History

Battle Casualties in Korea, Studies of the Surgical Research Team, Volume I

Circulatory Homeostasis Following Massive Injury Studies of Vasodepressor and Vaso-excitatory substances in the Circulating Blood*

First Lieutenant Russell Scott, Jr., MC, USAR
Captain John M. Howard, MC, USAR
Ephraim Shorr, M. D.
Natalie Lawson
and
Captain John H. Davis, MC, USAR

Introduction

The liver, kidneys and circulatory system take a major part in the response of the body to massive injury. The hepatic response is indicated by major changes in the metabolism or excretion of carbohydrate, albumin, prothrombin, fibrinogen, bilirubin, urobilinogen, bromsulphalein and other substances.⁵ The kidney responds by vasoconstriction² and by alterations in its excretions of electrolytes. The cardiovascular system responds initially by vasoconstriction⁹ and by changes in cardiac rate and output. The function of the cardiovascular system as a whole may be altered as indicated by a prolonged equilibration time of water (deuterium oxide) following its intravenous administration.¹

These studies of the systemic response to trauma, carried out at a Surgical Hospital on the Eastern Front in Korea, paralleled the clinical problems encountered there. Two of these problems were post-traumatic renal insufficiency and hypotension refractory to transfusion. The latter complication was not infrequently encountered at the forward hospital. Massive transfusions of 5,000, 10,000, and even 15,000 ml. of blood were used. Hypotension sometimes persisted following hemostasis and replacement therapy, and although a normal blood volume could seldom be demonstrated,⁴ surgeons often felt that transfusion requirements exceeded blood lost by hemorrhage. Since transfusions of this magnitude seemed necessary, as indicated by a broad clinical experience, the question arose as to whether the necessity was the result of changes in the peripheral vascular bed. The purpose of this preliminary study, therefore, was to investigate one of

*Previously published in Annals of Surgery 141: 504, 1955.

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the homeostatic mechanisms in an effort to describe the possible response to injury leading to the two clinical syndromes, refractory hypotension and post-traumatic renal insufficiency.

This homeostatic mechanism centers around two vasoactive substances, one vasodepressor (VDM, ferritin), the other vaso-excitatory (VEM), which are released by the ischemic liver and kidney respectively and exert their effects on the muscular vessels of the capillary bed. The relevance of these principles to the present study derives from their regular participation in the syndromes of experimental hemorrhagic and traumatic shock.^6,7

Material and Methods

During the period March 1952-March 1958, 20 patients were selected for study. With a single exception, these patients were healthy, young, adult soldiers prior to combat injury. Casualties were selected with various degrees of injury and at various times after injury. Some were studied on admission or prior to operation (8 to 5 hours after injury); others were studied during various stages of complications or convalescence. Patients were excluded if they had received morphine, anesthetic agents, or any other sedatives within the preceding 19 hours. Blood was drawn under sterile conditions using heparin as an anticoagulant. Maintaining sterile conditions, the blood was centrifuged, separated, the plasma placed in glass containers and frozen within 30 minutes. The frozen plasma was then shipped to the United States and kept frozen until analyses were performed 60 to 90 days later. Plasma from four control subjects was handled in a similar manner and demonstrated no significant amounts of VDM, VEM, or toxic substances when studied simultaneously in two different laboratories.

The analyses were performed by the meso-appendix assay method of Chambers and Zweifach¹⁰ as modified by Shorr and Zweifach.⁸

Analyses for the first 12 patients were carried out in the laboratory of Dr. Ephraim Shorr at the New York Hospital. In these studies the tests were carried out by a fractionation procedure which showed not only the predominant activity of the unaltered plasma but also revealed the oppositely acting factor, when present. The fractionation was based on the observation that hepatic VDM is ferritin and that its vaso activity can be abolished by incubation with rabbit anti-ferritin serum.⁸ Hence, when the unaltered plasma gives a vasodepressor reaction, a second test after incubation with antiserum will unmask any VEM present. If the unaltered plasma is neutral and gives a VEM reaction after antiserum, experience permits the assump-

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tion that an equivalent amount of hepatic VDM is also present in the unaltered plasma. Should the unaltered plasma exhibit VEM predominance, which was not the case in the samples studied at the New York Hospital, VDM can be unmasked by inactivating VEM through aerobic incubation with kidney slices. It is believed by one of the authors (E. S.) that the VDM titers obtained are a valid though semi-quantitative index of the hepatic VDM in the plasma at the time the specimens were analyzed. Deterioration of VDM while in storage could not, however, be ruled out so that the VDM reported is believed to represent a minimal titer. Since it is not as yet possible to establish by immunochemical means, as in the case of hepatic VDM, that the vaso-excitor activity of plasma is specifically due to renal VEM, if could not be excluded that other vaso-excitor materials might also have contributed to it. This was not suspected but remains a possibility. The instability of VEM, even in the frozen state, suggests that considerable deterioration of activity occurred prior to the analyses. The analysis of the specimens from the last 12 patients was carried out at the Army Medical Service Graduate School by one of the authors (N. L.) who had trained in Dr. Shorr`s laboratory. In the latter group, only the predominant activity of the unaltered plasma was determined; the VDM and VEM activity not being fractionated as in the first group.

