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Wound Shock: A History of Its Study and Treatment by Military Surgeons

Military Medicine, Apr 2004 by Hardaway, Robert M

The treatment of wounds has received considerable attention from the time of the Trojan War. However, it was not until the American Civil War that shock was described as an entity distinct from the wounds themselves and that efforts were directed at more than just treatment of the wound. The need for fluid resuscitation in the treatment of hemorrhagic shock was first recognized in the Spanish American War, as was the association of sepsis with shock. World War I showed the need for blood in the treatment of "wound shock," a lesson that had to be relearned in World War II through bitter experience. Studies in the Korean War described the concept of disseminated intravascular coagulation and multiple organ failure, and the existence of disseminated intravascular coagulation was confirmed by studies in Vietnam. The treatment of hemorrhagic shock is now very effective, but the treatment of traumatic and septic shock remains unsatisfactory.

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Introduction

Shock is the most common cause of death in noncardiac intensive care units.1 It has long been closely associated with wounds and in fact was called "wound shock" up until World War II. Shock has since been divided into hemorrhagic, traumatic, and septic categories, all of which frequently accompany severe wounds.

Early European Wars

During the Trojan War in 1200 BC, the first treatment for war wounds was recorded by Homer,2 who gave the mortality of war wounded as 77%. He offered the opinion that "Surgeons are worth more than armies to the public weal." Although he was probably overly enthusiastic, it is certain that the treatment of war wounded was carried out and considered important.

Over five centuries of Roman wars, Roman Legions always had a combat surgeon for each legion and maintained a surgical hospital at each legion fort. These were the first trauma centers. The foundations of these Roman military hospitals can still be seen in England and Germany. The concept of what actually caused wounded soldiers to die was vague and not thought about except perhaps to note that they could bleed to death.

During the European Wars of the 18th and 19th centuries, among the first to wonder why wounded soldiers died was the French surgeon Henri Francois Le Dran,3 who, in 1731, described a collapse of vital functions, which ended in death after being hit by a missile. He called it "secousse" (jar). Gross,4 in 1850, described shock as the "rude unhinging of the machinery of life."

Cooper,5 in 1838, in discussing gunshot wounds of the Crimean War, stated that many wounded soldiers died without significant loss of blood, severe pain, or serious injury. Surgeons "were in the habit of saying men died of shock." Shock was completely separated from hemorrhage. It was recognized that soldiers could bleed to death, but if there was little obvious hemorrhage, then death was attributed to "shock," a mysterious and indefinable death.

Early American Wars

After the British American War of 1812, Horner6 noted that the survival rate was higher in wounded soldiers whose amputation of a wounded extremity was postponed rather than performed at the first possible moment. Nevertheless, amputation as a prevention of gangrene and death persisted in the American Civil War. It was not until World War I that debridement replaced amputation for the prevention of infection in the war wounded. In spite of the fact that gangrene was a greatly feared cause of death, it was generally considered that shock itself was always secondary only to trauma. Septic shock was not thought of as shock until about 1898, during the Spanish American War.

The American Civil War of 1860 to 1865 saw the first efforts to treat "wound shock" as distinct from the injury alone. Infection and hemorrhage were the most common causes of death in the wounded. The possibility that shock and severe hemorrhage were the same was considered, but the concept persisted that they were different entities. In his history of the Civil War, written in 1876, Barnes, Surgeon General of the Army, stated "It is an open question whether a blow to the abdomen may produce death without an organic lesion. If pain is persistent and radiating from one spot, it may signify internal trouble and if collapse returns a few days after injury, it is supposed to mean internal hemorrhage. The collapse of bleeding, however, resembles syncope as distinguished from shock. Rest in bed, opium and warm fomentations constitute the treatment."7

It was during the Spanish-American War of 1898 that shock was first associated with sepsis. In speaking of the many wounded soldiers whose wounds were infected with Bacillus aerogenes capsulatus and gas gangrene, the Army Surgeon General stated in 1900, "Extreme degree of shock, with all its accompanying symptoms, was a marked feature of all of these cases." In this same report, it was noted how effective normal salt solution was in treating hemorrhage. "A soldier was stabbed in the neck, and the left common carotid artery and jugular vein were cut. He became exsanguinated and lost consciousness. The vessels were ligated and the patient given normal salt solution by enema and subcutaneous injection. The survival of this almost bloodless patient for 16 hours was attributed to the free use of salt solution. Patients in a state of shock were given normal salt solution rectally and subcutaneously, strychnine 1/60 grain, covered with blankets and kept warm."8

Health Care Industry

Wound Shock: A History of Its Study and Treatment by Military Surgeons

Military Medicine, Apr 2004 by Hardaway, Robert M

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