- Email: [email protected]
Ischemic necrosis from ice bag “burn”
ISCHEMIC NECROSIS FROM ICE BAG “BURN” GEORGE
H.
BUNCH, M.D.
COLUMBIA, S. C. EATH from exposure to cold has always been the fear of explorers in arctic regions and in high aItitudes. Except in the feeble and in the chronic aIcoholic, deaths from freezing are rare in the temperate zone, but chilbIain, frostbite and necrosis from coId are not uncommon. That ischemic necrosis of the superficia1 tissues may be caused by the therapeutic appIication of an ice bag is not generally appreciated even by physicians. In the Iiterature available, practicaIIy nothing is found on it. AIthough not of paramount importance it merits consideration for the general use of the ice bag makes the subject of more than academic interest. Figure 2 shows ischemic necrosis of the abdomina1 wal1 of a we11 nourished young negress folIowing the continuous appIication for five days, in midsummer of an unprotected ice bag for the reIief of pelvic inflammation of tuba1 origin. That heat and cold being so entirely different in character and in activity should produce, when applied IocaIIy, tissue changes that are almost identica1 is surprising. In each, three degrees of reaction are recognized by cIinicians and by pathoIogists: (I) hyperemia; (2) bIeb or blister, and (3) necrosis or gangrene. When coId is appIied there is a preIiminary anemia of the part which is foIIowed by a hyperemia. Each stage progresses into the next if the IocaI application is of sufficient degree and duration. In ordinary cases of frost-bite as expIained by Boyd’ the main factor in the production of the gangrene is the ischemia due to extreme contraction of the bIood vesseIs, together with damage to the capiIIaries with the formation of hyaIine thrombi. “If the coId is sufficientIy great the fluid of the ceIIs is CrystaIIized, and the ceIIs are torn to pieces
D
1 BOYD. Text Book of PathoIogy,
2nd Edition, 353.
MacCaIIum2 says the by ice crystaIs.” noxious effect of freezing is expIained either as due to tearing of the ceIIs as the ice crystaIs are formed, or to the concentration of the saIt around the crystaIs, or to the withdrawal of water from the ceI1 to form ice. However, he attributes the gangrene of the extremities foIIowing exposure to cold as the resuIt of protracted ischemia from extreme contraction of the bIood vesseIs or their obstruction from thrombi. Adami writes, It is not the active freezing of the tissues that induces cel1 death but the subsequent too sudden reestabhshment of the circuIation, with resuItant paraIytic dilatation of the vesseIs, intense exudation, and circulatory stasis Ieading to maInutrition. . . . That it is the vascuIar disturbance that is at fault and not the primary death of the ceIIs through the freezing process is further indicated by the fact that simiIar gangrene may affect the extremities of those with enfeebIed circuIation, aIcohoIics etc., from mere immersion in cold IT-ater-~i.e. above the freezing temperature.
That some kinds of fish may be frozen in soIid ice and revive apparentIy unharmed when the ice meIts is expIained by the fact that the concentrated pIasma in them freezes onIy at temperatures much Iower than the freezing point of water. If the pIasma freezes the fish die. In the human the effect of exposure of a part to coId varies with the degree and the duration of chiIIing that resuIts. Loss of heat from wet cIothes, by conduction is much more rapid than by radiation from exposure to the atmosphere, aIthough the ears, the nose, the cheeks and the fingers readily freeze when unprotected in cold, * MACCALLCM. Text Book of Pathology, 1~16 Edition, 3C9. 3ADAM. PrincipIes of Pathology, 2nd Edition, Vol. I, 287.
520
American JOWL
of Surgery
Bunch-Necrotic
windy weather. Freezing anesthetizes the skin so that the condition is often recognized first by the characteristic bIanching.
FIG. I. First stage, hyperemia from two days continuous application of unprotected ice bag to right abdomen for appendicitis in white girl.
