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May 4, 1964, Vol 188, No. 5 >
SPECIAL CONTRIBUTION | May 4, 1964

Septic Shock

Jacob Fine, MD
[+] Author Affiliations

Boston

From the Department of Surgery, Beth Israel Hospital, Harvard Medical School.


JAMA. 1964;188(5):427-432. doi:10.1001/jama.1964.03060310027006
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References

In THIS STATEMENT I will undertake to demonstrate that when traumatic shock fails to yield to appropriate treatment, death occurs because of the injury produced by a persisting deficiency of flow in the splanchnic circulation. Furthermore, as a corollary of this proposition, evidence will be given that treatment to improve flow in this area can succeed in relieving the state of shock when all other methods fail. This thesis will be stated in the form of an argument, followed by the evidence in support of it and, finally, by a summing up in which other views are considered.

The Argument  The critical feature common to all forms of traumatic shock is an acute and persisting deficiency of flow through the peripheral vessels. The longer it persists, the more likely the resulting injury will become irreversible, in which case death will follow in a matter of hours. The threat to life

REFERENCES

1 +
Assay for endotoxin showed the presence of endotoxin in the nondenervated half of the spleen; none was demonstrated in the denervated half.
2 +
Shapiro, B., et al:  Host Resistance to Hemorrhagic Shock: XI. Role of Deficient Flow Through Intestine in Development of Irreversibility , Proc Soc Exp Biol Med 97:372-376, 1958;.
3 +
Selkurt, E.E.:  Intestinal Ischemic Shock and Protective Role of Liver , Amer J Physiol 197:281-285, 1959;.
4 +
Frank, E.D., et al:  Hepatic Blood Flow in Experimental Hemorrhagic Shock , Amer J Physiol 202:7-11, 1962;.
5 +
Frank, H.A.; Seligman, A.M.; and Fine, J.:  Traumatic Shock: XIII. Prevention of Irreversibility in Hemorrhagic Shock by Viviperfusion of Liver , J Clin Invest 25:22-29, 1946;.
6 +
Lillehei, R.C., and MacLean, L.D.:  Intestinal Factor in Irreversible Endotoxic Shock , Ann Surg 148:513, 1958;.
7 +
Wiggers, H.C., et al:  Influence of Prolonged Vasoconstriction on Transition from Impending to Irreversible Hemorrhagic Shock , Fed Proc 6:226, 1947;.
8 +
Remington, J.W., et al:  Protective Action of Dibenamine After Hemorrhage and After Muscle Trauma , Proc Soc Exp Biol Med 69:150, 1948;.
9 +
Jacob, S., et al:  Antiadrenergic and Antihistaminic Therapy in Hemorrhagic Shock in Dog and Rat , Amer J Physiol 186:74, 1956;.
10 +
Nickerson, M.A.:  Protection Against Acute Trauma and Traumatic Shock by Vasodilators , Canad J Biochem Physiol 37:321-358, 1935;.
11 +
Reilly, J., et al:  Sur la pathogenie de la dothienenterie (2 Memoire): Le role du systeme neuro-vegetatif dans la genese des lesions intestinales , Ann Med 37:321-358, 1935;.
12 +
Tardieu, G.:  Le typhos: etude physio-pathologique de l'atteinte du dienciphale au course de la fievre typhoide , Presse Med 50:75-78, 1942;.
13 +
