Wednesday, April 18, 2007

History of shock

Today in Emergency Medicine Grand Rounds, OHSU professor and international trauma expert Dr. Donald Trunkey delivered a fast-paced talk on the thousand-year history of shock.

Starting with Egyptian papyri, Trunkey touched on Greek misconceptions (such as the simple experiment "proving" that tourniquets make you bleed more) before discussing the development of trauma care by the Romans. Galen, who became surgeon to the gladiators when he was 28 years old, was the first to suture tendons and muscle; however, he does not seem to have developed any conception of shock as a medical condition. He did develop a method of ligating vessels, a vast improvement over earlier treatments such as fig juice (Iliad), decoction of pepper (Chou Li), or packing the wound with vinegar-soaked lint (Celsus). Cautery was the treatment of choice during most of the Middle Ages, until Ambroise Pare resurrected ligation in his work during the Renaissance. Dominique Larrey elevated ligature to an art: it is said that he was able to amputate a leg and ligate all the associated vessels in one and a half minutes (as Napoleon's surgeon, he had a lot of opportunities to practice).

It wasn't until the mid-1800s that surgeons began to conceive of shock as a specific condition. Some of the early definitions were less than precise:
Shock is "a momentary pause in the act of death."--John Collins Warren
"Shock is the manifestation of the rude unhinging of the machinery of life."--Samuel Gross

In 1923, Walter Cannon published Traumatic Shock, the first work to adequately describe the condition. Cannon had spent three months observing wound treatment at Casualty Clearing Station No. 33 in France during World War I, and had compiled data on the various categories and stages of shock. According to Trunkey, most subsequent research on shock has shown Cannon's theories to be correct--and that, to this day, physicians and surgeons are ignoring this historical work. He wound up his talk with a slide from the ATLS on "Recognition of Shock State"--proceeding to discount four of the six listed indicators as either difficult to measure or actually misleading.

The lesson for the day: those who choose to ignore history do so at their own (and others') peril.

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