Because of the depressing effect on both the circuIation and the sensory nerve endings, coId has for many years been used in the IocaI treatment of inflammation of the active type. In order that the tissues shaI1 be subjected onIy to the proper degree of coId the patient shouId be under cIose supervision. Too severe or too proIonged therapy Iessens tissue vitaIity and hinders repair. Resistance of the body to coId varies with the age and the vigor of the individua1; resistance of a part to coId varies with the bIood suppIy but any area of skin may be frozen if the degree and the duration of exposure is sufficient. However, increasing experience has convinced me that cold has but IittIe pIace in the treatment of inflammation in genera1 surgery. I have yet to see a case of acute appendicitis reIieved by the appIication of an icebag. The course of the disease is not effected and the symptoms are not abated. The custom of using an ice bag on every case of
Ice Bag “Burn”
JUNE, 1936
appendicitis before operation is a fetish of the past without practica1 merit. Any good derived from it is psychic, not physica1.
FIG. 2. Third stage, ischemic necrosis of skin and superficia1 tissues from five days continuous application of unprotected ice bag to the abdomen of we11 nourished negress for reIief of peIvic peritonitis.
There is no such thing as “freezing out” an attack of appendicitis. From the hyperemia caused by the use of the bag there is an increased tendency to bIeed at operation. But if an ice bag is to be used proper appIication and care of it are necessary to protect the tissue from ischemia and burn. The bag must not come into direct contact with the skin, but one or more thicknesses of soft cIoth or towe shouId be pIaced between the skin and the bag. The cIoth not onIy acts as an insuIating medium and moderates the degree of coId to which the skin is exposed but its greatest service is absorbing the moisture which condenses on the bag from the warm air of the room. It keeps the skin dry in this way. A Ieaky bag shouId never be used. There is a Iayer of air between a dry bag and the skin that tends to prevent freezing. When a wet bag is next to the skin this protecting Iayer of air is repIaced by water and the Ioss of heat by conduction is much greater. The bag shouId not be kept on continuaIIy. After
NEW SERIES VOL.XxX11, No. 3
Bunch-Necrotic
Ice Bag “ Burn”
HAYMOND, H. E. Surg., Gynec. and Oh.,
693 (Nov.)
1935. HEDLUND,J. A. Hygeia, 17: 875, 1917. HENLE, J. “Handbuch d. Systemat. Anat. d. Menschen,” III (GeflssIehre) 161, 163. Braunschweig: 1868. INGEBRIGTSSEN, R. Norsk Mag. f. Laegeuid., 76: 341, 19’5. JACKSON,PORTERand QUINBY. Jour. Am. Med. Assn., 1469, 25, I IO, 183 (June 30, July 2,9, 16) 1904. JERAULDand WASHBURN.Ibid. 1827 (June I) 1929. KLEIN, EUGENE. Surg., Gynec. and Obst., 381 (Oct.) 1921. KOJEFF,H. Zentra&.f. Cbir., 1672 (JuIy 9) 1932. K~YSSMAUL. A. Wiirzbura. med. Ztscbr.. 4: 210. 186~. LAGANE,L&IS. Presse kkd., 1025 (D&123) 1$21. 1 LARSON,L. M. Surg., Gynec. and Obst., 54 (JuIy) 1931. LAWS, G. M. Ann. Surg., 378 (Sept.) 1916. LOOPE,R. G. Jour. Am. Med. Assn., 369 (JuIy 30) 1921. LOTHROP, H. A. Boston Med. and Surg. Jour., 557 (Dec. 6) 1894. MACCORNACK,R. L. Wisconsin Med. Jour., 702 (Oct.) 1932. MAUCLAIREET JACOULET.Arch. gh. de Cbir., 213, 341 (Feb., March) 1908. MAYLARD, A. E. Brit. Med. Jour., 1454 (Nov. 16) 1901. MCC~NAHAN, B. V. Illinois Med. Jour., 514 (June) 1926.
