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Chapter 1

Contents

Part I

RESUSCITATION, CONTROL OF PAIN, AND ANESTHESIA


CHAPTER I

Resuscitation of Men Severely Wounded in Battle

Henry K. Beecher, M. D.*

THE EVOLUTION OF METHODS OF RESUSCITATION IN THE MEDITERRANEAN THEATER

The fighting in the Mediterranean (North African) Theater of Operations in World War II began in November 1942 and ended early in May 1945. As a whole, the campaigns carried out during this time were among the longest fighting conducted by any American army since the Civil War. From the medical standpoint, and entirely aside from any military considerations, the duration of combat provided the inestimable advantage of time for the evolution of sound medical practices, for the correction of errors, and for the development of expeditious medicomilitary methods.

The two case histories which follow illustrate excellently how, over this period, earlier, erroneous concepts of therapy gave way to advanced, sounder concepts:

Case 1.-On 21 March 1943, during the fighting in Tunisia, an infantryman sustained a compound fracture of the left humerus and a laceration of the left side of the chest from a shell fragment. He was tagged at a regimental aid station at 1100 hours. First aid consisted of the intramuscular injection of 30 mg. (gr. ) of morphine and the application of sulfanilamide-powdered dressings and a Thomas arm splint. At the division clearing station, the man was given 1 cc. of tetanus toxoid and 500 cc. (2 units) of blood plasma. His general condition was not described on the medical tag.

During the afternoon of the same day, the patient was evacuated to a field-type hospital. At 1715 hours, his blood pressure was recorded as 110/70 and his pulse rate as 120. Examination revealed absent breath sounds and hyperresonance on the left side of the chest, with abdominal rigidity and tenderness. At 1745 hours, he was given a second transfusion of 500 cc. (2 units) of blood plasma. Roentgenologic examination of the left arm revealed a fracture of the lower third of the humerus, with lateral bowing. Fluoroscopic examination of the chest and upper abdomen showed increased density in the left hemithorax; the mediastinum was pushed over to the right, apparently by fluid. A large foreign body was observed in the region of the stomach. As there was no evidence of sucking in the chest wound, it was closed by suture. The diagnosis at this time was a combined thoracoabdominal wound, with rupture of a viscus and probable hemorrhage.

The blood pressure at the time the fluoroscopic examination was conducted was satisfactory, and the pulse was of fair quality. Immediate operation was therefore undertaken, after a transfusion of 500 cc. of whole blood. As soon as the abdomen was opened, through a long left rectus incision, there was a gush of blood and air. Respiratory difficulty was apparent immediately. The patient's condition improved after a 4-cm. laceration of the

*Except as otherwise noted, part I is based upon the personal experience of the author as consultant in resuscitation and anesthesia, North African-Mediterranean Theater of Operations, and upon reports submitted to him.


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dome of the abdomen had been closed. A 10-cm. laceration of the stomach, near the greater curvature, was also closed. It had been caused by a shell fragment 1 by 1 by 3 cm. The only other intraperitoneal injury was a small laceration of the spleen, which was not bleeding. The incision in the abdominal wall was closed after 12 gm. of sulfanilamide powder had been dusted into the peritoneal cavity.

Shortly after the operation had been concluded, sucking became apparent in the chest wound at the site of entrance of the missile, where simple suture closure had been done. Closed drainage was established at once, and the wound was packed tightly with vaseline gauze. The patient became deeply cyanotic, in spite of these measures, and died 21 March at 2315 hours, a little over 12 hours after injury.

Case 2.-On 21 April 1945, during the fighting in the Po Valley, a 26-year-old infantryman received compound fractures of the left femur and both ankles, a penetrating wound of the chest with hemothorax, and multiple lacerations of the legs and face from shell fragments. In the collecting station, to which he was brought at 1315 hours, 15 minutes after injury, he was given 15 mg. (gr. ) of morphine and 1,500 cc. (6 units) of blood plasma. Dressings were applied to his various wounds, and his legs were supported by splints. He was then evacuated to a clearing station, where he was given another 250 cc. (1 unit) of blood plasma and 20,000 units of penicillin intramuscularly. Because of his exceptionally poor appearance, he was also given a transfusion of 1,000 cc. of whole blood, which was obtained from the adjacent field hospital. His blood pressure was then 90/60.

When the patient was received in the field hospital at 2100 hours, his blood pressure was not measurable. His face was pale, but the skin was warm. The extremities were cool, and the veins were collapsed. He was classified as in severe shock. Laboratory studies showed the hemoglobin to be 9.8 gm. percent; the hematocrit 29; and the blood volume 5,010 cc., or 19 percent below his normal calculated blood volume. When the values were corrected for fluids which had been administered, it was found that, since wounding, he had lost 76 percent of his normal blood volume and 55 percent of his normal hemoglobin.

In the 4 hours which followed his admission to the field hospital, the patient was given 500 cc. (2 units) of plasma, 2,000 cc. of whole blood, and 25,000 units of penicillin intramuscularly. At the end of this period, his blood pressure had risen from 0 to 110/65, and his pulse was 138 and of good volume.

Operation was performed at 0330 hours 22 April, 14 hours after wounding, under endotracheal nitrous oxide-ether anesthesia. It lasted 2 hours. It consisted of a guillotine amputation of the lower third of the left leg, together with debridement of the wounds of the extremity and chest wall. Twenty-five thousand units of penicillin were placed in the right pleural cavity, after 1,000 cc. of blood had been aspirated from it. Nasal oxygen was instituted as soon as the operation was ended. Blood was also used liberally in the postoperative period.

The patient made a rapid, uncomplicated recovery.

Comment.-The first of these patients, who was clearly desperately wounded, was resuscitated by 4 units of plasma and 500 cc. of whole blood. Although the blood pressure was finally recorded as normal, the pulse, which continued rapid and of only fair quality, provided evidence that resuscitation had been inadequate. It was not possible to determine from the record the gravity of the pneumothorax that seems to have caused this man's death, or to determine whether a bilateral pneumothorax was overlooked, but the failure to tolerate accidents during and soon after operation was entirely characteristic of the seriously wounded, bled-out casualty who, in the first months of fighting in the North African theater, was resuscitated by plasma but did not receive adequate blood replacement.

The second patient, who was also desperately wounded, was resuscitated by


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2,250 cc. of blood plasma (9 units) and 3,000 cc. of whole blood. In addition, blood was used liberally during the postoperative period to overcome acute anemia and promote wound healing. Penicillin, which had not been available when the first of these soldiers was treated, was also used freely. The tremendous measured blood loss in the second case emphasizes how dangerous it would have been to attempt to prepare this man for operation by plasma alone. The use of oxygen should also be noted.

As both of these histories indicate, the major problem of resuscitation of badly wounded men in World War II had to do with the management of shock. Shock is a disability of the circulatory system that parallels, and is caused by, loss of effective blood volume and hemoglobin. The major problem in all combat areas was how best to overcome these losses, or, more correctly, how to overcome them sufficiently to enable the patient to tolerate transportation to the hospital nearest the frontline where surgical facilities were available and where he could be prepared to withstand the surgery required by his special injury. For all practical purposes, then, an account of the resuscitation of wounded men in a combat area is principally a matter of blood-volume replacement. The history of resuscitation in the Mediterranean theater is epitomized in the innovations made in blood-volume replacement therapy and in their consequences.

The incidence of shock varied according to the echelon at which the patient was seen. One study1 showed that about 2.5 percent of 2,853 wounded men were in need of special resuscitative measures on their arrival at an evacuation hospital in Italy, because surgical shock was established or impending. Two thousand two hundred and ninety-six of these men were injured on the Anzio beachhead, where, for tactical reasons, the evacuation hospital performed the functions ordinarily performed by a field hospital. Additional data supplied by the 2d Auxiliary Surgical Group and extended by material from the Office of the Surgeon, Mediterranean Theater of Operations, United States Army, showed about 2 percent of another group of wounded men to be in need of special resuscitative measures on their arrival at a field hospital. The incidence of shock on the level of the field hospital may therefore be assumed to have been from 2 to 2.5 percent.

GENERAL CONSIDERATIONS OF RESUSCITATION

The interval from the time the soldier was wounded until he had been restored to sufficiently good condition for his wound to be repaired was the most critical period he could undergo. In untreated patients, the balance during this interval was swung toward life or toward death by the operation of natural forces. The direction and extent of the swing could be influenced, in most cases, by the character and the timing of the treatment given the wounded man. 

As has already been intimated, the first concern of those who had the care

1Beecher, H.; and Burnett, C.: Field Experience in the Use of Blood and Blood Substitutes (Plasma, Albumin) in Seriously Wounded Men. M. Bull. North African Theater of Operations 2: 2-7, July 1944.


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of a freshly wounded man during this period was to do what was necessary to enable him to withstand transportation to a hospital. Their next concern was to prepare him to withstand the stress of emergency surgery. Everything else, even the question of his ultimate survival, was secondary to these immediate considerations.

The consequences of all wounds were cumulative. Pain often made rest impossible. Exhaustion was increased by emotional factors. Dehydration, which often was present before wounding, was increased by unusual fluid losses in sweat and vomitus, as well as by continuing hemorrhage and loss of plasma, with consequent reduction of hemoglobin and blood volume. If treatment was delayed, infection developed. These and other undesirable consequences were set in operation by the initial wound, and they continued unabated in the seriously wounded man until they were checked by surgery or interrupted by death. Resuscitative measures halted these effects temporarily, but such measures were merely palliative. Real relief from the grave consequences of the wound inflicted by enemy action could be accomplished only by surgery. After the wounded man had been received in a forward hospital, it is true that preparation for surgery was the immediate goal of resuscitation; but it was not an end in itself. In the broad general sense (p. 18) surgery was itself an essential phase of resuscitation.

