Shackleton’s Antarctic Doctors

Paul Firth

Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston, MA, USA

PACSA 2020 Virtual Congress 15th November No Financial Disclosures

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Photos and quotes: Open source internet; deidentified patients SBH; SPRI, State library NSW, published works OUTLINE

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□ Review Antarctic anaesthesia history Mackay, Marshall □ Pharmacokinetics of inhalational anaesthesia □ Physical properties of anaesthetic vapors

McIlroy, Macklin - Autumn, April 1916

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BMJ 1993: 307: 1587-9 …everything deeply snowed over, footgear frozen so stiff we could only put it on by degrees, not a warm pair of gloves amongst us. I think I spent this morning the most unhappy hour of my life—all attempts seemed so hopeless, and Fate seemed absolutely determined to thwart us. Men sat and cursed, not loudly but with an intenseness that shewed their hatred of this island on which we had sought shelter. … Macklin’s Diary

6 I don’t think there will be many survivors

Harry “Chippy” McNish

7 Frostbite “McIlroy and myself have several patients to see daily; this with the difficulty of getting hot water, shelter or good light was very difficult and trying. Added to this my own little finger got frostbitten... (during the boat trip), and has been insensitive ever since, and the tips of all my fingers had blisters from the same cause, making skillful bandaging or manipulation difficult.” Macklin’s Diary

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Ernest Shackleton 1874 -1922

Discovery 1901-4 (Scott)

Nimrod 1907-9

Endurance 1914-17

( 1921-2)

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Spring Ice Maximum Extent Overwinter on continent Nimrod Expedition 1907-9

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Eric Marshall Alistair Forbes Mackay □ When moving a barrel of beer, crate hook swung back hitting Mackintosh in Rt eye….Mackay… gave him chloroform ... Operation successfully performed though circumstances were adverse, owing to lack of space, appliances etc. (Note. One pair of curved scissors only were available). I made tenotomy hooks and retractors from rigging wire. Mackay’s Edinburgh method of giving anaesthetics with a towel added to the difficulties. Mackintosh lay on the cabin floor, on which we knelt and the only light was a single oil lamp. □ Diary – E. Marshall 30th Jan 1908 □ Prepared for a go at Brocklehurst this morning. Mac commenced putting him under at 3pm. A long time “going off”. Removed gangrenous tip, found it fairly attached to distal end of last phalanx, which was necrotic ... Removed phalanx and sutured flexor and extensor tendons to each other and periosteum.…. Came round and woke in 1 1/2 hours □ Diary - E. Marshall 6th April1908 Ascent of Mt Erebus

Physical Properties Chloroform versus Ether

14 Chloroform Ether □ MAC: 0.5% □ MAC: 2-3% □ SVP: 160 mmHg □ SVP: 442 mmHg

□ BG coefficient: 8 □ BG coefficient:12 □ Non-flammable □ Flammable

Farthest , South Magnetic Pole 1908-9 15 EXPEDITION 1914-17

16 □ Plan was to cross the continent “I don’t think there will be many survivors” Winter 1916

17 Frostbitten Feet

18 □ □ Lionel Greenstreet Frostbite - progression 19 Medicine on Elephant Island

20 James McIlroy Abscess – surgery without anaesthesia 21 Hudson has been suffering a great deal of pain for the last few days. I recommended McIlroy to drain his abscess a little while ago, and he attempted to do so, but did not succeed in doing it. I wish that he would decide to do something radical for Hudson: I would advise giving (chloroform), and making a thorough attempt. □ Macklin’s Diary Abscess – surgery without anaesthesia

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McIlroy made another and successful attempt to open Hudson’s abscess, with the result that he now has great relief… □ Macklin’s Diary ‘POISON’

23 “Fatal application of Chloroform”

24 A girl of 15 … died under the influence of chloroform ... I seated her in a chair, and put about a tablespoon of chloroform into a tablecloth and held it to her nose….The time would not be more than three minutes from her first inhaling the chloroform until her death….

Edinburgh Medical and Surgical Journal 1848; 407-9 Operating Theater 1: “The Snuggery”

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(Extreme) Off–site location Chloroform versus Sevoflurane

27 Chloroform Sevoflurane □SVP: 160mmHg □SVP: 157mmHg □MAC: 0.5% □MAC: 1.8% □B-G Co: 8 □B-G Co: 0.6

“Poison”? Saturated Vapor Pressure, MAC Chloroform

28 SVP 160 mmHg (~21%) Standard Temp: 200C

MAC 0.5% (3.5 mmHg) June 15, 1916 Temp: -0.5˚ C (31˚ F) SVP, MAC Chloroform: Temp - 0.50C (310F)

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SVP Temp 00C : 71.5 mmHg (9.4%) MAC: 0.5% (3.5 mmHg) Anaesthesia: June 15th 1916

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I think the most difficult part ... must have been the anaesthetic. The patient’s head was placed as near to our little oil-drum stove as was possible and the stove was then stoked up with lavish supplies of seal-blubber. This helped the chloroform to volatilise, which otherwise would have been difficult owing to the cold. Anesthetic Delivery

31 The operating table was built from a number of nut boxes covered with blankets, the temperature of the ‘Theater’ (our murky interior) being maintained at 79° by ardently stoking the bogie with penguin skins Hurley Diary

The operating table consisted of packing cases, and I had another case for a stool ... We managed to get the temp up to 80° (26.6°C) and the (chloroform) vaporised splendidly Macklin Diary 32 Western Front - June 22nd 1916

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□ CHCl3 – chloroform □ COCl2 – phosgene

□ Chloroform and oxygen ! Phosgene, chlorine gas

2 CHCl3 + O2 2 COCl2 + 2 HCl Anaesthetic record

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…the poor beggar (Blackborow) behaved splendidly and it went through without a hitch ... The time from start to finish 55 minutes. When Blackborow came to he was as cheerful as anything and started joking directly …. Diary Greenstreet

Post-operative recovery

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…he took his anaesthetic very well and was not at all sick afterwards ... We had only 8 oz. of chloroform, but although the operation lasted 55 minutes I only used 1 oz ... Blackboro’ was soon round from his anaesthetic, and asking for that now rare luxury - a cigarette … Macklin Diary 15th June 1916 Post-operative recovery (staff)

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After the job was finished there was some hot water left, so we decided not to waste it, and borrowed 3 lumps of sugar from tomorrow’s lunch and made a drink of hot sugar water. Macklin Diary, 15th June 1916 Saved by the

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August 30, 1916 Shackleton’s Doctors

“I have done it….. Not a life lost and we have been through Hell.” Shackleton, Letter to his wife

Never perhaps was anaesthetic administered under more extraordinary circumstances … it has been through the indefatigable diligence of Drs. Macklin and McIlroy, that numerous hands, fingers and feet have been saved.

Diary, ,15th June 1916 Thank you for your time. Questions?