FREEZING INJURY

From Big Medical Encyclopedia

FREEZING INJURY (congelatio) — the damage of fabrics caused by their cooling.

History

the Clinic and O.'s epidemiology were studied by preferential domestic researchers. Detailed data on O. at soldiers contain in N. I. Pirogov's works, and later — in N. V. Sklifosovsky's works, S. P. Fedorova, to-rye observed O. during the periods of military operations.

Comprehensive scientific study of O. began since 1934 S. S. Girgolav and his pupils (T. Ya. Aryev, V. N. Sheynis, etc.), to-rye experimentally and clinically studied questions of a pathogeny, a wedge, currents, prevention and treatment of the Lake.

I. P. Pavlov who proved existence of the neurogenic nature of generalization patol, processes at repeated coolings of a body for the first time pointed to great importance of reflex reactions in O.'s pathogeny. At O. drew the attention of H to a special role of sympathetic nervous reaction. N. Burdenko (1942). It developed the technique of assistance at O. in the doreaktivny period which formed a basis for improvement of treatment of O.

Classification

On features of emergence distinguish the following types of O.:

1. The lake at ambient temperature is lower than 0 °.

Most often distal departments of extremities, first of all fingers suffer, is slightly more rare — ears, a nose, cheeks, a chin, O. of a penis, a scrotum and other parts of a body closed by clothes are most rare. Defeat arises the quicker, than air temperature is lower and than humidity of skin of the cooled part of a body is higher.

2. The lake at ambient temperature is higher than 0 °. They result long (several days) from cooling in the conditions of high humidity, especially at the got wet footwear. According to it feet are surprised preferential.

3. Contact O. from direct contact of skin or a mucous membrane with strongly cooled, usually metal subject.

On depth of defeat distinguish freezing injuries of the I degree, at to-rykh the surface layer of epidermis, freezing injury of the II degree when the basal layer of epidermis with bulging is surprised, the freezing injuries of the III degree which are followed by a necrosis of skin and hypodermic cellulose, and freezing injury of the IV degree is surprised at to-rykh along with soft tissues the bone nekrotizirutsya. Freezing injury of extremities, especially lower, often happens bilateral.

On development patol, process in time distinguish two periods of O.: doreaktivny, i.e. the period of exposure of cold, during to-rogo patol, reactions, morfol, changes in fabrics and the wedge, manifestations are minimum; reactive, coming after warming of the freezed part of a body, during to-rogo all changes, inherent O., are shown completely.

Statistics

in the conditions of peaceful life of O. are more often observed in sowing. subpolar regions where they make 0,8 — 1,2% of number of all injuries. O.'s frequency increases in wartime when it be available the factors promoting defeat by cold. According to T. Ya. Aryev, the fr. army in World War I lost from O. on average 30 000 soldiers and officers in a year. In it. armies during World War II of loss from O. were very considerable and reached in separate years 25% of number a dignity. losses. According to G. N. Klintsevich, during the military operations an amer. troops in 1944 — 1945 O. occupied a dignity in structure. losses the second place on frequency after wounds.

According to Burton (A. S. Burton) and Edkholma (O. G. Edholm), losses from O. in an amer. troops at military operations in Korea (1950 — 1951) made about one quarter of all a dignity. losses.

In days of the Great Patriotic War in the Soviet Army thanks to good providing troops with warm clothes and footwear and organized specialized medical aid of loss from O. were smaller, having made on various fronts (according to G. N. Klintsevich, 1973) from 1 to 3%, and on the fleet — 5,4% of number a dignity. losses.

The number of victims of O. in all wars was in direct dependence on conditions of weather and during winter military operations especially increased. However O. were observed even in areas with warm climate, napr, at military operations in Algeria, in Spain during civil war.

The etiology

the Damaging action of cold on fabric especially strongly is shown in the presence of some other adverse environmental factors — strong wind, the increased air humidity. Emergence and weight of complications are promoted, besides, by too light or become impregnated with water clothes, the close or got wet footwear, and also easing of body resistance and disturbance of thermal control under the influence of exhaustion, starvations, overfatigue, painful states, and especially blood losses, alcoholic intoxication, the general cooling of an organism. With other things being equal the lower temperature also is longer cooling, the O.