MC&IRE, E. R. Surg., Gynec. and Obst., 40 (Jan.) 1913. MELCHIOR,E. Zentralbl. f. Cbir., 3088 (Dec. 3) 1927. MUNRO, DR. Loncet, 147 (Jan. 20) 1894.
Journal
uf Surgery
321
Iike mercurochrome may be applied. In the necrotic stage the treatment is that of necrosis from heat. Gangrene of an extremity is usuaIIy of the dry variety and amputation shouId be done when a Iine of demarkation forms.
two hours it shouId be removed for an hour and then reapplied. Some medica students say these principIes are taught them in schoo1. I find but IittIe about them in surgica1 literature. The treatment of ischemia from coId varies with the Iesion. The effected part should be warmed very sIowIy. Any one who has ever been very coId has experienced the extreme pain caused in an extremity by warming the part too quickIy. The white and bIoodIess tissue becomes red and swoIIen after thawing. The pain is from the reaction of the arteries to the sudden reIease from contraction and is best reIieved by pIunging the extremity into ice water or by rubbing it with snow. However, if the ceIIs have crystaIIized from coId they are dead and care in thawing the effected part is of no avai1. In the hyperemic stage of ice bag burn no treatment is necessary. In the bleb stage some miId antiseptic soIution
REFERENCES
American
SUMMARY
That an ice bag appIied continuousIy may cause IocaI tissue necrosis is not appreciated by physicians. The common use of the ice bag in the treatment of deep seated inflammation of the active type makes the possibiIity of burn from it of more than academic interest. The way in which IocaI coId causes necrosis is discussed. The proper appIication of an icebag, to prevent burn, with one or more thicknesses of cIoth between it and the skin to keep the skin at a11 times dry is expIained. The necessity for sIow warming of tissue after exposure to coId is noted.
OF
DR. BROWN* OCHSNER,ALTON. Ann. Surg., 643 (Oct.) 1935. OPHULS, WILLIAM. Stanford U. Med. Publications I: No. 3, 1926. POIRIER, PAUL. in Trait& d’Anat. Humaine, PoirierCharpy. 2me Ed. II, 779. Paris: 1901. REICH,ANTON. Ergebn. d. Cbir. IL. Ortb., 7: 515, 1913. RIXFORD,EMME~. Ann. Surg., 643 (Oct.) 1935. ROBEY, W. H. Med. CIinics of N. Amer., IZI (July) 1920. Ross, GEORGEG. Ann. Surg., 121 (JuIy) 1920. SARGENT, R. M. Brit. Med. Jour., 64 (JuIy 14) 1934. SARNOFF,JACOB.Ann. Surg., 745 (Dec.) 1923. SAXER, FR. Zentralb1.f. Allg. Patbol., 13: 577, 1902. SCHLEY, W. S. Ann. Surg., 252 (Aug.) 1911. SELBY, H. J. Brit. Med. Jour., 757 (May 5) 1928. SJOVAI.L,S. Acta Cbir. Scandinav., 61: 577, 1927. SKINNER,H. L. Ann. Surg., 788 (March) 1931. SMITH, WILBURN. C&j. and West. Med., 308 (May) ‘93“. TAUBE, N. Jour. Am. Med. Assn., 146 (May 2) 1931. TIEDEMANN, F. T. Von d. Verengerung u. SchIiessung d. PuIsadern in Krankheiten,” HeideIberg: 1843. TROTTER,LESLIE C. EmboIism and Thrombosis of the Mesenteric VesseIs, Cambridge: 1913. WARREN and EBERHARD.Surg., Gynec. and Obst., 102 (JuIY) 1935. WATSON, F. S. Boston Med. and Surg. Jour., 552 (Dec. 6) 1894. WILSON, K. J. G. Med. Jour. Australia, 386 (Dec. 13) 1923. WULSTEIU‘, J. Zentralbl.f. Cbir., 3155 (Dec. 14) 1929.
