Blood and War—Lest We Forget

Download Blood and War—Lest We Forget

Post on 04-Sep-2016




0 download


<ul><li><p>SCUDDER ORATION ON TRAUMA</p><p>Blood and WarLest We ForgetDa</p><p>EaThhaoxthefro</p><p>tradroofbaGrwesciintmoho</p><p>GrflicRoingHebawrcar</p><p>livblopuantinsta</p><p>andein</p><p>shithi</p><p>EmArAvtre</p><p>staretSalHefirsreedis</p><p>ThDecan14fortheGuVIdunetecfampraexestu</p><p>antreThingdisefftabthe</p><p>thenatiming of the pulse. This observation allowed Harvey tosubsequently calculate the ejection volume per hour of</p><p>DisPregres</p><p>Received August 31, 2009; Accepted September 2, 2009.From the Department of Surgery, University of California, Irvine, Orange, CA.CoversOra</p><p> 2Pubblood. He realized that if Galens theory of blood flow wascorrect, the human body would create 16 tons of blood in</p><p>rrespondence address: David B Hoyt, MD, Department of Surgery, Uni-ity of California, Irvine, City Tower, Suite 700, 333 City Blvd West,nge, CA 92868.</p><p>681009 by the American College of Surgeons ISSN 1072-7515/09/$36.00lished by Elsevier Inc. doi:10.1016/j.jamcollsurg.2009.09.005vid B Hoyt, MD, FACS</p><p>rly theories in medicinee goals of treatment as a target for blood transfusionve evolved over time and included volume resuscitation,ygen delivery, and hemostasis. These have accounted fortargets of a spectrum of volume resuscitation efforts,m saline to fresh whole blood.Early surgery consisted of trephination, treatment ofuma, and bloodletting for the treatment of many syn-mes. The Iliad describes 147 wounds, three-quarterswhich led to death at the scene; treatment consisted ofndaging with herbs and bloodletting. At the peak ofeek civilization, Alexander the Great conquered whatnow know as the Middle East and was the first to takeentists along with him because his teacher, Aristotle, waserested in the study of natural history. Alexander accom-dated him by bringing leading worldly discoveriesme.In doing so, he collected new information and spreadeekmedicine.The concept of research study during con-t was also established. Galen, a dominant figure duringman domination of the world, started his medical train-in the second century AD and studied at Alexandria.dissected animals and established his observations</p><p>sed on misinterpretation of objective animal data. Hisitings became gospel and determined much of medicale for the next 1,500 years.1</p><p>Galens theory of circulation described food going to theer, blood emerging from the liver going into arteries, andod crossing the heart and continuing into veins withlsatile flow. Draining blood was viewed as therapeuticd applied for multiple conditions. The basis of bloodlet-g was established, consistent with the current under-nding of cardiovascular physiology at the time.Roman domination included most of the Middle Eastd Europe, and the concept of far-forward care was firstmonstrated in early depictions of Roman military care,frescoes of the time.The seat of Roman power ultimately</p><p>closure Information: Nothing to disclose.sented at the American College of Surgeons 94th Annual Clinical Con-s, San Francisco, CA, October 2008.fted from Rome to Constantinople (Istanbul), and withs, Europe and Rome ultimately fell.Over the next 200 years, what was known as the Romanpire shifted to the influence of Islam. Latin turned intoabic, Galens readings and writings were endorsed byicenna, and bleeding continued to be the therapeuticatment of choice.Medicine returned to Europe in 1010 AD, when Con-ntine of Carthage, having studied medicine in Arabia,urned to Carthage and after being shunned, escaped toerno, where his Arabic was translated back into Latin.sought refuge in a monastery and this established thet knownmedical school in Europe.With this, dissectionmerged and the term chairman evolved from the mastersector overseeing pupils.1</p><p>e emergence of circulatory theoryspite these advances the incidence of injury and signifi-t surgical bleeding was low. Public registry data from theth century shows infection overwhelmingly responsiblemortality and bleeding as aminor cause ofmortality.1 In16th century, the Barbers Company and Surgeonsild were joined under a doctrine approved by HenryII and bloodletting, having been prohibited by monksring the previous two centuries, became the core busi-ss of barber surgeons. Reflecting the importance of thishnique at the time, the second publication from theous Guttenberg Press was a bloodletting calendar forctitioners at the time. In addition, they were given fourcuted criminals a year for dissection, and anatomicdy was reestablished.Par described early involvement with gunshot wounds,d the practice of cautery for wounds was replaced byatment with open dressings of turpentine and rosehips.1</p><p>e basis of transfusion emerged with a better understand-of anatomy, as described by Vesalius, who used humansection to create the De Fabrica Humani Corporis. Thisort led to his subsequent professional ostracism, but es-lished the basis of anatomy as we know it today and setstage for additional research in circulatory physiology.Galileo, known for his description of the universe andrelationships