History

Part I

RESUSCITATION, CONTROL OF PAIN, ANDANESTHESIA

CHAPTER I

Resuscitation of Men Severely Wounded inBattle

Henry K. Beecher, M. D.*

THE EVOLUTION OF METHODS OF RESUSCITATION IN THEMEDITERRANEAN THEATER

The fighting in the Mediterranean (North African) Theater ofOperations in World War II began in November 1942 and ended early in May 1945.As a whole, the campaigns carried out during this time were among the longestfighting conducted by any American army since the Civil War. From the medicalstandpoint, and entirely aside from any military considerations, the duration ofcombat provided the inestimable advantage of time for the evolution of soundmedical practices, for the correction of errors, and for the development ofexpeditious medicomilitary methods.

The two case histories which follow illustrate excellentlyhow, over this period, earlier, erroneous concepts of therapy gave way toadvanced, sounder concepts:

Case 1.-On 21 March 1943, during the fighting in Tunisia,an infantryman sustained a compound fracture of the left humerus and alaceration of the left side of the chest from a shell fragment. He was tagged ata regimental aid station at 1100 hours. First aid consisted of the intramuscularinjection of 30 mg. (gr. ?) of morphine and the application ofsulfanilamide-powdered dressings and a Thomas arm splint. At the divisionclearing station, the man was given 1 cc. of tetanus toxoid and 500 cc. (2units) of blood plasma. His general condition was not described on the medicaltag.

During the afternoon of the same day, the patient was evacuated to afield-type hospital. At 1715 hours, his blood pressure was recorded as 110/70and his pulse rate as 120. Examination revealed absent breath sounds andhyperresonance on the left side of the chest, with abdominal rigidity andtenderness. At 1745 hours, he was given a second transfusion of 500 cc. (2units) of blood plasma. Roentgenologic examination of the left arm revealed afracture of the lower third of the humerus, with lateral bowing. Fluoroscopicexamination of the chest and upper abdomen showed increased density in the lefthemithorax; the mediastinum was pushed over to the right, apparently by fluid. Alarge foreign body was observed in the region of the stomach. As there was no evidence of sucking in thechest wound, it was closed by suture. The diagnosis at this time was a combinedthoracoabdominal wound, with rupture of a viscus and probable hemorrhage.

The blood pressure at the time the fluoroscopic examination was conducted wassatisfactory, and the pulse was of fair quality. Immediate operation wastherefore undertaken, after a transfusion of 500 cc. of whole blood. As soon asthe abdomen was opened, through a long left rectus incision, there was a gush ofblood and air. Respiratory difficulty was apparent immediately. The patient'scondition improved after a 4-cm. laceration of the

*Except as otherwise noted, part I is based upon the personal experience ofthe author as consultant in resuscitation and anesthesia, NorthAfrican-Mediterranean Theater of Operations, and upon reports submitted to him.

dome of the abdomen had been closed. A 10-cm. laceration of thestomach, near the greater curvature, was also closed. It had been caused by a shell fragment 1 by 1 by3 cm. The only other intraperitoneal injury was a small laceration of thespleen, which was not bleeding. The incision in the abdominal wall was closedafter 12 gm. of sulfanilamide powder had been dusted into the peritoneal cavity.

Shortly after the operation had been concluded, sucking became apparent inthe chest wound at the site of entrance of the missile, where simple sutureclosure had been done. Closed drainage was established at once, and the woundwas packed tightly with vaseline gauze. The patient became deeply cyanotic, inspite of these measures, and died 21 March at 2315 hours, a little over 12 hoursafter injury.

Case 2.-On 21 April 1945, during the fighting in the Po Valley, a 26-year-oldinfantryman received compound fractures of the left femur and both ankles, apenetrating wound of the chest with hemothorax, and multiple lacerations of thelegs and face from shell fragments. In the collecting station, to which he wasbrought at 1315 hours, 15 minutes after injury, he was given 15 mg. (gr. ?) ofmorphine and 1,500 cc. (6 units) of blood plasma. Dressings were applied to hisvarious wounds, and his legs were supported by splints. He was then evacuated toa clearing station, where he was given another 250 cc. (1 unit) of blood plasmaand 20,000 units of penicillin intramuscularly. Because of his exceptionallypoor appearance, he was also given a transfusion of 1,000 cc. of whole blood,which was obtained from the adjacent field hospital. His blood pressure was then90/60.

When the patient was received in the field hospital at 2100 hours, his bloodpressure was not measurable. His face was pale, but the skin was warm. Theextremities were cool, and the veins were collapsed. He was classified as insevere shock. Laboratory studies showed the hemoglobin to be 9.8 gm. percent;the hematocrit 29; and the blood volume 5,010 cc., or 19 percent below hisnormal calculated blood volume. When the values were corrected for fluids whichhad been administered, it was found that, since wounding, he had lost 76 percentof his normal blood volume and 55 percent of his normal hemoglobin.

In the 4 hours which followed his admission to the fieldhospital, the patient was given 500 cc. (2 units) of plasma, 2,000 cc. of wholeblood, and 25,000 units of penicillin intramuscularly. At the end of thisperiod, his blood pressure had risen from 0 to 110/65, and his pulse was 138 andof good volume.

Operation was performed at 0330 hours 22 April, 14? hours after wounding,under endotracheal nitrous oxide-ether anesthesia. It lasted 2? hours. Itconsisted of a guillotine amputation of the lower third of the left leg,together with debridement of the wounds of the extremity and chest wall.Twenty-five thousand units of penicillin were placed in the right pleural cavity, after 1,000 cc. of blood had been aspirated from it. Nasaloxygen was instituted as soon as the operation was ended. Blood was also usedliberally in the postoperative period.

The patient made a rapid, uncomplicated recovery.

Comment.-The first of these patients, who was clearlydesperately wounded, was resuscitated by 4 units of plasma and 500 cc. of wholeblood. Although the blood pressure was finally recorded as normal, the pulse,which continued rapid and of only fair quality, provided evidence thatresuscitation had been inadequate. It was not possible to determine from therecord the gravity of the pneumothorax that seems to have caused this man'sdeath, or to determine whether a bilateral pneumothorax was overlooked, but thefailure to tolerate accidents during and soon after operation was entirelycharacteristic of the seriously wounded, bled-out casualty who, in the firstmonths of fighting in the North African theater, was resuscitated by plasma butdid not receive adequate blood replacement.

The second patient, who was also desperately wounded, wasresuscitated by

2,250 cc. of blood plasma (9 units) and 3,000 cc. of whole blood. Inaddition, blood was used liberally during the postoperative period to overcomeacute anemia and promote wound healing. Penicillin, which had not been availablewhen the first of these soldiers was treated, was also used freely. Thetremendous measured blood loss in the second case emphasizes how dangerous itwould have been to attempt to prepare this man for operation by plasma alone.The use of oxygen should also be noted.

As both of these histories indicate, the major problem ofresuscitation of badly wounded men in World War II had to do with the managementof shock. Shock is a disability of the circulatory system that parallels, and iscaused by, loss of effective blood volume and hemoglobin. The major problem inall combat areas was how best to overcome these losses, or, more correctly, howto overcome them sufficiently to enable the patient to tolerate transportationto the hospital nearest the frontline where surgical facilities were availableand where he could be prepared to withstand the surgery required by his specialinjury. For all practical purposes, then, an account of the resuscitation ofwounded men in a combat area is principally a matter of blood-volumereplacement. The history of resuscitation in the Mediterranean theater isepitomized in the innovations made in blood-volume replacement therapy and intheir consequences.

The incidence of shock varied according to the echelon atwhich the patient was seen. One study¹showed that about 2.5 percentof 2,853 wounded men were in need of special resuscitative measures on theirarrival at an evacuation hospital in Italy, because surgical shock wasestablished or impending. Two thousand two hundred and ninety-six of these menwere injured on the Anzio beachhead, where, for tactical reasons, the evacuationhospital performed the functions ordinarily performed by a field hospital.Additional data supplied by the 2d Auxiliary Surgical Group and extended bymaterial from the Office of the Surgeon, Mediterranean Theater of Operations,United States Army, showed about 2 percent of another group of wounded men to bein need of special resuscitative measures on their arrival at a field hospital.The incidence of shock on the level of the field hospital may therefore beassumed to have been from 2 to 2.5 percent.

GENERAL CONSIDERATIONS OF RESUSCITATION

The interval from the time the soldier was wounded until he had been restoredto sufficiently good condition for his wound to be repaired was the mostcritical period he could undergo. In untreated patients, the balance during thisinterval was swung toward life or toward death by the operation of naturalforces. The direction and extent of the swing could be influenced, in mostcases, by the character and the timing of the treatment given the wounded man.

As has already been intimated, the first concern of those who had the care

¹Beecher, H.; and Burnett, C.: Field Experience in the Use of Blood andBlood Substitutes (Plasma, Albumin) in Seriously Wounded Men. M. Bull. NorthAfrican Theater of Operations 2: 2-7, July 1944.

of a freshly wounded man during this period was to do whatwas necessary to enable him to withstand transportation to a hospital. Theirnext concern was to prepare him to withstand the stress of emergency surgery.Everything else, even the question of his ultimate survival, was secondary tothese immediate considerations.

The consequences of all wounds were cumulative. Pain often made restimpossible. Exhaustion was increased by emotional factors. Dehydration, whichoften was present before wounding, was increased by unusual fluid losses insweat and vomitus, as well as by continuing hemorrhage and loss of plasma, withconsequent reduction of hemoglobin and blood volume. If treatment was delayed,infection developed. These and other undesirable consequences were set inoperation by the initial wound, and they continued unabated in the seriouslywounded man until they were checked by surgery or interrupted by death.Resuscitative measures halted these effects temporarily, but such measures weremerely palliative. Real relief from the grave consequences of the woundinflicted by enemy action could be accomplished only by surgery. After thewounded man had been received in a forward hospital, it is true that preparationfor surgery was the immediate goal of resuscitation; but it was not an end initself. In the broad general sense (p. 18) surgery was itself an essential phaseof resuscitation.

