Historical Paper in Surgery a Brief History of Shock
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Historical Paper in Surgery A brief history of shock Frederick Heaton Millham, MD, Newton, MA From Newton Wellesley Hospital, Newton, MA RECENTLY,2MIDDLE-AGED COUSINS were admitted to context. My intention is to discuss the term as it is the Level I trauma center where I attend as a used in the surgical and trauma literature. In a trauma surgeon. Each had been shot twice. Their setting of hemodynamic instability, this word is wounds were similar; both suffered a single gun- frequently used to indicate a syndrome of hypoten- shot wound to the epigastrium and a second sion, tachycardia, and mental status change owing, wound in the left flank. The first cousin (let us presumably, to ‘‘inadequate tissue perfusion.’’ To- call him Joe), had a normal pulse and blood pres- day we use the word shock to describe patients in sure and was oriented and composed; his skin was extremis who suffer from a variety of distinct pink and dry. The second cousin (let us call him pathophysiologic processes, such as severe cardiac Frank) was hypotensive and tachycardic; he was ap- dysfunction or overwhelming infection that share athetic and disoriented, although paramedics re- insufficient tissue perfusion as a consequence. ported that he had been agitated and combative The story of how this word came to be attached in the field just minutes before. His skin was pale to these dramatic clinical syndromes and how our and he was diaphoretic. There was 1 operating predecessors conceptualized the physiology of room immediately available and 1 that would be shock is a central theme of the past 300 years of ready in 20 minutes. Frank was given priority. At surgical history. In this paper, I review the origin of surgery, he was found to have a bullet track passing the use of the word shock, and describe the through the left lobe of the liver, the gastric an- evolution of the concept of shock from its first trum, the pancreatic neck, and the splenic artery. use in the surgical literature to the present. This is There were $2 L of blood in his abdomen. Joe a story with hundreds of contributors. In the was found to have a bullet track that passed interest of economy, I have marked out a path through the right lobe of the liver (nonbleeding) that considers many, although not all. I limited the and through the hepatic flexure of colon. He source material to English language literature, had <500 mL of blood in his peritoneal cavity, with 3 notable exceptions. There are other path- and a moderate amount of free peritoneal fecal ways through this topic, which feature other prin- contamination. In both cases, the flank wounds cipal players. Please consider this a history rather were superficial. Both men recovered uneventfully. than the history of this fascinating subject. The answer to the question of which patient to op- The Oxford English Dictionary (OED) devotes erate upon first seems obvious: It does not require nearly 3 pages to the definition of shock.1 The a trauma surgeon to recognize that the second word itself may derive from the French choc, which man required immediate management. Why? was originally used to describe ‘‘an encounter be- Because Frank, unlike Joe, was in ‘‘shock.’’ tween two charging hostile forces, jousters, etc.’’2 A PubMed search for papers containing the key The OED defines the medical usage of this word as: word ‘‘shock’’ yields >140,000 citations. The mean- A sudden debilitating effect produced by over- ing of the term ‘‘shock’’ varies depending upon the stimulationofnerve,intense pain,violent emotion, or the like; the condition of nervous exhaustion Accepted for publication February 19, 2010. resulting from this. Now used more precisely for a Reprint requests: Frederick Heaton Millham, MD, Newton condition whose principal characteristic is low Wellesley Hospital, Department of Surgery, 2014 Washington 1 Street, Newton, MA 02462. E-mail: [email protected]. blood volume. Surgery 2010;148:1026-37. The OED credits Abernathy with using the word 0039-6060/$ - see front matter for the first time in 1804. However, the usually Ó 2010 Mosby, Inc. All rights reserved. authoritative OED is incorrect on this last point: doi:10.1016/j.surg.2010.02.014 Shock first appeared in the English language medical 1026 SURGERY Surgery Millham 1027 Volume 148, Number 5 literature in 1743 in a translation of a French treatise not possibly manufacture the volumes of blood on gunshot wounds by Henri-Francxois LeDran.3 the Galenic model required. He did this by esti- mating the stroke volume of the heart, and extrap- THE GALENIC ERA olating from this the volume of ‘‘cardiac output’’ Before 1743, there is no record of the word per hour. Thus, Harvey established that the blood shock used to describe a clinical syndrome. Cer- made a circuit, leaving and returning to the heart tainly the