== the Pathogeny == is heavier the experiments on cooling and freezing of the cells and living tissues isolated from an organism Made in 19 century convincingly proved their high resilience. Epithelial and connecting tissues, a parenchyma of a liver, kidneys, tissues of a lung and a brain transfer considerable and long cooling. In A. G. Lapchinsky and N. V. Lebedeva's experiences the differentiated tissues of hematothermal animals kept viability during the thawing even after freezing them in liquid nitrogen. At the same time life activity fiziol, systems of a complete human body suffers already at decrease in body temperature lower than 30 — 35 °, and at t of a body 22 — 25 ° irreversible disturbances develop. Direct death of fabrics in a live organism from cooling occurs extremely seldom on limited body parts after direct contact with very cold, usually metal subject.

Average temperature of an ambient air on the earth is lower than temperature of tissues of human body. Thus, the gradient of temperatures the environment — a body of the person predetermines a constant thermolysis from a body. This thermolysis (see) it is counterbalanced with the clothes and footwear warmed by dwellings, a balanced diet, etc., and also existence in an organism of adaptive mechanisms thermal controls (see). At insufficiency or exhaustion of thermal control the organism is not able to maintain standard temperature, first of all in peripheral fabrics, than and preferential defeat of distal parts of extremities, a nose and ears is caused. Freezing injury of proximal parts of top and bottom extremities, a stomach and back meets rather seldom. N. I. Gerasimenko on the basis of summary literary material specifies that O. of extremities is observed almost at 100% of all victims of freezing injury, including O. of legs — at 70%, O. of hands — at 26%. This results from the fact that the parts of a body having the big area with rather small mass of fabrics have ability to a high thermolysis. Besides, very essential role is played by features of blood supply. Soft tissues of the person plentifully of a vaskulya-rizovana, extremities (especially lower) have rather small network of collateral vessels and the limited blood stream. Vertical position of a body of the person causes higher tone of vessels of the lower extremities in this connection vasodilating reactions in them are implemented with great difficulty. In extremities there are critical ranges of arterial circulation, in to-rykh blood supply of considerable mass of fabric is carried out by a single arterial trunk without the compensating network of collaterals (on a hand — system of an elbow artery, on a leg — subnodal). All this in extreme conditions makes impossible bystry inflow of enough blood to the cooled extremity and promotes development of the Lake.

Fig. 1. Mikrovazogramma of shins of a dog (fruit liqueur of vessels solution of colloid silver): 1 — not cooled shin (a normal microcirculator bed); 2 — cooled to 16 — 18 ° (almost full zapustevaniye of vessels of a microcirculator bed).

The important role in O.'s pathogeny belongs to disturbances of nervous control of circulator processes in the cooled fabrics. Under the influence of cold first of all the tone of unstriated muscles of walls of blood vessels raises that leads to narrowing of their gleam and decrease in a blood-groove in capillaries in the beginning, then in venules and arterioles (fig. 1). Further decrease in temperature causes, according to E. V. Maystrakhu and Ward (M. Ward), a pachemia in vessels of the cooled fabric, then staz with aggregation of uniform elements and formation of pristenochny or occlusive blood clots. On cells

the short-term increase in a metabolism which is followed by an expenditure of sources of heat production (in particular, a glycogen), a cut is result of direct action of cold then is replaced by decrease in intensity biochemical, processes. At the same time N. S. Pushkar, W. D. Bowers, Layno (To. Laino) established that in cells of the cooled fabrics the glycogen disappears, activity of oxidation-reduction enzymes decreases, there are ultramikroskolichesky signs of increase in permeability of membranes, suppression of synthesis nucleinic to - t and proteins. After warming of fabrics bystry recovery of exchange processes (in several hours) at is long the remaining dystonia of vessels (up to several days) causes circulator hypoxia (see) with development of dystrophic, necrotic and secondary inflammatory changes. Edematization of fabrics at O. is connected by hl. obr. with increase in permeability of a vascular wall, and also the hydrophily of fabrics caused by disturbance of acid-base equilibrium (shift towards acidosis).

Pathological anatomy

Fig. 1. Microdrug of a derma with hypostasis in a zone of freezing injury; coloring hematoxylin-eosine; x 48. Fig. 2. Hands at freezing injury of the I degree. Fig. 3. Hands at freezing injury of the II degree. Fig. 4. Hands at freezing injury of the III degree. Fig. 5. Hands at freezing injury of the IV degree (mummification of fabrics).

Morfol. changes in fabrics develop in the main ambassador of warming of the injured extremity, during the reactive period of O. V the doreak-tivny period, i.e. during action of cold, these changes are minimum: at survey it is possible to see blanching of the cooled site of skin, and at microscopy — hypostasis of a derma (tsvetn. fig. 1) passing quite often according to G. A. Orlov, on hypodermic cellulose and muscles.