Results

The results of the assays are summarized in Tables 1, 2, and 3. VDM was often demonstrable and sometimes in relatively large amounts. VEM was seldom demonstrable in significant quantities.

Discussion

The data demonstrate the single fact: VDM is often present in the plasma in high concentration following major injury. Of the 20 patients, 10 were studied during the first 48 hours after injury; only 2 demonstrating more than a mild VDM reaction. Fifteen patients were studied at some time after the first 48 hours and 12 demonstrated a moderate to strong VDM response. Of the 12 patients studied by the fractionated plasma technic (Fig. 1), 6 were studied after the lapse of at least 48 hours following injury, and all 6 demonstrated a moderate or strong VDM response. The VEM concentration was seldom appreciably increased (Figs. 2 and 3).

It is of interest that in no instance was there any evidence of the presence of VDM of muscle origin, which is uniformly present in the blood following experimental traumatic shock. Muscle VDM, al-

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Table 1. Summary of Clinical Data

Patient No.	Injury	Degree of Shock			Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
Patient No.	Injury	Preoperative	Operative	Postoperative	Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
1	Bilateral traumatic amputation above the knees	Moderate	Slight	None	9,000	1^st day-Neutral 3d day-Strong VDM Moderate VEM 6^th day-Strong VDM Little or no VEM	Lived
2	Three perforations of the liver, a perforation of the stomach, colon, diaphragm, and lower lobe of the left lung	Severe	Moderate	None	5,500	Preop.-Mild to moderate VDM Moderate VEM 1^st day-Moderate VDM No VEM 5^th day-Moderate to strong VDM Very little VEM	Lived
3	Perforation of colon and internal iliac artery and vein	Moderate	Moderate	None	7,000	2^nd day-Moderate VDM No VEM 5^th day-Strong VDM Mild VEM (test only fairly satisfactory)	Lived
4	Perforation of femoral artery and small intestine. Amputation of left leg above the knee.	Severe	Moderate	Moderate, corrected with blood	15,000	1^st day-Mild VDM Mild VEM	Lived

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Table 1. Summary of Clinical Data-Continued

Patient No.	Injury	Degree of Shock			Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
Patient No.	Injury	Preoperative	Operative	Postoperative	Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
5	Perforation of stomach, duodenum, pancreas and kidney. Post-traumatic renal insufficiency	Moderate	Severe	Mild and transient	10,500	Preop.-Moderate VDM 5^th day-Moderate VDM	Died
6	Penetration of the popliteal artery	Severe	None	None	4,000	Preop.-Mild VDM	Lived
7	Perforation of the small intestine. Contusion of the spinal cord	None	Moderate	Severe and Prolonged	1,000	3d day-Moderate VDM	Died
8	Fracture of ilium and femur. Lacerated right lobe of liver.	Severe	Moderate	Moderate, persisted until death on 2d day.	13,000	1^st day-Slight VDM	Died
9	Small bowel obstruction with gangrene	Severe	None	None	1,000	Preop.-No VDM	Lived
10	Perforation of colon	Moderate	None	None	1,500	Preop.-No VDM	Lived
11	Head injury	Severe	No operation	Severe	---	Pre-terminal-Moderate VDM No VEM	Died
12	Penetrating wounds of the legs with amputation of both legs.	Severe	None	None	7,000	2d day-Strong VDM	Lived
13	Fracture both femurs, perforations of the liver, colon, small intestine, appendix. Concussion of the 2d and 3d lumbar vertebrae.	Severe	Moderate	Severe and continued leading to death	11,500	3d day-Strong VDM	Died
14	Perforation of the small and large intestines, diaphragm. Lacerations of the kidney and liver. Fracture of the pelvis. Post-traumatic renal insufficiency.	Moderate	Moderate	Moderate corrected by blood.	Unknown, presumed to be large.	3d day-Neutral	Died
15	Penetration of chest, diaphragm, stomach, colon, and liver.	None	None	None	1,000	3d day-Trace VDM 5^th day-Strong VDM 7^th day-Neutral	Lived
16	Perforation of femoral artery, liver, small intestine and eye. Amputation of one hand.	Moderate	Moderate	None	3,500	2d day-Strong VDM	Lived
17	Penetration of the small intestine, colon, bladder, and fracture of the femur.	Moderate	Moderate	Moderate, continued	11,500	2d day-VEM 3d day-Neutral 6^th day-Neutral	Lived
18	Perforation of the small intestine, colon, and liver.	Moderate	Moderate	None	5,000	Postop.-Strong VDM 3d day-Neutral	Lived