These were not academic considerations. Any other concept of surgery would have led to an unfortunate separation between the activities of shock teams and surgical teams. The care of the wounded man had to be continuous, and his supervision had to be uninterrupted. Neither activity could be separated into compartments. The recognition of the essential unity of resuscitation and operation, though it was somewhat late in coming, was an important surgical advance in World War II.

That the operation itself should be an integral part of the resuscitative procedure was a perfectly logical concept. When internal hemorrhage persisted, for instance, there could be no resuscitation without surgery, and it was wasteful of both time and blood to attempt to raise the patient's blood pressure to normal before operation. The blood or plasma which was administered merely leaked into the traumatized regions and was wasted, while at the same time the patient was submitted to the hazard of an unnecessary number of transfusions. Surgery, with control of the hemorrhage, was the simplest and most effective way of accomplishing full resuscitation in such a case. Similarly, when extensive fecal contamination of the peritoneal cavity had occurred, or when leakage into or possible absorption from large areas of devitalized tissue was taking place, the shock and toxic manifestations which ensued could be terminated only by control of the causative factors at the source.

The best method of management in all such cases was to resort to surgery as soon as the patient had been brought to the desired stage of resuscitation (p. 18) and to continue resuscitative measures during the operation. This was the cardinal principle which, by a process of evolution, was finally worked out for the management of battle casualties during World War II. It does


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not seem to have been emphasized or practiced to any considerable degree during World War I.

Differences in medical organization, evacuation policies, technical and human resources, and even the denotations and connotations of medical terminology differed so greatly in World War I and World War II that comparisons are, in general, neither useful nor valid. The following comparative data are, however, presented because the organization and mission of the 127th Field Hospital, which served in France in 1918, seem reasonably comparable to the organization and mission of the 33d Field Hospital, which served in the Mediterranean theater in 1943:

Over a 7-day period in 1918, the 127th Field Hospital admitted 256 wounded casualties, 41 of whom died before operation and 34 after operation.2 The total case fatality rate was thus 29.3 percent and the surgical case fatality rate 15.8 percent. Over a 30-day period in 1943, the 33d Field Hospital admitted 297 wounded men, all of whom underwent operation, with 56 deaths.3 The total case fatality rate, which was entirely surgical, was thus 18.9 percent.

These figures, while perhaps not precisely comparable from a statistical point of view, illustrate very clearly the difference in concepts of management of severely wounded men in World War I and World War II. The significant point of the comparison is that, in 1918, 41 of 256 wounded soldiers (16 percent) died without operation, probably because they were never regarded as fit subjects for surgery, while in 1943, every one of 297 freshly wounded men was resuscitated and given his chance of survival through surgical intervention. The key to the difference is, of course, the emphasis placed upon preoperative resuscitation in World War II and the lesser emphasis placed upon this phase of medical care in World War I.

The problems of resuscitative therapy in World War II were greatly simplified once there was general acceptance of the concept that the cause of the deterioration of the status of a seriously wounded man was a reduction in the circulating blood volume because of loss of blood. Still further simplification occurred when the additional concept won general acceptance that, except for processes leading to dehydration, fluid loss from the circulation could be explained by loss at the site of injury alone. When profound anoxia was present, there was also some loss because of the general increase in capillary permeability associated with this condition.

The studies upon which these concepts were based4 showed in a useful and practical way the almost quantitative relationship between the blood loss after wounding and the degree of shock. This relationship had long been recognized, but it had lacked substantial proof up to this time. The proof was needed to outride the storms which arise again and again from suggestions

2The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. I, pp. 109-110.
3Annual Report, Medical Section, North African Theater of Operations, U. S. Army, 1943.
4Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952.


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that the cause of shock is mysterious and is to be explained by toxins or by the breakdown of some vague but vital force.

This emphasis on the relationship between blood loss and shock, which was one of the outstanding features of the management of the battle-incurred injuries in World War II, did not in any way decrease the interest of medical officers in the problems of shock which remained to be solved. It also did not lead to any underestimation of the complexity of the mechanisms involved in the production of shock. It did, however, simplify the application of effective therapy, the chief component of which, as all the experience showed, was the prompt administration of blood in the quantities in which the individual wounded man required it.

All the available evidence pointed to blood loss, with the corresponding reduction of the circulating blood volume, as the explanation of the poor general condition of seriously wounded men when they were first seen in forward hospitals. All the evidence also pointed to the correction of these losses by replacement of the lost blood as the only method of improving the condition of these injured men and rendering them fit for surgery. The treatment of the local wound and the relief of pain and of mental distress were important, but not in comparison with the replacement of the lost blood. Furthermore, the more rapidly the losses could be corrected up to the point at which the deterioration of the man's condition could be checked, the better for him. These facts were demonstrated in every preoperative ward and every operating room from the beginning of the fighting in North Africa to the end of the fighting in Germany.

The stress of surgery for battle injuries.-The chief reason for the resuscitation of the freshly wounded soldier was to correct his impaired status. An additional reason was to prepare him for the strain to be imposed upon him by the operative procedure necessary to repair his injuries. How severe that strain was likely to be is suggested by the following data concerning the duration of typical operations, for the most part performed on the Anzio beachhead. The single large hospital area on the beachhead was near, and often in the midst of, the area of active combat. Many of the wounded were injured in the actual hospital area, and others on the adjacent road, which came to be known as Purple Heart Highway.

The duration (exclusive of the time occupied in the induction of anesthesia) of 130 typical major operations, chiefly performed in this hospital area, was as follows:

For 20 craniotomies in which the dura was opened, 10911 minutes. 
For 10 laminectomies, 1227 minutes.
For 20 thoracotomies, 14814 minutes. 
For 20 laparotomies, 11712 minutes.
For 20 vascular operations on the extremities involving ligation of the large vessels, 625 minutes.
For 20 operations for compound fractures of the femur, including the application of the spica, 838 minutes.


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For 20 guillotine amputations of the femur, 697 minutes.

These data are for consecutive, unselected cases. The operations were done by a number of different surgeons, all of whom were able and experienced. In spite of that fact, only wounds of the extremities could be handled surgically in approximately an hour. Operations on the head, chest, or abdomen without exception required about 2 hours or more. These operating times were typical of the experience in all forward areas. They do not differ materially from the operating times for similar operations in civil life. The strain of surgery of such magnitude, carried out over such long periods of time, could not have been withstood if the patients had not been adequately prepared in the shock tent to tolerate prolonged surgical stress.

At the beginning of World War II, it was the general impression that major surgical procedures in time of war seldom occupy more than an hour. Possibly this impression arose from the experience in World War I,5 in which operations on the extremities constituted a much higher proportion of the total operations than they did in World War II. As the figures cited show, this was not the experience in World War II, and these data symbolize the revolution in surgical thinking and progress which occurred between the world wars.

CHAIN OF EVACUATION

Since the status of a wounded man was influenced by the methods employed to remove him from the battlefield and transport him to a field hospital where he could be treated, a brief outline of the chain of evacuation is necessary in a discussion of resuscitation.

Resuscitation began at the battalion aid station, which was ordinarily located about 500 yards behind the line of combat, and which was reached, depending upon the wounded man's condition, by foot or by litter carry. Here, as well as in the collecting and clearing stations farther to the rear, the main objective of treatment was to make the wounded man transportable and to refrain from any procedure which would make him nontransportable. Therapy was therefore limited to such simple but essential measures as the control of hemorrhage; the application of splints and bandages, and of tourniquets if they were necessary (p. 35); the closure of sucking chest wounds; and the administration of plasma and morphine according to the indications of the special case.

Collecting stations, which were located about a mile beyond the battalion aid stations, were reached on foot, by litter carry, or by ambulance. As in aid stations, treatment was limited to what was absolutely essential. At times nothing more than inspection was required.

The division clearing station, which could care for approximately 100-150 patients at one time, was usually about 5 miles behind the collecting station. It was reached by ambulance. Here the patient's status was carefully ap-

5The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. I, p. 5.


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praised, and it was decided whether he could withstand the additional journey of several miles to the evacuation hospital, where necessary surgery could be performed, or should be taken at once to the field hospital for emergency surgery. The field hospital, which consisted of three platoons, with a capacity of 100 beds per platoon, was located adjacent to the division clearing station. It was staffed and equipped for major emergency surgery, and, equally important, for the care of patients for a maximum of 12 days after operation.

The patient's condition chiefly determined whether he should be removed to a field hospital for immediate surgery or transported farther to the rear for surgery later, but many other factors influenced the decision at the clearing station. It was necessary to take into consideration whether the road connecting the clearing station with the evacuation hospital was long or short, good or bad, and easy or difficult to traverse during a blackout. Conditions in the field hospital were also a consideration. This type of installation was invaluable when the nature of the injury or the status of the soldier contraindicated additional transportation, or when, for any reason, the time factor was important. The staff was usually competent, especially when teams from an auxiliary surgical group were assigned to supplement the regular staff. On the other hand, this type of hospital was frankly set up to handle emergency surgery. Because the medical staff was small, resuscitation was sometimes less rapid than in an evacuation hospital. Equipment was relatively limited, and the environment for postoperative care had some undesirable features. The field hospital was always far forward-near, or sometimes in front of, heavy artillery positions. Incessant cannonading made it difficult for the patient to get the rest he needed after operation, and limitations of personnel sometimes made postoperative care difficult, particularly during periods of heavy military action.

The patient operated on in a field hospital was eventually moved to the rear. Whenever possible, he was returned to duty directly from an army hospital. If this was not practical, he was moved, as soon as his condition permitted, from the evacuation hospital to a station or a general hospital. These were fixed installations, equipped and staffed for the performance of reparative operations designed to hasten healing, prevent irreparable damage or deformity, and expedite the wounded man's return to military duty. Resuscitation was seldom an essential phase of treatment in these fixed hospitals.

