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Title: Bombs, earthquakes and rhabdomyolysis
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Bombs, earthquakes and rhabdomyolysis

Seventy years ago the Battle of Britain led to recognition of a new disease and to important discoveries about acute renal failure

   The Blitz, East London September 1940 (Wikimedia Commons)

In the Summer of 1940, the German Luftwaffe switched its bombing targets from English airfields and aircraft factories to cities, and in September 1940 large scale air raids on London began. Shortly afterwards, a new type of acute renal failure was noticed in some of those rescued from fallen buildings.
Case 6 from the BMJ March 22nd 1941 (Mayon-White and Solandt, pages 434-5). She died after 6 days of oliguria by which time her serum urea was 62 mmol/l (369 mg/dl)

Typically the patient had been buried for several hours with pressure on a limb. On admission they often looked in good condition except for local swelling. Shock developed as fluid was lost into the crush site, but despite measures to restore the circulation, only small amounts of dark smoky urine were seen. Potassium and urea rose briskly, leading to death within 3-7 days despite careful management.
At autopsy, brown pigmented casts were described in the renal tubules, along with changes of what we now call acute tubular necrosis.
Six cases were published in the British Medical Journal of March 22nd 1941, 5 by Dr Eric Bywaters from Hammersmith Hospital in West London. All of the patients died, as did most of the others that the authors had been told of. Dialysis was not available in 1940, but the team was clearly aware of the importance of correcting shock and other core principles of managing acute renal failure (management of potassium, sodium intake).

Further pioneering work at Hammersmith on acute renal failure led to it becoming a referral centre for patients with acute renal failure of other causes. Soon after the war Bywaters obtained one of Kolff’s first haemodialysis machines to try out, and the Hammersmith team became the third in the world to use dialysis successfully. But it was high risk and very hard work with uncertain outcomes, and as medical management improved the machine was put on one side. Prof Kenneth Lowe, who later became a professor of medicine and cardiology, later described to Dr John Turney working with the Kolff rotating drum dialyzer in 1947 (see further reading below).

By 1942 Bywaters had proved that the brown pigment in the tubules was myoglobin from muscle, and was nearly convinced that this was the culprit in causing kidney damage. He proposed urinary alkalinisation (which had been tested for haemoglobinuria) and treatment of shock by fluid replacement as the emergency treatment most likely to prevent myoglobin precipitating in tubules and acute renal failure. This remains the recommended first line therapy today.
Bywaters later discovered similar cases in German literature from the 1914-1918 war, and references to it from accounts of the Messina earthquake of 1909. By 1942 the MRC had received notification of 70 cases, and Bywaters estimated that it may occur in 5% of air raid casualties in urban areas.

Rhabdomyolysis continues to occur today after bomb blasts during peace and war, and in devastatingly large numbers in earthquakes when getting the survivors to the needed treatment is most difficult. At the time of writing this there is breaking news of an earthquake in Haiti which is certain to create another surge in cases requiring urgent treatment. It is also seen after prolonged unconsciousness caused by epilepsy or drugs, and sometimes by sudden arterial occlusion by thrombosis or inadvertent arterial injection. The threshold for causing rhabdomyolysis may be low for inherited reasons, or by taking certain drugs.
Dialysis is often life-saving in rhabdomyolysis. Medical management would always struggle to cope with the rate of metabolite release in rhabdomyolysis and in other catabolic acute renal failure. Dialysis returned to the management of acute renal failure in the UK in 1956, some years after it had been tested severely in the Korean war.

Further information
Bywaters EGL, D Beall. Crushing injury. Br Med J 1942 ii 643-6
Wellcome Witnesses to the History of Medicine 2009. History of Dialysis in the UK. (p79-83 for Prof Lowe's account)
Rhabdomyolysis (edrep textbook)
London Blitz Image (public domain)

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