Morfol, changes in fabrics in the reactive period depend on depth and duration of cooling. In the most mild cases, at freezing injury of the I degree, it is observed: cyanosis and hypostasis of an affected area of skin (tsvetn. fig. 2). Gistol. the research reveals a plethora of vessels, a loosening of connective tissue structures of skin serous liquid, pycnosis, reksis and a lysis of kernels of epithelial cells of surface layers of epidermis. Further the damaged cells dry and are exfoliated. In 5 — 7 days morfol, O.'s signs disappear. Freezing injury of the II degree is characterized by more expressed exudation with education during 2 — 3 days of the intra epidermal bubbles containing transparent or opalescent liquid (tsvetn. fig. 3). Microscopically the bottom of a bubble is presented by a papillary layer of a derma with partially died basal layer of epidermis. Healing comes to an end with a complete recovery skin (see). At freezing injury of the III degree the necrosis of skin of N of hypodermic cellulose is noted (tsvetn. fig. 4). Bubbles with hemorrhagic exudate can be observed. Sites of defeat after rejection of nekrotizirovanny fabrics, a cut begins in 5 — 7 days, heal with formation of a hem. At freezing injury of the IV degree there is a necrosis of skin, soft tissues and a bone (tsvetn. fig. 5).

Fig. 2. The scheme of an arrangement of zones of pathological changes in foot at freezing injury of the IV degree: 1 — a zone of a total necrosis; 2 — a zone of a demarcation inflammation; 3 — a zone of the ascending dystrophic and focal necrotic changes.
Fig. 3. A type of feet at freezing injury of the IV degree: and — mummification of I and II fingers with the initial phenomena of rejection (dry gangrene); — I—III tissues of fingers and distal department of foot are melted, foot is sharply edematous (wet gangrene).
by Fig. 6. The centers of a necrosis in proximal departments of feet at freezing injury. Fig. 7. A type of feet at freezing injury in the doreaktivny period, skin in places of defeat turned white. Fig. 8. Foot at freezing injury after warming, hypostasis is visible. Fig. 9. Hands later a long time after freezing injury of the IV degree. Fig. 10. The color thermogram of feet at freezing injury of fingers of the III—IV degree; fields of an isotherm of blue color correspond to areas of defeat in which infrared radiation is suppressed

At freezing injury of III and IV degrees after development of reactive processes three zones form: a total necrosis, a demarcation inflammation, the ascending dystrophic and focal necrotic changes (fig. 2). The most profound changes are localized usually in distal sites of an extremity. However can take place and a gnezdny arrangement of the centers of destruction when sites of a necrosis are located also in proximal departments of an extremity (tsvetn. fig. 6). The zone of a total necrosis forms after complete cessation of blood circulation when nekrotizirovanny fabrics are exposed mummifications (see) from the outcome in dry gangrene (fig. 3, a). Gistol, a research finds lack of kernels in cells, existence of acellular homogeneous tapes of collagenic bunches in a derma, transformation of a sarcolemma of muscle fibers into homogeneous or glybchaty mass. Gleams of vessels slit-like or are filled with the stuck together blood cells and blood clots. If passability of blood vessels remains or recovered, develops wet gangrene (see). At the same time leukocytes get into sites necrosis (see), to-rye then melt the enzymes which are released at destruction of leukocytes. Putrefactive microbes can strengthen these processes considerably. At a wet necrosis (fig. 3, b) epidermis otsloyen, fabrics are edematous, diffuzno infiltrirovana leukocytes, on a surface and in depth are found accumulations of microbes, and is frequent also fungi.

The zone of a demarcation inflammation arises on edge of a necrosis in the form of more or less wide red strip clearly expressed on 10 — the 12th day. At microscopic examination the purulent inflammation comes to light. On the 3rd week it is replaced by the proliferative processes which are shown growth of granulyatsionny fabric. If demarcation develops at the level of a joint, in a cavity of the last pus accumulates. At the same time the joint cartilage partially collapses.

Fig. 4. Microdrug of a diaphysis of a plusnevy bone is higher than the level of demarcation after freezing injury of the IV degree: 1 — the remains of compact substance; 2 — osteoclasts in lacunas; coloring hematoxylin-eosine; x 120.
Fig. 5. Microdrug of a branch of a back tibial artery in the remote period after freezing injury of foot: 1 — a gleam of an artery; The internal cover of an artery 2 — thickened, sclerosed; 3 — an inner elastic membrane; the combined coloring with identification of elastic and collagenic fibers; x 120.