PREOPERATIVE (SHOCK) WARDS

In the course of World War II, numerous arrangements were tried out for the efficient management of wounded men to be prepared for surgery in forward installations. Some plans were unsatisfactory in their conception. Others were cumbersome and impractical. Experience eventually showed that, while details varied materially from one installation to another, some arrangement such as the following was the most generally satisfactory:

1. Shock wards or tents were set up, and all casualties in shock were


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admitted to them, whether or not it was thought that they would require surgery.

2. Each shock ward was in charge of a single medical officer, who remained in the position for a matter of weeks, at least. Quick rotation of personnel merely promoted inefficiency.

In a field hospital the officer in charge of the shock ward was preferably chosen from the internists or junior surgeons on the staff. This was not a position for an inexperienced man, but the prolonged assignment of an experienced surgeon was also not wise; it inevitably led to discontent on his part and, eventually, to poor care of casualties. An assistant shock officer was trained to cover half of the 24-hour period, and at least 1 nurse or 1 aidman, or preferably both, were on duty at all times to assist the officer in charge. Twelve-hour periods of duty were not too taxing, even during times of heavy action, but longer assignments invariably led, within 2 or 3 days, to inadequate performance during rush periods.

In the evacuation hospital, a single medical officer was in charge of the shock ward, but an assistant was on duty with him at all times. The situation in this type of hospital differed from that in a field hospital. In a field hospital, all patients admitted were in need of resuscitation, but their number was limited. In an evacuation hospital, the incidence of shock was much lower, but the number of patients admitted during heavy drives made it necessary for two officers to be on duty continuously. Two additional officers were required to relieve these officers for half of the 24-hour period. At least 2 aidmen and 2 nurses were on duty at all times during rush periods. One of the officers on duty in the shock ward directed the flow of patients through it to the operating room, separating the patients who were in poor condition and in need of resuscitation from the others. The other officer directed resuscitative measures.

It is difficult to overestimate the importance of the function of the officer in charge of the shock ward. Toward the end of the war, some of the most experienced surgeons overseas took over the duty of its supervision.

3. The shock ward, when properly set up and administered, was a good deal more than a valve to regulate the flow of patients into the operating room, though this was a common and serious misconception of its function. Individual evaluation was necessary in every case. It was never possible to set up, on a mechanical basis, a relation between the optimum time for surgery and the number of casualties awaiting treatment, although such a relationship was inherent in the metered-flow point of view which there was sometimes a temptation to adopt.

4. The preoperative ward functioned satisfactorily only when the chief of the surgical service made frequent visits to it. It was part of his function, in collaboration with the shock officer, to set up priorities of operating time. As soon as possible, all patients awaiting surgery were assigned to specific surgical teams, and thereafter, as far as possible, the surgeon into whose charge the patient had been committed shared in all decisions concerning him, including decisions involving preparation for operation.


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The plan just outlined insured continuity of attention for the wounded man, which was an integral part of good surgical care. Any system would have been fundamentally bad which allowed one group-the personnel of the shock ward-to carry a patient so far and no farther, after which his care was assumed by an entirely new group-the surgical team-whose personnel were completely unfamiliar with the man's previous status and therapy.

SHOCK: PREDISPOSING AND PRECIPITATING FACTORS

The treatment given wounded men in battalion aid stations, collecting companies, and clearing stations was generally good and often lifesaving. On the other hand, erroneous and inadequate therapy sometimes accounted for the poor condition of the patients when they arrived at forward hospitals. Among the common faults were overmedication, chiefly in the form of an excessive use of morphine (p. 41); the administration of too much plasma, or, less often, of too little plasma (p. 22); failure to recognize and close an open pneumothorax, or its inadequate closure; inadequate measures to control serious hemorrhage; transportation of wounded men with head injuries and injuries of the pharynx in the dorsal instead of the prone position; and failure to protect casualties properly during transportation. Under the last heading are included a wide variety of errors and omissions, ranging from careless splinting of broken bones to inadequate use of blankets, especially failure to place blankets under, as well as over, the patients in cold weather.

The pathologic processes set in motion when wounding occurred were basically responsible for the poor condition in which many wounded men arrived at forward hospitals. External circumstances, however, increased the number of those in precarious condition and in many instances precipitated, as well as aggravated, shock. The most important of these circumstances were exposure, incorrect treatment in forward areas, and delay in evacuation.

Exposure.-North Africa, Sicily, and Italy provided a wide variety of geographic and climatic conditions, including desert heat and mountain cold, high and low altitudes, and dry terrain and marshy land. It was over this terrain, some of which is among the most difficult in the world, that fighting was conducted by means of amphibious landings, isolated beachheads, rapid advances, and prolonged holding operations. Exposure under these conditions of combat was inevitable. Sometimes it led to heat exhaustion and sometimes to cold injury. It was usually associated with inadequate intake of food and fluid, and often with lack of rest.

Timelag.-The effect of delay on the wounded man's condition and the favorable influence of a brief lapse of time from wounding until operation were naturally appreciated from the beginning of the fighting in North Africa in November 1942. It was not, however, until the Italian phase of the war that it came to be generally realized that too much time was being lost before surgery, and that patients were being handled far too much, because of strict adherence to the formula of delays for inspection purposes along the line of


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evacuation. These delays were defeating the efforts of the medical personnel, which were directed toward a single aim, that of presenting to the surgeon a patient who was as favorable as possible an operative risk.

As the plan of evacuation was set up, the patient was removed from the ambulance or inspected on the litter at each stop. Almost inevitably, the medical personnel attached to the special installation felt it incumbent on them to do something to him. This was to be expected. Because of shortages of experienced physicians, division clearing and collecting stations were necessarily manned by young men whose judgment had not yet been formed by experience, and who, in their eagerness to do their full duty, did not always distinguish between what was essential and what was superfluous. The timelag was materially lengthened by these practices. When the men were critically injured, that fact was usually apparent. Additional inspections were not necessary to establish it. It was to the patients' best interest that they be handled as little as possible and be taken at once to the nearest hospital in which essential surgery could be carried out.

Possibly some patients with extremity wounds would have profited from being held at forward installations for an hour or two, but to teach corpsmen and inexperienced young doctors to identify those who would be helped by delay was simply not possible. The selection of the wrong patients for delay could be disastrous. Medical officers who did frontline work repeatedly stated that they had never seen a patient lose his life because he was evacuated too promptly, but all could recall instances in which lives had been lost because evacuation was too slow. This was sometimes unavoidable, but sometimes it was attributable to the cumbersome and time-consuming routine which had to be followed.

While reduction in the timelag from wounding to surgery was not the only factor in the reduction of morbidity and mortality, it was an important consideration. It influenced the salvage of extremities. It lessened deformity. It shortened convalescence. Sometimes it altered the outcome. The solution of the problem would have been the elimination of one or more stops along the line of evacuation, and it was repeatedly suggested that the system in use, which did not permit such bypassing, should be critically reviewed and modified in the light of experience. This did not happen. The system instituted at the beginning of the war remained essentially unaltered to the end.

In addition to the lowering of the patient's reserves by the delays on the battlefield and along the evacuation chain, rough handling was sometimes unavoidable in difficult litter transportation down mountain trails and in prolonged ambulance hauls over rough roads. These additional stresses, whether they were avoidable or unavoidable, could precipitate shock or increase it if it already existed.

APPRAISAL OF THE WOUNDED MAN

Although a certain routine of resuscitation was carried out in all shock wards, resuscitative measures were always applied on the basis of individual


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needs, after a careful estimate (1) of the extent to which the casualty had suffered from his wounds and (2) of the therapy needed to enable him to tolerate immediate surgery in a field hospital or to withstand transportation to a hospital farther to the rear. Once he had reached the field or evacuation hospital, his reaction to the rigors of his journey, as well as his response to the resuscitative measures employed, furnished essential information concerning the additional treatment required to fit him to tolerate whatever surgery might be necessary. The first step was to rescue him from the state of shock in which organic damage could occur as the result of inadequate circulation. The next decision concerned the institution and timing of additional measures of resuscitation and of the operation itself-the operation, as already emphasized, being considered to be one phase of the resuscitative regimen.

The man's clothing (fig. 1) was removed completely before examination was undertaken or any resuscitative measures were instituted. Flagrant errors could follow failure to observe this elementary precaution. Its necessity can be shown by a single illustration. A soldier accidently discharged his own rifle, wounding himself in the buttocks. The bullet reached its destina-

FIGURE 1.-Routine of early care of wounded man in forward hospital. Removal of all clothing.


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tion only after it had passed between his scalp and the inside of his helmet and then reversed its direction.

After the man's clothing had been removed, the litter was checked to make certain that blankets had been placed underneath him as well as over him. He was then completely examined, and a plan of management was drawn up. Basically, all patients were placed in two categories:

1. The patient with a slight wound, in good condition, was operated on as soon as there was space for him in the operating room, with due regard to the needs of those who were more seriously wounded.

2. The patient in poor condition was sent to the ward or tent set aside for men in shock and was given over to the charge of the shock team.

Patients in the first category required little of no special preparation for operation. For severely wounded patients in the second category, the preparation which they received for operation might make the difference between survival and death.

Classification of shock.-For practical purposes, the seriously wounded man was placed in 1 of 4 possible categories (table 1), depending upon the presence or absence of shock, and, if it were present, upon its degree. All of the following statements refer to the average patient:

1. The patient not in shock had a normal blood pressure and normal pulse. The temperature and color of the skin were normal. The pressure test, which showed a prompt return of color to the skin, indicated the integrity of the circulation. The patient might be thirsty, but his thirst was not abnormal. His mental state was clear, and he was capable of feeling depressed.