These were not academic considerations. Any other concept of surgery wouldhave led to an unfortunate separation between the activities of shock teams andsurgical teams. The care of the wounded man had to be continuous, and hissupervision had to be uninterrupted. Neither activity could be separated intocompartments. The recognition of the essential unity of resuscitation andoperation, though it was somewhat late in coming, was an important surgicaladvance in World War II.

That the operation itself should be an integral part of theresuscitative procedure was a perfectly logical concept. When internalhemorrhage persisted, for instance, there could be no resuscitation withoutsurgery, and it was wasteful of both time and blood to attempt to raise thepatient's blood pressure to normal before operation. The blood or plasma whichwas administered merely leaked into the traumatized regions and was wasted,while at the same time the patient was submitted to the hazard of an unnecessarynumber of transfusions. Surgery, with control of the hemorrhage, was thesimplest and most effective way of accomplishing full resuscitation in such acase. Similarly, when extensive fecal contamination of the peritoneal cavity hadoccurred, or when leakage into or possible absorption from large areas ofdevitalized tissue was taking place, the shock and toxic manifestations whichensued could be terminated only by control of the causative factors at thesource.

The best method of management in all such cases was to resort to surgery assoon as the patient had been brought to the desired stage of resuscitation (p.18) and to continue resuscitative measures during the operation. This was thecardinal principle which, by a process of evolution, was finally worked out forthe management of battle casualties during World War II. It does

not seem to have been emphasized or practiced to any considerable degreeduring World War I.

Differences in medical organization, evacuation policies, technical and humanresources, and even the denotations and connotations of medical terminologydiffered so greatly in World War I and World War II that comparisons are, ingeneral, neither useful nor valid. The following comparative data are, however,presented because the organization and mission of the 127th Field Hospital,which served in France in 1918, seem reasonably comparable to the organizationand mission of the 33d Field Hospital, which served in the Mediterranean theaterin 1943:

Over a 7-day period in 1918, the 127th Field Hospital admitted 256 woundedcasualties, 41 of whom died before operation and 34 after operation.² The totalcase fatality rate was thus 29.3 percent and the surgical case fatality rate15.8 percent. Over a 30-day period in 1943, the 33d Field Hospital admitted 297wounded men, all of whom underwent operation, with 56 deaths.³Thetotal case fatality rate, which was entirely surgical, was thus 18.9 percent.

These figures, while perhaps not precisely comparable from astatistical point of view, illustrate very clearly the difference in concepts ofmanagement of severely wounded men in World War I and World War II. Thesignificant point of the comparison is that, in 1918, 41 of 256 wounded soldiers(16 percent) died without operation, probably because they were never regardedas fit subjects for surgery, while in 1943, every one of 297 freshly wounded menwas resuscitated and given his chance of survival through surgical intervention.The key to the difference is, of course, the emphasis placed upon preoperativeresuscitation in World War II and the lesser emphasis placed upon this phase ofmedical care in World War I.

The problems of resuscitative therapy in World War II were greatly simplifiedonce there was general acceptance of the concept that the cause of thedeterioration of the status of a seriously wounded man was a reduction in thecirculating blood volume because of loss of blood. Still further simplificationoccurred when the additional concept won general acceptance that, except forprocesses leading to dehydration, fluid loss from the circulation could beexplained by loss at the site of injury alone. When profound anoxia was present,there was also some loss because of the general increase in capillarypermeability associated with this condition.

The studies upon which these concepts were based⁴ showed in a useful andpractical way the almost quantitative relationship between the blood loss afterwounding and the degree of shock. This relationship had long been recognized,but it had lacked substantial proof up to this time. The proof was needed tooutride the storms which arise again and again from suggestions

²The Medical Department of the United States Army in the World War.Washington: U. S. Government Printing Office,1927, vol. XI, pt. I, pp. 109-110.
³Annual Report, Medical Section, North African Theater of Operations, U. S. Army, 1943.
⁴Medical Department, United States Army, Surgery in World War II. ThePhysiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952.

that the cause of shock is mysterious and is to be explained by toxins or bythe breakdown of some vague but vital force.

This emphasis on the relationship between blood loss and shock, which was oneof the outstanding features of the management of the battle-incurred injuries inWorld War II, did not in any way decrease the interest of medical officers inthe problems of shock which remained to be solved. It also did not lead to anyunderestimation of the complexity of the mechanisms involved in the productionof shock. It did, however, simplify the application of effective therapy, thechief component of which, as all the experience showed, was the promptadministration of blood in the quantities in which the individual wounded manrequired it.

All the available evidence pointed to blood loss, with the correspondingreduction of the circulating blood volume, as the explanation of the poorgeneral condition of seriously wounded men when they were first seen in forwardhospitals. All the evidence also pointed to the correction of these losses byreplacement of the lost blood as the only method of improving the condition ofthese injured men and rendering them fit for surgery. The treatment of the localwound and the relief of pain and of mental distress were important, but not incomparison with the replacement of the lost blood. Furthermore, the more rapidlythe losses could be corrected up to the point at which the deterioration of theman's condition could be checked, the better for him. These facts weredemonstrated in every preoperative ward and every operating room from thebeginning of the fighting in North Africa to the end of the fighting in Germany.

The stress of surgery for battle injuries.-The chief reason for theresuscitation of the freshly wounded soldier was to correct his impaired status.An additional reason was to prepare him for the strain to be imposed upon him bythe operative procedure necessary to repair his injuries. How severe that strainwas likely to be is suggested by the following data concerning the duration oftypical operations, for the most part performed on the Anzio beachhead. Thesingle large hospital area on the beachhead was near, and often in the midst of,the area of active combat. Many of the wounded were injured in the actualhospital area, and others on the adjacent road, which came to be known as PurpleHeart Highway.

The duration (exclusive of the time occupied in the induction of anesthesia)of 130 typical major operations, chiefly performed in this hospital area, was asfollows:

For 20 craniotomies in which the dura was opened, 109?11 minutes.
For 10 laminectomies, 122?7 minutes.
For 20 thoracotomies, 148?14 minutes.
For 20 laparotomies, 117?12 minutes.
For 20 vascular operations on the extremities involving ligation of the largevessels, 62?5 minutes.
For 20 operations for compound fractures of the femur, including theapplication of the spica, 83?8 minutes.

For 20 guillotine amputations of the femur, 69?7 minutes.

These data are for consecutive, unselected cases. The operations were done bya number of different surgeons, all of whom were able and experienced. In spiteof that fact, only wounds of the extremities could be handled surgically inapproximately an hour. Operations on the head, chest, or abdomen without exception required about 2 hours or more. These operating times were typicalof the experience in all forward areas. They do not differ materially from theoperating times for similar operations in civil life. The strain of surgery ofsuch magnitude, carried out over such long periods of time, could not have beenwithstood if the patients had not been adequately prepared in the shock tent totolerate prolonged surgical stress.

At the beginning of World War II, it was the general impression that majorsurgical procedures in time of war seldom occupy more than an hour. Possiblythis impression arose from the experience in World War I,⁵ in whichoperations on the extremities constituted a much higher proportion of the totaloperations than they did in World War II. As the figures cited show, this wasnot the experience in World War II, and these data symbolize the revolution insurgical thinking and progress which occurred between the world wars.

CHAIN OF EVACUATION

Since the status of a wounded man was influenced by the methods employed toremove him from the battlefield and transport him to a field hospital where hecould be treated, a brief outline of the chain of evacuation is necessary in adiscussion of resuscitation.

Resuscitation began at the battalion aid station, which wasordinarily located about 500 yards behind the line of combat, and which wasreached, depending upon the wounded man's condition, by foot or by litter carry.Here, as well as in the collecting and clearing stations farther to the rear,the main objective of treatment was to make the wounded man transportable and torefrain from any procedure which would make him nontransportable. Therapy wastherefore limited to such simple but essential measures as the control ofhemorrhage; the application of splints and bandages, and of tourniquets if theywere necessary (p. 35); the closure of sucking chest wounds; and theadministration of plasma and morphine according to the indications of thespecial case.

Collecting stations, which were located about a mile beyond the battalion aidstations, were reached on foot, by litter carry, or by ambulance. As in aidstations, treatment was limited to what was absolutely essential. At timesnothing more than inspection was required.

The division clearing station, which could care forapproximately 100-150 patients at one time, was usually about 5 miles behind thecollecting station. It was reached by ambulance. Here the patient's status wascarefully ap-

⁵The Medical Department of the United States Army in the World War.Washington: U. S. Government Printing Office, 1927, vol. XI, pt. I, p. 5.

praised, and it was decided whether he could withstand theadditional journey of several miles to the evacuation hospital, where necessarysurgery could be performed, or should be taken at once to the field hospital foremergency surgery. The field hospital, which consisted of three platoons, with acapacity of 100 beds per platoon, was located adjacent to the division clearingstation. It was staffed and equipped for major emergency surgery, and, equallyimportant, for the care of patients for a maximum of 12 days after operation.

The patient's condition chiefly determined whether he should be removed to afield hospital for immediate surgery or transported farther to the rear forsurgery later, but many other factors influenced the decision at the clearingstation. It was necessary to take into consideration whether the road connectingthe clearing station with the evacuation hospital was long or short, good orbad, and easy or difficult to traverse during a blackout. Conditions in thefield hospital were also a consideration. This type of installation wasinvaluable when the nature of the injury or the status of the soldiercontraindicated additional transportation, or when, for any reason, the timefactor was important. The staff was usually competent, especially when teamsfrom an auxiliary surgical group were assigned to supplement the regular staff.On the other hand, this type of hospital was frankly set up to handle emergencysurgery. Because the medical staff was small, resuscitation was sometimes lessrapid than in an evacuation hospital. Equipment was relatively limited, and theenvironment for postoperative care had some undesirable features. The fieldhospital was always far forward-near, or sometimes in front of, heavy artillerypositions. Incessant cannonading made it difficult for the patient to get therest he needed after operation, and limitations of personnel sometimes madepostoperative care difficult, particularly during periods of heavy militaryaction.

The patient operated on in a field hospital was eventuallymoved to the rear. Whenever possible, he was returned to duty directly from anarmy hospital. If this was not practical, he was moved, as soon as his conditionpermitted, from the evacuation hospital to a station or a general hospital.These were fixed installations, equipped and staffed for the performance ofreparative operations designed to hasten healing, prevent irreparable damage ordeformity, and expedite the wounded man's return to military duty. Resuscitationwas seldom an essential phase of treatment in these fixed hospitals.