The zone of the ascending dystrophic and focal necrotic changes forms proksimalny zones of a demarcation inflammation. It has no clear boundary due to the lack of changes of integuments visible with the naked eye. Dystrophic, necrotic and secondary inflammatory processes are found here only at microscopic examination. If after O. it is long disorders of microcirculation remain or there are disturbances of blood circulation of inflammatory character, dystrophic and necrotic processes can accrue, extending proksimalny zones of a demarcation inflammation. In a bone tissue above border of demarcation there are processes of reorganization in the form of an osteoklastichesky resorption (fig. 4) and a new growth of bone crossbeams proliferating osteoblasts. Further in arteries and veins the sclerosis of walls, growth of an internal cover and the organization of blood clots is found that leads to narrowing of a gleam of vessels (fig. 5). Develop neuritis (see), to-rye are morphologically shown by growth of axons in the form of neuromas, proliferation an endonevriya and a perineurium.

A clinical picture

the Main symptoms of O. in the doreaktivny period are albication of skin in the cooling zone (tsvetn. fig. 7) and an anesthesia in the cooled fabrics. At O. which arose in the wet environment (the got wet footwear) the cyanosis and erubescence of the affected extremities (namely they most often are surprised) amplifying after warming are quite often noted. Victims complain of weight in extremities, loss of feeling of a support, impossibility to go independently. The general condition of patients at O. of extremities can remain not changed, however in cases when O. is followed by considerable general cooling of a body, signs can be observed coolings of an organism (see) — a condition of a depression, disturbance of breath, short wind, tachycardia. At heavy O. falling of the ABP and development is possible shock (see).

The clinical picture O. in the reactive period is shown by a serous or serous and hemorrhagic inflammation (holodovy derkhmatit) from the outcome in an aseptic necrosis. The most precursory symptoms of the reactive period are edematization, reddening (with a cyanotic shade) skin (tsvetn. fig. 8), then (except freezing injury of the I degree) emergence of bubbles. Gvkhmorragichesky contents of bubbles most often demonstrate that O.'s weight exceeds the second degree. Already the first minutes of warming, even before development of visible inflammatory and destructive changes, there is pain, intensity and duration the cut depends on weight of defeat.

It is not possible to determine depth and weight of defeat, i.e. O.'s degree, its distribution by the area during the first hours and even days after warming. During this period it is only possible to judge scales of destructive changes presumably, more obviously signs of a necrosis appear only at the end of the first decade.

Freezing injury of the I degree arises after rather short exposure of cold, at a cut considerable fall of temperature of fabrics does not develop. At this degree of O. the general condition of the patient is broken slightly. Right after the termination of exposure of cold and warming patients complain of thermalgias in the field of defeat by cold, feeling of an itch, feeling of colic pains, hyperesthesias develop (see. Sensitivity ) and paresthesias (see). These feelings remain several days.

The affected skin reddens, swells up a little, puffiness often has character of pastosity (tsvetn. fig. 8). Hypostasis in some cases extends not only to the fabrics which were exposed to direct cooling but also adjacent to them. Especially expressed hypostasis is observed on a face, ears, a prepuce. Bubbles do not appear. Hypostasis and pastosity of fabric usually decrease in 5 — 8 days, process comes to an end with an extensive peeling of surface layers of epidermis.

Recovery occurs in 7 — 10 days. In the subsequent victims note the raised chill in a zone of defeat, often there is a xanthopathy.

Freezing injury of the II degree causes considerable pain, unpleasant feeling of tension of fabrics. Bubbles (tsvetn. fig. 3) appear within 2 — 3 days after defeat, sometimes later — for the first week of the reactive period. Localization of bubbles in the field of defeat, their number, the sizes can be various. They are seldom formed on a palmar and bottom surface and if arise in these zones, then usually have the smaller sizes, than on the back of foot or brush. Contents of bubbles depending on concentration of fibrin can be liquid or jellylike. At the bottom of a bubble fibrin in the form of the plaque which is evenly covering the unimpaired basal (rostkovy) layer of epidermis on all surface of amotio of the damaged its layers accumulates. Coloring of contents of bubbles yellowish. Hypostasis at freezing injury of the II degree considerable, takes extensive zones, including and not being exposed to direct cooling. The surface of bubbles very brittle and in many cases collapses spontaneously or at the careless movements of the patient.

