Beecher (1955), in the Surgeon General of the Army's Surgery in War Worm II, warned that crystalloids should be used primarily to replace body fluid lost through dehydration and stated that "As blood substitutes, these solutions were not effective, and they could be dangerous" (p. 32). Despite this concern, massive transfusion with crystalloid was routine during the Vietnam conflict. Additionally, studies undertaken during and immediately following the Vietnam conflict raised the concern that a large volume of salt-containing solution increased the incidence of acute respiratory distress syndrome (ARDS) and promoted multiple-organ dysfunction syndrome (MODS; see Figure 3-1). A loss of endothelial integrity and capillary leak coupled with the infusion of protein-free fluid, which in turn diluted plasma proteins, could contribute to pulmonary edema. A significant emphasis was subsequently placed on acute respiratory failure as well as ventilatory management in the shock patient with massive blood losses. Despite the lessons learned in Vietnam (increased incidence of pulmonary failure and ARDS with aggressive fluid resuscitation from shock), crystalloid solutions gained increasing acceptance in both clinical and military areas for fluid resuscitation from trauma. Studies with baboons and sheep confirmed that the hypoproteinemia that occurs after resuscitation with salt-containing solutions did not promote water movement into the lung interstitium (Moss et al., 1981). These studies contributed to increased acceptance of crystalloid volume replacement.