PREOPERATIVE (SHOCK) WARDS

In the course of World War II, numerous arrangements were tried out for theefficient management of wounded men to be prepared for surgery in forwardinstallations. Some plans were unsatisfactory in their conception. Others werecumbersome and impractical. Experience eventually showed that, while detailsvaried materially from one installation to another, some arrangement such as thefollowing was the most generally satisfactory:

1. Shock wards or tents were set up, and all casualties inshock were

admitted to them, whether or not it was thought that they would requiresurgery.

2. Each shock ward was in charge of a single medical officer, who remained inthe position for a matter of weeks, at least. Quick rotation of personnel merelypromoted inefficiency.

In a field hospital the officer in charge of the shock ward was preferablychosen from the internists or junior surgeons on the staff. This was not aposition for an inexperienced man, but the prolonged assignment of an experienced surgeon was also not wise; it inevitably led to discontent on his partand, eventually, to poor care of casualties. An assistant shock officer wastrained to cover half of the 24-hour period, and at least 1 nurse or 1 aidman,or preferably both, were on duty at all times to assist the officer in charge.Twelve-hour periods of duty were not too taxing, even during times of heavyaction, but longer assignments invariably led, within 2 or 3 days, to inadequateperformance during rush periods.

In the evacuation hospital, a single medical officer was in charge of theshock ward, but an assistant was on duty with him at all times. The situation inthis type of hospital differed from that in a field hospital. In a fieldhospital, all patients admitted were in need of resuscitation, but their numberwas limited. In an evacuation hospital, the incidence of shock was much lower,but the number of patients admitted during heavy drives made it necessary fortwo officers to be on duty continuously. Two additional officers were requiredto relieve these officers for half of the 24-hour period. At least 2 aidmen and2 nurses were on duty at all times during rush periods. One of the officers onduty in the shock ward directed the flow of patients through it to the operatingroom, separating the patients who were in poor condition and in need ofresuscitation from the others. The other officer directed resuscitativemeasures.

It is difficult to overestimate the importance of the function of the officerin charge of the shock ward. Toward the end of the war, some of the mostexperienced surgeons overseas took over the duty of its supervision.

3. The shock ward, when properly set up and administered, was a good dealmore than a valve to regulate the flow of patients into the operating room,though this was a common and serious misconception of its function. Individualevaluation was necessary in every case. It was never possible to set up, on amechanical basis, a relation between the optimum time for surgery and the numberof casualties awaiting treatment, although such a relationship was inherent inthe metered-flow point of view which there was sometimes a temptation to adopt.

4. The preoperative ward functioned satisfactorily only whenthe chief of the surgical service made frequent visits to it. It was part of hisfunction, in collaboration with the shock officer, to set up priorities ofoperating time. As soon as possible, all patients awaiting surgery were assignedto specific surgical teams, and thereafter, as far as possible, the surgeon intowhose charge the patient had been committed shared in all decisions concerninghim, including decisions involving preparation for operation.

The plan just outlined insured continuity of attention forthe wounded man, which was an integral part of good surgical care. Any systemwould have been fundamentally bad which allowed one group-the personnel of theshock ward-to carry a patient so far and no farther, after which his care wasassumed by an entirely new group-the surgical team-whose personnel werecompletely unfamiliar with the man's previous status and therapy.

SHOCK: PREDISPOSING AND PRECIPITATING FACTORS

The treatment given wounded men in battalion aid stations, collectingcompanies, and clearing stations was generally good and often lifesaving. On theother hand, erroneous and inadequate therapy sometimes accounted for the poorcondition of the patients when they arrived at forward hospitals. Among thecommon faults were overmedication, chiefly in the form of an excessive use ofmorphine (p. 41); the administration of too much plasma, or, less often, of toolittle plasma (p. 22); failure to recognize and close an open pneumothorax, orits inadequate closure; inadequate measures to control serious hemorrhage;transportation of wounded men with head injuries and injuries of the pharynx inthe dorsal instead of the prone position; and failure to protect casualtiesproperly during transportation. Under the last heading are included a widevariety of errors and omissions, ranging from careless splinting of broken bonesto inadequate use of blankets, especially failure to place blankets under, aswell as over, the patients in cold weather.

The pathologic processes set in motion when wounding occurred were basicallyresponsible for the poor condition in which many wounded men arrived at forwardhospitals. External circumstances, however, increased the number of those inprecarious condition and in many instances precipitated, as well as aggravated,shock. The most important of these circumstances were exposure, incorrecttreatment in forward areas, and delay in evacuation.

Exposure.-North Africa, Sicily, and Italy provided a wide variety ofgeographic and climatic conditions, including desert heat and mountain cold,high and low altitudes, and dry terrain and marshy land. It was over thisterrain, some of which is among the most difficult in the world, that fightingwas conducted by means of amphibious landings, isolated beachheads, rapidadvances, and prolonged holding operations. Exposure under these conditions ofcombat was inevitable. Sometimes it led to heat exhaustion and sometimes to coldinjury. It was usually associated with inadequate intake of food and fluid, andoften with lack of rest.

Timelag.-The effect of delay on the wounded man's conditionand the favorable influence of a brief lapse of time from wounding untiloperation were naturally appreciated from the beginning of the fighting in NorthAfrica in November 1942. It was not, however, until the Italian phase of the warthat it came to be generally realized that too much time was being lost beforesurgery, and that patients were being handled far too much, because of strictadherence to the formula of delays for inspection purposes along the line of

evacuation. These delays were defeating the efforts of themedical personnel, which were directed toward a single aim, that of presentingto the surgeon a patient who was as favorable as possible an operative risk.

As the plan of evacuation was set up, the patient was removed from theambulance or inspected on the litter at each stop. Almost inevitably, themedical personnel attached to the special installation felt it incumbent on themto do something to him. This was to be expected. Because of shortages ofexperienced physicians, division clearing and collecting stations werenecessarily manned by young men whose judgment had not yet been formed byexperience, and who, in their eagerness to do their full duty, did not alwaysdistinguish between what was essential and what was superfluous. The timelag wasmaterially lengthened by these practices. When the men were critically injured,that fact was usually apparent. Additional inspections were not necessary toestablish it. It was to the patients' best interest that they be handled aslittle as possible and be taken at once to the nearest hospital in whichessential surgery could be carried out.

Possibly some patients with extremity wounds would have profited from beingheld at forward installations for an hour or two, but to teach corpsmen andinexperienced young doctors to identify those who would be helped by delay wassimply not possible. The selection of the wrong patients for delay could bedisastrous. Medical officers who did frontline work repeatedly stated that theyhad never seen a patient lose his life because he was evacuated too promptly,but all could recall instances in which lives had been lost because evacuationwas too slow. This was sometimes unavoidable, but sometimes it was attributableto the cumbersome and time-consuming routine which had to be followed.

While reduction in the timelag from wounding to surgery wasnot the only factor in the reduction of morbidity and mortality, it was animportant consideration. It influenced the salvage of extremities. It lesseneddeformity. It shortened convalescence. Sometimes it altered the outcome. Thesolution of the problem would have been the elimination of one or more stopsalong the line of evacuation, and it was repeatedly suggested that the system inuse, which did not permit such bypassing, should be critically reviewed andmodified in the light of experience. This did not happen. The system institutedat the beginning of the war remained essentially unaltered to the end.

In addition to the lowering of the patient's reserves by thedelays on the battlefield and along the evacuation chain, rough handling wassometimes unavoidable in difficult litter transportation down mountain trailsand in prolonged ambulance hauls over rough roads. These additional stresses,whether they were avoidable or unavoidable, could precipitate shock or increaseit if it already existed.

APPRAISAL OF THE WOUNDED MAN

Although a certain routine of resuscitation was carried out in all shockwards, resuscitative measures were always applied on the basis of individual

needs, after a careful estimate (1) of the extent to whichthe casualty had suffered from his wounds and (2) of the therapy needed toenable him to tolerate immediate surgery in a field hospital or to withstandtransportation to a hospital farther to the rear. Once he had reached the fieldor evacuation hospital, his reaction to the rigors of his journey, as well ashis response to the resuscitative measures employed, furnished essentialinformation concerning the additional treatment required to fit him to toleratewhatever surgery might be necessary. The first step was to rescue him from thestate of shock in which organic damage could occur as the result of inadequatecirculation. The next decision concerned the institution and timing ofadditional measures of resuscitation and of the operation itself-the operation,as already emphasized, being considered to be one phase of the resuscitativeregimen.

The man's clothing (fig. 1) was removed completely before examination wasundertaken or any resuscitative measures were instituted. Flagrant errors couldfollow failure to observe this elementary precaution. Its necessity can be shownby a single illustration. A soldier accidently discharged his own rifle,wounding himself in the buttocks. The bullet reached its destina-

FIGURE 1.-Routine of early care of wounded man in forward hospital. Removal of all clothing.

tion only after it had passed between his scalp and the inside of his helmetand then reversed its direction.

After the man's clothing had been removed, the litter was checked to makecertain that blankets had been placed underneath him as well as over him. He wasthen completely examined, and a plan of management was drawn up. Basically, allpatients were placed in two categories:

1. The patient with a slight wound, in good condition, was operated on assoon as there was space for him in the operating room, with due regard to theneeds of those who were more seriously wounded.

2. The patient in poor condition was sent to the ward or tent set aside formen in shock and was given over to the charge of the shock team.

Patients in the first category required little of no special preparation foroperation. For severely wounded patients in the second category, the preparationwhich they received for operation might make the difference between survival anddeath.

Classification of shock.-For practical purposes, the seriously wounded manwas placed in 1 of 4 possible categories (table 1), depending upon the presenceor absence of shock, and, if it were present, upon its degree. All of thefollowing statements refer to the average patient:

1. The patient not in shock had a normal blood pressure and normal pulse. Thetemperature and color of the skin were normal. The pressure test, which showed aprompt return of color to the skin, indicated the integrity of the circulation.The patient might be thirsty, but his thirst was not abnormal. His mental statewas clear, and he was capable of feeling depressed.