between planets orbiting the sun, origi-</p><p>lly startedmedical school andwas the first to describe the</p></li><li><p>24 hours and this was impossible. This allowed him toestassacclar</p><p>ClBometiosedjecLoanveiblo</p><p>AbloInwiwhthethi</p><p>paledDebasuifor</p><p>isBeduGebeint</p><p>EaBlutiedietrablo</p><p>besalerathainfmo</p><p>who described subcomponents of electrolytes and their ef-fec 11</p><p>firsfor</p><p>hyThintadrid19</p><p>BeThcartutniqselwi</p><p>erschchbebadalife</p><p>suranothcoma 3stape</p><p>abcomMowhLewifusopreatow</p><p>UsDushocures</p><p>682 Hoyt Scudder Oration on Trauma J Am Coll Surgablish his theory of circulation, published in 1628. Heumed that because Galens theory was impossible toept, blood must circulate. He died 4 years before capil-ies were observed.2</p><p>Harvey was a member of the Experimental Philosophyub at Oxford and Charles Wren, the architect, andyle, the chemist, were also members and did experi-nts based on Harveys theories. They proved that injec-n of antimony or opium in dogs induced vomiting andation, respectively, demonstrating that intravenous in-tions circulated. A medical student of Wren and Boyle,wer applied this concept and drained blood from a dogd resuscitated the bled dog with another dog, artery ton, demonstrating that one animal can live with theod of another.3</p><p>classical moment in the history ofod transfusion1667, Jean-Baptiste Denys transfused Antoine Mauryth a lambs blood, which led to calming of the patient,o suffered from known mental dementia. He describedfirst human hemolytic reaction (black urine), and afters demonstration, the technique spread to Europe.The practice continued to be controversial and Denystient returned for two subsequent transfusions; the thirdto his death and caused the patients wife to sue Denys.nys was absolved at trial but the French Parliamentnned the practice and the Pope subsequently followedt. As a result, transfusion as a medical practice went dark150 years.4</p><p>Bloodletting returned and ruled, and the Lancet journalnamed after the instruments used for this treatment.njamin Rush was sued for this practice in Philadelphia,ring his treatment of the malaria epidemic of 1799.orge Washington was bled four times in the last 2 daysfore his death, andWilliamOsler continued this practiceo the early 20th century.2</p><p>rly transfusionndell, an obstetrician at Guys Hospital, transfused pa-nts after obstetric hemorrhage. His first four patientsd, but in 1829 he had an initial survivor and bloodnsfusion was reestablished. There was little record ofod transfusion during the Civil War.The history of saline solution as a volume replacementgan developing in the early 19th century. The use ofine resuscitation evolved from observations during chol-epidemics, which described concentrated dark bloodt suggested loss of fluid and electrolytes.5,6 In 1832 theusion of normal saline was associated with a reduction inrtality.7-10 This was followed 50 years later by Ringer,t onmyocardial activity in an in vitro heart model. Thet use of saline in a resuscitation effort instead of bloodobstetric hemorrhage was in 1898.12</p><p>The use of acacia, a carbohydrate colloid, with saline andpertonic saline solutions emerged during World War I.e concept of a postoperative or perioperative drip wasroduced by Matas in 1924.13 Hartman14 described thedition of lactate and the debate regarding sodium chlo-e and lactated Ringers emerged during the 1950s and60s.15</p><p>ginning of rapid progresse first transfusion in the United States was probablyried out by Alex Carrel working at the Rockefeller Insti-e, having been recruited by Flexner to investigate tech-ues of vascular anastomosis. Carrel had concerned him-f with this when, as a medical student in France, hetnessed the death of a patient with a portal vein injury.In 1908 he was summoned by Lambert (who had broth-who were surgeons) and asked to help with Lambertsild, who suffered from acute anemia associated withildbirth. Carrel, despite having no license, went to Lam-rts apartment and sewed the fathers radial artery to thebys saphenous vein and they witnessed father-to-ughter transfusion, which subsequently saved the babys. He celebrated the childs birthday 21 years later.2</p><p>Transfusion was popularized, and direct transfusion (agical procedure) was required because anticoagulationd technical problems precluded successful use of anyer technique. Dr George Crile established the mostmonly used technique, but it was still accompanied by5% hemolytic transfusion reaction. It was, by todaysndards, one of the most expensive surgical proceduresrformed at the time.A landmark in making transfusions more widely avail-le occurred through Landsteiners discovery of ABOpatibility and simplification of testing by Ottenberg atunt Sinai.3 This reduced hemolysis to essentially zeroen blood was adequately tested. At the same time,wisohn, in 1915, demonstrated that anticoagulationth sodium citrate allowed the technique of blood trans-ion to be as simple as, and equal to, saline infusion.Thisened the door for longterm storage. It was the criticalson that blood could, for the first time, be