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ISTORY

eorge Washington Crile, MD

ames A. Lee, MD,* Warren D. Widmann, MD,† and Mark A. Hardy, MD†

New York Presbyterian Hospital, Columbia Campus, and †Columbia University College of Physicians and
urgeons, New York, New York
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ike many great surgeons of the era, George Washington Crileas raised on a farm. Born on November 11, 1864, near Chili,hio to parents of Dutch and Scotch-Irish descent, he was

nstilled with a puritanical work ethic. He applied this ethic tois professional life where he performed as many as 20 opera-ions a day at St. Alexis Hospital. Agrarian life also served as anarly biology laboratory for the young surgeon as he learnedasic principles of genetics from engineering crops and aboutbstetrics from animal husbandry. Perhaps more important,hrough catastrophes like droughts, he “early [made] acquain-ance with Fate and recognize[d] that there are certain naturalorces which [one]cannot resist. [one]plans how to gamble bet-er with Fate.”1 This early modeling of the “surgeons mentality”as further nurtured by Crile’s close relationship with hisrandfather whom he described as a “human dynamo. . . what-ver he thought he said. . . whatever he said he meant. . .hether right or wrong, he had an opinion,” a description that

losely approximates the old surgical motto “sometimes wrong,ever in doubt.”2

From early on in his life, Crile was a voracious reader andecause of this love of learning, he soon became the localchoolmaster. At the age of 17, he enrolled at Ohio Northernniversity located in Ada, Ohio. He paid his way through

ollege by teaching elementary school. In what he called hisroudest achievement, he was soon appointed Principal of thelainfield (Ohio) School. A. E. Walker, a local doctor who tookim on his rounds, nurtured Criles’s burgeoning interest inedicine. In 1886, he matriculated at Wooster Medical School

n Cleveland. Crile realized that it was not as prestigious asarvard or the College of Physicians & Surgeons in New York,

ut it “was the cheapest. . . and would allow me to carry myedical work collaterally while serving in the winter as Princi-

al.”3 He graduated with highest honors and went on to be-ome a house officer at the University Hospital in Cleveland.is tireless energy and keen scientific mind impressed the thenirector Frank Weed to such a degree that he made Crile his

unior partner.Perhaps the moment that most focused Crile’s career came

orrespondence: Inquiries to James A. Lee, MD, Columbia University, 177 Fort Washington
venue, MHB 7 GS 313, New York, NY 10032; fax: (212) 305-8321; e-mail: [email protected]
URRENT SURGERY • © 2005 by the Association of Program Directors inPublished by Elsevier Inc.

n the occasion of his first operative mortality. His patient, aolleague, was hit by a streetcar and had to have both legsmputated. As Crile maintained a bedside vigil, he watched hisriend slowly succumb to shock. Galvanized by the experience,e conducted experiments on cats and dogs to ascertain theechanism of shock. As Crile recounts, “Little did I realize that

o solve the problem of his death was to solve the mystery ofife.”4 Thus began a passion for research that led to the publi-ation of over 400 papers and 24 books.

Throughout his career, the problems of the physiology of shockere the focus of Crile’s scientific interest. From humble begin-ings in a rough-hewn laboratory annexed to his office, he was onef the first researchers to conduct extensive animal trials. Not ev-ryone was enthusiastic about the use of animals for research, ande was lambasted in Life Magazine for his experiments. He per-isted and studied various injuries, including terminal bleeding andead trauma in dogs to observe the physiologic changes using aakeshift pressure-heart rate recorder. From his extensive physio-

ogic, anatomic, and pathologic investigations into different typesf multiple injuries, he deduced many fundamental changes inhock. Central to his theories on shock was the belief that shockas caused by “a state of prostration and there is no reserve energy

vailable.”5 In line with this theory of exhaustion of reserve, heosited that there was a depletion of central nervous system sym-athetic tone because of a critical deficit in adrenaline and otherasoconstrictors.

From these investigations, he discovered that the then com-on treatments of alcohol and strychnine only served to worsen

he state. He determined that shock of any origin was bestreated with judicious fluid resuscitation. He also found thatentrally delivered adrenaline could resuscitate animals fromardiac arrest, a principle that remains at the core of advancedardiac life support protocols to this day. Part of this outstand-ng body of work won him the prestigious Cartwright Prizerom Columbia University in1898 for the best medical or sur-ical research, and this was published as An Experimentalesearch into Surgical Shock. In subsequent years, his theory ofasoconstrictor depletion seemed to have been disproved byumerous animal and human studies demonstrating that vaso-onstrictor hormones are generally present in excess during va-odilatory shock.