2. The patient in slight shock had a blood pressure about 20 mm. Hg below thenormal level. The quality of the pulse was normal. The skin was cool. Its colorwas pale. The response to the blanching test was somewhat delayed. Thirst wasnot abnormal. The mental state was clear, but the patient was distressed.

3. The patient in moderate shock had a 20-mm. to 40-mm. Hg depression of blood pressure. The pulse volume wasdiminished. The skin was cool and pale. The response to the blanching test wasunmistakably slow. The patient complained of thirst. His mental state was clear,but he was likely to be apathetic unless he was stimulated.

4. The patient in severe shock had a greatly depressed blood pressure,ranging from 40 mm. Hg below normal to an unrecordable level. The pulse was weakor imperceptible. The response to the blanching test was greatly delayed. Thepatient might complain bitterly of thirst, but otherwise he was apathetic andcomatose and seemed to suffer very little distress.

While all of the observations listed furnished useful diagnostic information,the most important considerations in the appraisal of the status of a freshlywounded man were the trend of the pulse rate and the trend of the blood pressure. The trends were a great deal more significant than the levels at any giventime. A rising pulse and a falling blood pressure nearly alwaysindicated trouble

TABLE 1.-Relationship of degree of shock and average bloodloss in 67 patients with all types of wounds

Degree of shock	Clinical observation							Average blood loss (corrected values in round numbers, in percentage of normal)
Degree of shock	Blood pressure (approximate)	Pulse quality	Skin temperature	Skin color	Skin circulation (response to pressure, blanching)	Thirst	Mental state	Blood volume	Hemo- globin
								Percent	Percent
None	Normal	Normal	Normal	Normal	Normal	Normal	Clear and distressed.	14	20
Slight	Decreased 20 percent or less.	...do...	Cool	Pale	Definite slowing.	...do...	...do...	21	30
Moderate	Decreased 20 to 40 percent.	Definite decrease in volume.	...do...	...do...	...do...	Definite	Clear and some apathy unless stimulated.	34	46
Severe	Decreased 40 percent to nonrecordable.	Weak to imperceptible.	Cold	Ashen to cyanotic (mottling).	Very sluggish.	Severe	Apathetic to comatose; little distress except thirst.	46	55

Source: Medical Department, United States Army, Surgery in World WarII. ThePhysiologic Effects of Wounds. Washington: U. S. Government Printing Office,1952, pp. 28, 56.

to come, especially if, in association with these phenomena, the skin of thepatient who had been in a comfortably warm room felt cool to the touch.

It was essential that resuscitation teams understand thepractical implications of shock as a dynamic and not a static state. The wholewartime experience proved that patients in shock did not remain in the samecondition for any length of time. Their condition improved, or it deteriorated.This is why trends were sounder guides to therapy than absolutes. When thesystolic blood pressure showed a constant upward tendency and had reached alevel of 80 mm. Hg, the pulse rate usually showed a constant downward tendency,and the skin was usually warm and of good color. The patient was ready forsurgery when these things occurred and could be operated on with safety longbefore the blood volume or blood pressure had been restored to absolute normal.

It was seldom difficult to recognize in the preoperative tentthe casualty who was in poor condition. He seldom furnished any problem ofidentification. He usually carried obvious hallmarks of his status. The realproblem was to identify the casualty whose condition, while still not critical,was deteriorating, and to identify him early enough to check the adverse forcesat work in him. His prompt recognition was of benefit to him and also ofbenefit to his wounded associates. It meant economy of care, of materials, andof nursing and medical

effort. Because these things were expended only where theywere needed, more rapid preparation of all wounded men for surgery was possible.This was indispensable if intolerable congestion in the preoperative ward was tobe avoided. In the end, it meant the salvage of more lives. Experiencerepeatedly proved that it was far simpler from every standpoint to preventserious deterioration in the condition of a wounded man than to rescue him fromshock, once he had slipped into it.

The selection of patients who required close observation was made on clinicalevidence: Their arms and legs were cool or cold. Their skin was pale. When itwas blanched by pressure, the return of color was considerably delayed. Thepulse was of rather small volume. The blood pressure might or might not be belownormal levels. When it was below normal, resuscitative care was urgently needed.

Additional useful diagnostic points were the appearance of the wound; itscharacter and extent; the evidence of considerable blood loss, whether internalor external; the evidence supplied by blood-soaked clothing; a history ofexposure or exhaustion; and a history of delay in evacuation. Thirst was likelyto be intense in the patient in critical condition; frequently it caused muchsuffering.

Except for those with head wounds, severely wounded men whowere not in shock were usually clear mentally and often could give surprisinglyaccurate accounts of the events of wounding. Later, there was likely to beconsiderable amnesia for the early periods. In a sample of 201 badly wounded menwho were not in shock when they arrived at a field hospital on the Anziobeachhead, 200 were in possession of their faculties.

In World War I, the absolute pulse rate, sweating, nausea, and vomiting wereregarded as valuable signs and symptoms in the composite picture of shock. InWorld War II, they were not so regarded. Instead, they were thought to berelated to the character of the wound or to psychologic factors, or to bereactions to the administration of morphine. The actual pulse rate could beinfluenced by too many factors to be of great value in itself in the estimate ofshock, but its quality and its upward or downward trend were both mostimportant. The degree of thirst and the patient's mental status, to neither ofwhich much attention was paid in World War I (or is paid in civilian practice),were found to be extremely useful in the evaluation of the degree of shock inWorld War II.

One of the principles of resuscitation established in WorldWar II was that if operation could not be undertaken immediately, as itfrequently could not be when the flow of casualties was heavy and selection ofcases had to be practiced, it was not necessary to achieve improvement beyond arising blood pressure of at least 80 mm. Hg and a warm skin of good color. Itwas essential, however, not to permit regression, though it was best to withholdfurther resuscitative measures if the need for them was not evident. The patientwho was merely kept in the satisfactory status described was unlikely to lose asmuch hemo-

globin if bleeding recurred as he would lose if plasma were given to raisethe blood pressure higher than was necessary during the waiting period.

Laboratory data.-Laboratory data which could be secured in the field during thefirst hours after wounding were limited and were likely to be misleading.Estimates of the hemoglobin, hematocrit, and plasma-protein values showed littlechange immediately after wounding, when blood dilution had not yet taken place,though the information was of great usefulness in evaluating the needs of thewounded man during the postoperative period.⁶ Determination of the blood-volumelevel would have been of real assistance immediately after wounding, but themethods available for making this determination in World War II were too timeconsuming to justify their routine use in a frontline hospital. For thesereasons, the simple clinical symptoms and signs described were used almostexclusively to gage the condition of the patient and the quantity of bloodnecessary to satisfy his individual need. If rightly interpreted, they provedentirely adequate for the purpose.

STABILIZATION VERSUS RAPID PREPARATION OF BATTLE CASUALTIESFOR SURGERY

Early in November 1943, at about the time the Volturno Riverwas crossed and the fighting below Venafro was heavy, a new point of view beganto appear in the shock wards of the Fifth United States Army. In effect, it wasthat too much urgency was being exercised in the preparation of the wounded forsurgery. At first, it was an entirely negative concept. After 2 or 3 months, andespecially during the prolonged fighting before Cassino in the early months of1944, it came to be expressed more positively that the wounded fared better whensurgery was delayed for what was vaguely termed equilibration or stabilization.Exactly what was supposed to be accomplished by this period of delay was neverclearly defined. The patient was merely supposed to be better for it.

There was, of course, some logic in this point of view. Therewas no doubt that a seriously wounded man who had suffered a period of exposure,who had been bounced in a speeding ambulance over rough roads for several hours,who had had little rest, and who sometimes was in great pain because of theeffect of the trauma of transportation on his original wound frequently was thebetter after a period of rest. He was likely to arrive with a rapid, weak pulseand low blood pressure. After he had rested for 10 or 15 minutes, even if he hadno other treatment, he usually looked better, his pulse improved in quality, andhis blood pressure rose. These gains, however, were usually achieved in about 15minutes.

The point of view of those who favored immediate operationand who opposed delay after the patient had been brought out of shock and afterthe downward trend of the blood pressure and the upward trend of the pulse hadbeen reversed could be stated about as follows:

A wound sets in action several continuing processes. There isloss of blood.

⁶See footnote 4, p. 7.

There is loss of plasma from serous surfaces and into traumatized tissues.Contamination leads to infection, and infection is progressive. All of theseprocesses drain the resources of the seriously wounded man. They must becombated, and he must be supported, by the use of blood and plasma. It is ageneral principle that in any given case the smallest amount of blood and plasmashould be used that is compatible with the patient's well-being. If surgery isdelayed, larger quantities of these agents must be used to maintain him on aneven keel than would be necessary if operation were performed earlier. This isundesirable from many standpoints, including the practical consideration that inWorld War II both blood and plasma were often in limited supply in the earlypart of the war.

On the basis of this reasoning, the advocates of early surgery contended thatdelay to achieve stabilization of the patient was without merit. They also basedtheir reasoning on the analogy of perforated peptic ulcer in civilian practice.In that catastrophe, peritoneal contamination occurs, and the mortality risessharply with the passage of time. Experience had shown that with the grossercontamination encountered in battle-incurred wounds, a rise in the case fatalityrate when surgery was delayed could also reasonably be expected.

A deliberate test was undertaken in order to establish the proposition thatas prompt surgery as possible was best for the patient and that delay for thesake of so-called stabilization did him no good and was often actually harmful.⁷The management of 2,853 wounded men who were injured at Cassino and on the Anziobeachhead was conducted on the principle of operating as soon as resuscitationhad been accomplished. In every instance, the patient was taken to the operatingroom as soon as the systolic blood pressure had reached 80 mm. Hg and wastending upward, the pulse rate was consistently falling and the quality of thepulse was improving, and the skin was warm and of good color. If additionalblood was considered necessary, it was given in the course of the operation.