The healing which was not complicated by suppuration proceeds 2 — 3 weeks, there is no hem left. In the subsequent, as well as after freezing injury of the I degree, hypersensitivity of affected skin by cold remains.

Freezing injury of the III degree is followed by severe pains, to-rye in some cases have the irradiating character. The anesthesia in the field of defeat proceeds also in the early reactive period, most often it is observed in zones, in the subsequent exposed to necrosis. Skin of an affected area remains cold, accepts cyanotic coloring, the formed bubbles are filled with hemorrhagic contents (tsvetn. fig. 4). Pulse on foot (or a wrist) weakens or at all disappears that is connected with the increasing tension of fabrics owing to severe hypostasis.

At the end of the first week hypostasis begins to fall down gradually, and there are accurately delimited areas of the fabrics which darkened nekrotiziruyushchikhsya. At accession of a purulent infection hypostasis continues to accrue. Demarcation reparative processes are considerably slowed down. At development of dry gangrene the scab is formed, to-ry it is torn away in 2 — 3 weeks, and under it the surface covered with granulyatsionny fabric is found. The period of a rassasyvaniye and rejection of nekrotizirovanny fabrics, epithelization of the granulating surface proceed within several weeks with formation of a deep hem. Partial or full rejection of body (a nose, auricles, a penis) is in rare instances observed.

Extremities most often are exposed to freezing injury of the IV degree. The zone of necrosis at the same time is not always limited to fingers of hands or legs, but extends to a brush, foot, is rare on distal parts of a shin or forearm. At the very beginning of the reactive period hypostasis develops on the square considerably exceeding area of direct cooling. The necrosis can proceed as wet gangrene or in the form of mummification of fabrics. The last form of necrosis develops preferential at damage of fingers (tsvetn. fig. 5). Course of processes of rejection of devitalized fabrics, development of granulations, epithelizations and scarrings very long. So, demarcation of a zone of necrosis at damage of fingers comes in 2 — 4 weeks, and at the necrosis which extended to a diaphysis of bones, in nek-ry cases comes to an end only 2 — 3 months later.

Moderate long cooling of the lower extremities at impossibility to dry footwear threatens O. of feet with a special clinical picture. Mass emergence of such O. at the military personnel, raftsmen, fishermen, etc. was observed (see. Trench foot ). At the non-constant, but systematically repeating cooling arises, hl. obr. on fingers of hands, a peculiar dermatitis (see. Perfigeration ). Stay in a cold water can also call O. Odnako as in an aqueous medium of people loses many times more heat, than at the same temperature in air, the dominating value gets life-threatening general cooling of an organism, and focal lesions not always manage to develop. But if they arise, then flow hard. Already in exposure time of cold extremity pains, quite often spasms develop; in the subsequent there are paresthesias, an anesthesia; quickly hypostasis of an extremity develops; pulse on the periphery disappears. At long stay of the person in water there can be a maceration of skin, in the affected extremities find circulator and neurotic disturbances, bubbles are formed, in hard cases distal parts of extremities nekrotizirutsya. Process of recovery happens slowly, sometimes to development angiotrofonevroza (see).

Complications

Weight of a current of O. and their outcome in many respects define-seater and general complications. Are most often noted inf. complications. At freezing injury of the II degree infection of contents of bubbles can lead to death of a basal layer of epidermis and appendages of skin that considerably extends the period of healing, leads to formation of hems. After freezing injuries of III and IV degrees development of all kinds of a wound fever is possible: anaerobic, putrefactive, purulent (see. Mephitic gangrene , Putrefactive infection , Purulent infection ). At freezing injury of the III degree such complications are observed at 10 — 15%, at freezing injury of the IV degree — at 17 — 20% of patients. The purulent infection differs in an exclusive variety. According to T. Ya. Aryev, hypodermic and intermuscular phlegmons outside a demarcation inflammation make apprx. 25% of all local purulent complications, quite often there is an ugly face; these complications can be followed by purulent phlebitis and thrombophlebitises, limfangiita and lymphadenites. From suppurated limf, nodes abscesses and adenoflegmona form. During the passing of a line of demarcation through a bone the inflammation can gain character of progressing osteomyelitis (see), during the passing through a joint — progressing purulent osteoarthritis (see). Widespread local suppurative processes are followed is purulent - resorptive fever (see), leads edges at long suppuration to wound exhaustion (see. Traumatic exhaustion ). Also changes of nerves, circulatory and limf, vessels are observed. It is possible a wedge, a picture of ischemia of an extremity. At patients with Holodov neyrovas-kulity the pulsation of vessels in distal parts of extremities sharply weakens, hands and legs swell, the strengthened sweating remains owing to what extremities become wet. Patients feel feeling of a raspiraniye, prelum, burning in the affected extremities. Tactile sensitivity in the field of brushes and feet changes, patients cannot carry out exact movements, surely take objects, tools, lose feeling of a support during the walking. In nek-ry cases after O. the increased tactile sensitivity develops, at the same time the touch, a prelum, load of extremities, wearing footwear are followed by pain.