2. The patient in slight shock had a blood pressure about 20 mm. Hg below the normal level. The quality of the pulse was normal. The skin was cool. Its color was pale. The response to the blanching test was somewhat delayed. Thirst was not abnormal. The mental state was clear, but the patient was distressed.

3. The patient in moderate shock had a 20-mm. to 40-mm. Hg depression of blood pressure. The pulse volume was diminished. The skin was cool and pale. The response to the blanching test was unmistakably slow. The patient complained of thirst. His mental state was clear, but he was likely to be apathetic unless he was stimulated.

4. The patient in severe shock had a greatly depressed blood pressure, ranging from 40 mm. Hg below normal to an unrecordable level. The pulse was weak or imperceptible. The response to the blanching test was greatly delayed. The patient might complain bitterly of thirst, but otherwise he was apathetic and comatose and seemed to suffer very little distress.

While all of the observations listed furnished useful diagnostic information, the most important considerations in the appraisal of the status of a freshly wounded man were the trend of the pulse rate and the trend of the blood pressure. The trends were a great deal more significant than the levels at any given time. A rising pulse and a falling blood pressure nearly always indicated trouble


16

TABLE 1.-Relationship of degree of shock and average blood loss in 67 patients with all types of wounds

Degree of shock

Clinical observation

Average blood loss 
(corrected values in round numbers, in percentage of normal)

Blood pressure (approximate)

Pulse quality

Skin temperature

Skin color

Skin circulation (response to pressure, blanching)

Thirst

Mental state

Blood volume

Hemo-
globin

 

Percent

Percent

None

Normal

Normal

Normal

Normal

Normal

Normal

Clear and distressed.

14

20

Slight

Decreased 20 percent or less.

...do...

Cool

Pale

Definite slowing.

...do...

...do...

21

30

Moderate

Decreased 20 to 40 percent.

Definite decrease in volume.

...do...

...do...

...do...

Definite

Clear and some apathy unless stimulated.

34

46

Severe

Decreased 40 percent to nonrecordable.

Weak to imperceptible.

Cold

Ashen to cyanotic (mottling).

Very sluggish.

Severe

Apathetic to comatose; little distress except thirst.

46

55


Source: Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952, pp. 28, 56.

to come, especially if, in association with these phenomena, the skin of the patient who had been in a comfortably warm room felt cool to the touch.

It was essential that resuscitation teams understand the practical implications of shock as a dynamic and not a static state. The whole wartime experience proved that patients in shock did not remain in the same condition for any length of time. Their condition improved, or it deteriorated. This is why trends were sounder guides to therapy than absolutes. When the systolic blood pressure showed a constant upward tendency and had reached a level of 80 mm. Hg, the pulse rate usually showed a constant downward tendency, and the skin was usually warm and of good color. The patient was ready for surgery when these things occurred and could be operated on with safety long before the blood volume or blood pressure had been restored to absolute normal.

It was seldom difficult to recognize in the preoperative tent the casualty who was in poor condition. He seldom furnished any problem of identification. He usually carried obvious hallmarks of his status. The real problem was to identify the casualty whose condition, while still not critical, was deteriorating, and to identify him early enough to check the adverse forces at work in him. His prompt recognition was of benefit to him and also of benefit to his wounded associates. It meant economy of care, of materials, and of nursing and medical


17

effort. Because these things were expended only where they were needed, more rapid preparation of all wounded men for surgery was possible. This was indispensable if intolerable congestion in the preoperative ward was to be avoided. In the end, it meant the salvage of more lives. Experience repeatedly proved that it was far simpler from every standpoint to prevent serious deterioration in the condition of a wounded man than to rescue him from shock, once he had slipped into it.

The selection of patients who required close observation was made on clinical evidence: Their arms and legs were cool or cold. Their skin was pale. When it was blanched by pressure, the return of color was considerably delayed. The pulse was of rather small volume. The blood pressure might or might not be below normal levels. When it was below normal, resuscitative care was urgently needed.

Additional useful diagnostic points were the appearance of the wound; its character and extent; the evidence of considerable blood loss, whether internal or external; the evidence supplied by blood-soaked clothing; a history of exposure or exhaustion; and a history of delay in evacuation. Thirst was likely to be intense in the patient in critical condition; frequently it caused much suffering.

Except for those with head wounds, severely wounded men who were not in shock were usually clear mentally and often could give surprisingly accurate accounts of the events of wounding. Later, there was likely to be considerable amnesia for the early periods. In a sample of 201 badly wounded men who were not in shock when they arrived at a field hospital on the Anzio beachhead, 200 were in possession of their faculties.

In World War I, the absolute pulse rate, sweating, nausea, and vomiting were regarded as valuable signs and symptoms in the composite picture of shock. In World War II, they were not so regarded. Instead, they were thought to be related to the character of the wound or to psychologic factors, or to be reactions to the administration of morphine. The actual pulse rate could be influenced by too many factors to be of great value in itself in the estimate of shock, but its quality and its upward or downward trend were both most important. The degree of thirst and the patient's mental status, to neither of which much attention was paid in World War I (or is paid in civilian practice), were found to be extremely useful in the evaluation of the degree of shock in World War II.

One of the principles of resuscitation established in World War II was that if operation could not be undertaken immediately, as it frequently could not be when the flow of casualties was heavy and selection of cases had to be practiced, it was not necessary to achieve improvement beyond a rising blood pressure of at least 80 mm. Hg and a warm skin of good color. It was essential, however, not to permit regression, though it was best to withhold further resuscitative measures if the need for them was not evident. The patient who was merely kept in the satisfactory status described was unlikely to lose as much hemo-


18

globin if bleeding recurred as he would lose if plasma were given to raise the blood pressure higher than was necessary during the waiting period. 

Laboratory data.-Laboratory data which could be secured in the field during the first hours after wounding were limited and were likely to be misleading. Estimates of the hemoglobin, hematocrit, and plasma-protein values showed little change immediately after wounding, when blood dilution had not yet taken place, though the information was of great usefulness in evaluating the needs of the wounded man during the postoperative period.6 Determination of the blood-volume level would have been of real assistance immediately after wounding, but the methods available for making this determination in World War II were too time consuming to justify their routine use in a frontline hospital. For these reasons, the simple clinical symptoms and signs described were used almost exclusively to gage the condition of the patient and the quantity of blood necessary to satisfy his individual need. If rightly interpreted, they proved entirely adequate for the purpose.

STABILIZATION VERSUS RAPID PREPARATION OF BATTLE CASUALTIES FOR SURGERY

Early in November 1943, at about the time the Volturno River was crossed and the fighting below Venafro was heavy, a new point of view began to appear in the shock wards of the Fifth United States Army. In effect, it was that too much urgency was being exercised in the preparation of the wounded for surgery. At first, it was an entirely negative concept. After 2 or 3 months, and especially during the prolonged fighting before Cassino in the early months of 1944, it came to be expressed more positively that the wounded fared better when surgery was delayed for what was vaguely termed equilibration or stabilization. Exactly what was supposed to be accomplished by this period of delay was never clearly defined. The patient was merely supposed to be better for it.

There was, of course, some logic in this point of view. There was no doubt that a seriously wounded man who had suffered a period of exposure, who had been bounced in a speeding ambulance over rough roads for several hours, who had had little rest, and who sometimes was in great pain because of the effect of the trauma of transportation on his original wound frequently was the better after a period of rest. He was likely to arrive with a rapid, weak pulse and low blood pressure. After he had rested for 10 or 15 minutes, even if he had no other treatment, he usually looked better, his pulse improved in quality, and his blood pressure rose. These gains, however, were usually achieved in about 15 minutes.

The point of view of those who favored immediate operation and who opposed delay after the patient had been brought out of shock and after the downward trend of the blood pressure and the upward trend of the pulse had been reversed could be stated about as follows:

A wound sets in action several continuing processes. There is loss of blood.

6See footnote 4, p. 7.


19

There is loss of plasma from serous surfaces and into traumatized tissues. Contamination leads to infection, and infection is progressive. All of these processes drain the resources of the seriously wounded man. They must be combated, and he must be supported, by the use of blood and plasma. It is a general principle that in any given case the smallest amount of blood and plasma should be used that is compatible with the patient's well-being. If surgery is delayed, larger quantities of these agents must be used to maintain him on an even keel than would be necessary if operation were performed earlier. This is undesirable from many standpoints, including the practical consideration that in World War II both blood and plasma were often in limited supply in the early part of the war.

On the basis of this reasoning, the advocates of early surgery contended that delay to achieve stabilization of the patient was without merit. They also based their reasoning on the analogy of perforated peptic ulcer in civilian practice. In that catastrophe, peritoneal contamination occurs, and the mortality rises sharply with the passage of time. Experience had shown that with the grosser contamination encountered in battle-incurred wounds, a rise in the case fatality rate when surgery was delayed could also reasonably be expected.

A deliberate test was undertaken in order to establish the proposition that as prompt surgery as possible was best for the patient and that delay for the sake of so-called stabilization did him no good and was often actually harmful.7 The management of 2,853 wounded men who were injured at Cassino and on the Anzio beachhead was conducted on the principle of operating as soon as resuscitation had been accomplished. In every instance, the patient was taken to the operating room as soon as the systolic blood pressure had reached 80 mm. Hg and was tending upward, the pulse rate was consistently falling and the quality of the pulse was improving, and the skin was warm and of good color. If additional blood was considered necessary, it was given in the course of the operation.

Comparison of the Anzio-Cassino experience in 1944 with experiences in field and evacuation hospitals below Venafro and Mignano on the Cassino front in November and December of 1943 established the soundness of speedy resuscitation and prompt operation. In 1943, resuscitation of the seriously wounded to the point of operability often required 6 to 8 hours after the patients had reached the hospital. In 1944, even patients who were extremely bad risks when they were first seen were prepared for operation and submitted to surgery on an average of 2 hours and 20 minutes after wounding. The readier availability of whole blood in 1944 naturally had much to do with the reduction in the timelag as compared with 1943, but the change in the concept of the optimum time for operation played the major role in the improvement.

