Doctor's Review: Medicine on the Move

August 24, 2017

© Dr S. Falz

Toes suffering from frostbite.

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The coldest war

Frostbite ravaged untold armies, people and appendages until doctors warmed up to the right treatment

With the long, frigid months of winter upon us, Canadian doctors are bracing themselves against the cold once again. Most of us consider the cold to be more of a nuisance than a hazard, especially since the vast majority of our population lives in the relatively milder climes of southern Canada.

Still, the cold does remain a credible threat to some; more Canadians die of cold-related injuries and exposure than from the far more sensational threats of tornadoes, lightning and windstorms combined. Of the unlucky 80 or so of our countrymen who freeze to death annually, many more are brought into the ER with serious frostbite. The tips of fingers, noses and ears are lost, and occasionally entire limbs. The homeless, those living in arctic regions, “extreme” outdoor enthusiasts and, of course, black-out drunks are particularly at risk.

ONE COOL MUMMY

It was a lesson learned the hard way for one hapless, anonymous, pre-Columbian soul: a mummy whose remains reveal the first evidence of frostbite ever found. Radiological studies performed by the now-defunct U.S. Armed Forces Institute of Pathology on a roughly 5000-year-old mummy excavated in the 1950s from the Atacama Desert of northern Chile revealed bilateral pre-mortem amputation of the toes — and the haunting suggestion of an additional and particularly cruel cold-related injury.

Despite the fact that Mummy 3448 was clearly male, he was buried in a particular position known to be reserved only for women. This strongly suggests the loss of another important extremity, likely through frostbite as well. While the Chinchorro culture had amazing understanding of the complexities that went into the mummification process, it seems they had a ways to go in their understanding of gender.

Although frostbite as a distinct pathological entity appeared rarely in the medical literature over the ages, the pages of history do have tales to tell. Not surprisingly, the condition seemed inextricably linked with military campaigns. When Hannibal (247-183 BCE) unexpectedly (and foolishly) traversed the Alps during the winter on his way from Carthage to Italy in 218 BCE, he reportedly lost around 20,000 soldiers — about half of his formidable army — many of them falling to the ravages of frostbite and hypothermia. Most of the legendary 37 war elephants he dragged along with him succumbed, too.

Explorers faced frostbite, too. The ill-fated British Antarctic Expedition of 1910-1913 saw five explorers lose their lives, including leader Robert Falcon Scott. The surgeon Edward Atkinson of the Royal Navy survived, but came close to not making it back to camp one day during a snow squall. Scott described the doctor’s hand in vivid detail: “Atkinson has a bad hand to-day, immense blisters on every finger giving them the appearance of sausages.”

The Antarctic holds the record for the coldest temperature ever recorded on our planet: a crazy -89.2°C at Russia’s Vostok Station, on July 21, 1983. Another Russian cold record comes from the abysmal Siberian town of Oymyakon, where the ink freezes in your pen and it takes three days and a blanket of hot coal just to dig a grave (lest you be tempted to try a locum out there, please know that most homes still only have outhouses.) This outpost of 500 people is home to the lowest temperature ever recorded in the Northern Hemisphere: -67.7°C on February 6, 1933. It seems only fitting then, that Mother Russia was also the inspiration behind medicine’s first official foray in the world of frostbite.

AWESOME AMPUTATIONS

Dominique Jean Larrey (1766-1842) was perhaps the greatest military doctor of all time. Under Napoleon, he took part in 25 campaigns, and developed the first ambulance system in medical history, “les ambulances volantes.” He described many effective techniques in his journals, including descriptions of tetanus, a battlefield triage system, wound and hemorrhage control, care of chest wounds, and amputations, his personal forte.