N. I. Batygina, K. Ya. Zhuravleva consider that the postponed O. of legs complicated by the Cold neurovasculitis often is the reason of an obliterating endarteritis. Against the background of neurovascular frustration at patients a dermatosis, trophic changes of tissues of extremities with formation of «the sucked round fingers», club-shaped fingers, ulcers of skin develop. N. F. Kramchaninov reports about cases of development of planocellular cancer on site of hems after the Lake.

At severe forms of O. also changes from the bodies which were not exposed to direct cooling are observed — inflammatory respiratory diseases, a stomach, a duodenum, a large intestine, gums; there are artrozoartrita, fungal infections of skin, etc.

the Diagnosis

Fig. 6. Infrared thermograms of hands: and — at freezing injury of fingers and brushes in the early reactive period (distal departments of fingers do not come to light, the thermogram has character of amputating); — the thermogram of hands of the healthy person.

The main objectives of diagnosis at O. consist in definition of its degree, and also in early detection of borders of impractical fabrics and fabrics with the lowered viability. The solution of these tasks in the doreaktivny period is almost impossible, in the first days of the reactive period — is extremely complicated. Survey, a palpation, definition of sensitivity in a zone of defeat, local thermometry and a kapillyaroskopiya are a little informative in this connection they apply a number of additional researches. Oscillography (see), pletizmografiya (see), reografiya (see) allow to assume the level of future demarcation of a necrosis approximately. More perspective in this respect should be considered angiography (see) and infrared termografiya (see). The last is very valuable diagnostic method of disturbances of metabolic and circulator processes in extremities, it allows to define borders, degree and the nature of defeat of fabrics during various periods of disease. However in the early reactive period of O. infrared radiation is suppressed at all extents of defeat. On thermograms distal departments of fingers of hands or legs do not come to light, the infrared thermogram has character «amputating» (fig. 6).

Fig. 7. The infrared thermogram of legs in a stage of development of an inflammation after freezing injury of feet: the increased radiation of feet (light zones) and sites of the suppressed radiation of fingers (dark zones) is visible.

In process of development of a reactive stage the infrared radiation of extremities amplifies that is explained by emergence of inflammatory reaction (fig. 7). Depending on intensity of inflammatory process the gradient of isothermal fields happens unequal and in comparison with healthy fabrics reaches ΔТ = 2±4 — 8 °.

Fig. 8. The infrared thermogram of legs in 2 weeks after freezing injury of fingers and feet: the suppressed radiation in proximal departments of the feet which are exposed to destruction (are specified by shooters), along with the intensive radiation of the centers taken by a reactive inflammation.

In the first weeks after O. (i.e. earlier, than any other method) by means of an infrared termografiya possible to reveal the zones which are exposed to destructive processes. On thermograms they are defined in the form of sites of the weakened or suppressed radiation against the background of the intensive radiation of the areas occupied by a reactive inflammation (fig. 8).

By means of a color termografiya at O. the exact characteristic of disturbance of circulation in the struck fabrics is possible. At the same time fields of various isotherms are defined by color, and the border of the impractical and badly supplied by blood fabrics comes to light very accurately (tsvetn. fig. 10).

At O. it is possible not only to define zones of necrosis of fabrics by an infrared termografiya, to reveal sites with the lowered reactivity owing to disorder of circulation (that is of great importance for determination of level of a necretomy or radical amputation), but also to control efficiency of treatment.

Fig. 9. The roentgenogram of foot at freezing injury of the IV degree after the necretomy of fingers made within clinically viable fabrics: proksimalny the level of a necretomy — the expressed osteoporosis of plusnevy bones, an aseptic necrosis of a segment of a head of the I plusnevy bone (it is specified by an arrow).
Fig. 10. The roentgenogram of foot in 2 months after freezing injury of the IV degree (the necretomy was made): against the background of osteoporosis sites of a necrosis in the form of consolidations in carinate, wedge-shaped and calcaneal bones are visible (are specified by shooters).
Fig. 11. The roentgenogram of a brush in 8 weeks after freezing injury of the IV degree (the necretomy was made): the centers of an osteonecrosis of the main phalanxes and metacarpal bones with existence of light lines of demarcation are visible (are specified by shooters).