Recent research by Donald Landry’s group at Columbia has

Surgery 0149-7944/05/$30.00doi:10.1016/j.cursur.2004.08.019

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hown that vasopressin is depleted in vasodilatory shock.6

hus, 100 years later, clinicians at the institution that firstecognized his research are proving a part of Crile’s originalheory to have been correct. Crile’s comprehensive investiga-ions into the origin and treatment of shock were published inhe landmark manuscript Blood Pressure in Surgery. Building onhis research, he developed a “pneumatic rubber suit” to de-rease postural hypotension by increasing the blood volume inhe central system. He applied this device to operations inhich he expected to encounter shock or hypotension such as

adical neck dissection and neurosurgical procedures. This de-ign was later used in the World War II in the gravity suits ofilots and during the Vietnam War as military anti-shock trou-ers. Another discovery from his shock experiments was thending that manipulation of the larynx could precipitate respi-atory arrest. To combat this phenomenon, he would anesthe-ize the area with cocaine and then could safely intubate andven perform laryngectomies, feats that were previously fraughtith peril.Crile is best known for his contributions to head, neck, thy-

oid, and breast surgery. Building on the principles of his labo-atory research, he used cocaine for a field block and atropine torevent cardiac inhibition from vagal manipulation. This tech-ique allowed him to safely operate in cases of compressiveoiters in which inhalational anesthetics would have been con-raindicated. To further increase the safety of radical neck dis-ection, he invented a rubber-shod, spring-loaded vascularlamp to perform “bloodless” surgery by temporary occlusionf both carotid arteries.7 With the help of such techniques, heescribed his now classic work on en bloc cervical lymphade-ectomy in which he spared the spinal accessory and hypoglos-al nerves in 1906. This form of radical neck dissection is stillhe standard to which all modifications are compared.

Perhaps Crile’s most outstanding contribution to the fieldas his success in dramatically reducing the mortality for treat-ent of acute toxic goiter. In the days before mandatory iodi-

ization of table salt, goiters were endemic in the Midwest.rile performed thousands of thyroid operations, and he once

ven performed 32 thyroidectomies in a single day. At this time,ew diseases were as feared as acute toxic goiter. These patientsepresented the end-stage of the disease. Crile describes theudden, calamitous deterioration of many of these patients as adetonation” that was almost uniformly fatal.8 These cases ofcute toxic goiter were nearly inoperable because of the produc-ion of thyroid storm with operative manipulation of the thy-oid gland. Crile believed that emotional and environmentaltimuli triggered the extreme sympathetic release of thyrotoxi-osis. He hypothesized that by eliminating all upsetting stimulincluding the anxiety of anticipating an operation, he couldvoid triggers to thyroid storm. He dubbed this process anoci-ssociation. For patients with acute toxic goiters, he would tellhe patient that they were to receive an “inhalational treatment”nd some morphine. In reality, this treatment was the inductionf anesthesia. By not obtaining what we would now call in-
ormed consent, he eliminated the fears and anxiety associated m
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ith an operation, and by inducing anesthesia in a nontrau-atic way, he found he could “steal” the goiters.9 This processorked so well that he performed hundreds of such cases with-ut casualty until 1 patient was told that she would know whenhe was going to have surgery when they came to administer thenhalational treatment. As Crile states, “The gossip of thatriend sealed her fate.”10 Despite this incredible success in re-ucing the mortality of acute toxic goiter, his theory of anoci-ssociation was widely derided. Critics accused him of hypno-izing his patients, whereas others said he was “just a skilledperator who didn’t know it.”11 Still, his remarkable success contin-ed. He later formalized his thoughts on anoci-association in his bookrigin and Nature of Emotions.12 His final conclusion was that

he concept should:

Teach us to view our patients as a whole; and especially itshould teach the surgeon gentleness. It should teach usthat there is something more in surgery than mechanicsand something more in medicine than physical diagnosisand drugs.

As demonstrated by his belief in anoci-association, Crile ar-ently believed that the “skills of the anesthetist [were] almost as

mportant as that of the surgeon.”13 Noting the widely varyingesults in the practice of anesthesia, which at that time wasdministered by the surgical residents, he established the firstchool of anesthesia with his longtime nurse Agatha Hodgins.he was the only person he allowed to administer anesthesia foris elective cases and helped her to codify the process. In addi-ion, he was one of the first proponents of intraoperative mon-toring of vital signs. From his experiments in shock, he knewhat frequent blood pressure measurements could help identifyigns of shock early enough to allow timely resuscitation. Partlyecause of this improved use of anesthesia, Crile and his part-ers dramatically reduced their operative mortality from 6.8%o 1.9% in a short period of time.14 Soon, surgeons fromround the area and the world sent people to be trained bygatha.One defining trait of Crile’s professional life was his drive to

mprove the state of medicine. He was an early adopter of newechniques and was constantly visiting other clinics and doctorsn disparate disciplines to ferret out the latest advancements sohat he could apply them in his practice. This drive led Crile tostablish several “firsts.” He was the first physician to request alinically applicable x-ray when he asked Dayton Miller of Case

estern to x-ray a hand fracture. He owned the first micro-cope in the greater Cleveland area. He designed several devicesnd instruments including the Crile clamp and Crile forcepswhich serves as a forceps and a needle holder). He also pur-orted to be the “inventor of the one-handed square knot (Crilenot).”15 Perhaps most impressive were his investigations into

linical blood transfusion.Spurred on by his earlier research into shock, Crile hypoth-

sized that blood transfusion should be vastly superior to salinedministration to raise the blood pressure. In previous experi-
ents, he found that after a time dogs infused with large vol-
URRENT SURGERY • Volume 62/Number 4 • July/August 2005