Delaunay, A., et al:  Le mode d'action des endotoxines bacteriennes; les troubles vasomoteurs chez les animaux intoxique et leurs consequences , J Physiol (Paris) 40:89, 1948;.
14 +
Penner, A., and Bernheim, A.I.:  Studies in Pathogenesis of Experimental Dysentery Intoxication , J Exp Med 111:145, 1960;.
15 +
Palmerio, C., et al:  Denervation of Abdominal Viscera for Treatment of Traumatic Shock , New Eng J Med 269:709-716, 1963;.
16 +
Braude, A.I.; Carey, F.G.; and Zelsky, M.:  Studies with Radioactive Endotoxin: II. Correlation of Physiologic Effects with Distribution of Radioactivity in Rabbits Injected with Lethal Doses of E. Coli Endotoxin Labeled with Radioactive Sodium Chromate , J Clin Invest 39:858, 1955;.
17 +
Fine, J.; Rutenburg, S.; and Schweinburg, F.B.:  Role of Reticulo-Endothelial System in Hemorrhagic Shock , J Exp Med 110:547-569, 1959;.
18 +
Zetterstrom, B.E.M.; Palmerio, C.; and Fine, J.:  Preservation of Functional and Vascular Integrity of Spleen in Traumatic Shock by Denervation , Bull Soc Int Chir , to be published.
19 +
Jacob, S., et al:  Bacterial Action in Development of Irreversibility to Transfusion in Hemorrhagic Shock in the Dog , Amer J Physiol 179:523-531, 1954;.
20 +
Schweinburg, F.B., and Fine, J.:  Evidence for a Lethal Endotoxemia as the Fundamental Feature of Irreversibility in Three Types of Traumatic Shock , J Exp Med 112:793, 1960;.
21 +
Ravin, H.A.; Schweinburg, F.B.; and Fine, J.:  Host Resistance in Hemorrhagic Shock: XV. Isolation of Toxic Factor from Hemorrhagic Shock , Proc Soc Exp Biol Med 99:426, 1958;.
22 +
Ravin, H.A., et al:  On Absorption of Bacterial Endotoxin from the Gastro-Intestinal Tract of Normal and Shocked Animal , J Exp Med 112:783, 1960;.
23 +
Rubenstein, H.S.; Fine, J.; and Coons, A. H.:  Localization of Endotoxin in Walls of Peripheral Vascular System During Lethal Endotoxemia , Proc Soc Exp Biol Med 111:458-467, 1962;.
24 +
Frank, E., and Friedman, E.:  Hemodynamics of Shock in Man , presented at the New England Surgical Society Meeting , (Oct 5) , 1963;.
25 +
Smith, L.L., and Moore, F. D.:  Refractory Hypotension in Man , New Eng J Med 267:733, 1962;.
26 +
Udhoji, U.N., et al:  Hemodynamic Studies on Clinical Shock Associated with Infection , Amer J Med 34:461, 1963;.
27 +
Knisely, M.H.; Warner, L.; and Harding, F.:  AnteMortem Settling: Microscopic Observations and Analyses of the Settling of Agglutinated Bloodcell Masses to Lower Sides of Vessels During Life; A Contribution to Biophysics of Disease , Angiology 11:535-588, 1960;.
28 +
Gelin, L.-E.: " Fluid Substitution in Shock ," in Shock: Pathogenesis and Therapy , K. D. Bock, ed., Berlin: Springer-Verlag, 1962;, pp 332-347.
29 +
Hardaway, R.M., and Burns, J.W.:  Mechanism of Action of Fibrinolysin in Prevention of Irreversible Hemorrhagic Shock , Ann Surg 157:305, 1963;.
30 +
Miles, A.A.:  Local and Systemic Factors in Shock , Fed Proc (suppl IX) 20:141-150, 1961;.
31 +
Williams, J.A., and Fine, J.:  Measurement of Blood Volume with New Apparatus , New Eng J Med 264:842-848, 1961;.
32 +
Grable, E., et al:  Blood Volume in Experimental Endotoxic and Hemorrhagic Shock , Ann Surg 157:361-365, n1963;.