When the experience in the hospitals employed at Anzio and Cassino was compared with the theaterwide experience, other significant differences became apparent: In the Anzio and Cassino hospitals, each patient received an average of 1 unit of plasma, against an average of 3 units for the theater as a whole, and

7 See footnote 1, p. 5.


20

an average of 1,537 cc. of blood, against an average of 2,610 cc. for the theater as a whole. Transfusions averaged 3 per patient in the Anzio and Cassino hospitals, against 5 per patient for the theater as a whole. In other words, proper timing of resuscitation and surgery, in addition to cutting the time occupied by resuscitation in half, greatly reduced the amount of plasma and whole blood required for resuscitation. These are not trifling considerations. In spite of the generous provision of whole blood in the later part of World War II, it was always necessary to use it economically, and it will probably be necessary to use it even more economically in all future wars. The key to its economical use, without hardship to the wounded man, lies in the correct timing of resuscitation and surgery. 

When the test of speedy resuscitation and prompt operation was undertaken in 1944, the concept was viewed with skepticism, and there was considerable discussion and disagreement before the conditions of the test were set up. The results, however, were so good from every standpoint that the concept of stabilization was gradually discarded and the concept of operation at the earliest possible moment came to be accepted as a satisfactory working principle. The time interval between wounding and operation was, on the whole, materially reduced by its adoption, but until the end of the war many medical officers felt that sufficient progress along these lines had not yet been accomplished.

The concept of prompt operation required an understanding of what could be achieved by resuscitative measures and what was impossible. The aim was not the restoration of the shocked patient to normal status before surgery was undertaken. That goal was unattainable. Those responsible for resuscitation had to face the realities of the situation and to decide what was desirable, what was possible, and what was impossible in the shocked patient. One thing that was impossible was the repair, in a matter of hours, of the organic damage produced by even fairly brief periods of low blood pressure. Many days would have been required for this in some cases. This amount of time could not be granted, nor was it necessary to take it in a man who was organically sound before he was wounded. All that was necessary was to make him safe for surgery. This was not always possible in patients with continuing internal bleeding or wide contamination of the peritoneal cavity. When resuscitative measures failed, in such cases, to produce their desired effects, the surgeon was faced with the necessity of undertaking operation in a patient in poor condition. This was a bold and critical decision, but many lives were saved in World War II because it was made affirmatively.

An important reason for not delaying surgery after the seriously wounded man had been brought out of shock was the readiness with which he could slip back into it. For reasons not altogether clear, a seriously wounded man or a man depleted by loss of blood could often be resuscitated to the point at which he was regarded as fit to tolerate the additional strain of surgery. If, however, operation were delayed and be were allowed to slip back into shock, a second resuscitation was always difficult, was often not as adequate as the first, and was sometimes not possible at all. All military surgeons, no matter


21

what their original point of view, eventually realized the importance of operating as soon as the patient had been brought to optimum status within a minimum period of time.

PLASMA

The difficulties experienced in resuscitation in the early fighting in Tunisia in World War II were in large part directly attributable to the completely mistaken concept, with which most surgeons entered the war, of the limits of usefulness of human blood plasma. These matters are discussed in detail elsewhere in this history,8 but no account of resuscitation in the Second World War would be complete without a brief account of that concept and how it was finally overturned.

The first recorded suggestion that plasma be used as a substitute for blood was made during World War I by Capt. Gordon R. Ward9 in a letter to the editor of the British Medical Journal in 1918:

There is abundant clinical and experimental evidence that it is not the corpuscles that are wanted, but the ideal fluid for keeping blood pressure at a proper level. * * * A man apparently dying from haemorrhage is not dying from lack of haemoglobin * * * but from draining away of fluid, resulting in devitalization and low blood pressure.

These remarks were followed by the eminently sensible suggestion that a trial of plasma should be undertaken and should be controlled by a comparable trial of transfusions of whole blood (and gum acacia). Plasma, however, did not become available in World War I, and Ward's suggestion seems never to have been carried out. Presumably, it stemmed from the belief that the methods of blood transfusion then available, with the hazards they involved, offered such great obstacles to the widespread use of blood in the resuscitation of battle casualties that the risks were not justified by the possible results.

The numerous studies made on plasma in the years between World War I and World War II are not pertinent to this brief account. The wartime enthusiasm for this agent began in 1939, when Tatum, Elliott, and Nesset10 recommended it as "an ideal substitute for whole blood in emergency treatment of shock and hemorrhage from war wounds." Their recommendation was echoed by numerous other observers in the subsequent months. The result, as DeBakey and Carter11 commented, was that sound clinical judgments were pushed aside and the misconception became widespread that plasma was a complete and effective substitute for whole blood in the management of shock in the seriously wounded. This misconception, they continued, became so firmly entrenched in the minds of both administrative and professional personnel that it handicapped the organization and development of more effective measures for the management of shock.

With increasing experience in the management of shock in the fighting in

8See footnote 4, p. 7.
9Ward, G.: Transfusion of Plasma (correspondence). Brit. M. J. 1: 301, 9 March 1918.
10Tatum, W. L.; Elliott, J.; and Nesset, N.: A Technique for the Preparation of a Substitute for Whole Blood Adaptable for Use During War Conditions. Mil. Surgeon 85: 481-489, December 1939.
11DeBakey, M. E.; and Carter, B. N.: Current Considerations of War Surgery. Ann. Surg. 121: 545-563, May 1945.


22

North Africa, it became increasingly evident that plasma was by no means the physiologic substitute for whole blood which it had originally been believed to be. It was useful for bringing the wounded man out of shock and maintaining his blood volume during the period of transportation and immediately after his admission to the hospital, before a blood transfusion could be started, but its effects were transient. Moreover, it created a completely false sense of security, particularly if the surgeon in charge was of limited experience in combat surgery. Superficially, the patient to whom plasma had been administered might seem fully prepared for surgery. Actually, he was ill prepared. Often he could not tolerate movement, let alone anesthesia and other procedures which were part of the preparation for surgery. Their mere institution often caused him to fall back into shock. If operation were proceeded with under the circumstances, the result could be disastrous. In short, the early experience with plasma made it clear that whole blood was the only therapeutic agent which would prepare seriously wounded men for the surgery essential for the saving of life and limb.

The course of events might have been expected. Since plasma contains no hemoglobin, there was never any logical reason for believing that it would be a satisfactory substitute for blood in a wounded man who had lost a great deal of blood, as most seriously wounded men had. The use of plasma in these circumstances could be actually dangerous. The patient in poor condition because of blood loss, with a low blood volume and possibly a low hematocrit, could be placed in jeopardy if his blood (and effective vascular) volume was increased by plasma while his hemoglobin remained deficient. The blood volume might have been restored, but the meager quantity of hemoglobin available in the blood stream would have been correspondingly diluted and, within a brief time, would be further decreased because of the leakage permitted by restoration of the blood pressure. Many times in the early part of the Tunisian campaign, before the deficiencies of plasma for resuscitation were fully realized, a small additional loss of hemoglobin from renewed bleeding or in the course of operation was sufficiently critical to be disastrous. The patient's specious appearance of well-being promptly disappeared, and it became evident that, though he was apparently well prepared, he was completely unfitted to withstand the stress of anesthesia and surgery.

Although the misconceptions and errors that attended the early use of plasma in World War II are now widely recognized, they should not be permitted to obscure the remarkable value of this substance as a lifesaving agent. All through the war, it superbly fulfilled the role of supporting life until transportation could be accomplished to an installation at which whole-blood transfusion was feasible, as was not usually the case in battalion aid stations or division collecting or clearing stations near the frontline (fig. 2). By temporarily sustaining a seriously falling blood pressure and increasing cardiac output, it kept the patient alive long enough for more effective measures to be taken. When this concept of the possibilities and limitations of plasma became general and the stopgap character of plasma therapy was realized,


23

FIGURE 2.-Sicilian women and children watch from a doorway as blood plasma is administered to an American infantryman wounded by shrapnel in 1943. (U. S. Army photograph.)

the concept of resuscitation was correspondingly altered, and whole blood came to occupy its proper place as an agent of primary importance in the preparation of seriously wounded men for surgery.

It was not always easy to determine in a forward installation how much plasma a seriously wounded man needed and could safely be given. The initial dose, as a rule, was 500 cc. (2 units), and it was seldom necessary to give more than 1,000 cc. (4 units) during the 4 or 5 hours which usually elapsed before his admission to the field hospital. The objective was to give only enough plasma to raise the systolic blood pressure to about 80 mm. Hg and to keep the skin warm and the color good. The casualty did not suffer further deterioration when the blood pressure was at this level, nor did he sustain the needless and harmful loss of hemoglobin which might occur as a consequence of bleeding when the pressure was elevated more than was necessary to keep him out of shock. After he had reached a field or evacuation hospital, preparation for operation, as a general rule, required about 1 additional unit of plasma to 3 units of whole blood.

Burns.-Although plasma, in time, ceased to occupy the dominant place it


24

originally occupied in the preparation of wounded men for surgery, all through the war it formed part of the definitive therapy of burns. It compensated, indeed, for the chief deficit in that injury, since plasma is the fraction of the blood which is lost. Various rules were made for the quantities to be used, but the most common and most useful was that 2 units of plasma should be given in the first 24 hours of injury for each 10 percent of body surface burned, and that this regimen should be continued until hemoconcentration had been corrected. When laboratory examinations could be made, the rule was to give 100 cc. of plasma for each point the hematocrit was above the normal level of 45. If plasma-protein values were low, the quantity of plasma calculated to be necessary was increased by 25 percent for every gram below the 6-gm. percent level. Economies were effected in the treatment of burns, if the required quantity of plasma could be administered over the whole 24-hour period rather than in the space of a few hours, since, if more plasma than was needed was given at any one time, it was probably lost from the circulation.