Continued jrom p. 507.
H.
BUNCH, M.D.
COLUMBIA, S. C. EATH from exposure to cold has always been the fear of explorers in arctic regions and in high aItitudes. Except in the feeble and in the chronic aIcoholic, deaths from freezing are rare in the temperate zone, but chilbIain, frostbite and necrosis from coId are not uncommon. That ischemic necrosis of the superficia1 tissues may be caused by the therapeutic appIication of an ice bag is not generally appreciated even by physicians. In the Iiterature available, practicaIIy nothing is found on it. AIthough not of paramount importance it merits consideration for the general use of the ice bag makes the subject of more than academic interest. Figure 2 shows ischemic necrosis of the abdomina1 wal1 of a we11 nourished young negress folIowing the continuous appIication for five days, in midsummer of an unprotected ice bag for the reIief of pelvic inflammation of tuba1 origin. That heat and cold being so entirely different in character and in activity should produce, when applied IocaIIy, tissue changes that are almost identica1 is surprising. In each, three degrees of reaction are recognized by cIinicians and by pathoIogists: (I) hyperemia; (2) bIeb or blister, and (3) necrosis or gangrene. When coId is appIied there is a preIiminary anemia of the part which is foIIowed by a hyperemia. Each stage progresses into the next if the IocaI application is of sufficient degree and duration. In ordinary cases of frost-bite as expIained by Boyd’ the main factor in the production of the gangrene is the ischemia due to extreme contraction of the bIood vesseIs, together with damage to the capiIIaries with the formation of hyaIine thrombi. “If the coId is sufficientIy great the fluid of the ceIIs is CrystaIIized, and the ceIIs are torn to pieces
D
1 BOYD. Text Book of PathoIogy,
2nd Edition, 353.
MacCaIIum2 says the by ice crystaIs.” noxious effect of freezing is expIained either as due to tearing of the ceIIs as the ice crystaIs are formed, or to the concentration of the saIt around the crystaIs, or to the withdrawal of water from the ceI1 to form ice. However, he attributes the gangrene of the extremities foIIowing exposure to cold as the resuIt of protracted ischemia from extreme contraction of the bIood vesseIs or their obstruction from thrombi. Adami writes, It is not the active freezing of the tissues that induces cel1 death but the subsequent too sudden reestabhshment of the circuIation, with resuItant paraIytic dilatation of the vesseIs, intense exudation, and circulatory stasis Ieading to maInutrition. . . . That it is the vascuIar disturbance that is at fault and not the primary death of the ceIIs through the freezing process is further indicated by the fact that simiIar gangrene may affect the extremities of those with enfeebIed circuIation, aIcohoIics etc., from mere immersion in cold IT-ater-~i.e. above the freezing temperature.
That some kinds of fish may be frozen in soIid ice and revive apparentIy unharmed when the ice meIts is expIained by the fact that the concentrated pIasma in them freezes onIy at temperatures much Iower than the freezing point of water. If the pIasma freezes the fish die. In the human the effect of exposure of a part to coId varies with the degree and the duration of chiIIing that resuIts. Loss of heat from wet cIothes, by conduction is much more rapid than by radiation from exposure to the atmosphere, aIthough the ears, the nose, the cheeks and the fingers readily freeze when unprotected in cold, * MACCALLCM. Text Book of Pathology, 1~16 Edition, 3C9. 3ADAM. PrincipIes of Pathology, 2nd Edition, Vol. I, 287.
520
American JOWL
of Surgery
Bunch-Necrotic
windy weather. Freezing anesthetizes the skin so that the condition is often recognized first by the characteristic bIanching.
FIG. I. First stage, hyperemia from two days continuous application of unprotected ice bag to right abdomen for appendicitis in white girl.
