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F. Linder 1. Steffens M. Ziegler
Surgical Observations
and Their Consequences
With 6 Figures
Vorgelegt in der Sitzung vom 18. November 1989
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo Hong Kong
Fritz Linder
Chirurgische U niversitatsklinik
1m Neuenheimer Feld 110
6900 Heidelberg
Joachim Steffens
Manfred Ziegler
Urologische Universitatsklinik
6650 Homburg/Saar
ISBN-13: 978-3-540-52363-5 e-ISBN-13: 978-3-642-46701-1
DOl: 10.1007/978-3-642-46701-1
LC card number: 12-8903
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Contents
F. LINDER
Accidental Hypothermia 7
F. LINDER, 1. STEFFENS, M. ZIEGLER
Renin Secreting Tumors of the Kidney with Secondary Hypertension 12
- 245 -
Accidental Hypothermia *
F. LINDER
The study of accidental hypothermia has intensified, especially during World
War II. Pilots who had to bailout of their planes into the sea lost their normal
body temperature very rapidly. At a water temperature of 16°C, the core tempera
ture, fell to below 30 °C after immersion for 1 - 5 h, and there was the danger of
cardiac arrest. In September 1940, pilots picked up still alive from the North Sea
were often unable to climb out of the water into the life boat or plane because
general stiffness had reduced their mobility. Precise data were obtained by means
of animal experiments in many physiological institutes - not to mention the
shocking icewater tests on willing and not-so-willing persons.
It is well known that immersion reduces the body temperature 15 to 20 times
faster than a dry cold atmosphere. This is the reason why BIGEWW and LEWIS
applied the wet method to produce hypothermia, e.g., in a bathtub filled with cold
water, in early open heart surgery.
The few cases that have survived after an immersion of longer duration are
fascinating. An outstanding example is the history of an Icelandic fisherman who
capsized and who reached the shore after swimming in seawater of 5°C for 5 h.
The explanation for this lucky event was probably the good insulation provided
by the adipose subcutaneous tissue. The case has been described in the Icelandic
Journal of Physiology.
Another dramatic accident happened to a 4-year-old boy who broke through
the crystal clear, but very thin ice of Lake Steinhude near Hannover. An emergen
cy helicopter detected the boy in his green wintersuit floating directly under the
ice about 50 m from the hole. The copilot went down on a rope, cracked the ice
with his boots and snatched the boy out of the water (23 min after the alarm).
On the plane the water was expelled from his lungs, followed by intubation,
respiration and cardiac massage. At the Intensive Care Unit of the Hannover
Medical School Hospital, the rectal temperature was found to be below 20°C.
Within 88 min after respiratory and cardiac arrest, however, the boy revived after
external application of warmth. There was complete recovery without any obser
vable brain damage.
* Lecture, held at the Anglo-American Conference, Reykjavik, Iceland, August 22, 1988.
- 247 -
8 F. Linder
DEU'fSCHES ARCHIV
KLINIS'CIIE MEDICIN
II.
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- 248 -
Accidental Hypothermia 9
Naturally, the history of hypothermia is very long. As long as 100 years ago
such conditions were analyzed by accurate measurements. In the German
literature, a medical officer of the Hamburg Police described a totally drunk per
son who was found unconscious in the street in 1875. The air temperature was
+ 1 °C and the person's rectal temperature was 24°C at 8. a. m., which rose to
37.8°C within 24 h. The report was enriched by the case histories of 17 other
alcoholics with rectal temperatures of between 30° and 34°C, with 12 survivors
(Fig. 1). I assume that many comparable reports could be found in the medical
literature of other nations as well.
We all know of the terrible losses that have occurred during various wars as
a result of hypothermia, losses that were often increased by injury and hunger.
Of the 500000 to 800000 French and allied troops that Napoleon led to Moscow,
only 20000 to 40000 lancers returned to central Europe. Even worse was the Ger
man experience during December and January 1944-1945 when, according to
the best estimates, almost 2000 men per day suffered lethal or non-lethal cold in
juries.
Now let us return to more peaceful accidents. In the European Alpine coun
tries numerous accidents have also been observed as a result of cold weather.
Within 5 years, Austria alone had more than 500 victims from avalanches,
creavasses, or sudden cold weather conditions.
Mountaineers who have lost their core temperature through exposure for
hours should not be mobilized actively or passively because of the danger of the
temperature dropping again when the colder blood from the vasoconstricted
periphery returns to the heart. Tourniquets to stop bleeding in fractures or open
wounds can also lead to sudden cardiac death due to the same drop in tempera
ture described in victims who were dug out of a snowy cave and who then tried
active walking.
In the outdoors, the following ten factors (Table 1) may be beneficial to
hypothermia victims because they may prevent further loss of body temperature.
