RENAL COMPLICATIONS OF BATTLE INJURIES
1
658 producing enterotoxin were found in 30 of the 32 patients. Surgalla and Dack conclude that, whereas in food- poisoning toxin is developed in the food before ingestion and not afterwards, in enterocolitis toxin production persists within the body’ as long as competing members of the gut flora are suppressed by continued antibiotic therapy. RENAL COMPLICATIONS OF BATTLE INJURIES CHANGES in renal function are part- of the normal reaction to severe injury and result in oliguria with temporarily increased excretion of potassium, nitrogen, phosphorus, and sulphur, and reduced excretion of sodium and chloride. True renal failure is, however, a rare complication of injury ; and it is seldom diagnosed at an early stage, possibly because its most obvious early indication-reductidn in the volume of urine-coincides in time with the oliguria which normally follows severe injury. True renal failure after injury is very commonly fatal. Beecher reported a mortality-rate of 65% in 78 patients with this complication. Only 47% of those with oliguria died, compared with 91% of those with anuria ; in this series 94% of the deaths occurred within ten days of the injury. Of 100 fatal cases reported by Lucké,2 74 of the deaths occurred within eight days of injury. With improved understanding of the disorders which accompany acute renal failure the futility of attempts to bring about diuresis by massive intravenous infusions has been recognised, and accordingly the incidence of waterlogging has been reduced. In addition, potassium intoxication is now recognised as the commonest single factor in bringing about death, and measures to remove potassium from the extracellular fluid are widely, though not always successfully, practised. The management of the primary injury is greatly impeded by acute renal failure. This is well illustrated by Balch et al.,3 who discuss the surgical care of 37 patients admitted to a renal centre established in Korea in 1953. 2 of their patients had been injured in road accidents, 1 was severely burned, and the remainder had suffered wounds due to various types of missile. Resusci- tation and primary operation had been carried out in other surgical units, and the patients were evacuated by air to the renal centre when renal failure was suspected because urinary output had fallen below 500 ml. per twenty-four hours although the systolic blood-pressure exceeded 90 mm. Hg. In the renal centre fluid intake (excluding transfused blood) was restricted to 500-800 ml. per day beyond a volume equal to the fluid output. It was found that the plasma-potassium level tended to fall when a sodium deficit was made good, or after the administration of hypertonic glucose solution with insulin ; administration of calcium reduced the clinical effects of a high extracellular-potassium level without altering the plasma-potassium level. Dialysis was employed when these measures failed. In 18 of the 24 oliguric patients dialysis was applied, usually more than once, and 6 survived. Balch et al. emphasise that such special treatment for acute renal failure will not avail in the presence of other complications such as infection, especially of dead muscle. Of 16 patients in whom the plasma-potassium level exceeded 6 m.eq. per litre I were submitted to dialysis and only 2 survived, but Balch et al. believe that the elimination of the renal factor by dialysis reduced the mortality-rate and may have pro- longed survival in some who died. When dialysis corrected the biochemical alterations in the extracellular fluid but the clinical manifestations of " uraemia " persisted, it was found that some other cause, such as sepsis, was responsible for the persisting symptoms and clinical disturbance. Of the 37 patients, 24 were oliguric 1. Beecher, H. K. The Physiologic Effects of Wounds. Washing- ton, D.C., Office of the Surgeon-General, Department of the Army, 1952. 2. Lucké, B. Milit. Surg. 1946, 99, 371. 3. Balch, H. M., Meroney, W. H., Sako, Y. Surg. Gynec. Obstet. 1955, 100, 439. and 18 (75%) of these died ; of 13 who were not oliguric 8 (62%) died. The average day of death was 8 in the oliguric group and 6 in the non-oliguric patients. Balch et al. make clear the initial difficulty of early diagnosis of renal failure and emphasise that the general policy was to avoid moving hypotensive patients from surgical units to the renal centre. Nevertheless 9 patients with per- sistent hypotension were evacuated to the centre because of oliguria ; oliguria persisted after resuscitation in 3 of these, and 2 others could not be resuscitated. That only 3 of these 9 patients survived for more than two days and only 2 recovered is some indication of the grave condition of the patients, but also raises the question whether they should have been moved at all; 6 of them had sustained extensive abdominal injuries. In this series the primary cause of death was estab. lished in 21 out of 26 cases. In 11 this was infection of some kind, and in.7 7 of these cases there was evidence of more or less extensive myositis. Myositis occurred in 18 of the 37 patients, and the need to reamputate or excise extensive areas of necrotic muscle in both the illustrative cases cited in the report implies that primary wound treatment was inadequate. - The kind of severe bodily disturbance described in this report is not uncommon also in civilian injuries, and its treatment demands a high degree of surgical skill and knowledge. That such patients survive at all is due to the efforts of those responsible for the primary treatment. Balch et al. emphasise that their studies have cast no new light on etiology, but they note the importance of the high incidence of infection. The early complete excision of all dead and damaged tissue until only quivering bleeding muscle remains, and the decompression of through-and-through limb wounds by division of fascia and the removal