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Table 1. Summary of Clinical Data-Continued

Patient No.	Injury	Degree of Shock			Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
Patient No.	Injury	Preoperative	Operative	Postoperative	Total Blood and Blood Substitutes (ml.)	Period and Amount of VDM and VEM	Survival
19	Compound fracture of both tibias and fibulas. Laceration of femoral artery. Post-traumatic renal insufficiency.	Moderate	Moderate	Moderate	11,000	5^th day-Strong VDM	Lived
20	Laceration of liver and kidney.	None	None	None	1,000	4^th day-Strong VDM 6^th day-Trace VDM	Lived

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Table 2. Data on Fractionated and Unfractionated Plasma(Patients 1-12)

Patient No.	Period	Type and Duration of Activity of Unfractionated Plasma	Reaction After Anti-ferritin Added to Plasma	Results (Appraisal)
1	1^st day	Essentially neutral, with trace VEM	Neutral	Neutral
	3^rd day	Moderate VDM (42 minutes)*	VEM (46 minutes-4x)**	Strong VDM Moderate VEM
	6^th day	Strong VDM (52 to 60 minutes)	Essentially neutral, with trace VEM	Strong VDM Little or no VEM
2	Preoperative	Mild to moderate VDM	Moderate VEM (36 minutes-2x)	Mild to moderate VDM Moderate VEM
	1^st day	Moderate VDM (46 minutes)	Neutral	Moderate VEM No VEM
	5^th day	Moderate to strong VDM (38 to 52 minutes) (2 toxic reactions)	Mild VDM (20 minutes-2x) (toxic reactions)	Moderate to strong VDM Very little VEM
3	2d day	Moderate VDM (45 minutes)	Neutral	Moderate VDM No VEM
	5^th day	Strong VDM (60 minutes) (severe toxic reaction)	Mild VEM (28 minutes-2x)	Strong VDM Mild VEM
4	1^st day	Neutral	Mild VEM (28 minutes-2x)	Mild VDM Mild VEM
5	Preoperative	VDM (33 minutes)	Neutral	Moderate VDM
	5^th day	VDM (27 minutes)	Neutral	Moderate VDM

See footnotes at end of table.

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Table 2. Data on Fractionated and Unfractionated Plasma(Patients 1-12)-Continued

Patient No.	Period	Type and Duration of Activity of Unfractionated Plasma	Reaction After Anti-ferritin Added to Plasma	Results (Appraisal)
6	Preoperative	VDM (24 minutes)	Neutral	Mild VDM
7	3d day (shortly before death)	VDM (39 minutes, delayed reaction)	Neutral	Moderate VDM
8	1^st day	VDM-neutral to mild	Neutral	Slight VDM
9	Preoperative	Neutral	Neutral	No VDM
10	Pre-resuscitation	Neutral	Neutral	No VDM
11	Pre-resuscitation	Moderate VDM (36 minutes)	Neutral	Moderate VDM No VEM
12	2d day	Strong VDM (56 minutes)	Neutral	Strong VDM No VEM

*The duration of the depressed response of the vessels in the meso-appendix to the topical application of epinephrine solution.
**Dilution of the control epinephrine solution required to produce the control type of vasoconstrictor response.

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Table 3. Data on Unfractionated Plasma (Patients 13-20)

Patient No.	Period	Reaction of Unfractionated Plasma
13	3d day	Strong VDM (28 minutes)
14	3d day	Neutral
15	3d day	Trace VDM (8 minutes)
	5^th day	Strong VDM (24 minutes)
	7^th day	Neutral
16	2d day	Moderate VDM (34 minutes)
17	2d day	VEM Reaction (12 minutes-x8)
	3d day	Neutral
	6^th day	Neutral
18	1^st day	VEM Reaction (16 minutes-x8)
	3d day	Neutral
19	5^th day	Very strong VDM repeated at ½ dilution with 20-minute duration.
20	4^th day	Strong VDM (24 to 28 minutes)
	6^th day	Trace VDM

though having the same vasodepressor properties, differs chemically from hepatic VDM (ferritin) and is not inactivated by anti-ferritin serum. In no plasma subjected to fractionation by antiserum was there any residual vasodepressor activity which could be attributable to muscle VDM.