Changes in bones at freezing injury of the III—IV degree are found radiological later 1 — 2 week preferential in distal departments of extremities in a look osteoporosis (see), quite often spotty character. At freezing injuries of the IV degree osteoporosis accrues and extends to the sites of a skeleton which are proksimalny the borders of damage determined clinically (fig. 9). Its expressiveness not always corresponds to weight of damage of bones. Osteoporosis remains up to several months after a wedge, recovery. In 3 — 4 weeks against the background of osteoporosis the sites of an aseptic necrosis of a bone having an appearance of various size of the consolidations delimited from the related departments of a skeleton which kept viability (fig. 10) can come to light. Osteonecrosis (see) usually is not followed by a periostitis, often brings to patol, to changes, especially plusnevy, metacarpal bones or nail phalanxes of fingers. On 8 — 12th week there is a line of demarcation (fig. 11) tsirkulyarno covering a zone of an osteonecrosis in the form of the narrow indistinctly delimited strip of an enlightenment — ossifluence (see). The zone of bone demarcation usually is located at one level or demarcations of soft tissues are slightly higher (to 3 cm) and on terms of emergence corresponds to the last. Timely recognition of an osteonecrosis and definition of its borders facilitate the solution of a question of indications to an operative measure and its volume. At severe forms of O. in 3 — 4 weeks or a little later there can come the rassasyvaniye (ossifluence) of distal departments of trailer phalanxes. With accession of consecutive infection and development hron, osteomyelitis and purulent arthritis of interphalangeal joints find characteristic of these processes rentgenol, signs, but without the expressed reparative processes, cavities and sequesters. Dynamic rentgenol. the research after operative measures allows to find timely signs of the proceeding osteonecrosis or osteomyelitis (lack of variability of structure and contours of a bone stump and formation of the closing bone plate in a stump later 6 — 10 weeks after amputation, amotio of a periosteum, a razvolokneniye of cortical substance, etc.). At purulent arthritises osteoporosis of an epiphysis, destruction of one or both joint surfaces, a diaphyseal periostitis of the affected bones is defined. At considerable destruction of an epiphysis there are incomplete dislocations. For exact definition of border of damage of bones at O. resort to arteriography (see), the affected extremity allowing to estimate a condition of vessels and their passability.

Treatment

Treatment in the doreaktivny period, i.e. first-aid treatment at O., has crucial importance for the subsequent course of a disease. The purpose of treatment during this period is whenever possible bystry and full recovery of blood circulation and metabolic processes in the struck fabrics what first of all requires bystreyshy warming of the struck fabrics.

At impossibility to quickly bring the patient with O. to the room or to lay down. establishment, help shall be given him on site. In this case warming can be made at a fire, footwear or gloves are taken off at the same time. Gentle massage, grinding of the struck part of a body are very important. The victim should be covered with a blanket, a tent, a fur coat and to pound under the shelter the clean hands at an opportunity washed by vodka or alcohol. Massage is made from finger-tips to the center of a trunk, at the same time recommended to the victim to move fingers, feet, brushes. In the subsequent the extremity is covered with warm clothes and take measures for the fastest delivery of the victim to the room with room temperature, and at an opportunity — in to lay down. establishment.

Gradual warming in cold rooms, grinding of affected extremities snow, their immersion in water, cold with floating ice, inadmissibly.

Warming of extremities should be made in a bathtub, water temperature in a cut gradually (within 20 — 30 min.) lead up from room to 35 — 40 °. Add to water antiseptics (potassium permanganate, Furacilin), detergents (roccal and Diocidum). If skin is injured, instead of wet heat apply any thermal radiator, UVCh-therapy in a slaboteplovy dosage. Along with warming in a bathtub make massage of extremities sterilely the prepared hands or hands in sterile gloves.

