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

Military Medicine,  Apr 2004  by Hardaway, Robert M

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The Japanese attack on Pearl Harbor on December 7, 1941 resulted in several hundred army wounded at Schofield Barracks and Wheeler Field.14 I operated on some 400 of them. About 160 of these were the result of bomb fragment and machine gun wounds from Japanese planes as they repeatedly strafed the barracks. Even the hospital came under fire, as it was located at the end of the row of barracks. Many more soldiers were wounded that day and in the days after by "friendly fire." Blackout was enforced immediately, and for several nights, any light or noise was a target. Wounded soldiers at Schofield Barracks were wounded within a mile of the hospital. Medical evacuation was swift, and the wounded were brought directly to the hospital for definitive treatment. This was fortunate, as casualties in North Africa and Europe were evacuated from much greater distances, taking far more time to reach a treatment facility. Hospital mortality figures at Schofield appeared to be unreasonably high compared with those arenas, however, precisely because more of the mortally wounded actually reached the hospital while they were still alive. These soldiers would have died in the field in North Africa and Europe, and would not have been added to hospital mortality statistics. Also contributing to the high hospital mortality in Schofield was the lack of IV fluids (blood and saline). I found that the dried plasma supply was so limited as to be almost useless. It came in 200-cc bottles into which 200 mL of distilled water was injected. Years later, it was discovered that much of the pooled dried plasma was contaminated with hepatitis virus. No other IV solutions were available at that time. Even normal saline had limited use due to the difficulty of its preparation. It was prepared from distilled water made by a small still in the operating room. A spoonful of salt was dissolved in it and the salt water was put in a Salversan flask, a glass cylinder about 12 × 1.5 inches with an outlet at the bottom to which was attached an old rubber tube and needle. The tube was sterile but so filled with pyrogens that a patient would often have a fever of 105 degrees or so if given this homemade solution.

At that time, shock was considered to be characterized by a low blood pressure and a high hematocrit. In fact, this was the official opinion of the National Research Council and the Army. Plasma was thought to be adequate, and blood was not recommended. There were not even any blood banks in the Army. Blood was given occasionally, usually to a patient with sepsis, and then only in small amounts (100 to 150 mL) by the direct method involving a syringe and three-way stopcock. The syringe was washed with a heparin solution, and then 30 mL of blood was pulled from the donor lying beside the patient. By turning the stopcock, the blood was then injected into the patient. Having both needles patent at once was always difficult.

It was soon evident that this misunderstanding of shock was a major problem. The result was a high mortality rate. The hospital mortality of soldiers admitted to the North sector General Hospital on December 7, 1941 was 20%,14 whereas that of combat wounded in Vietnam was 1.8%.15 It was a case of forgetting what had been learned in World War I, when it was recognized that shock and resuscitation were important, and that IV fluids and blood were required and should be given in large amounts. It was only much later, in 1942, during the African campaign, that Dr. Churchill, surgical consultant for the theater, saw the great need for blood in treating shock. His recommendation resulted in setting up the great blood transfusion program that proved so essential for the rest of the war.16