In the management of burns, it had to be remembered that secondary shock might occur after the initial injury. This meant that anemia might be a secondary development in these cases and might require treatment with transfusions of whole blood.

WHOLE BLOOD

The shifting emphasis in the use of plasma and whole blood is evident in certain statistics from the Mediterranean Theater of Operations for 1943-45: 

During the campaign in Tunisia, between 1 February and 31 March 1943, 972 casualties from the II Corps (34.3 percent of all wounded men requiring plasma) received an average of 320 units per thousand wounded.

Between 21 January and 28 February 1943, 101 of 431 seriously wounded II Corps casualties received plasma, the total quantity not being stated, and 31 also received blood transfusions.

In March 1943, 561 patients were given 97 transfusions in preparation for 741 operations in a field hospital.

In March 1943, at the 9th Evacuation Hospital, during the Tunisian campaign, 1,146 casualties were given 17 blood transfusions, 1:67.4 In April, 1,588 casualties received 54 transfusions, 1:29.4. In May, 397 casualties received 27 transfusions, 1:14.7.

During the first hundred days of the Italian campaign, which began 9 September 1943, the ratio of transfusions to battle casualties was 1:4.5. In January 1944, the ratio in all Fifth United States Army hospitals was 1:2.4. In March, a month after a blood bank had been established in the base area, the ratio was 1:1.9.

Between September 1944 and May 1945, 122 casualties in Fifth United States Army forward hospitals received, before operation, an average of 3.8 units of plasma per man, and 10 received, during operation, an average of 1.68 units per man. One hundred and twenty-seven patients received on the


25

average, before operation, 1,450 cc. of whole blood, and ninety-five received, during operation, an average of 1,160 cc. of whole blood. In other words, these patients, in contrast to those treated in Tunisia in 1943, received from the time of wounding to the end of operation an average of 5 transfusions of whole blood and an average of 3 to 4 units of plasma per man.

The use of blood and plasma varied, of course, among hospitals and casualties. During the first hundred days of the Italian campaign, the field hospitals of the Fifth United States Army, which cared for only one-thirteenth of the total number of battle casualties, used one-third of the available blood. Disproportionately large amounts were also required by individual severely wounded men. The establishment of the base blood bank early in 1944 made it possible, when necessary, to give as much as several liters of blood over a brief period of time to a single severely wounded man.

Blood was available in large quantities before the theater blood transfusion unit began to function. It was secured from local blood banks, from emergency donors, and on loan from the British. There was no comparison, however, between the convenience and safety of transfusion from the base blood bank and from these sources. These are not matters which can be easily shown in statistics or graphs.

Indications for blood replacement.-It has already been pointed out (p. 17) that the most helpful guides to the need for blood replacement were secured by simple clinical observation. To reiterate, they included the presence of blood soaked clothing; the location and extent of the wound; the timelag since wounding; the rate and quality of the pulse, with particular emphasis on the trend; the level of the blood pressure, with particular emphasis on the trend; the state of the peripheral circulation, as indicated by the temperature of the skin and the speed of the response to blanching by pressure; the color of the mucous membranes; and the complaint (or lack of complaint) of thirst.

The paradoxical situation that the blood pressure might sometimes be normal when the patient was seriously depleted of blood led some physiologists remote from the battlefront to disparage the level of the blood pressure, even when it was low, as a useful sign in determining the need for blood. This was not a safe attitude, though, as has been pointed out, the upward or downward direction of the blood pressure, coupled with the quality of the pulse and its upward or downward swing, was far more useful than reliance upon arbitrary levels of pressure or pulse rate.

Quantitative blood replacement.-Studies made on the Anzio beachhead12 may be taken as typical of the amounts of plasma and blood needed to prepare seriously wounded casualties for surgery. In this area, the most seriously wounded patients arrived at hospital installations about 4 hours after wounding. The average ambulance haul was about 10 miles, over good roads. The comparatively short timelag justified deliberate appraisal of the patients, it being scarcely likely that an additional delay of a few minutes, added to the

12See footnote 1, p. 5. 


26

delay already experienced, would do them any serious harm. On the other hand, it had to be remembered that these men could not tolerate any extended delay, since the wounds themselves, the necessary handling, and the ambulance ride immediately preceding their entry into the hospital had probably reduced their reserves to their lowest point.

About a quarter of these most seriously wounded men studied in the Anzio beachhead hospital entered with no measurable blood pressure. From the time they were received in the hospital until definitive surgery was undertaken, an average of 1 unit of plasma (or albumin) and an average of 870 cc. of whole blood were given to each man in preparation for operation. During operation, about two-thirds of the patients received an additional 500 cc. of blood each, and about one-third received an additional 1,000 cc. of blood each. The quantities of blood administered by no means replaced the quantities lost; yet these men were apparently well prepared for surgery. None of them died in the course of operation. During the period of the investigation, the case fatality rate in the hospital involved was 1.48 percent, which was extremely low for surgery at this echelon. Finally, the surgeons who operated on these patients were unanimous in their opinion that preparation for operation was satisfactory.

All of the patients were prepared on the principles already outlined. They were considered fit for surgery when the systolic blood pressure was 80 mm. Hg and tending upward, when the pulse volume was good and the rate was tending downward, and when the skin was warm and the color good. When these criteria had been met, operation was undertaken without further delay. If additional blood was indicated, it was given in the course of the procedure. The medical officers responsible for the preparation of these patients considered that transfusion should be given on these principles for two fundamental reasons:

1. Transfusion is a potentially hazardous procedure, which should not be employed any more often than is absolutely necessary.

2. Economy in the use of whole blood was obligatory, because it was often in short or potentially short supply, particularly during periods of heavy action. 

Certain other observers who did not share this point of view prepared patients in serious condition with quantities of blood which averaged 1,000 cc. more per man than these most seriously wounded men received at the Anzio hospital. The results of excessive administration were equally as good as, but no better than, the results accomplished in patients who had received smaller quantities of blood.

Technique of administration.-Except in serious emergencies, all blood given to wounded men was grouped and crossmatched with their own blood. Although this was not always easy under combat conditions, it was seldom impossible. The precautions obviously were necessary. Unless the greatest care was taken in the use of blood, accidents could nullify its value and place the patient in grave danger. Possibly, in the future, fuller information concerning low-titer O blood may reduce the necessity for grouping and cross-


27

matching in the field, but, at the close of World War II, these precautions were still essential for the safe transfusion of whole blood.

After 1,000 to 1,500 cc. of non-type-specific blood had been given to a bled-out casualty, a new sample of his blood was obtained for crossmatching. This precaution was repeated after the administration of every additional liter.

The speed with which blood was administered depended entirely upon how critical was the status of the man to whom it was being given, though certain general principles were also followed. If the patient's condition was considered to be desperate (that is, if the systolic blood pressure was below 60 mm. Hg), he was placed at once in the head-down position, with the foot of the litter elevated about 12 inches (fig. 3). A unit of plasma or albumin was administered while a transfusion of low-titer (iso-agglutinin titer of 1:64 or less) O blood was prepared. Blood was always obtained at the first venipuncture for grouping and crossmatching in subsequent transfusions; but in desperate cases time was not taken at the first transfusion for these precautions and they were sometimes omitted at the second also.

The first blood was often forced in rapidly by the use of a bulb from a blood-pressure apparatus attached to the air inlet of the blood flask. Oc-

FIGURE 3.-Routine of early care of wounded man in forward hospital. Elevation of foot of litter.


28 

casionally, a second transfusion was also given by this technique. It was not a desirable method, for in careless hands it could, and did, cause fatalities from air embolism. As soon as the blood pressure had begun to rise, the speed of introduction of the blood was reduced, though the rate was promptly increased if signs of improvement were not maintained.

In critically injured patients, to be certain that the blood would flow in promptly, cannulas were introduced under direct vision after the vein had been cut down on. In emergencies, two or more transfusions were run in simultaneously through different veins.

Subsequent transfusions were given more slowly. When the systolic blood pressure had risen to 80 mm. Hg, the administration of 500 cc. over a 30-minute to 60-minute period was usually adequate. The same rate was adequate when the transfusion was given for prophylactic purposes, to guard against a fall of blood pressure which was probable or possible, but which had not yet occurred.

Reactions.-The transfusion of blood is always a complicated procedure filled with opportunities for human error. These opportunities, naturally, were greater in warfare than in civilian practice. As transfusions increased in number and the volume of blood used also increased, additional strains were placed on laboratory facilities and on personnel who dealt out the blood and checked it against the blood of the recipient.

The rapid use of large quantities of non-type-specific blood also opened the way to serious reactions, although their number, exclusive of those which followed the use of clearly mismatched blood, was on the whole remarkably low. Experiences in hundreds of hospitals with many thousands of transfusions showed that, with the proper precautions, the incidence of transfusion reactions need not exceed 3 percent. Reactions chiefly took the form of transient malaise, chills, fever, and urticaria. All of them could usually be traced to faulty preparation of the apparatus used. The chief errors were inadequate cleaning of equipment and delay of more than 2 hours in sterilization after cleaning. Fatal reactions were almost entirely attributable to urinary depression and uremia, apparently associated with renal damage arising from the deposition of free hemoglobin in the kidneys.

Blood transfusions in fixed hospitals.-Blood transfusions fulfilled the greatest need and had their greatest usefulness in forward (field and evacuation) hospitals, but they also had a wide field of usefulness in station and general hospitals, where reparative surgery was done. Many operations in these installations were major undertakings. An operation on a compound fracture, for instance, might require inspection of the fracture site, removal of bone fragments, and internal fixation of the fracture. Often fractures were multiple, as were the procedures undertaken to correct them. These and other operations were therefore often attended by a considerable blood loss, with resulting depression of the hemoglobin and hematocrit.

