A historical perspective on crush syndrome: the clinical application of its pathogenesis, established by the study of wartime crush injuries.

Crush syndrome is a fine example of how pathology can play a direct role in revealing the best treatment and management for diseases. It can occur when crush injuries are sustained. Skeletal muscle becomes damaged under the weight of a heavy object, and victims experience severe shock and renal failure. The discovery of the pathology of crush syndrome belongs to two individuals: Seigo Minami and Eric Bywaters. They separately helped to define the pathogenesis of crush syndrome during World Wars I and II. Seigo Minami is believed to have been the first to record the pathogenesis of crush syndrome. In 1923, he described the cases of three soldiers who died of renal failure caused by crush injury during World War I. Using microscopic studies to investigate the pathology of their kidneys, he found the soldiers had died due to 'autointoxication' caused by rhabdomyolysis. This discovery was not known to Eric Bywaters, who described crush syndrome in 1941, having studied victims of the London Blitz during World War II. He defined the 'autointoxication' as the release of rhabdomyolysis products via reperfusion. He therefore established the need for emergency fluid replacement to treat crush syndrome. The findings made by Minami and Bywaters highlight a remarkable achievement in clinical pathology, despite the adversity of war. It is these findings on which current guidelines are based. By reviewing their work, it is hoped that the role of pathology can be better appreciated as a valuable resource for delineating the treatment and management of diseases.

The priority of Antonino D'Antona in describing rhabdomyolysis with acute kidney injury, following the Messina earthquake (December 28, 1908). Commentary.

Following the Messina-Reggio Calabria earthquake (December 28, 1908) outstanding medical reports were published by Franz von Colmers (1875-1960), Antonino D'Antona (1842-1913), and Rocco Caminiti (1868-1940). The reports of D'Antona and Caminiti were heretofore neglected. Colmers, D'Antona and Caminiti described crush-syndrome. D'Antona who cured patients in shock also described two deaths due to uraemia. This gives him a priority in the description of crush syndrome with renal injury which has been traditionally attributed to Bywaters and Beall.

Professor Eric G.L. Bywaters, Acute Kidney Injury and the "forgotten" letter.

The Bywaters seminal 1941 British Medical Journal paper on the crush syndrome was important both for its written content and for using a photomicrograph demonstrating pigmented casts in the renal tubules. He appeared to be reporting the first cases of renal failure secondary to crushing injuries. Most at this point would have been content yet Bywaters demonstrated both determination and humility by publishing a letter in the BMJ 4 months later. This letter, now almost forgotten and rarely referenced, significantly corrected his original paper. He identified that descriptions of the syndrome had been made before, not least by German pathologists in World War 1. The letter recognised various pathologists and surgeons, Colmers (1909) reporting on casualties from the Messina earthquake suffering from acute pressure necrosis and Frankenthal (1916) describing soldiers who had been buried in the trenches showing oedema, bloody urine and post mortem ischaemic muscle necrosis. Others were credited as describing similar cases in inaccessible journals or in "inaugural dissertations". Hackradt (1917) described injuries from burial with oedema of the leg and bloody urine containing albumin and casts, necropsy showed muscle necrosis and tubular degeneration in the kidneys with blood casts and Lewin (1919) described 3 similar cases. Bywaters subsequently credits Minami (1923) a Japanese dermatologist working in Germany for summarizing the literature and providing a description that tallied exactly with his own. Finally Bywaters puzzles why the standard textbooks on war surgery available in Great Britain and the U.S.A. in 1941 make no mention of this entity.

Antonino D'Antona (1842-1913) was the first in describing the crush syndrome with renal failure following the Messina earthquake of December 28, 1908.