widely usedard the end of World War I.2</p><p>e of blood during warring the beginning of World War I, the etiology ofck was debated. The prevailing theory was that cir-lating shock factors, as part of the neuroendocrineponse, were responsible for the shock syndrome, as</p></li><li><p>advocated by Cannon andCrile. Volume resuscitation wasdothealtsicextthacauobsurthabletio</p><p>evaacagrooccasfuswh</p><p>ofresOthedifofexainftun</p><p>ecopitusizensys</p><p>joidediodidstrtan</p><p>strplaHeiesressal</p><p>hurst, NJ.19 Dr Scudder was an advocate of the BloodBeDrasktotio</p><p>tiamenethetimatlunpo</p><p>blofraRaalbHares</p><p>mithea ffaccomthaWomemi</p><p>patatwaeffthaopmodeblogendethamaha</p><p>blowadu</p><p>683Vol. 209, No. 6, December 2009 Hoyt Scudder Oration on Traumane primarily with crystalloid and acacia. Robertson wasfirst to introduce citrated type O blood in curing casu-ies well after the start of World War I.3 Cannon, a phy-ian and physiologist at Harvard, subsequently publishedensive literature on traumatic shock, based on his theoryt a dilated capillary region led to entrapment and thissed hypovolemia. In addition, Cannon and colleagues16</p><p>served that the injection of fluid increased blood pres-e, which was dangerous in itself, and they demonstratedt blood pressure could pop the clot and aggravateeding, begging the question whether volume resuscita-n was appropriate at all.In 1918 the US adopted citrated blood and a postwarluation demonstrated that blood was better than gumcia and salt solution. It was noted that if blood wasuped using techniques of Ottenberg, no serum reactionurred. To quote a battlefield surgeon at the time slightmy experience has been with this method of blood trans-ion, I know that at this hospital we save lives by its use,ich would have otherwise have been lost.3</p><p>An interesting quote byWalter Cannon after an analysishis experience inWorldWar I noted that fundamentally,earch in this area had been accompanied by reason for our ignorance is the relative irregularity ofappearance of shock ensuing in life and the consequentficulty of pursuing persistent studies. The circumstanceswar however, are such to permit at times systematicmination of large numbers of shock cases instead ofrequent single cases as in civilian life. With such oppor-ity theoretic consideration should be set aside.16</p><p>After World War I, Keynes, the brother of the famousnomist, set up a blood bank at St Bartholomews hos-al in London, and the US had several similar efforts,ng the concept of donors on the hoof, in which citi-s were on call to donate blood based a prescreeningtem.17</p><p>Meanwhile, Alfred Blaylock was beginning his career,ned Harrison at Vanderbilt, where both were chief resi-nts, and studied the relationship of blood loss and car-genic shock. He collaborated with Vivian Thomas anddefinitive shock studies before World War II, demon-</p><p>ating the importance of volume loss as the most impor-t cause of hypovolemic shock.18</p><p>In 1936 Elliott, a surgeon in North Carolina, demon-ated after separating blood into plasma and red cells, thatsma transfusion of a stab wound victim was life saving.approached John Scudder, who was known for his stud-of shock at Columbia and had been responsible foruscitating the German pilots and crew with hypertonicine solutions after the Hindenburg disaster in Lake-tterment Association in New York City and based onScudders recommendations, Dr Charles Drew wased to design a program for plasma therapy, which ledthe collection of 9 million units for plasma prepara-n during World War II.20</p><p>Started initially as a program for Britain, which was ini-ted by Carrel, who moved back to France after retire-nt, the Americans were approached to help with theed for blood. It was realized that blood would not survivejourney to Europe because transatlantic flights at thate were not routine and the delay associated with trans-antic shipping would cause increased infection of theits shipped. As such, a shift to focus on plasma to sup-rt blood pressure was established.Dr Edwin Cohn, concerned about infection risk ofod, had also embarked on a program known as Cohnctionation and this led to the isolation of albumin. Dr ISdvin was commissioned to take the first 50 bottles ofumin and test them 4 days after the invasion of Pearlrbor. As such, plasma and albumin therapy was the fluiduscitation of choice at the beginning of World War II.2</p><p>The National Research Council established the Com-ttee on Transfusion, chaired by Walter Cannon towardend of his career, and they concluded that shock is reallyorm of hemoconcentration and that plasma would, int, be more effective than blood. Despite this, the Sub-mittee on Blood Substitutes had the contrary opiniont whole blood would be best as resuscitation duringrldWar II.This was omitted from their minutes in theireting in 1941 and was subsequently placed intomeetingnutes 2 years later.2</p><p>It was Dr Churchill, a thoracic surgeon fromHarvard, asrt of an in-theater evaluation team, who studied resusci-ion during his deployment and concluded that plasmas not the best blood substitute. He described the...</p></li></ul>