There does not appear to be a positive correlation between the VEM-VDM response and the amount of blood required to resuscitate a casualty. Patients No. 4 and 5 required 15,000 and 10,500 ml. of blood respectively and had essentially the same VDM response as Patient No. 7, who received only 1,000ml. of blood. Patient No. 12, who required 7,000 ml., actually had a higher VDM titer than did Patients No. 4 and 5 who received approximately twice this amount.

Similarly, there does not appear to be a positive correlation between the VDM-VEM response and the survival of the patient. Of the six patients who died, two showed slight or no VDM (Patients No. 8 and 14). Three patients were shown to have moderate VDM and one patient was shown to have strong VDM.

No positive correlation between the development of post-traumatic renal insufficiency and the titer of VDM or VEM was demonstrable. Three patients developed post-traumatic renal insufficiency (Patients No. 5, 14 and 19).They demonstrated moderate, neutral and strong VDM responses respectively.

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FIGURE1.
VDM in fractionated plasma. The VDM concentration appears
to increase during the first few days after injuy.

FIGURE2.
VEM in fractionated plasma. The occasional specimen
containing VEM also contained VDM.

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FIGURE3.
Unfractionated plasma demonstrating the predominant effect.

Summary

VDM and VEM assays were performed on 20 Korean battle casualties. A high titer of VDM was frequently demonstrable during the first week following severe injury. The VDM activity was shown by immunochemical means to be due to ferritin, and hence of hepatic origin.

Within the limitations of the study no positive correlation can be made between the VDM-VEM titers with the blood pressure, the development of refractory shock, the transfusion requirements, the development of post-traumatic renal insufficiency, or the ultimate prognosis of the patient.

There appeared to be no positive correlation between the occurrence of traumatic shock refractory to transfusion and the titer of VDM or VEM. Three patients suffered traumatic shock which, after operation, would not respond to transfusion (Patients No. 8, 13 and 17). They were shown to have slight, strong and neutral VDM reactions respectively. Similarly, the development of postoperative hypertension could not be related to the VDM-VEM titers.

References

1. Howard, J. M., and Scott, Russell, Jr.: The Equilibration Time of Water, (Deuterium Oxide) following Intravenous Injection in the Battle Casualty. Surg., Gynec. & Obst. 99: 703, 1954 (Chapter4 in Volume II of this series).

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2. Ladd, M.: Renal Function in the Battle Casualty. A report to the Army Medical Service Graduate School, 1952.

3. Mazur, A., and Shorr, E.: Quantitative Immunochemical Study of Ferritin and Its Relation to Hepatic Vasodepressor Material. J. Biol. Chem. 182: 607, 1950.

4. Prentice, T. G., Olney, J. M., Artz, C. P., and Howard, J. M.: Studies of Blood Volume and Transfusion Therapy in the Korean Battle Casualty. Surg., Gynec. & Obst. 99: 542, 1954 (Chapter 9 in Volume II of this series).

5. Scott, Russell, Jr., Howard, J. M., and Olney, J. M.: Hepatic Function in the Battle Casualty (Chapter 8 of this volume).

6. Shorr, E., Zweifach, B. W., Furchgott, R. F.: Hepato-renal Factors in Circulatory Homeostasis, III. The influence of humoral factors of hepato-renal origin on the vascular reaction to hemorrhage. Annals New York Acad. Sc. 49: 571, 1948.

7. Shorr, E., Zweifach, B. W., Furchgott, R. F., and Baez, S.: Hepato-renal Factors in Circulatory Homeostasis, IV. Tissue origins of the vasotropic principles, VEM and VDM, which appear during evolution of hemorrhagic and tourniquet shock. Circulation 3: 42, 1951.

8. Shorr, E., Zweifach, B. W., Furchgott, R. F., and Baez, S.: Hepato-renal factors in Experimental Shock and Renal Hypertension. Trans. Assoc. Am. Physicians 60: 28, 1947.

9. Stahl, R. R., Artz, C. P., Howard, J. M., and Simeone, F. A.: Studies of response of the Autonomic Nervous System Following Combat Injury. Surg., Gynec. & Obst. 99: 595, 1954 (Chapter 6 of this volume).

10. Zweifach, B. W.: Methods in Medical Research. Year Book Publishers 1: 131, 1948.