Thanks to a ridiculous amount of practice, Larrey could amputate a leg above the knee in three minutes flat and disarticulate a shoulder in 17 seconds. It may seem a bit of a dubious virtue, unless of course you were the unanesthetized soldier he happened to be operating on. Larrey’s kindness extended to both sides of the battlefield; he would treat any inured soldier he came across, regardless of which side he was fighting for. Napoleon called him “the most virtuous man I have ever known.”

But among Larrey’s most significant contributions to medicine at the time were his understanding and treatment of cold injuries. He put forth the first pathological description of frostbite in his journal: “The natural heat is absorbed and a discharge of calorick takes place, the pores close and the capillary vessels fall into a state of contraction; the fluids are condensed and flow more slowly.”

In the winter of 1812, as Napoleon’s miserable troops retreated from the Russian front during the disastrous Moscow campaign, Larrey had plenty of time to ponder the horrors of frostbite. He noticed that part of the problem was that soldiers would rewarm their frozen feet and hands on the fire at night, only to be frozen again the next day — a freeze-thaw-refreeze cycle that lead to increased tissue damage and necrosis.

Larrey believed that frostbite was similar to burn injury, and employed cold as an ally to combat it. He eschewed the extreme heat of the fire as treatment, at least in part because the frozen-toed soldiers couldn’t feel their flesh burning! Instead, he advocated a slower rewarming technique inspired by the way he saw Russians thawing frozen fish: either by using a friction massage of snow and ice, or by immersion in cold water. If only feet and fingers were as receptive as the flesh of flounders.

On a particularly bad day — the bloody Battle of Borodino, on September 7, 1812 — Larrey recorded performing 200 amputations over a 24-hour period, or one every seven or so minutes. The coming winter would put his skills in amputation to further use, as the retreating troops were decimated by cold. Napoleon led around 500,000 strong young men into Russia. Half a year later, the vast majority of them had died, victims of frostbite and starvation. A saying developed that the Emperor was defeated not by the Russians, but by Generals Janvier and Fevrier.

Later, during World War II, cold once again proved a fearsome enemy to those trying to defeat the Russian army. When Hitler invaded Russia in the summer of 1941, a campaign that was supposed to last for only six weeks dragged on into the dark winter months. For the weary Germans dressed in summer uniforms, things went from bad to worse when weeks of cold rain turned to snow in November and frigid temperatures took hold.

Fighting the well-dressed and winter-wise Russian soldiers, the Germans were sorely outmatched by -40°C Celsius cold, unrelenting snow, icy mud and constant hunger. By December of 1941, there were 130,000 reported cases of frostbite and 15,000 resulting amputations among German soldiers along the Eastern front. German troops got to within 25 kilometres of Moscow, but it might as well have been 1000. Hitler was eventually forced to retreat, in what many historians agree was the turning point in World War II — thanks in some part at least, to frostbite. The German soldiers who were issued the Eastern Front Medal for their service in the campaign quickly gave it a new nickname: Gefrierfleischorden, or “Badge of the Frozen Flesh.”

GETTING WARMER

Amazingly, even during the Second World War, Larrey’s methods for treating frostbite still held sway. There’s no way to quantify the exact outcome of these treatments, but they were far-reaching: an estimated 10 percent of the casualties suffered by American soldiers during WWII and later the Korean War were due to cold.

In the West it wasn’t until 1956 that a Dr H.T. Merryman, working for the Public Health Service in Tanana, Alaska, began to question the efficacy of gradual rewarming. He found that rapid rewarming in warm, not cold, water was actually much more effective in promoting circulation and reducing damage. Another Alaska-based doctor, orthopedist Dr William Mills, promoted these new rewarming techniques in the 1960s, changing medical opinion at last. Dr Mills continued to be an authority in frostbite up until his death in 2011.

In 1983, plastic surgeon Dr Robert L. McCauley and his colleagues developed a scientific protocol for frostbite treatment based on all the available pathological research at the time. It remains the gold standard to this day, although Dr Larrey’s influence can still be seen in the countless lay people who believe that rubbing snow on frostbite is the best way to treat it.

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