260 JOSEPH C. AUB 



alkali reserve, and also a diminished total metabolism. At the same time 

 that there is a diminished metabolism, there is an accumulation in the 

 blood of non-protein nitrogen and particularly of creatin, which suggests 

 that products of muscle necrosis are appearing in the blood stream. None 

 of the constituents analyzed are in the least toxic, or could be the cause 

 of shock, yet it is possible that some other chemical substances may accom- 

 pany them into the blood stream which may be toxic in their action, some 

 such substance possibly as histamin, which has been extensively studied by 

 Dale and Laidlaw (a) as the cause of one form of shock. 



Treatment of Shock 



From these considerations, the treatment usually recommended in 

 shock becomes logically indicated. With the reduced temperature so dis- 

 tinctly seen in the condition, and with the reduced metabolism, which has 

 been demonstrated, it is clear that warming the body by outside heat is 

 indicated. It is, therefore, wise to maintain body heat as near normal 

 as possible, and if it has fallen, to raise it promptly to its original level. 

 This can most readily be done by a hot air bath and hot water bottles, 

 but great good can be accomplished by giving very warm and large drinks 

 of fluid ; and strong coffee with its stimulating effect seems to be beneficial. 

 The second important indication is to increase the blood volume. This 

 may be very readily accomplished by forcing fluids by mouth and rectum, 

 as shown by Robertson and Bock. If vomiting is present, fluids must be 

 forced preferably by rectum but they may also be given intravenously. 

 But in severe shock with low blood pressure where it is important for the 

 vital centers to have the blood pressure promptly raised, immediate trans- 

 fusion is of great value. Blood is the medium of choice, and if it can 

 possibly be obtained should always be used. If blood is not available, how- 

 ever, the gum acacia solution suggested by Bayliss (a) is the next choice, 

 since it maintains a normal blood pressure for a far longer period than will 

 saline solution. Raising the blood volume is of the utmost importance, 

 and associated with the transfusion of blood, one should never forget that 

 forcing fluids over a long period of time is of great therapeutic value. 

 These fluids, of course, should be warm. Giving large doses of morphin 

 is usually recommended, but except to quiet the patient, the logical reason 

 for its use is difficult to understand. The first treatment of shock should 

 take the form of preventive measures, and particularly in hospitals where 

 patients can be watched from the beginning, a severe prolonged shock 

 should never be allowed to develop. As the blood pressure begins to fall, 

 prompt action in forcing fluids and in applying warmth should be insti- 

 tuted to keep the blood pressure above the critical level of 80 mm. Hg. 



The treatment of the metabolic conditions accompanying traumatic 