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1 +
Assay for endotoxin showed the presence of endotoxin in the nondenervated half of the spleen; none was demonstrated in the denervated half.
2 +
Shapiro, B., et al:  Host Resistance to Hemorrhagic Shock: XI. Role of Deficient Flow Through Intestine in Development of Irreversibility , Proc Soc Exp Biol Med 97:372-376, 1958;.
3 +
Selkurt, E.E.:  Intestinal Ischemic Shock and Protective Role of Liver , Amer J Physiol 197:281-285, 1959;.
4 +
Frank, E.D., et al:  Hepatic Blood Flow in Experimental Hemorrhagic Shock , Amer J Physiol 202:7-11, 1962;.
5 +
Frank, H.A.; Seligman, A.M.; and Fine, J.:  Traumatic Shock: XIII. Prevention of Irreversibility in Hemorrhagic Shock by Viviperfusion of Liver , J Clin Invest 25:22-29, 1946;.
6 +
Lillehei, R.C., and MacLean, L.D.:  Intestinal Factor in Irreversible Endotoxic Shock , Ann Surg 148:513, 1958;.
7 +
Wiggers, H.C., et al:  Influence of Prolonged Vasoconstriction on Transition from Impending to Irreversible Hemorrhagic Shock , Fed Proc 6:226, 1947;.
8 +
Remington, J.W., et al:  Protective Action of Dibenamine After Hemorrhage and After Muscle Trauma , Proc Soc Exp Biol Med 69:150, 1948;.
9 +
Jacob, S., et al:  Antiadrenergic and Antihistaminic Therapy in Hemorrhagic Shock in Dog and Rat , Amer J Physiol 186:74, 1956;.
10 +
Nickerson, M.A.:  Protection Against Acute Trauma and Traumatic Shock by Vasodilators , Canad J Biochem Physiol 37:321-358, 1935;.
11 +
Reilly, J., et al:  Sur la pathogenie de la dothienenterie (2 Memoire): Le role du systeme neuro-vegetatif dans la genese des lesions intestinales , Ann Med 37:321-358, 1935;.
12 +
Tardieu, G.:  Le typhos: etude physio-pathologique de l'atteinte du dienciphale au course de la fievre typhoide , Presse Med 50:75-78, 1942;.
13 +
Delaunay, A., et al:  Le mode d'action des endotoxines bacteriennes; les troubles vasomoteurs chez les animaux intoxique et leurs consequences , J Physiol (Paris) 40:89, 1948;.
14 +
Penner, A., and Bernheim, A.I.:  Studies in Pathogenesis of Experimental Dysentery Intoxication , J Exp Med 111:145, 1960;.
15 +
Palmerio, C., et al:  Denervation of Abdominal Viscera for Treatment of Traumatic Shock , New Eng J Med 269:709-716, 1963;.
16 +
Braude, A.I.; Carey, F.G.; and Zelsky, M.:  Studies with Radioactive Endotoxin: II. Correlation of Physiologic Effects with Distribution of Radioactivity in Rabbits Injected with Lethal Doses of E. Coli Endotoxin Labeled with Radioactive Sodium Chromate , J Clin Invest 39:858, 1955;.
17 +
Fine, J.; Rutenburg, S.; and Schweinburg, F.B.:  Role of Reticulo-Endothelial System in Hemorrhagic Shock , J Exp Med 110:547-569, 1959;.
18 +
Zetterstrom, B.E.M.; Palmerio, C.; and Fine, J.:  Preservation of Functional and Vascular Integrity of Spleen in Traumatic Shock by Denervation , Bull Soc Int Chir , to be published.
19 +
Jacob, S., et al:  Bacterial Action in Development of Irreversibility to Transfusion in Hemorrhagic Shock in the Dog , Amer J Physiol 179:523-531, 1954;.
20 +
Schweinburg, F.B., and Fine, J.:  Evidence for a Lethal Endotoxemia as the Fundamental Feature of Irreversibility in Three Types of Traumatic Shock , J Exp Med 112:793, 1960;.
21 +
Ravin, H.A.; Schweinburg, F.B.; and Fine, J.:  Host Resistance in Hemorrhagic Shock: XV. Isolation of Toxic Factor from Hemorrhagic Shock , Proc Soc Exp Biol Med 99:426, 1958;.
22 +
Ravin, H.A., et al:  On Absorption of Bacterial Endotoxin from the Gastro-Intestinal Tract of Normal and Shocked Animal , J Exp Med 112:783, 1960;.
23 +
Rubenstein, H.S.; Fine, J.; and Coons, A. H.:  Localization of Endotoxin in Walls of Peripheral Vascular System During Lethal Endotoxemia , Proc Soc Exp Biol Med 111:458-467, 1962;.
24 +
Frank, E., and Friedman, E.:  Hemodynamics of Shock in Man , presented at the New England Surgical Society Meeting , (Oct 5) , 1963;.
25 +
Smith, L.L., and Moore, F. D.:  Refractory Hypotension in Man , New Eng J Med 267:733, 1962;.
26 +
Udhoji, U.N., et al:  Hemodynamic Studies on Clinical Shock Associated with Infection , Amer J Med 34:461, 1963;.
27 +
Knisely, M.H.; Warner, L.; and Harding, F.:  AnteMortem Settling: Microscopic Observations and Analyses of the Settling of Agglutinated Bloodcell Masses to Lower Sides of Vessels During Life; A Contribution to Biophysics of Disease , Angiology 11:535-588, 1960;.
28 +
Gelin, L.-E.: " Fluid Substitution in Shock ," in Shock: Pathogenesis and Therapy , K. D. Bock, ed., Berlin: Springer-Verlag, 1962;, pp 332-347.
29 +
Hardaway, R.M., and Burns, J.W.:  Mechanism of Action of Fibrinolysin in Prevention of Irreversible Hemorrhagic Shock , Ann Surg 157:305, 1963;.
30 +
Miles, A.A.:  Local and Systemic Factors in Shock , Fed Proc (suppl IX) 20:141-150, 1961;.
31 +
Williams, J.A., and Fine, J.:  Measurement of Blood Volume with New Apparatus , New Eng J Med 264:842-848, 1961;.
32 +
Grable, E., et al:  Blood Volume in Experimental Endotoxic and Hemorrhagic Shock , Ann Surg 157:361-365, n1963;.

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