Comparison of the Anzio-Cassino experience in 1944 with experiences in fieldand evacuation hospitals below Venafro and Mignano on the Cassino front inNovember and December of 1943 established the soundness of speedy resuscitationand prompt operation. In 1943, resuscitation of the seriously wounded to thepoint of operability often required 6 to 8 hours after the patients had reachedthe hospital. In 1944, even patients who were extremely bad risks when they werefirst seen were prepared for operation and submitted to surgery on an average of2 hours and 20 minutes after wounding. The readier availability of whole bloodin 1944 naturally had much to do with the reduction in the timelag as comparedwith 1943, but the change in the concept of the optimum time for operationplayed the major role in the improvement.

When the experience in the hospitals employed at Anzio and Cassino wascompared with the theaterwide experience, other significant differences becameapparent: In the Anzio and Cassino hospitals, each patient received an averageof 1 unit of plasma, against an average of 3 units for the theater as a whole,and

7 See footnote 1, p. 5.

an average of 1,537 cc. of blood, against an average of 2,610 cc. for thetheater as a whole. Transfusions averaged 3 per patient in the Anzio and Cassinohospitals, against 5 per patient for the theater as a whole. In other words,proper timing of resuscitation and surgery, in addition to cutting the timeoccupied by resuscitation in half, greatly reduced the amount of plasma andwhole blood required for resuscitation. These are not trifling considerations.In spite of the generous provision of whole blood in the later part of World WarII, it was always necessary to use it economically, and it will probably benecessary to use it even more economically in all future wars. The key to itseconomical use, without hardship to the wounded man, lies in the correct timingof resuscitation and surgery.

When the test of speedy resuscitation and promptoperation was undertaken in 1944, the concept was viewed with skepticism, andthere was considerable discussion and disagreement before the conditions of thetest were set up. The results, however, were so good from every standpoint thatthe concept of stabilization was gradually discarded and the concept ofoperation at the earliest possible moment came to be accepted as a satisfactoryworking principle. The time interval between wounding and operation was, on thewhole, materially reduced by its adoption, but until the end of the war manymedical officers felt that sufficient progress along these lines had not yetbeen accomplished.

The concept of prompt operation required an understanding of what could beachieved by resuscitative measures and what was impossible. The aim was not therestoration of the shocked patient to normal status before surgery wasundertaken. That goal was unattainable. Those responsible for resuscitation hadto face the realities of the situation and to decide what was desirable, whatwas possible, and what was impossible in the shocked patient. One thing that wasimpossible was the repair, in a matter of hours, of the organic damage producedby even fairly brief periods of low blood pressure. Many days would have beenrequired for this in some cases. This amount of time could not be granted, norwas it necessary to take it in a man who was organically sound before he waswounded. All that was necessary was to make him safe for surgery. This was notalways possible in patients with continuing internal bleeding or widecontamination of the peritoneal cavity. When resuscitative measures failed, insuch cases, to produce their desired effects, the surgeon was faced with thenecessity of undertaking operation in a patient in poor condition. This was abold and critical decision, but many lives were saved in World War II because itwas made affirmatively.

An important reason for not delaying surgery after the seriously wounded manhad been brought out of shock was the readiness with which he could slip backinto it. For reasons not altogether clear, a seriously wounded man or a mandepleted by loss of blood could often be resuscitated to the point at which hewas regarded as fit to tolerate the additional strain of surgery. If, however,operation were delayed and be were allowed to slip back into shock, a secondresuscitation was always difficult, was often not as adequate as the first, andwas sometimes not possible at all. All military surgeons, no matter

what their original point of view, eventually realized theimportance of operating as soon as the patient had been brought to optimumstatus within a minimum period of time.

PLASMA

The difficulties experienced in resuscitation in the earlyfighting in Tunisia in World War II were in large part directly attributable tothe completely mistaken concept, with which most surgeons entered the war, ofthe limits of usefulness of human blood plasma. These matters are discussed indetail elsewhere in this history,⁸ but no account of resuscitation in the SecondWorld War would be complete without a brief account of that concept and how itwas finally overturned.

The first recorded suggestion that plasma be used as asubstitute for blood was made during World War I by Capt. Gordon R. Ward⁹ina letter to the editor of the British Medical Journal in 1918:

There is abundant clinical and experimental evidence that itis not the corpuscles that are wanted, but the ideal fluid for keeping bloodpressure at a proper level. * * * A man apparently dying from haemorrhage is notdying from lack of haemoglobin * * * but from draining away of fluid, resultingin devitalization and low blood pressure.

These remarks were followed by the eminently sensiblesuggestion that a trial of plasma should be undertaken and should be controlledby a comparable trial of transfusions of whole blood (and gum acacia). Plasma,however, did not become available in World War I, and Ward's suggestion seemsnever to have been carried out. Presumably, it stemmed from the belief that themethods of blood transfusion then available, with the hazards they involved,offered such great obstacles to the widespread use of blood in the resuscitationof battle casualties that the risks were not justified by the possible results.

The numerous studies made on plasma in the years betweenWorld War I and World War II are not pertinent to this brief account. Thewartime enthusiasm for this agent began in 1939, when Tatum, Elliott, and Nesset¹⁰ recommended it as "an ideal substitute for whole blood in emergencytreatment of shock and hemorrhage from war wounds." Their recommendationwas echoed by numerous other observers in the subsequent months. The result, asDeBakey and Carter¹¹ commented, was that sound clinical judgments were pushedaside and the misconception became widespread that plasma was a complete andeffective substitute for whole blood in the management of shock in the seriouslywounded. This misconception, they continued, became so firmly entrenched in theminds of both administrative and professional personnel that it handicapped theorganization and development of more effective measures for the management ofshock.

With increasing experience in the management of shock in thefighting in

⁸See footnote 4, p. 7.
⁹Ward, G.: Transfusion of Plasma (correspondence). Brit. M. J. 1: 301, 9 March 1918.
¹⁰Tatum, W. L.; Elliott, J.; and Nesset, N.: A Technique for the Preparationof a Substitute for Whole Blood Adaptable for Use During War Conditions. Mil.Surgeon 85: 481-489, December 1939.
¹¹DeBakey, M. E.; and Carter, B. N.: Current Considerations ofWar Surgery. Ann. Surg. 121: 545-563, May 1945.

North Africa, it became increasingly evident that plasma was by no means thephysiologic substitute for whole blood which it had originally been believed tobe. It was useful for bringing the wounded man out of shock and maintaining hisblood volume during the period of transportation and immediately after hisadmission to the hospital, before a blood transfusion could be started, but itseffects were transient. Moreover, it created a completely false sense ofsecurity, particularly if the surgeon in charge was of limited experience incombat surgery. Superficially, the patient to whom plasma had been administeredmight seem fully prepared for surgery. Actually, he was ill prepared. Often hecould not tolerate movement, let alone anesthesia and other procedures whichwere part of the preparation for surgery. Their mere institution often caused him to fall back into shock. If operation were proceeded with underthe circumstances, the result could be disastrous. In short, the earlyexperience with plasma made it clear that whole blood was the only therapeuticagent which would prepare seriously wounded men for the surgery essential forthe saving of life and limb.

The course of events might have been expected. Since plasmacontains no hemoglobin, there was never any logical reason for believing that itwould be a satisfactory substitute for blood in a wounded man who had lost agreat deal of blood, as most seriously wounded men had. The use of plasma inthese circumstances could be actually dangerous. The patient in poor conditionbecause of blood loss, with a low blood volume and possibly a low hematocrit,could be placed in jeopardy if his blood (and effective vascular) volume wasincreased by plasma while his hemoglobin remained deficient. The blood volumemight have been restored, but the meager quantity of hemoglobin available in theblood stream would have been correspondingly diluted and, within a brief time,would be further decreased because of the leakage permitted by restoration ofthe blood pressure. Many times in the early part of the Tunisian campaign,before the deficiencies of plasma for resuscitation were fully realized, a smalladditional loss of hemoglobin from renewed bleeding or in the course ofoperation was sufficiently critical to be disastrous. The patient's speciousappearance of well-being promptly disappeared, and it became evident that,though he was apparently well prepared, he was completely unfitted to withstandthe stress of anesthesia and surgery.

Although the misconceptions and errors that attended theearly use of plasma in World War II are now widely recognized, they should notbe permitted to obscure the remarkable value of this substance as a lifesavingagent. All through the war, it superbly fulfilled the role of supporting lifeuntil transportation could be accomplished to an installation at whichwhole-blood transfusion was feasible, as was not usually the case in battalionaid stations or division collecting or clearing stations near the frontline(fig. 2). By temporarily sustaining a seriously falling blood pressure andincreasing cardiac output, it kept the patient alive long enough for moreeffective measures to be taken. When this concept of the possibilities andlimitations of plasma became general and the stopgap character of plasma therapywas realized,

FIGURE 2.-Sicilian women and children watch from a doorway as blood plasma is administered to an American infantryman wounded by shrapnel in 1943. (U. S. Army photograph.)

the concept of resuscitation was correspondingly altered, andwhole blood came to occupy its proper place as an agent of primary importance inthe preparation of seriously wounded men for surgery.

It was not always easy to determine in a forward installationhow much plasma a seriously wounded man needed and could safely be given. Theinitial dose, as a rule, was 500 cc. (2 units), and it was seldom necessary togive more than 1,000 cc. (4 units) during the 4 or 5 hours which usually elapsedbefore his admission to the field hospital. The objective was to give onlyenough plasma to raise the systolic blood pressure to about 80 mm. Hg and tokeep the skin warm and the color good. The casualty did not suffer furtherdeterioration when the blood pressure was at this level, nor did he sustain theneedless and harmful loss of hemoglobin which might occur as a consequence ofbleeding when the pressure was elevated more than was necessary to keep him outof shock. After he had reached a field or evacuation hospital, preparation foroperation, as a general rule, required about 1 additional unit of plasma to 3units of whole blood.

Burns.-Although plasma, in time, ceased to occupy the dominantplace it

originally occupied in the preparation of wounded men for surgery, allthrough the war it formed part of the definitive therapy of burns. Itcompensated, indeed, for the chief deficit in that injury, since plasma is thefraction of the blood which is lost. Various rules were made for the quantitiesto be used, but the most common and most useful was that 2 units of plasmashould be given in the first 24 hours of injury for each 10 percent of bodysurface burned, and that this regimen should be continued untilhemoconcentration had been corrected. When laboratory examinations could bemade, the rule was to give 100 cc. of plasma for each point the hematocrit wasabove the normal level of 45. If plasma-protein values were low, the quantity ofplasma calculated to be necessary was increased by 25 percent for every grambelow the 6-gm. percent level. Economies were effected in the treatment ofburns, if the required quantity of plasma could be administered over the whole24-hour period rather than in the space of a few hours, since, if more plasmathan was needed was given at any one time, it was probably lost from thecirculation.

