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

Military Medicine, Apr 2004 by Hardaway, Robert M

The administration of whole blood was thought to be extremely effective and was fairly widely used. It was stated that "blood can permanently raise arterial pressure, or gum salt solution can; but in addition [blood] contributes to the recipient a large increase of oxygen-carrier, the red corpuscles."9

Methods of processing and administering blood were relatively primitive. A transfusion apparatus for administering 600 mL of blood mixed with 100 mL of sodium citrate in 0.9% saline solution was most commonly used. Blood typing was done routinely. It was thought that more than 600 mL of blood was unnecessary, and more than this volume was seldom given. Blood was given immediately or within a few hours of being drawn from the donor. It was also thought that no matter what solution was given (blood, gum salt, or saline), the blood volume increased by only a fraction of the amount given due to the escape of considerable fluid into the tissue. This concept was based on blood volume measurements. This presaged the recognition years later in Korea that much more blood must be given than was lost to gain an adequate blood volume. The primary reason for this is still controversial, but is probably due to the pooling of blood in certain capillary beds with subsequent hemolysis and, in part, loss of fluid into the tissues.

In the standard treatment of shock as described in Army manuals, considerable attention was given to warmth, and special heating chambers were used, as well as blankets. However, it was appreciated that too much warmth would aggravate dehydration. The importance of elevating the feet in shock was also emphasized. The need for oxygen administration was intimated by the observation of a "slight cyanotic appearance," but the means for administering oxygen were not available during World War I.

It is interesting to note that vasoconstricting drugs such as epinephrine were condemned as causing a decrease in blood flow and tissue perfusion, and they practically disappeared from use during the war. This advanced concept was forgotten after World War I and was still not completely accepted in 1965. In 1918, it was thought that the "increased arterial pressure (after epinephrine) gave a wholly spurious impression of the state of circulation. Damming the blood in the arterial portion of the circulatory system, when the organism is suffering primarily from a diminished quantity of blood obviously does not improve the flow in the capillaries."9 We now know that the administration of vasopressors to a patient in hypovolemic shock will result in two very adverse effects: the onset of a severe acidosis with lactate levels of up to 131 mg percent and arterial pH of 7.0 or less, and elevation of central venous pressure to levels that preclude administration of IV fluids, which is what the patient needs.13 In fact, so dire were the consequences of vasopressors in this setting that, in Vietnam, they were dubbed "lethophed."

World War II

It is interesting that concepts of shock in World War I were quite advanced and in many ways superior to those of early World War II. The United States entry into World War II in 1941 began as a complete surprise and with complete unpreparedness. This lack of preparation is well illustrated by my own experience in October 1941, when I was assigned to the North Sector General Hospital. That was then the main Army hospital in Hawaii, having 1,000 beds and being much larger than Tripler, which was then a small wooden hospital at Fort Shafter. There, I was appointed Chief of Septic Surgery, a section of the surgical service treating trauma, infections, burns, and miscellaneous conditions not abdominal. I had about 100 beds on two wards and nearly that many patients.