Experience in civilian surgery before World War II had demonstrated the importance of liberal blood transfusions in preparing the patient with


29

chronic sepsis for operation. In station and general hospitals, transfusions on this indication were fully as important as they were in civilian practice. 

Finally, in spite of the liberal use of whole blood in the army area, many of the wounded, after undergoing initial wound surgery, arrived at general hospitals with profound reductions in hemoglobin and hematocrit values. In time, under the influence of an adequate diet supplemented by iron therapy, this type of anemia would undoubtedly have undergone spontaneous correction. Time, however, was lacking. There were a number of reasons in every case for getting ahead with the surgical program as promptly as possible, in addition to the general reason that the bed space was likely to be needed shortly for another wounded man. The sooner secondary surgery was done, the less likely was infection to occur or become established. The timelag between initial and reparative surgery was a very important period in wound management, sometimes equal in importance to the period between injury and initial surgery. Early closure of a gaping wound was imperative, if for no other reason than to prevent bacterial seeding of the raw surface during repeated dressings. It was also important to repair large defects by suture before fibroplasia stiffened the tissues and made approximation impossible without dead spaces.

For these various reasons, an extensive program of blood transfusion was developed in fixed hospitals. As a result, patients with low hemoglobin and hematocrit values were able to withstand secondary surgery promptly, while full advantage was taken of any favorable effect that the correction of anemia might have on the process of wound healing.

ALBUMIN

Albumin, like plasma, has the property of elevating a low blood pressure. This fraction of the blood exerts greater osmotic pressure than any of the other plasma proteins; 80 percent of the colloid osmotic pressure of normal plasma is accounted for by the albumin fraction. These and other observations had been made in the laboratory, and clinical trials had been conducted with albumin, before the United States entered World War II; and they were continued in Zone of Interior hospitals during the early months of American participation.

On the surface, it appeared that albumin would be an ideal agent for military use. As it was put up, it was ready for immediate administration, no reconstitution being necessary. Its small bulk and ready availability made it particularly attractive, in view of the limitations of space and weight which military necessities imposed on the transportation of supplies. It was remarkably stable. It could be administered in a third to a half of the time required for the administration of plasma. Finally, its administration was free from the risk of such sequelae as hepatitis and other infections. These various advantages suggested that albumin would be particularly useful in forward installations in a combat zone.


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Certain disadvantages, however, had to be weighed against these advantages. Albumin is expensive in terms of the quantities of blood needed to prepare it. It was known, before the outbreak of the war, that its effects were likely to be transient. Since the albumin molecule is smaller than the molecule of the globulins, albumin presumably leaks out of the blood stream more rapidly. The antibodies naturally present in plasma are, of course, lost as albumin is separated out of plasma, and it was not known positively during World War II whether this loss was important. Finally, the use of undiluted albumin was dangerous in dehydrated patients.

For an adequate evaluation of its effectiveness, albumin should have been compared with plasma in a controlled study of its influence on the cardiac output and blood volume. This apparently had not been done in the various studies carried out in civilian hospitals before World War II, and the combat zone was not the place to pursue such an investigation. When, however, this agent first became available in Italy, in 1944, it was investigated in the first 200 patients in whom it was used, with the following results:

Blood-pressure determinations were made at 10-minute intervals in 61 men who had each received 25 gm. (1 unit) of albumin, and these values were compared with similar determinations in 89 patients who had each received 1 unit of plasma. The spread of the initial blood pressures, which were all below 80 mm. Hg, was comparable in both groups, as were the age, the nature of the wounds, the state of hydration, and the general condition of the patients. All observations could not be secured in all cases, but the available results were as follows:

In 19 cases treated with plasma, in which the average initial blood pressure was 49/21, the average pressure after 1 unit of plasma had been given was 88/52 in 15 cases. In 16 cases, the average minimum time required to achieve the maximum blood pressure was 19 minutes, while in 9 cases the average minimum time for the fall of blood pressure to begin was 29 minutes. In 40 cases treated with albumin, in which the average initial blood pressure was 47/22, the average pressure after 1 unit of albumin had been given was 83/53. In 34 cases, the average minimum time required to achieve the maximum blood pressure was 22 minutes, while in 19 cases the average minimum time for the fall of blood pressure to begin was 33 minutes. Comparative studies in other groups of cases in which the initial blood-pressure levels were higher gave results of substantially the same order as these.

These data were supplemented by observations of the general condition, skin temperature, and rate and quality of the pulse in the treated patients. All these observations, like the data on the blood pressure, had to be secured under the crude conditions of a combat zone, but clinically they added up to the conclusion that there was no demonstrable difference in the effects produced by the administration of 1 unit of albumin and 1 unit of plasma, although theoretically albumin was a much more powerful agent.

Plasma also had certain clinical advantages over albumin. The water in which it was administered was an asset in a wounded man with a tendency


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toward dehydration. Concentrated albumin, on the other hand, depends for its effects on the withdrawal of fluid from the tissues into the blood stream; it therefore produces tissue dehydration. In a well-hydrated patient this was not a serious consideration. In a dehydrated patient it was, and in such cases albumin was administered in physiologic salt solution, usually in the amount of 2 units to the liter.

No severe untoward effects were observed from the use of albumin in the 200 patients studied. In 2 cases, a mild, transient urticaria was attributed to its use, and transient moist rales were observed in another patient with a thoracic injury. Albumin was always used with caution in patients with thoracic injuries, because of the possible risks of a sudden increase in blood volume.

The limited clinical trials carried out with albumin in the Mediterranean Theater of Operations led to the conclusion that its chief advantages were its small bulk and ready availability. These properties suggested that it might be useful in battalion aid stations and other posts difficult of access in a combat area, as well as in submarines and ambulance planes and for airborne troops. In other words, its usefulness seemed limited to places in which space and weight were at a premium. Whether it will be used for these purposes in a future war will depend upon the general principles by which military medical supplies are selected.

OTHER FLUID REPLACEMENT THERAPY

Numerous discussions of fluid-replacement therapy during World War II began with the injunction to give fluids by mouth if the wounded man would tolerate them. Instructions exactly to the contrary would have been more nearly in line with good medicomilitary practice. Fluids by mouth were usually definitely contraindicated before operation, especially if, as was almost always true, anesthesia was to be induced and operation performed within a matter of hours. An additional reason for withholding fluids during this period, aside from the fact that the man might have a gastric or intestinal perforation, was the fact that after wounding the gastric emptying time was always much longer than normal. Not infrequently, one observed the regurgitation of fluids and food which had been ingested as long as 10 hours earlier.

There were still other reasons for the restriction of oral fluids. They often precipitated vomiting, especially in patients who were already nauseated from the administration of morphine. Under these conditions, the net result of the ingestion of fluids by mouth was often a loss rather than a gain.

Furthermore, it became increasingly clear as the war progressed that one of the commonest preventable accidents on all surgical services was aspiration of gastric contents into the lungs. Sometimes the accident was the result of vomiting during anesthesia; very often it was the result of quiet aspiration, by the deeply anesthetized patient, of gastric contents forced into the pharynx as the result of surgical manipulations in the upper abdomen. However it


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occurred, this was always a serious accident, and it could be fatal, especially if it was not realized that it had happened and if no steps were taken to correct it. 

As a general rule, dehydration was not a special problem in recently wounded men in the Mediterranean theater, at least when the plan was followed of operating on them as promptly as possible after resuscitation had been accomplished. If a man complained of thirst, allowing him to rinse his mouth with water or suck a moist sponge would keep him more comfortable. These simple expedients kept the lips and mouth moist but introduced no fluid into the gastrointestinal tract. In the occasional case in which dehydration was sufficiently marked to require prompt correction, fluids were administered by the parenteral route, chiefly the intravenous route, in the form of physiologic salt solutions and dextrose solutions.

During periods of heavy action, when scores and even hundreds of wounded men were sometimes awaiting surgery in a single hospital, the maintenance of an adequate fluid intake might become a difficult problem because of the delay in treatment. Patients without gastrointestinal injuries were sometimes given fluids by mouth, with due regard to the time they were scheduled for operation. Others were given subcutaneous injections of physiologic salt solution or intravenous infusions of 5-percent dextrose in a similar solution. In no circumstances was more than a single liter of fluid given at a single infusion or injection, and the quantity administered was just sufficient to prevent dehydration.

At one period during the fighting on the Anzio beachhead, more than 300 patients were awaiting operation at the same time in one of the several hospitals in the area. Almost the same situation prevailed in other hospitals. It would have been a difficult task to keep all of these patients properly hydrated and otherwise cared for until their turns came for surgery. The situation was relieved, and the necessity of fluid replacement eliminated, by a shuttle of evacuation planes to the large hospital base at Naples, 40 minutes away by air, where there were facilities and personnel for prompt operation on all the patients.

The use of physiologic salt solution and dextrose solution was limited to the correction of dehydration. As blood substitutes, these solutions were not effective, and they could be dangerous. The elevation in blood volume and blood pressure which they accomplished was so transient as to be of little value, because the fluid promptly leaked out of the blood stream. If they were used in head injuries in large enough amounts to have a significant effect on the blood pressure, intracranial pressure might be seriously increased. Finally, their use in patients suffering from pulmonary injuries or in patients whose hearts were already subjected to stress might precipitate pulmonary edema or increase it if it were already present.

OTHER RESUSCITATIVE MEASURES

Relief of pain.-The control of pain under field conditions is discussed at length elsewhere in this volume (p. 46), but since it is a part of resuscitation general principles should be restated here.


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FIGURE 4.-Routine of early care of wounded man in forward hospital. Control of mental and physical distress by sedation (barbiturate) and administration of morphine.