In the management of burns, it had to be remembered thatsecondary shock might occur after the initial injury. This meant that anemiamight be a secondary development in these cases and might require treatment withtransfusions of whole blood.

WHOLE BLOOD

The shifting emphasis in the use of plasma and whole blood is evident incertain statistics from the Mediterranean Theater of Operations for 1943-45:

During the campaign in Tunisia, between 1 February and 31 March 1943, 972casualties from the II Corps (34.3 percent of all wounded men requiring plasma)received an average of 320 units per thousand wounded.

Between 21 January and 28 February 1943, 101 of 431 seriouslywounded II Corps casualties received plasma, the total quantity not beingstated, and 31 also received blood transfusions.

In March 1943, 561 patients were given 97 transfusions in preparation for 741operations in a field hospital.

In March 1943, at the 9th Evacuation Hospital, during theTunisian campaign, 1,146 casualties were given 17 blood transfusions, 1:67.4 InApril, 1,588 casualties received 54 transfusions, 1:29.4. In May, 397 casualtiesreceived 27 transfusions, 1:14.7.

During the first hundred days of the Italian campaign, which began 9September 1943, the ratio of transfusions to battle casualties was 1:4.5. InJanuary 1944, the ratio in all Fifth United States Army hospitals was 1:2.4. InMarch, a month after a blood bank had been established in the base area, theratio was 1:1.9.

Between September 1944 and May 1945, 122 casualties in Fifth United StatesArmy forward hospitals received, before operation, an average of 3.8 units ofplasma per man, and 10 received, during operation, an average of 1.68 units perman. One hundred and twenty-seven patients received on the

average, before operation, 1,450 cc. of whole blood, andninety-five received, during operation, an average of 1,160 cc. of whole blood.In other words, these patients, in contrast to those treated in Tunisia in 1943,received from the time of wounding to the end of operation an average of 5transfusions of whole blood and an average of 3 to 4 units of plasma per man.

The use of blood and plasma varied, of course, among hospitals andcasualties. During the first hundred days of the Italian campaign, the fieldhospitals of the Fifth United States Army, which cared for only one-thirteenthof the total number of battle casualties, used one-third of the available blood.Disproportionately large amounts were also required by individual severelywounded men. The establishment of the base blood bank early in 1944 made itpossible, when necessary, to give as much as several liters of blood over abrief period of time to a single severely wounded man.

Blood was available in large quantities before the theaterblood transfusion unit began to function. It was secured from local blood banks,from emergency donors, and on loan from the British. There was no comparison,however, between the convenience and safety of transfusion from the base bloodbank and from these sources. These are not matters which can be easily shown instatistics or graphs.

Indications for blood replacement.-It has already beenpointed out (p. 17) that the most helpful guides to the need for bloodreplacement were secured by simple clinical observation. To reiterate, theyincluded the presence of blood soaked clothing; the location and extent of thewound; the timelag since wounding; the rate and quality of the pulse, withparticular emphasis on the trend; the level of the blood pressure, withparticular emphasis on the trend; the state of the peripheral circulation, asindicated by the temperature of the skin and the speed of the response toblanching by pressure; the color of the mucous membranes; and the complaint (orlack of complaint) of thirst.

The paradoxical situation that the blood pressure mightsometimes be normal when the patient was seriously depleted of blood led somephysiologists remote from the battlefront to disparage the level of the bloodpressure, even when it was low, as a useful sign in determining the need forblood. This was not a safe attitude, though, as has been pointed out, the upwardor downward direction of the blood pressure, coupled with the quality of thepulse and its upward or downward swing, was far more useful than reliance uponarbitrary levels of pressure or pulse rate.

Quantitative blood replacement.-Studies made on the Anziobeachhead¹² may be taken as typical of the amounts of plasma and blood neededto prepare seriously wounded casualties for surgery. In this area, the mostseriously wounded patients arrived at hospital installations about 4? hoursafter wounding. The average ambulance haul was about 10 miles, over good roads.The comparatively short timelag justified deliberate appraisal of the patients,it being scarcely likely that an additional delay of a few minutes, added to the

¹²See footnote 1, p. 5.

delay already experienced, would do them any serious harm. Onthe other hand, it had to be remembered that these men could not tolerate anyextended delay, since the wounds themselves, the necessary handling, and theambulance ride immediately preceding their entry into the hospital had probablyreduced their reserves to their lowest point.

About a quarter of these most seriously wounded men studied in the Anziobeachhead hospital entered with no measurable blood pressure. From the time theywere received in the hospital until definitive surgery was undertaken, anaverage of 1 unit of plasma (or albumin) and an average of 870 cc. of wholeblood were given to each man in preparation for operation. During operation,about two-thirds of the patients received an additional 500 cc. of blood each,and about one-third received an additional 1,000 cc. of blood each. Thequantities of blood administered by no means replaced the quantities lost; yetthese men were apparently well prepared for surgery. None of them died in thecourse of operation. During the period of the investigation, the case fatalityrate in the hospital involved was 1.48 percent, which was extremely low forsurgery at this echelon. Finally, the surgeons who operated on these patientswere unanimous in their opinion that preparation for operation was satisfactory.

All of the patients were prepared on the principles already outlined. Theywere considered fit for surgery when the systolic blood pressure was 80 mm. Hgand tending upward, when the pulse volume was good and the rate was tendingdownward, and when the skin was warm and the color good. When these criteria hadbeen met, operation was undertaken without further delay. If additional bloodwas indicated, it was given in the course of the procedure. The medical officersresponsible for the preparation of these patients considered that transfusionshould be given on these principles for two fundamental reasons:

1. Transfusion is a potentially hazardous procedure, which should not beemployed any more often than is absolutely necessary.

2. Economy in the use of whole blood was obligatory, because it was often inshort or potentially short supply, particularly during periods of heavy action.

Certain other observers who did not share this point of view prepared patientsin serious condition with quantities of blood which averaged 1,000 cc. more perman than these most seriously wounded men received at the Anzio hospital. Theresults of excessive administration were equally as good as, but no better than,the results accomplished in patients who had received smaller quantities ofblood.

Technique of administration.-Except in serious emergencies,all blood given to wounded men was grouped and crossmatched with their ownblood. Although this was not always easy under combat conditions, it was seldomimpossible. The precautions obviously were necessary. Unless the greatest carewas taken in the use of blood, accidents could nullify its value and place thepatient in grave danger. Possibly, in the future, fuller information concerninglow-titer O blood may reduce the necessity for grouping and cross-

matching in the field, but, at the close of World War II, these precautionswere still essential for the safe transfusion of whole blood.

After 1,000 to 1,500 cc. of non-type-specific blood had been given to abled-out casualty, a new sample of his blood was obtained for crossmatching.This precaution was repeated after the administration of every additional liter.

The speed with which blood was administered depended entirely upon howcritical was the status of the man to whom it was being given, though certaingeneral principles were also followed. If the patient's condition was consideredto be desperate (that is, if the systolic blood pressure was below 60 mm. Hg),he was placed at once in the head-down position, with the foot of the litterelevated about 12 inches (fig. 3). A unit of plasma or albumin was administeredwhile a transfusion of low-titer (iso-agglutinin titer of 1:64 or less) Oblood was prepared. Blood was always obtained at the first venipuncture forgrouping and crossmatching in subsequent transfusions; but in desperate casestime was not taken at the first transfusion for these precautions and they weresometimes omitted at the second also.

The first blood was often forced in rapidly by the use of a bulb from ablood-pressure apparatus attached to the air inlet of the blood flask. Oc-

FIGURE 3.-Routine of early care of wounded man in forward hospital. Elevation of foot of litter.

casionally, a second transfusion was also given by this technique. It was nota desirable method, for in careless hands it could, and did, cause fatalitiesfrom air embolism. As soon as the blood pressure had begun to rise, the speed ofintroduction of the blood was reduced, though the rate was promptly increased ifsigns of improvement were not maintained.

In critically injured patients, to be certain that the blood would flow inpromptly, cannulas were introduced under direct vision after the vein had beencut down on. In emergencies, two or more transfusions were run in simultaneouslythrough different veins.

Subsequent transfusions were given more slowly. When the systolic bloodpressure had risen to 80 mm. Hg, the administration of 500 cc. over a 30-minuteto 60-minute period was usually adequate. The same rate was adequate when thetransfusion was given for prophylactic purposes, to guard against a fall ofblood pressure which was probable or possible, but which had not yet occurred.

Reactions.-The transfusion of blood is always a complicatedprocedure filled with opportunities for human error. These opportunities,naturally, were greater in warfare than in civilian practice. As transfusionsincreased in number and the volume of blood used also increased, additionalstrains were placed on laboratory facilities and on personnel who dealt out theblood and checked it against the blood of the recipient.

The rapid use of large quantities of non-type-specific blood also opened theway to serious reactions, although their number, exclusive of those whichfollowed the use of clearly mismatched blood, was on the whole remarkably low.Experiences in hundreds of hospitals with many thousands of transfusions showedthat, with the proper precautions, the incidence of transfusion reactions neednot exceed 3 percent. Reactions chiefly took the form of transient malaise,chills, fever, and urticaria. All of them could usually be traced to faultypreparation of the apparatus used. The chief errors were inadequate cleaning ofequipment and delay of more than 2 hours in sterilization after cleaning. Fatalreactions were almost entirely attributable to urinary depression and uremia,apparently associated with renal damage arising from the deposition of freehemoglobin in the kidneys.

Blood transfusions in fixed hospitals.-Blood transfusions fulfilled thegreatest need and had their greatest usefulness in forward (field andevacuation) hospitals, but they also had a wide field of usefulness in stationand general hospitals, where reparative surgery was done. Many operations inthese installations were major undertakings. An operation on a compoundfracture, for instance, might require inspection of the fracture site, removalof bone fragments, and internal fixation of the fracture. Often fractures weremultiple, as were the procedures undertaken to correct them. These and otheroperations were therefore often attended by a considerable blood loss, withresulting depression of the hemoglobin and hematocrit.

