely deleterious one. The main factors helping recovery were rest and the restoration of fluid loss.

It was known that there were fairly constant changes in certain body tissues, especially the brain, the liver, and the adrenals, and also in the acid content of the blood giving rise to a condition of acidosis.

During the war there was ample scope for observation of, and the development of treatment for, shock encountered in the exhausting and prolonged battles in France, and following the severe wounds sustained in such very large numbers. Rapid evacuation to the operating centres in the CCSs, where early operation could be undertaken and comfort and nursing provided, was arranged. Warmth was supplied by stoves, hot-water bottles and, when possible, by page 94 electric cradles, and was of special use during the cold and wet weather on the Continent. Fluids were provided by the mouth and in serious cases were given intravenously as isotonic saline, glucose solution, and sodium bicarbonate solution, the latter in order to combat the acidosis-known to be present.

In the latter part of the war some blood transfusions were also given, but the supply was limited, both by the absence of any blood bank and also by the lack of a simple and uniform method of transfusion. Many methods were employed at that time, and even anastomosis, by small cannulae, of the artery of the donor and vein of the recipient was practised. Waxed glass tubes and oiled syringes enabled unaltered blood to be given. The citrate method was also used and gradually ousted the more complicated methods. Volunteer donors were obtained, and rewards, such as extra leave, were granted to them. Naturally under such conditions the amount of blood given was strictly limited, but it was recognised that this treatment was of the utmost value. Seldom was more than a pint given to any wounded man.

The deleterious effects of the ordinary inhalation anaesthetics, especially chloroform, were recognised, and gas and oxygen was often utilised.

The frequency of gas gangrene infections complicated the picture, and intravenous alkalies were frequently used in these cases to combat the associated acidosis, but with little effect. The great benefit of early excision of wounds, and efficient splinting of fractures, was recognised. It was also known that in the serious cases transportation had a deleterious effect, especially in certain types of cases such as chests and abdomens.

Between the wars research continued and further knowledge was gained. Blalock drew attention to the marked loss of serum into the body tissues following burns, with the development of haemoconcentration, a discovery that revolutionised our treatment of this condition.

The citrate method became the universal method of blood transfusion for ordinary conditions, though unaltered blood was still used for the treatment of some blood diseases. Transfusion services had been widely established in many countries, and blood banks had been set up in many large centres. The giving of bloed had become a regular part of medical practice. Blood grouping had been stabilised, as had the techniques used in the determination of the individual group.

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