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mes of crystalloid eventually exuded the fluid into their thirdpace without a significant increase in blood pressure. However,e soon found that far more blood could be given before third-pacing occurred and that the increases in blood pressure wereignificant. Building on the work of Alexis Carrel who taughtim how to anastomose blood vessels, Crile performed his firstuccessful human-to-human blood transfusion via a temporaryrteriovenous shunt in 1906. This feat was remarkable not onlyn that each needle had to be individually threaded by handith a thinner than hair filament and that no local or systemic

nticoagulation was available, but also that blood groups wereot yet described. Crile’s first successful transfusion was a for-uitous match between 2 family members. Although his arte-iovenous connection was effective, it was time consuming andechnically demanding, which made it impractical for emergen-ies. With the help of his friend S. J. Mixter, he developed ailver arteriovenous canula that greatly improved the efficiencyf the technique and allowed him to use it in acute cases ofhock. It would be nearly 30 years before blood transfusion wasidely practiced.In subsequent years, Crile also investigated blood transfusion

s a means for conferring immunity to certain diseases. He wasne of the earliest investigators of cancer vaccines as he reportedeveral cases of tumor shrinkage in patients with large sarcomasfter blood transfusion. In 1 particular case, the patient had 4ephews who would rotate donating blood. Sometimes thereere severe hemolytic reactions. Crile’s case report is reputed toave spurred W. L. Moss in his codifying of blood grouping.16

Crile’s desire to push the limits of knowledge was most evi-ent in his cofounding of the Society of Clinical Surgeonshose sole purpose was to counter the “old boys’ network”

The American Surgical Association) of gentlemen surgeonsnd institute an egalitarian sharing of ideas of young surgeons.he society was a traveling society that held annual meetings

hat discussed and observed the latest in operative techniques asell as in experimental research. Among the handful of bylawse included17:

Visiting fellows shall be free to ask questions at themeetings

The host shall not provide any entertainment beyondthe product of his head and hands.

The visiting fellows are to be provided a simple dinner,so simple as not to interfere with surgical discussions.

Impressed by this revolutionary spirit, Franklin Martinsked Crile and others in the Society to help them found aNorth America-wide Super Society of Clinical Surgery”hose mission was enlightenment and education.18 From

his idea, the American College of Surgeons was born, andrile later served as its director.Crile served his country in 2 wars. In the Spanish-Americanar, he was a Brigade Surgeon. Later, in World War I, he

stablished the medical support for the American Expeditionaryorce. These years proved invaluable in confirming many of his
eliefs concerning the physiology and treatment of shock. On

is return to Cleveland, Crile rejoined his former partnersilliam Lower, Fred Bunts, and John Phillips. They soon

ounded one of the first medical nonprofit corporations thatecame known as the Cleveland Clinic Foundation.Crile’s personal life was as rich and varied as his professional

ne. He met his wife Grace at a debutante ball. While waltzing,he mentioned that she had read his book on shock, and as Crileuts it, “This opened an interest that has continued unbrokenearly forty-six years.”19 In fact, she served as one of his mostaithful laboratory assistants over the many years, acting as hishief recorder and jack of all trades. Together, they were invet-rate travelers who scoured the corners of the earth for novelxperiences, once even braving a yellow fever epidemic to expe-ience the local culture of a small African town. His family wasis top priority in life. He never failed in telling his children atory in the morning before taking them to school. His familyas equally devoted to him and affectionately called him “thehief.”In his seventies, Crile developed bilateral cataracts and grad-

ally lost his vision. After bilateral cataract excision in 1940, hisight eye became infected and had to be removed. In 1942, heeveloped endocarditis, and the next year, he suffered a strokend subsequently died (January 7, 1943).

Throughout his life, Crile applied the discipline and lessonsrom his early childhood days on the farm to all aspects of his life,hich made him a passionate teacher and a tireless innovator.

he cover photo was provided courtesy of the National Library ofedicine.

EFERENCES

1. Crile G. George Crile: An Autobiography. Philadelphia, PA:J. B. Lippincott & Co.; 1947:14.





6. Robin, JK, Oliver, JA, Landry, DW. Vasopressin defi-ciency in the syndrome of irreversible shock. J Trauma.2003;54(Suppl 5):S149-S154.



9. Crile G. George Crile: An Autobiography. Philadelphia, PA:
J. B. Lippincott & Co.; 1947:9.
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