of foreign bodies, have been the foundations of successful early surgery in both world wars ; the part played by the antibiotics is valuable but secondary. A significant infection occurred in 83% of the oliguric and in 63% of the non-oliguric patients of this series. Severe infection may have a noxious effect on the circulatory system as well as on renal function. COMICS IN British Comics : an Appraisal the" " Comics " Campaign Council examines the contents of existing " comics " and puts forward some useful suggestions for their future development. The council lacks neither sympathy nor insight. " If," it says, " many comics are studied, certain recurring themes can be noted: children having adventures on their own, children coming to the rescue of adults, adults making erroneous decisions, adults who are unkind to children meeting disaster, and so on. Adults enjoy a funny picture of a tiresome child, children enjoy funny pictures of tiresome adults even more. Children have to put up with so much correction from adults ; we should not forget the burden of frustra- tion which we have to put upon them. Many of the situations in comics are as improbable as day-dreams, but this does not bother the children any more than the improbabilities of an adult cartoon bother the adults." Something like 350 million comics are bought annually by our children ; and it is’believed that on. an average each comic bought is seen by eight children. The council does not hazard an estimate of the number of adult readers. THE Federation Internationale Pharmaceutique is holding its 16th general assembly in London this week under the presidency of Sir Hugh Linstead, M.p. At the opening meeting on Monday Mr. lain Macleod, on behalf of the Government, and Mr. H. Steinman, on behalf of the Pharmaceutical Society of Great Britain, welcomed over 1000 delegates from 46 countries. 1. Edited by Miss P. M. Pickard. Obtainable from the secretary of the council, Dr. S. Yudkin, 23, Tillingbourne Gardens, London, N.3. Pp. 32. 1s. 7 1/2 d. post free.
Transcript of RENAL COMPLICATIONS OF BATTLE INJURIES
658
producing enterotoxin were found in 30 of the 32 patients.Surgalla and Dack conclude that, whereas in food-
poisoning toxin is developed in the food before ingestionand not afterwards, in enterocolitis toxin productionpersists within the body’ as long as competing membersof the gut flora are suppressed by continued antibiotictherapy.RENAL COMPLICATIONS OF BATTLE INJURIES
CHANGES in renal function are part- of the normalreaction to severe injury and result in oliguria withtemporarily increased excretion of potassium, nitrogen,phosphorus, and sulphur, and reduced excretion ofsodium and chloride. True renal failure is, however, arare complication of injury ; and it is seldom diagnosedat an early stage, possibly because its most obvious earlyindication-reductidn in the volume of urine-coincidesin time with the oliguria which normally follows severeinjury. True renal failure after injury is very commonlyfatal. Beecher reported a mortality-rate of 65% in 78patients with this complication. Only 47% of those witholiguria died, compared with 91% of those with anuria ;in this series 94% of the deaths occurred within ten daysof the injury. Of 100 fatal cases reported by Lucké,274 of the deaths occurred within eight days of injury.With improved understanding of the disorders whichaccompany acute renal failure the futility of attempts tobring about diuresis by massive intravenous infusionshas been recognised, and accordingly the incidence ofwaterlogging has been reduced. In addition, potassiumintoxication is now recognised as the commonest singlefactor in bringing about death, and measures to removepotassium from the extracellular fluid are widely, thoughnot always successfully, practised.The management of the primary injury is greatly
impeded by acute renal failure. This is well illustratedby Balch et al.,3 who discuss the surgical care of 37
patients admitted to a renal centre established in Koreain 1953. 2 of their patients had been injured in roadaccidents, 1 was severely burned, and the remainder hadsuffered wounds due to various types of missile. Resusci-tation and primary operation had been carried out inother surgical units, and the patients were evacuated byair to the renal centre when renal failure was suspectedbecause urinary output had fallen below 500 ml. pertwenty-four hours although the systolic blood-pressureexceeded 90 mm. Hg. In the renal centre fluid intake
(excluding transfused blood) was restricted to 500-800ml. per day beyond a volume equal to the fluid output.It was found that the plasma-potassium level tended tofall when a sodium deficit was made good, or after theadministration of hypertonic glucose solution withinsulin ; administration of calcium reduced the clinicaleffects of a high extracellular-potassium level withoutaltering the plasma-potassium level. Dialysis was
employed when these measures failed. In 18 of the 24
oliguric patients dialysis was applied, usually more thanonce, and 6 survived. Balch et al. emphasise that suchspecial treatment for acute renal failure will not availin the presence of other complications such as infection,especially of dead muscle. Of 16 patients in whom theplasma-potassium level exceeded 6 m.eq. per litre I weresubmitted to dialysis and only 2 survived, but Balch et al.believe that the elimination of the renal factor bydialysis reduced the mortality-rate and may have pro-longed survival in some who died. When dialysiscorrected the biochemical alterations in the extracellularfluid but the clinical manifestations of " uraemia "
persisted, it was found that some other cause, such assepsis, was responsible for the persisting symptoms andclinical disturbance. Of the 37 patients, 24 were oliguric1. Beecher, H. K. The Physiologic Effects of Wounds. Washing-
ton, D.C., Office of the Surgeon-General, Department of theArmy, 1952.