There is confusion about the first description of the association between crush syndrome and renal failure. It has been traditionally attributed to Bywaters and Beall. The present study aims to analyze the problem by analyzing medical reports on the Messina-Reggio Calabria earth-quake of December 28, 1908 by using documents heretofore unknown. It demonstrates that first description of rabdomyolysis with renal failure is attributed to Antonino DAntona (1842- 1913). DAntona, professor of surgery at the University of Naples, coordinated the health net organized in Naples to assist persons wounded during the quake. Many of them in shock were transferred to Naples by ships. Franz von Colmers (1875-1960) was the chief surgeon of the German Mission of the Red Cross after the quake. Because his late arrival, he did not treat patients with shock. He described rabdomyolysis. The third medical report is that of Rocco Caminiti (1868-1946), collaborator of DAntona at the University of Naples, and chief of surgery at the Loreto Hospital. He directed a rescue group in Villa San Giovanni and Reggio Calabria. In 1910, he reported on rabdomyolysis in patients treated in the place of the disaster. Therefore the present study indicates that Antonino DAntona holds the priority for description of rabdomyolysis and kidney injury. There is no longer a place for the eponym Bywaters syndrome.

[New study on the history of anesthesiology--(12). A biography of Seigo Minami, the first to describe crush syndrome].

Crush syndrome causes a social concern as we experienced in the devastating earthquake in Kobe area in 1995. In the laboratory of Prof. Pick of Berlin, Seigo Minami (1893-1975), a dermatologist, made a detailed microscopic study of the kidneys of three German soldiers in 1922. They had died from renal failure caused by traumatic injuries during the World War 1. Minami concluded that the common cause of their deaths was "Autointoxication" due to necrotic breakdown of damaged muscles. His paper appeared in Virchows Archiv in 1923. This is the first description of crush syndrome in the world. Thereafter Minami joined the members of Prof. Warburg, Kaiser-Wilhelm Institute to investigate respiration and glycolysis of cancer tissues of rats. This research made an important contribution to the works of Prof. Warburg to whom a Nobel prize for medicine and physiology was awarded in 1931. Minami's name as the first describer of crush syndrome remains quite unknown in Japan, although almost all Japanese dermatologists know him by Minami Prize of Japanese Society of Dermatology.

The Oklahoma City bombing: a personal account.

On April 19, 1995, Oklahoma City (and the United States) lost its innocence. Almost all Oklahomans can relate exactly what they were doing either at 9:02 AM that day or when they first learned of the bombing. Of course, the whole world watched the events unfold through around-the-clock television coverage. One of the resident physicians in the University Hospital Emergency Medicine program, Dr Carl Spengler, was the first physician on the scene and directed early triage efforts. Because the Journal of Child Neurology is the only major biomedical journal with editorial offices in Oklahoma, we considered it appropriate that his personal account of this disaster be published in JCN.

Acute renal failure in the Armenian earthquake.

A destructive earthquake devastated northwestern Armenia on December 7, 1988. The size of the affected area (radius of 50 miles), the time of the day when it occurred (11:41 a.m.), deficiencies in the design and construction of buildings, and inadequate initial rescue and relief capabilities resulted in one of the most lethal and traumatic natural disasters of the century. A large but unknown number (estimated at 225 to 385) of the extricated victims who had sustained crush injury developed myoglobinuric acute renal failure requiring dialytic support. The limited number (8-10 dialysis machines) of antiquated dialysis facilities available locally were overwhelmed. International dialysis relief efforts resulted in meeting the immediate acute needs and provided the motivation and elements of the more efficient system for the future delivery of maintenance dialysis.

The crush syndrome revisited (1940-1990).

This article reviews the local and systemic effects of crush injury. Within minutes to hours after extrication of survivors trapped under fallen masonry (and immediately following decompression of limbs), a massive volume of extracellular fluid is lost into the injured muscles, leading to circulatory failure. Solutes leaking out of damaged muscles cause a spectrum of metabolic disturbances. Chief among them are hyperkalemia and hypocalcemia which, synergistically, have a lethal cardiotoxic potential, particularly in hypotensive patients. Early volume replacement, preferably already started at the rescue site, may combat shock and correct the hyperkalemia. If urine flow is established, this regimen should be followed by a forced solute-alkaline diuresis for the prevention of myoglobinuric and uricosuric acute renal failure, which is a common and ominous late complication of crush injury. Preparation for future catastrophes occurring particularly in remote regions where an 'epidemic' of crush syndrome may be forecast, should include the setting up of a radio communications network to coordinate rescue and salvage operations and the forwarding of intravenous fluid bags and lines to the disaster site. Also, it is advisable to prepare artificial kidney devices which do not require pumps and electricity and which utilize a low dialysate volume for emergency temporary use, until conventional definitive medical facilities and services have been reestablished.