The progression of shock , from the initial injury on the battlefield to the CCS, was documented by Sir Ernest Marshall Cowell, by regular measuring blood pressure on the way to the CCS. He recognised that soldiers were generally very cold and dehydrated before being wounded, that the extent of shock was related to the amount of tissue injury and that this probably favoured the development of gas gangrene.
To solve the riddle of shock, a Shock Committee was established in 1917 and was comprised of a number of eminent surgeons and physiologists, led by physiologist Ernest Starling.
Investigations showed that soldiers were acidotic (an increased level of acidity in the blood and tissues), and Sir Almroth Wright, a pathologist, realised this was the result of shock, not the cause. Tissues were poorly perfused and soldiers needed blood and fluids. With this realisation came a method for treatment:
- Give fluids – warm tea and coffee by mouth and if this is not possible, rectally
- Keep soldiers warm with heated blankets at advanced dressing stations and heated ambulances
- If intravenous fluids are required then gum acacia, invented by William M Bayliss, was superior to saline
- If possible, give blood. Blood transfusions carried the risk of incompatibility and transmission of infection but were life saving
- Operate to prevent haemorrhage as soon as the patient is stabilised.
In 1917 a CCS was opened at Brandhoek in Belgium, close to the front line, to deal with soldiers suffering from the most severe wounds (femoral fractures, abdominal and chest wounds) as early as possible.
Unfortunately it was closed after a month, after a direct shell hit which killed a sleeping nurse, and the work was moved back from the front line.
In 1918 shock centres opened at Gezaincourt CCS on the Somme, with doctors warming and transfusing patients – in effect processing them for surgery.
Alan Worsley Holmes áCourt of the Australian Army developed shock teams to go onto the battlefield and rescue soldiers as close to the front line as possible . By the Battle of Hamel in July 1918 they were ready for use.
By modern standards soldiers were given a paltry amount of blood: the maximum for a transfusion was 1000cc, around half of the average amount given in 2015. However, it was enough to save some of them from the dangers of shock, with an enormous boost to morale.