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

Military Medicine, Apr 2004 by Hardaway, Robert M

The first written documentation of resuscitation in World War II was a year after Pearl Harbor, in December 1942, from the 77th Evacuation Hospital in North Africa, as follows: "The wounded in action had for the most part either succumbed or recovered from any existing shock before we saw them. However, later cases came to us in shock, and some of the early cases were found to be in need of whole blood transfusion. There was plenty of reconstituted blood plasma available. However, some cases were in dire need of whole blood. We had no transfusion sets, although such were readily available in the United States; no sodium citrate; no sterile distilled water; and no blood donors."16

Hospital mortality was moderate, but many wounded died before getting to a hospital. The initial decision to rely on plasma rather than blood appears to have been based, in part, on the view held in the Office of the Surgeon General of the Army and, in part, on the opinion of the civilian investigators of the National Research Council that in shock, the blood was thick and the hematocrit high.

According to the Surgeon General's report during World War II, "The Army would likely discourage the use of blood banks. If war should come closer, they might want to use blood that could be transported by airplane. In more distant places where blood could not be procured locally, plasma (either plain or dried) would have to be used."16

Thus, the U.S. Army entered World War II considerably behind the standards of World War I, particularly regarding blood. In fact, on April 8, 1943, the Surgeon General stated that no blood would be sent to the combat zone.16 On November 13, 1943, the Surgeon General again refused to send blood overseas, citing three reasons: 1) His observation in overseas theaters had convinced him that plasma was adequate for resuscitation of wounded men; 2) From a logistics standpoint, it was impractical to make locally collected blood available farther forward than general hospitals in the Communications Zone; and 3) Shipping space was too scarce.

However, things soon looked up. Dr. Churchill, the Surgical Consultant in the North African Theater of Operations, reported on April 16, 1943 that "there is a need for whole blood transfusion in the treatment of a significant portion of wounded."16 He recommended that a system to provide whole blood to the combat wounded be established immediately. Dr. Douglas Kendrick organized the system. The story of the development of a system of whole blood distribution is one of the most important events of the medical history of World War II.

In general, the use of whole blood in World War II was to replace blood lost, volume for volume. This concept was later found to be inadequate in Korea and Vietnam, where it was soon recognized that it was necessary to give much more blood than was actually lost.

In World War I, shock was attributed to inadequate capillary perfusion, but this lesson was soon forgotten, and during World War II, the concept of inadequate arterial blood pressure was given precedence. The importance of timeliness in preventing and treating shock received a setback when it was stated by the Surgeon General, "There was no correlation between passage of time and shock encountered."16 This was very misleading. The reason there appeared to be no correlation was that most of the wounded who were in shock died before they arrived at a treatment facility, or they may never have reached the facility. If wounded arrive at a hospital in less than 1 hour, as usually occurred in Vietnam, many of them are saved. This is in spite of the fact that the mortality of those reaching the hospital in less than 1 hour is twice that of those who arrive after surviving an 18-hour delay. This, of course, increases the hospital mortality rate, even though many additional lives are saved.