Experience in civilian surgery before World War II had demonstrated theimportance of liberal blood transfusions in preparing the patient with

chronic sepsis for operation. In station and general hospitals, transfusionson this indication were fully as important as they were in civilian practice.

Finally, in spite of the liberal use of whole blood in the army area, many ofthe wounded, after undergoing initial wound surgery, arrived at generalhospitals with profound reductions in hemoglobin and hematocrit values. In time,under the influence of an adequate diet supplemented by iron therapy, this typeof anemia would undoubtedly have undergone spontaneous correction. Time,however, was lacking. There were a number of reasons in every case for gettingahead with the surgical program as promptly as possible, in addition to thegeneral reason that the bed space was likely to be needed shortly for anotherwounded man. The sooner secondary surgery was done, the less likely wasinfection to occur or become established. The timelag between initial andreparative surgery was a very important period in wound management, sometimesequal in importance to the period between injury and initial surgery. Earlyclosure of a gaping wound was imperative, if for no other reason than to preventbacterial seeding of the raw surface during repeated dressings. It was alsoimportant to repair large defects by suture before fibroplasia stiffened thetissues and made approximation impossible without dead spaces.

For these various reasons, an extensive program of blood transfusion wasdeveloped in fixed hospitals. As a result, patients with low hemoglobin andhematocrit values were able to withstand secondary surgery promptly, while fulladvantage was taken of any favorable effect that the correction of anemia mighthave on the process of wound healing.

ALBUMIN

Albumin, like plasma, has the property of elevating a lowblood pressure. This fraction of the blood exerts greater osmotic pressure thanany of the other plasma proteins; 80 percent of the colloid osmotic pressure ofnormal plasma is accounted for by the albumin fraction. These and otherobservations had been made in the laboratory, and clinical trials had beenconducted with albumin, before the United States entered World War II; and theywere continued in Zone of Interior hospitals during the early months of Americanparticipation.

On the surface, it appeared that albumin would be an ideal agent for militaryuse. As it was put up, it was ready for immediate administration, noreconstitution being necessary. Its small bulk and ready availability made itparticularly attractive, in view of the limitations of space and weight whichmilitary necessities imposed on the transportation of supplies. It wasremarkably stable. It could be administered in a third to a half of the timerequired for the administration of plasma. Finally, its administration was freefrom the risk of such sequelae as hepatitis and other infections. These variousadvantages suggested that albumin would be particularly useful in forwardinstallations in a combat zone.

Certain disadvantages, however, had to be weighed against these advantages.Albumin is expensive in terms of the quantities of blood needed to prepare it.It was known, before the outbreak of the war, that its effects were likely to betransient. Since the albumin molecule is smaller than the molecule of theglobulins, albumin presumably leaks out of the blood stream more rapidly. Theantibodies naturally present in plasma are, of course, lost as albumin isseparated out of plasma, and it was not known positively during World War IIwhether this loss was important. Finally, the use of undiluted albumin wasdangerous in dehydrated patients.

For an adequate evaluation of its effectiveness, albuminshould have been compared with plasma in a controlled study of its influence onthe cardiac output and blood volume. This apparently had not been done in thevarious studies carried out in civilian hospitals before World War II, and thecombat zone was not the place to pursue such an investigation. When, however,this agent first became available in Italy, in 1944, it was investigated in thefirst 200 patients in whom it was used, with the following results:

Blood-pressure determinations were made at 10-minute intervals in 61 men whohad each received 25 gm. (1 unit) of albumin, and these values were comparedwith similar determinations in 89 patients who had each received 1 unit of plasma. The spread of the initial blood pressures,which were all below 80 mm. Hg, was comparable in both groups, as were the age,the nature of the wounds, the state of hydration, and the general condition ofthe patients. All observations could not be secured in all cases, but theavailable results were as follows:

In 19 cases treated with plasma, in which the average initialblood pressure was 49/21, the average pressure after 1 unit of plasma had beengiven was 88/52 in 15 cases. In 16 cases, the average minimum time required toachieve the maximum blood pressure was 19 minutes, while in 9 cases the averageminimum time for the fall of blood pressure to begin was 29 minutes. In 40 casestreated with albumin, in which the average initial blood pressure was 47/22, theaverage pressure after 1 unit of albumin had been given was 83/53. In 34 cases,the average minimum time required to achieve the maximum blood pressure was 22minutes, while in 19 cases the average minimum time for the fall of bloodpressure to begin was 33 minutes. Comparative studies in other groups of casesin which the initial blood-pressure levels were higher gave results ofsubstantially the same order as these.

These data were supplemented by observations of the general condition, skintemperature, and rate and quality of the pulse in the treated patients. Allthese observations, like the data on the blood pressure, had to be secured underthe crude conditions of a combat zone, but clinically they added up to theconclusion that there was no demonstrable difference in the effects produced bythe administration of 1 unit of albumin and 1 unit of plasma, althoughtheoretically albumin was a much more powerful agent.

Plasma also had certain clinical advantages over albumin. The water in whichit was administered was an asset in a wounded man with a tendency

toward dehydration. Concentrated albumin, on the other hand, depends for itseffects on the withdrawal of fluid from the tissues into the blood stream; ittherefore produces tissue dehydration. In a well-hydrated patient this was not aserious consideration. In a dehydrated patient it was, and in such cases albuminwas administered in physiologic salt solution, usually in the amount of 2 unitsto the liter.

No severe untoward effects were observed from the use of albumin in the 200patients studied. In 2 cases, a mild, transient urticaria was attributed to itsuse, and transient moist rales were observed in another patient with a thoracicinjury. Albumin was always used with caution in patients with thoracic injuries,because of the possible risks of a sudden increase in blood volume.

The limited clinical trials carried out with albumin in theMediterranean Theater of Operations led to the conclusion that its chiefadvantages were its small bulk and ready availability. These propertiessuggested that it might be useful in battalion aid stations and other postsdifficult of access in a combat area, as well as in submarines and ambulanceplanes and for airborne troops. In other words, its usefulness seemed limited toplaces in which space and weight were at a premium. Whether it will be used forthese purposes in a future war will depend upon the general principles by whichmilitary medical supplies are selected.

OTHER FLUID REPLACEMENT THERAPY

Numerous discussions of fluid-replacement therapy during World War II beganwith the injunction to give fluids by mouth if the wounded man would toleratethem. Instructions exactly to the contrary would have been more nearly in linewith good medicomilitary practice. Fluids by mouth were usually definitelycontraindicated before operation, especially if, as was almost always true,anesthesia was to be induced and operation performed within a matter of hours.An additional reason for withholding fluids during this period, aside from thefact that the man might have a gastric or intestinal perforation, was the factthat after wounding the gastric emptying time was always much longer thannormal. Not infrequently, one observed the regurgitation of fluids and foodwhich had been ingested as long as 10 hours earlier.

There were still other reasons for the restriction of oral fluids. They oftenprecipitated vomiting, especially in patients who were already nauseated fromthe administration of morphine. Under these conditions, the net result of theingestion of fluids by mouth was often a loss rather than a gain.

Furthermore, it became increasingly clear as the warprogressed that one of the commonest preventable accidents on all surgicalservices was aspiration of gastric contents into the lungs. Sometimes theaccident was the result of vomiting during anesthesia; very often it was theresult of quiet aspiration, by the deeply anesthetized patient, of gastriccontents forced into the pharynx as the result of surgical manipulations in theupper abdomen. However it

occurred, this was always a serious accident, and it could befatal, especially if it was not realized that it had happened and if no stepswere taken to correct it.

As a general rule, dehydration was not a specialproblem in recently wounded men in the Mediterranean theater, at least when theplan was followed of operating on them as promptly as possible afterresuscitation had been accomplished. If a man complained of thirst, allowing himto rinse his mouth with water or suck a moist sponge would keep him morecomfortable. These simple expedients kept the lips and mouth moist butintroduced no fluid into the gastrointestinal tract. In the occasional case inwhich dehydration was sufficiently marked to require prompt correction, fluidswere administered by the parenteral route, chiefly the intravenous route, in theform of physiologic salt solutions and dextrose solutions.

During periods of heavy action, when scores and even hundredsof wounded men were sometimes awaiting surgery in a single hospital, themaintenance of an adequate fluid intake might become a difficult problem becauseof the delay in treatment. Patients without gastrointestinal injuries weresometimes given fluids by mouth, with due regard to the time they were scheduledfor operation. Others were given subcutaneous injections of physiologic saltsolution or intravenous infusions of 5-percent dextrose in a similar solution.In no circumstances was more than a single liter of fluid given at a singleinfusion or injection, and the quantity administered was just sufficient toprevent dehydration.

At one period during the fighting on the Anzio beachhead,more than 300 patients were awaiting operation at the same time in one of theseveral hospitals in the area. Almost the same situation prevailed in otherhospitals. It would have been a difficult task to keep all of these patientsproperly hydrated and otherwise cared for until their turns came for surgery.The situation was relieved, and the necessity of fluid replacement eliminated,by a shuttle of evacuation planes to the large hospital base at Naples, 40minutes away by air, where there were facilities and personnel for promptoperation on all the patients.

The use of physiologic salt solution and dextrose solutionwas limited to the correction of dehydration. As blood substitutes, thesesolutions were not effective, and they could be dangerous. The elevation inblood volume and blood pressure which they accomplished was so transient as tobe of little value, because the fluid promptly leaked out of the blood stream.If they were used in head injuries in large enough amounts to have a significanteffect on the blood pressure, intracranial pressure might be seriouslyincreased. Finally, their use in patients suffering from pulmonary injuries orin patients whose hearts were already subjected to stress might precipitatepulmonary edema or increase it if it were already present.

OTHER RESUSCITATIVE MEASURES

Relief of pain.-The control of pain under field conditions isdiscussed at length elsewhere in this volume (p. 46), but since it is a part ofresuscitation general principles should be restated here.