Because of the depressing effect on both the circuIation and the sensory nerve endings, coId has for many years been used in the IocaI treatment of inflammation of the active type. In order that the tissues shaI1 be subjected onIy to the proper degree of coId the patient shouId be under cIose supervision. Too severe or too proIonged therapy Iessens tissue vitaIity and hinders repair. Resistance of the body to coId varies with the age and the vigor of the individua1; resistance of a part to coId varies with the bIood suppIy but any area of skin may be frozen if the degree and the duration of exposure is sufficient. However, increasing experience has convinced me that cold has but IittIe pIace in the treatment of inflammation in genera1 surgery. I have yet to see a case of acute appendicitis reIieved by the appIication of an icebag. The course of the disease is not effected and the symptoms are not abated. The custom of using an ice bag on every case of
Ice Bag “Burn”
JUNE, 1936
appendicitis before operation is a fetish of the past without practica1 merit. Any good derived from it is psychic, not physica1.
FIG. 2. Third stage, ischemic necrosis of skin and superficia1 tissues from five days continuous application of unprotected ice bag to the abdomen of we11 nourished negress for reIief of peIvic peritonitis.
There is no such thing as “freezing out” an attack of appendicitis. From the hyperemia caused by the use of the bag there is an increased tendency to bIeed at operation. But if an ice bag is to be used proper appIication and care of it are necessary to protect the tissue from ischemia and burn. The bag must not come into direct contact with the skin, but one or more thicknesses of soft cIoth or towe shouId be pIaced between the skin and the bag. The cIoth not onIy acts as an insuIating medium and moderates the degree of coId to which the skin is exposed but its greatest service is absorbing the moisture which condenses on the bag from the warm air of the room. It keeps the skin dry in this way. A Ieaky bag shouId never be used. There is a Iayer of air between a dry bag and the skin that tends to prevent freezing. When a wet bag is next to the skin this protecting Iayer of air is repIaced by water and the Ioss of heat by conduction is much greater. The bag shouId not be kept on continuaIIy. After
NEW SERIES VOL.XxX11, No. 3
Bunch-Necrotic
Ice Bag “ Burn”
HAYMOND, H. E. Surg., Gynec. and Oh.,
693 (Nov.)
1935. HEDLUND,J. A. Hygeia, 17: 875, 1917. HENLE, J. “Handbuch d. Systemat. Anat. d. Menschen,” III (GeflssIehre) 161, 163. Braunschweig: 1868. INGEBRIGTSSEN, R. Norsk Mag. f. Laegeuid., 76: 341, 19’5. JACKSON,PORTERand QUINBY. Jour. Am. Med. Assn., 1469, 25, I IO, 183 (June 30, July 2,9, 16) 1904. JERAULDand WASHBURN.Ibid. 1827 (June I) 1929. KLEIN, EUGENE. Surg., Gynec. and Obst., 381 (Oct.) 1921. KOJEFF,H. Zentra&.f. Cbir., 1672 (JuIy 9) 1932. K~YSSMAUL. A. Wiirzbura. med. Ztscbr.. 4: 210. 186~. LAGANE,L&IS. Presse kkd., 1025 (D&123) 1$21. 1 LARSON,L. M. Surg., Gynec. and Obst., 54 (JuIy) 1931. LAWS, G. M. Ann. Surg., 378 (Sept.) 1916. LOOPE,R. G. Jour. Am. Med. Assn., 369 (JuIy 30) 1921. LOTHROP, H. A. Boston Med. and Surg. Jour., 557 (Dec. 6) 1894. MACCORNACK,R. L. Wisconsin Med. Jour., 702 (Oct.) 1932. MAUCLAIREET JACOULET.Arch. gh. de Cbir., 213, 341 (Feb., March) 1908. MAYLARD, A. E. Brit. Med. Jour., 1454 (Nov. 16) 1901. MCC~NAHAN, B. V. Illinois Med. Jour., 514 (June) 1926.