syndrome itself existed. William Brad- at regular intervals, and that there was a fixed, and ford Cannon credited Hippocrates with first use of presumably optimal, volume of blood circulating the term ‘‘exemia’’ to describe patients in hypovo- in the human body.10 Harvey did not make a con- lemic shock.4 Cannon’s aim was to replace the nection between the syndrome we recognize as term ‘‘shock’’ with exemia, believing the latter shock and disordered blood volume; it would more specific. My search of existing translations take 3 centuries for this to happen. However, it is of Hippocratic corpus failed to locate this word. with Harvey that our present understanding of Nonetheless, the ancient physicians must have en- shock began. countered patients in shock, even though little rec- ord of the syndrome or its treatment survives. THE AGE OF ENLIGHTENMENT: For the first 1,600 years of the modern era, HENRI-FRANCxOIS LEDRAN medical thought was dominated by the works of Galen of Pergamon (CE 129--200).5 Galen, who The first use of the word ‘‘shock’’ to describe a gained fame as a surgeon to gladiators,6 was inti- trauma victim appears in the English translation of 7 Henri-Francxois LeDran’s 1740 text, Traite´ ou Reflex- mately familiar with hemorrhage, and thus, one 3,11 supposes, with hypovolemic shock. Despite this, ions Tire’es de la Pratique sur les Playes d’armes a` feu (A treatise, or reflections, drawn from practice on he never mentions a constellation of signs and 12 symptoms consistent with what we understand as gun-shot wounds ). A number of authorities assert shock. Ironically, whereas Galen made important that the term was a mistranslation of such words as 5,7,8 choc and secousse, the French term meaning to jar or contributions to the field of anatomy, his no- 13-20 tions that bodily functions were dependent on 4 hu- disturb. However, neither of these words ap- mors---white bile, black bile, phlegm, and blood, peared in the 1740 French text. LeDran’s meaning, each associated with a particular attribute: choleric, and the intent of the translator, can be determined melancholic, phlegmatic and sanguine6---led him to by reviewing the original text and the translation the unfortunate conclusion that hemorrhage was side by side. The word shock occurs 7 times in the En- among the conditions that benefited from bloodlet- glish version: In 3 instances, it is used to translate the ting.9 Galen did not invent therapeutic venotomy, word saisissement; in another 3 instances, it is used to but his advocacy of the treatment led many to adopt translate the word commotion, and in 1 case it is in- serted for the French term, coup. Saisissement in mod- it in his name. It is sobering to contemplate the 21 number of preventable deaths occurring over the ern usage is translated as ‘‘astonishment.’’ In the 18th century, the definition may have been more span of the ‘‘Galenic Era’’ attributable to the belief 22 that bleeding is a good therapy for hemorrhage. consistent with ‘‘fright’’ or ‘‘violent emotion.’’ Many of Galen’s notions about human anatomy The passage below, followed by the English transla- and physiology were erroneous. In the Galenic tion, best demonstrates LeDran’s intent: model, blood flowed outward in both the arteries Mais Quand meˆme un blesse´ ne froit pas ple´thorique, and veins, having been created in the liver and il suffit que le saississement & la commotion qui ac- vitalized by the lungs. Not until 1543 was Galenic compagnent souvent les playes d’armes a` feu, sus- anatomy corrected, when Andreas Vesalius pub- pendent pour queques moments l’odre œconomique; lished De Humani Corporis Fabrica. However, it re- ce qui est prouve´ par les sincopes & autres accidents mained for William Harvey to make the seminal primatifs que nous avons dit arriver affez souvent. discoveries that the understanding of shock re- (p. 74) quired. In Excercitatio de Motu Cordis et Sanquinis in Animalibus (Anatomical exercises on the motion (But though the patient be not previously labor- of the heart and blood in animals, often shortened ing under a plethoric habit of the body, the shock to as ‘‘De Motu Cordis’’) published in 1628, Harvey and agitation which commonly follows gun-shot made 2 important discoveries: First, blood flowed wound will be sufficient to suspend the laws of away from the heart in the arteries and returned œconomy for a few moments: we have a proof of in the veins, meaning that the blood circulated. this from the syncopes and other symptoms we Second, Harvey determined that the liver could have said happen at least often enough.) (p. 48) 1028 Millham Surgery November 2010 LeDran described a syndrome associated with who served in the Spanish War of Independence gunshot wounds where victims are stunned and (1808--1814), expanded the concept of shock to agitated as suspending the ‘‘laws of economy’’ include both a stimulus resulting from trauma and (restless).