FIGURE 4.-Routine of early care of wounded man in forwardhospital. Control of mental and physical distress by sedation (barbiturate) andadministration of morphine.

Severe pain in badly wounded men was found to be much less common than it hadpreviously been believed to be (p. 44). Excitement, fear, hysteria, and therestlessness caused by hemorrhage did not require morphine. They were besttreated by small doses of a barbiturate (fig. 4), such as Sodium Amytal (sodiumisoamylethylbarbiturate, p. 49). Many men reacted better to a cigarette andfriendly reassurance than to a narcotic drug.

Although the principle was not always followed in practice, the only properuse of morphine was for the relief of severe pain. The ideal was to employ thesmallest dose which would be effective. Large dosages caused nausea and vomitingand induced sweating, which led to undesirable losses of fluid. Most dangerousof all the effects of morphine was depression of the respiratory centers, whichresulted in anoxia and was followed by an increase in shock. It was not possibleto standardize dosages, but only occasionally, if at all, was a dose as large as 30 mg. (gr.?) necessary or indicated. Adose of this size was never repeated for at least 4 hours.

When small doses of morphine failed to relieve pain, theexplanation was

often poor absorption of the drug. The peripheral circulationof wounded men with low blood pressure, particularly in cold weather, was oftenso sluggish as to delay the absorption of any drug which had been administeredsubcutaneously or intramuscularly. When relief of pain was urgent, theintravenous route was therefore the route of choice. Almost immediate reliefcould be secured by the intravenous injection, over a period of a minute, of 10mg. (gr. ¹/6) of morphine, or of 15 mg. (gr.?) diluted in not more than 1.0cc. of sterile water.

Proper preparation of the freshly wounded patient for initialwound surgery required not only that his pain be relieved but also that hispsychologic and emotional problems be regarded as real and treated withsympathetic consideration (fig. 5). Understanding of these problems might, atthe moment, seem less important than prompt surgical action, but disregard ofthem could leave psychologic and emotional scars which would be as harmful laterin life as the results of poor surgery.

Management of the local wound.-The local wound in thepreoperative period required little more than the control of hemorrhage and theapplication of splints. Control of hemorrhage was accomplished, in the order ofprefer-

FIGURE 5.-Routine of early care of wounded man in forwardhospital. Spiritual care.

ence, by ligation of the bleeding vessel, insertion of a pressure pack, andthe application of a tourniquet.

A tourniquet was necessarily employed when traumatic amputation had occurredor when a limb was badly mangled and was attached to the body by little morethan shreds of tissue. It was applied just below the site of election foramputation and was not removed until the extremity had been severed.

When a tourniquet was applied to a limb in which there was a possibility ofsalvage, control of hemorrhage was frequently lifesaving, but the risk ofischemia and serious nerve damage was always present. When a tourniquet wasapplied under these circumstances, it was always placed as low on the limb aspossible, and it was not loosened or removed except by a medical officer and notthen until blood was already running into a vein. The risks of ignoring thisprecaution were first pointed out in the Mediterranean Theater of Operations,where it was shown that a man could lose his life from the additional blood losswhich occurred when the tourniquet was loosened or removed casually. If,however, the man's condition was good, his blood pressure normal, the previousblood loss slight, and a medical officer available, then the tourniquet could beremoved at half-hour intervals in an attempt to avoid additional tissue damage.Cooling of the extremity distal to the tourniquet was desirable, particularlywhen the environment was hot.

Temporary splinting of a wounded extremity prevented further damage and lossof blood and prevented or relieved pain. A badly applied splint could, initself, cause pain and do damage. A frequent error early in the Tunisiancampaign was to apply the Thomas splint without removing the shoe. Swellinginvariably occurred distal to the wound and caused great pain, which wasentirely unnecessary. The difficulty was overcome when it became the practice tounlace and slit the shoe if it was left on the foot in the application of aThomas splint.

Position.-The quickest way of improving the wounded man's general conditionon his arrival at the forward hospital was to elevate the foot of the litterabout 12 inches (fig. 3) and permit him to rest in this position, with the headand upper part of the body lower than the rest of the body. In almost all caseswhich were not frankly hopeless, improvement was observed, with return ofperceptible blood pressure, when this position was instituted, even before fluidreplacement had been started. All badly wounded patients were therefore placedin the Trendelenburg position upon their arrival at the forward hospital, unlesscontraindications existed.

Pulmonary edema was one such contraindication. The head-downposition was also used both tentatively and cautiously in patients with chestwounds, in whom it might produce respiratory difficulties, and in patients withhead wounds. If, however, these casualties were in frank shock or had systolicblood pressures below 80 mm. Hg, the Trendelenburg position was employed underclose observation and was maintained unless obvious signs of distress, laboredrespiration, or cyanosis required its abandonment. When once the systolic

blood pressure had risen to 80 mm. Hg, the head of the litterwas gradually elevated; often as long as 20 to 30 minutes were spent in bringingthe patient back to the recumbent position.

Conservation of body heat.-The wounded man frequently arrived at a medicalfacility cold and thoroughly chilled. Additional exposure to cold wouldnaturally have affected him undesirably, but rapid warming was equallyundesirable. Additional fluid loss through perspiration, increased metabolicneeds, and dilatation of the protective vascular constriction were all possibleand dangerous consequences of rapid, careless warming. The problem was toconserve the man's own body heat, not to increase it by artificial means.

Gradual warming was best accomplished by placing the patient in bed in a tentor ward at normal room temperature, with blankets under him as well as over him,while blood replacement was accomplished. Experience showed that this was aneffective means of warming freshly wounded men. During the fighting beforeCassino, although the ground was frozen hard and the nearby mountains werecovered with snow, no other method had to be resorted to in any of thecasualties observed by the surgeons in the mobile hospitals supporting the FifthUnited States Army. Similar observations were made on the Anzio beachhead. Onlyoccasionally, in fact, was artificial heat necessary. In May 1944, when theweather had become warm, one casualty with a rectal temperature of 84^?F. was brought into an army hospital at Anzio. His temperature remained at thislevel for many hours in spite of the application of hotwater bottles to variousparts of the body, and did not reach a normal level for more than 24 hours. Thisman had suffered a blast injury, with intracranial damage which was thought tohave involved the hypothalamic area.

Emptying of the stomach.-Correct preoperative preparation included emptyingof the stomach before anesthesia, to avoid the risk of aspiration of gastriccontents (p. 31). This measure was desirable in all wounded men and urgentlynecessary if food or fluid had been taken after wounding or as recently as 2hours or less prior to wounding. An additional reason for employing it was theobservation that in some cases gastric dilatation might be great enough tointerfere with the circulation. The mechanism of the circulatory improvementwhich was frequently observed after the stomach had been emptied was not clear,but there was no doubt of its occurrence. Possibly the greatly distended stomachinterfered with proper filling of the heart. Another theory was that the vagalreflexes were involved.

Aspiration was occasionally necessary to empty the stomach (fig. 6), but as arule it was better to induce vomiting. The largest size gastric tube that wouldslip down easily was introduced and was manipulated judiciously as it went down.Gastric lavage was seldom necessary and was always contraindicated if thelocation or manifestations of thoracic or abdominal wounds suggested thatperforation of the esophagus or stomach might have occurred.

Oxygen administration.-Oxygen inhalations (fig. 7) were usedfreely for resuscitation during World War II, for the logical reason that theyproduced definite signs of clinical improvement in the form of a lowered pulserate and

FIGURE 6.-Routine of early care of wounded man in forward hospital. Emptyingof stomach.

a better coloration of the blood. Whether they were of lifesaving value inthe management of severely wounded men was not established.

In the discussions of the use of oxygen, much was made of the fact thatcyanosis will not appear as long as hemoglobin concentration is maintained atabout a third of normal. Such low levels were not common in freshly

FIGURE 7.-Routine of early care of wounded man in forwardhospital. Artificial respiration with oxygen.

wounded men. In a study of 37 severely wounded men filteredout from 2,853 casualties¹³who, for the most part, had sustainedtheir wounds on the Anzio beachhead, the average hemoglobin level was still 12.3gm. percent at the end of 4? hours after wounding, becausesufficient time had not yet elapsed for complete blood dilution. The hematocritvaried. It was in the twenties in 5 of these cases, in the thirties in 16, andbetween 40 and 44 in 8. In the remaining case in which it was determined, it was50.

Cyanosis was a more important and a more readily detectablesign of anoxia and oxygen deficiency than low hemoglobin levels. It wasfrequently overlooked, however, because of hasty examination under poor light inthe preoperative tent. When it was present, an increase in the oxygen tension ofthe inspired air was undoubtedly desirable, though to what degree this objectivewas achieved in the field by the use of oxygen was open to considerablequestion. When oxygen was employed on any indication except respiratoryobstruction or respiratory depression, it was used with the full realizationthat the patient's chief needs were an increase in the volume of the circulatingblood and in the total quantity of circulating hemoglobin in the blood.

¹³See footnote 1, p. 5.

Oxygen was most conveniently administered by nasal tube,after it had been humidified by being bubbled through a water column. Thetechnique made it possible to service 4 or 5 patients from a single oxygen tank.A small catheter (12 to 14, French), well lubricated, was inserted into thenasal pharynx until the patient was observed to swallow a bolus of air. The tubewas then withdrawn for half an inch and was firmly anchored to the cheek withadhesive tape. The correct distance of insertion was ordinarily about half aninch less than the distance between the ala nasi on one side and the lobe of theear on the same side.

A gas flow of 4 to 5 liters per minute of 100-percent oxygen was usually welltolerated. If signs of oxygen deficit were not promptly relieved, higherconcentration in the alveoli could be achieved through a closed system (fig. 7)with carbon dioxide absorption. The Beecher anesthesia machine provedsatisfactory for this purpose.

Oxygen in high concentrations was not given continuously formore than 12 hours at a time. If, as occasionally happened, it was requiredbeyond this time, the periods of administration in high concentrations werealternated with 12-hour periods during which the concentration was reduced to 50to 60 percent. Care had to be taken to avoid gastric dilatation, particularly inunconscious patients.

Drugs.-Vasoconstrictor and stimulating drugs were of littleor no value in the management of freshly wounded men and were almost never used.When they were employed, it was always in small dosages.

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