MC&IRE, E. R. Surg., Gynec. and Obst., 40 (Jan.) 1913. MELCHIOR,E. Zentralbl. f. Cbir., 3088 (Dec. 3) 1927. MUNRO, DR. Loncet, 147 (Jan. 20) 1894.
Journal
uf Surgery
321
Iike mercurochrome may be applied. In the necrotic stage the treatment is that of necrosis from heat. Gangrene of an extremity is usuaIIy of the dry variety and amputation shouId be done when a Iine of demarkation forms.
two hours it shouId be removed for an hour and then reapplied. Some medica students say these principIes are taught them in schoo1. I find but IittIe about them in surgica1 literature. The treatment of ischemia from coId varies with the Iesion. The effected part should be warmed very sIowIy. Any one who has ever been very coId has experienced the extreme pain caused in an extremity by warming the part too quickIy. The white and bIoodIess tissue becomes red and swoIIen after thawing. The pain is from the reaction of the arteries to the sudden reIease from contraction and is best reIieved by pIunging the extremity into ice water or by rubbing it with snow. However, if the ceIIs have crystaIIized from coId they are dead and care in thawing the effected part is of no avai1. In the hyperemic stage of ice bag burn no treatment is necessary. In the bleb stage some miId antiseptic soIution
REFERENCES
American
SUMMARY
That an ice bag appIied continuousIy may cause IocaI tissue necrosis is not appreciated by physicians. The common use of the ice bag in the treatment of deep seated inflammation of the active type makes the possibiIity of burn from it of more than academic interest. The way in which IocaI coId causes necrosis is discussed. The proper appIication of an icebag, to prevent burn, with one or more thicknesses of cIoth between it and the skin to keep the skin at a11 times dry is expIained. The necessity for sIow warming of tissue after exposure to coId is noted.
OF
DR. BROWN* OCHSNER,ALTON. Ann. Surg., 643 (Oct.) 1935. OPHULS, WILLIAM. Stanford U. Med. Publications I: No. 3, 1926. POIRIER, PAUL. in Trait& d’Anat. Humaine, PoirierCharpy. 2me Ed. II, 779. Paris: 1901. REICH,ANTON. Ergebn. d. Cbir. IL. Ortb., 7: 515, 1913. RIXFORD,EMME~. Ann. Surg., 643 (Oct.) 1935. ROBEY, W. H. Med. CIinics of N. Amer., IZI (July) 1920. Ross, GEORGEG. Ann. Surg., 121 (JuIy) 1920. SARGENT, R. M. Brit. Med. Jour., 64 (JuIy 14) 1934. SARNOFF,JACOB.Ann. Surg., 745 (Dec.) 1923. SAXER, FR. Zentralb1.f. Allg. Patbol., 13: 577, 1902. SCHLEY, W. S. Ann. Surg., 252 (Aug.) 1911. SELBY, H. J. Brit. Med. Jour., 757 (May 5) 1928. SJOVAI.L,S. Acta Cbir. Scandinav., 61: 577, 1927. SKINNER,H. L. Ann. Surg., 788 (March) 1931. SMITH, WILBURN. C&j. and West. Med., 308 (May) ‘93“. TAUBE, N. Jour. Am. Med. Assn., 146 (May 2) 1931. TIEDEMANN, F. T. Von d. Verengerung u. SchIiessung d. PuIsadern in Krankheiten,” HeideIberg: 1843. TROTTER,LESLIE C. EmboIism and Thrombosis of the Mesenteric VesseIs, Cambridge: 1913. WARREN and EBERHARD.Surg., Gynec. and Obst., 102 (JuIY) 1935. WATSON, F. S. Boston Med. and Surg. Jour., 552 (Dec. 6) 1894. WILSON, K. J. G. Med. Jour. Australia, 386 (Dec. 13) 1923. WULSTEIU‘, J. Zentralbl.f. Cbir., 3155 (Dec. 14) 1929.
Continued jrom p. 507.