Table 1. Some factors in the field treatment of accidental hypothermia
1. Shelter against wind
2. Change wet for dry clothes
3. Warm wet pack ings from hot water bottles on breast and abdomen (HIBLER)
4. Do not rub frozen extremities with snow, but with warm towels
5. Warm the whole patient in normal room temperature
6. Use plastic bags
7. Adipose people are better insulated
8. Watch cardiac function (disturbances < 30°C)
9. Psychological factors and fatigue are of some importance
10. Black people are 4 - 6 times higher endangered
- 249 -
10 F. Linder
Table 2. Deep accidental hypothermia: rewarming with extracorporal methods in 14 pa
tients (Clinic of Cardiovascular Surgery, Prof. ALTHAUS)
Crevasse Exposure Avalanche/ Total
(suicide) immersion
Survival 8 2 0 10
Exitus 2 3 6
(Cranial injury) (Reanimation
unsuccessful)
Table 3. Deep accidental hypothermia: experience in Berne (Prof. ALTHAUS)
Treatment of 16 cases (6 deaths)
- Age: 13 - 56 years
Rectal temperature: 18° - 25°C
Cardiac arrest 14 patients
Serious low output syndrome 2 patients
Cranial injuries with 2 deaths
Therapeutic technique No. cases
Extracorporeal warming without sternotomy 13
Extracorporeal warming with sternotomy
Thoracotomy, mediastinal lavage
Peritoneal dialysis
The initial treatment can be given in a wind shelter, a mountain hut or, even better,
in an intensive care unit of a hospital with all the proper equipment and a
heliport. Peritoneal warm dialysis with two catheters in the abdomen is (or was)
a potential method of rewarming the body core. Since 1967 (DAVIS and Moss),
however, the first experimental and human experiences with extracorporal blood
warming (connected to iliac artery and vein) has demonstrated that the rewarming
speed with a heart exchanger can be 4 times faster than with external methods.
The Swiss University Hospital in Berne has a collection of cases. A con
siderable number (16) of their severe hypothermic patients were saved by the
heart-lung machine (Tables 2 and 3). However, heparinization is a contraindica
tion for patients with brain lesions or other serious injuries.
In conclusion, accidental hypothermia is a lifethreatening condition that re
quires the quickest transportation possible to a place with optimal therapeutic
facilities. It is clear that one's geographic location on the globe alone, with its
variation in heights, is no absolute protection against sustaining a cold injury.
- 250 -
Accidental Hypothermia 11
Let me just add one gruesome footnote (or fingernote) which also contains
some other information on hypothermia. This extraordinary case is part of the
criminal scene. Last November, the owner of a Dutch supermarket chain was kid
napped by a single person and shot within the next 24 h. His corpse was then hid
den in a shallow hole. Before this provisional interment, a little finger was cut off
and preserved with ice cubes in a vacuum flask. At intervals, the gangster provid
ed the relatives with some belongings of the victims. Also included was the iced
finger as definitive proof that his hostage was still alive. No pathologist or foren
sic specialist was certain whether the tissue was taken from a living or from a dead
individual.
References
ALTHAUS U, AEBERHARD P, SCHUPBACH P, NACHBUR BH, MUHLEMANN W (1982)
Management of profound accidental hypothermia with cardiorespiratory arrest. Ann
Surg 195:492
BERGHOLD F (1982) Lawinenunfall - Richtige Erste Hilfe entscheidet uber Leben und
Tod. Notfallmedizin 8: 1503
BIGELOW WG (1984) Cold hearts and vital lessons. Am ColI Surg Bull 69:12
BRENDEL W, MULLER C, MESSMER K, REULEN HJ (1968) Der klinische Tod in Hypother
mie. Z Gesamte Exp Med 146:189
DAVIES DM, MILLAR EJ, MILLER IA (1967) Extracorporeal bloodwarming. Lancet I: 1036
Deutsche Gesellschaft zur Rettung Schiffbruchiger (1982) 2. Symposion, Cuxhaven: Un
terkuhlung im Seenotfall
FRITZ K-W, KASPERCZYK W, GALASKE R (1988) Erfolgreiche Reanimation bei akzidentel
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HARNETT RM, O'BRIEN EM, SLAS FR, PRUITT JR (1980) Initial treatment of profound
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KLOSS T (1983) Pathophysiologie, Diagnose und Behandlung akzidenteller Unterkuhlung.
Anasth Intensivmed 18: 199
LINDER F (1987) Medical services in wintertime. Med Corps int 6:29
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OTFLEIGSSON OJ (1980) Cold water therapy in burns. Z Pist Chir
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SPLlTTGERBER FH, TALBERT J, SWEEZER WP, WILSON RF (1986) Partial cardiopulmonary
bypass for core rewarming in profound accidental hypothermia. Am Surg 52:407
THAUER R, BRENDEL W (1962) Hypothermia. Prog Surg 2:73
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Lawinen. Jurist-Verlag, Zurich, Swiss Medical Committee (1. V. R.)
- 251 -
Renin Secreting Tumors of the Kidney with Secondary Hypertension *. **
F. LINDER, J. STEFFENS, M. ZIEGLER
For a long time a relation between the blood circulation and the function of
kidneys has been suspected. An early classic example can be found in the museum
of the Guys Hospital in London where BRIGHT 1836 anticipated a causal relation
and preserved a hypertrophic heart and two shrivelled kidneys in the same
specimen jar. They demonstrate what as we learnt much later the first etiological
connection between renal disease and hypertension. In 1898, TIGERSTEDT and
BERGMANN in Stockholm succeeded in showing that a pressor substance was pre
sent in the kidneys of rabbits. They called it renin from its origin.
Since the 1930's clinical experience has shown that certain bi- and unilateral
renovascular diseases of different pathology, besides urinary strictures, can in
duce systemic hypertension (Table 1).
Guy's Hospital Reports 1, 1836
( 338 )
CASES AND OBSERVATIONS,
lLLUSTIU.TIVE O!"
RENA.L DISEASE
ACC0311,,,,.°IED WITH
THE SECRETIO~ OF ALDUll!INOUS URINE,
BY DR. BRIGHT.
Fig. 1. BRIGHT 1836: Specimen of hypertrophic heart and shrivelled kidneys
* Lecture in Edinburgh 1989 (RCSE).
** Dedicated to Wilhelm DOERR.
- 252 -