Severe pain in badly wounded men was found to be much less common than it had previously been believed to be (p. 44). Excitement, fear, hysteria, and the restlessness caused by hemorrhage did not require morphine. They were best treated by small doses of a barbiturate (fig. 4), such as Sodium Amytal (sodium isoamylethylbarbiturate, p. 49). Many men reacted better to a cigarette and friendly reassurance than to a narcotic drug.

Although the principle was not always followed in practice, the only proper use of morphine was for the relief of severe pain. The ideal was to employ the smallest dose which would be effective. Large dosages caused nausea and vomiting and induced sweating, which led to undesirable losses of fluid. Most dangerous of all the effects of morphine was depression of the respiratory centers, which resulted in anoxia and was followed by an increase in shock. It was not possible to standardize dosages, but only occasionally, if at all, was a dose as large as 30 mg. (gr.) necessary or indicated. A dose of this size was never repeated for at least 4 hours.

When small doses of morphine failed to relieve pain, the explanation was


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often poor absorption of the drug. The peripheral circulation of wounded men with low blood pressure, particularly in cold weather, was often so sluggish as to delay the absorption of any drug which had been administered subcutaneously or intramuscularly. When relief of pain was urgent, the intravenous route was therefore the route of choice. Almost immediate relief could be secured by the intravenous injection, over a period of a minute, of 10 mg. (gr. 1/6) of morphine, or of 15 mg. (gr. ) diluted in not more than 1.0 cc. of sterile water.

Proper preparation of the freshly wounded patient for initial wound surgery required not only that his pain be relieved but also that his psychologic and emotional problems be regarded as real and treated with sympathetic consideration (fig. 5). Understanding of these problems might, at the moment, seem less important than prompt surgical action, but disregard of them could leave psychologic and emotional scars which would be as harmful later in life as the results of poor surgery.

Management of the local wound.-The local wound in the preoperative period required little more than the control of hemorrhage and the application of splints. Control of hemorrhage was accomplished, in the order of prefer-

FIGURE 5.-Routine of early care of wounded man in forward hospital. Spiritual care.


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ence, by ligation of the bleeding vessel, insertion of a pressure pack, and the application of a tourniquet.

A tourniquet was necessarily employed when traumatic amputation had occurred or when a limb was badly mangled and was attached to the body by little more than shreds of tissue. It was applied just below the site of election for amputation and was not removed until the extremity had been severed.

When a tourniquet was applied to a limb in which there was a possibility of salvage, control of hemorrhage was frequently lifesaving, but the risk of ischemia and serious nerve damage was always present. When a tourniquet was applied under these circumstances, it was always placed as low on the limb as possible, and it was not loosened or removed except by a medical officer and not then until blood was already running into a vein. The risks of ignoring this precaution were first pointed out in the Mediterranean Theater of Operations, where it was shown that a man could lose his life from the additional blood loss which occurred when the tourniquet was loosened or removed casually. If, however, the man's condition was good, his blood pressure normal, the previous blood loss slight, and a medical officer available, then the tourniquet could be removed at half-hour intervals in an attempt to avoid additional tissue damage. Cooling of the extremity distal to the tourniquet was desirable, particularly when the environment was hot.

Temporary splinting of a wounded extremity prevented further damage and loss of blood and prevented or relieved pain. A badly applied splint could, in itself, cause pain and do damage. A frequent error early in the Tunisian campaign was to apply the Thomas splint without removing the shoe. Swelling invariably occurred distal to the wound and caused great pain, which was entirely unnecessary. The difficulty was overcome when it became the practice to unlace and slit the shoe if it was left on the foot in the application of a Thomas splint.

Position.-The quickest way of improving the wounded man's general condition on his arrival at the forward hospital was to elevate the foot of the litter about 12 inches (fig. 3) and permit him to rest in this position, with the head and upper part of the body lower than the rest of the body. In almost all cases which were not frankly hopeless, improvement was observed, with return of perceptible blood pressure, when this position was instituted, even before fluid replacement had been started. All badly wounded patients were therefore placed in the Trendelenburg position upon their arrival at the forward hospital, unless contraindications existed.

Pulmonary edema was one such contraindication. The head-down position was also used both tentatively and cautiously in patients with chest wounds, in whom it might produce respiratory difficulties, and in patients with head wounds. If, however, these casualties were in frank shock or had systolic blood pressures below 80 mm. Hg, the Trendelenburg position was employed under close observation and was maintained unless obvious signs of distress, labored respiration, or cyanosis required its abandonment. When once the systolic


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blood pressure had risen to 80 mm. Hg, the head of the litter was gradually elevated; often as long as 20 to 30 minutes were spent in bringing the patient back to the recumbent position.

Conservation of body heat.-The wounded man frequently arrived at a medical facility cold and thoroughly chilled. Additional exposure to cold would naturally have affected him undesirably, but rapid warming was equally undesirable. Additional fluid loss through perspiration, increased metabolic needs, and dilatation of the protective vascular constriction were all possible and dangerous consequences of rapid, careless warming. The problem was to conserve the man's own body heat, not to increase it by artificial means.

Gradual warming was best accomplished by placing the patient in bed in a tent or ward at normal room temperature, with blankets under him as well as over him, while blood replacement was accomplished. Experience showed that this was an effective means of warming freshly wounded men. During the fighting before Cassino, although the ground was frozen hard and the nearby mountains were covered with snow, no other method had to be resorted to in any of the casualties observed by the surgeons in the mobile hospitals supporting the Fifth United States Army. Similar observations were made on the Anzio beachhead. Only occasionally, in fact, was artificial heat necessary. In May 1944, when the weather had become warm, one casualty with a rectal temperature of 84 F. was brought into an army hospital at Anzio. His temperature remained at this level for many hours in spite of the application of hotwater bottles to various parts of the body, and did not reach a normal level for more than 24 hours. This man had suffered a blast injury, with intracranial damage which was thought to have involved the hypothalamic area.

Emptying of the stomach.-Correct preoperative preparation included emptying of the stomach before anesthesia, to avoid the risk of aspiration of gastric contents (p. 31). This measure was desirable in all wounded men and urgently necessary if food or fluid had been taken after wounding or as recently as 2 hours or less prior to wounding. An additional reason for employing it was the observation that in some cases gastric dilatation might be great enough to interfere with the circulation. The mechanism of the circulatory improvement which was frequently observed after the stomach had been emptied was not clear, but there was no doubt of its occurrence. Possibly the greatly distended stomach interfered with proper filling of the heart. Another theory was that the vagal reflexes were involved.

Aspiration was occasionally necessary to empty the stomach (fig. 6), but as a rule it was better to induce vomiting. The largest size gastric tube that would slip down easily was introduced and was manipulated judiciously as it went down. Gastric lavage was seldom necessary and was always contraindicated if the location or manifestations of thoracic or abdominal wounds suggested that perforation of the esophagus or stomach might have occurred.

Oxygen administration.-Oxygen inhalations (fig. 7) were used freely for resuscitation during World War II, for the logical reason that they produced definite signs of clinical improvement in the form of a lowered pulse rate and


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FIGURE 6.-Routine of early care of wounded man in forward hospital. Emptying of stomach.

a better coloration of the blood. Whether they were of lifesaving value in the management of severely wounded men was not established.

In the discussions of the use of oxygen, much was made of the fact that cyanosis will not appear as long as hemoglobin concentration is maintained at about a third of normal. Such low levels were not common in freshly


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FIGURE 7.-Routine of early care of wounded man in forward hospital. Artificial respiration with oxygen.

wounded men. In a study of 37 severely wounded men filtered out from 2,853 casualties13 who, for the most part, had sustained their wounds on the Anzio beachhead, the average hemoglobin level was still 12.3 gm. percent at the end of 4 hours after wounding, because sufficient time had not yet elapsed for complete blood dilution. The hematocrit varied. It was in the twenties in 5 of these cases, in the thirties in 16, and between 40 and 44 in 8. In the remaining case in which it was determined, it was 50.

Cyanosis was a more important and a more readily detectable sign of anoxia and oxygen deficiency than low hemoglobin levels. It was frequently overlooked, however, because of hasty examination under poor light in the preoperative tent. When it was present, an increase in the oxygen tension of the inspired air was undoubtedly desirable, though to what degree this objective was achieved in the field by the use of oxygen was open to considerable question. When oxygen was employed on any indication except respiratory obstruction or respiratory depression, it was used with the full realization that the patient's chief needs were an increase in the volume of the circulating blood and in the total quantity of circulating hemoglobin in the blood.

13See footnote 1, p. 5.


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Oxygen was most conveniently administered by nasal tube, after it had been humidified by being bubbled through a water column. The technique made it possible to service 4 or 5 patients from a single oxygen tank. A small catheter (12 to 14, French), well lubricated, was inserted into the nasal pharynx until the patient was observed to swallow a bolus of air. The tube was then withdrawn for half an inch and was firmly anchored to the cheek with adhesive tape. The correct distance of insertion was ordinarily about half an inch less than the distance between the ala nasi on one side and the lobe of the ear on the same side.

A gas flow of 4 to 5 liters per minute of 100-percent oxygen was usually well tolerated. If signs of oxygen deficit were not promptly relieved, higher concentration in the alveoli could be achieved through a closed system (fig. 7) with carbon dioxide absorption. The Beecher anesthesia machine proved satisfactory for this purpose.

Oxygen in high concentrations was not given continuously for more than 12 hours at a time. If, as occasionally happened, it was required beyond this time, the periods of administration in high concentrations were alternated with 12-hour periods during which the concentration was reduced to 50 to 60 percent. Care had to be taken to avoid gastric dilatation, particularly in unconscious patients.

Drugs.-Vasoconstrictor and stimulating drugs were of little or no value in the management of freshly wounded men and were almost never used. When they were employed, it was always in small dosages.

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