2. Lucké, B. Milit. Surg. 1946, 99, 371.3. Balch, H. M., Meroney, W. H., Sako, Y. Surg. Gynec. Obstet.
1955, 100, 439.
and 18 (75%) of these died ; of 13 who were not oliguric8 (62%) died. The average day of death was 8 in theoliguric group and 6 in the non-oliguric patients. Balchet al. make clear the initial difficulty of early diagnosis ofrenal failure and emphasise that the general policy was toavoid moving hypotensive patients from surgical unitsto the renal centre. Nevertheless 9 patients with per-sistent hypotension were evacuated to the centre becauseof oliguria ; oliguria persisted after resuscitation in 3 ofthese, and 2 others could not be resuscitated. That only3 of these 9 patients survived for more than two daysand only 2 recovered is some indication of the gravecondition of the patients, but also raises the questionwhether they should have been moved at all; 6 of themhad sustained extensive abdominal injuries.
In this series the primary cause of death was estab.lished in 21 out of 26 cases. In 11 this was infection ofsome kind, and in.7 7 of these cases there was evidence ofmore or less extensive myositis. Myositis occurred in 18of the 37 patients, and the need to reamputate or exciseextensive areas of necrotic muscle in both the illustrativecases cited in the report implies that primary woundtreatment was inadequate. -
The kind of severe bodily disturbance described in thisreport is not uncommon also in civilian injuries, and itstreatment demands a high degree of surgical skill andknowledge. That such patients survive at all is due tothe efforts of those responsible for the primary treatment.Balch et al. emphasise that their studies have cast nonew light on etiology, but they note the importance ofthe high incidence of infection. The early completeexcision of all dead and damaged tissue until onlyquivering bleeding muscle remains, and the decompressionof through-and-through limb wounds by division offascia and the removal of foreign bodies, have been thefoundations of successful early surgery in both worldwars ; the part played by the antibiotics is valuable butsecondary. A significant infection occurred in 83% ofthe oliguric and in 63% of the non-oliguric patients ofthis series. Severe infection may have a noxious effecton the circulatory system as well as on renal function.
COMICS
IN British Comics : an Appraisal the" " Comics "
Campaign Council examines the contents of existing" comics " and puts forward some useful suggestions fortheir future development. The council lacks neither
sympathy nor insight. " If," it says, " many comicsare studied, certain recurring themes can be noted:children having adventures on their own, children comingto the rescue of adults, adults making erroneous decisions,adults who are unkind to children meeting disaster, andso on. Adults enjoy a funny picture of a tiresome child,children enjoy funny pictures of tiresome adults evenmore. Children have to put up with so much correctionfrom adults ; we should not forget the burden of frustra-tion which we have to put upon them. Many of thesituations in comics are as improbable as day-dreams, butthis does not bother the children any more than theimprobabilities of an adult cartoon bother the adults."Something like 350 million comics are bought annuallyby our children ; and it is’believed that on. an averageeach comic bought is seen by eight children. Thecouncil does not hazard an estimate of the number ofadult readers.
THE Federation Internationale Pharmaceutique isholding its 16th general assembly in London this weekunder the presidency of Sir Hugh Linstead, M.p. At theopening meeting on Monday Mr. lain Macleod, on behalfof the Government, and Mr. H. Steinman, on behalf ofthe Pharmaceutical Society of Great Britain, welcomedover 1000 delegates from 46 countries.
1. Edited by Miss P. M. Pickard. Obtainable from the secretaryof the council, Dr. S. Yudkin, 23, Tillingbourne Gardens,London, N.3. Pp. 32. 1s. 7 1/2 d. post free.