Stay of the victim in a bathtub and massage continue before emergence of signs of the recovered blood circulation in the cooled extremities (decolourization of covers, a hyperemia). After that apply water dressings with solution of an antiseptic agent the affected parts of extremities. At extensive defeats extremities are given sublime situation on tires or on pillows. The patient is given hot food, warm hot-water bottles, cover with warm blankets, enter sedatives, antitetanic serum and tetanic anatoksinony

it is necessary to apply anticoagulants To the prevention of thromboses, to-rye at the beginning of the reactive period render positive effect. Usually at first enter vnut-riarterialno heparin and fibrinolysin in combination with novocaine, a papaverine, Promedolum, and later appoint anticoagulants of indirect action. At heavy O. early begin infusional therapy — intravenous administration of low-molecular dextrans (a reopoliglyukin on 400 — 800 ml daily). They positively influence anticoagulative system of blood, strengthening mobilization of endogenous heparin. For the purpose of the prevention of a thrombogenesis it is possible to apply also an urokinase, drugs salicylic to - you.

At the developed intoxication appoint antihistaminic drugs, in particular Dimedrol, to-ry not only blocks histamines of blood, but also reduces permeability of capillaries, softens the course of allergic and inflammatory reactions. Dimedrol is entered intramusculary on 1 — 5 ml of 1% of solution by 2 — 4 times a day. Also isopromethazine, tavegil has antihistaminic effect, etc.

T. Ya. Aryev considers that in the dore-active period, before warming, short bring benefit novocainic blockade (see), at to-rykh 0,5% solution of novocaine in number of 60 — 100 ml is entered proksimalny by zones Oh, tsirkulyarno on all perimeter of an extremity. Use of lytic mixes in the first days after O. (Promedolum, Pipolphenum, aminazine) deserves attention, to-rye enter intramusculary repeatedly in 6 — 8 hour.

The bubbles which are formed at Oh, spontaneously are opened in 1 — 2 week after their emergence. At the uncontaminated surface of skin in the area O. it is reasonable to keep bubbles under a bandage or to puncture them at the basis and, having produced exudate, to keep on site a sawn-off epithelium for the prevention of infection of the bared derma. At obviously contaminated skin bubbles and scraps of an epithelium should be removed, carefully to process the surface of skin alcohol (Iodinolum, hydrogen peroxide or other antiseptic solutions) and to cover a naked surface of a derma with a bandage with antiseptic ointments (furacilinum, rivanolovy, etc.).

After processing of the center of defeat, depending on indications, carry out conservative or operational treatment. Before the Great Patriotic War O.'s treatment of all degrees was exclusively conservative, waiting and came down to stimulation of independent rejection of devitalized fabrics, a granulation and epithelization. In the subsequent amputations at the level, the most rational were applied to prosthetics. In practice of modern surgery conservative treatment is a part of complex therapy of the Lake. In the course of conservative treatment also its correction, actions for the prevention and treatment of infectious complications by means of antibiotics, sulfanamide drugs, etc., fight against intoxication are of particular importance constant control behind indicators of a homeostasis; topical administration of proteolytic enzymes, physiotherapeutic treatment is of great importance, to lay down. physical culture, etc. Treatment of patients with heavy O. in the conditions of gnotobiologichesky isolation of a zone of defeat is very effective and perspective (see. Chamber sterile , the Managed abacterial environment ).

Experience showed that conservative treatment of O. which caused a necrosis influences duration of a current a little. It especially belongs to freezing injuries of the IV degree. Amputation of an extremity, inevitable in large part cases, it was necessary to postpone for a long time, expecting independent rejection of devitalized fabrics and clarification of the formed defect. The school of the Soviet surgeons led by S. S. Gere-golavom and Y. Y. Burdenko created a technique of operational treatment of O., the cut is the cornerstone the double-stage primary surgical treatment including follow-up necrotomies (see) and necretomies (see). The section, and then excision of devitalized fabrics sharply reduce intoxication, promote bystreyshy rejection of the remained thin coat of necrotic masses and subsiding of the inflammatory phenomena in viable fabrics. The formed and cleared granulating defect is closed by means of a secondary seam or by skin plastics. In need of amputation the last manages to be made, having kept the longest stump and having completed operation by imposing of primary or delayed primary seams. To refuse double-stage primary surgical treatment and to resort to early amputation it is necessary at far extended necrosis of an extremity with heavy intoxication and threat of development of sepsis. Even the fabrics which are not changed approximately in these cases have reduced ability to regeneration, and therefore H. N. Priorov, V. A. Etc. similar amputations recommend not to finish with mending of a wound storm, but to apply an early secondary seam to its closing. At amputations it is always necessary to provide a possibility of the subsequent reamputations, reconstructive and recovery operations, including recovery of fingers of hands. Therefore amputations shall be economical; it is necessary to spare healthy fabrics, an integument as much as possible.

For closing of defects of skin after a necretomy and amputation often there is a need for skin transplantation (see. Skin plastics ). Terms of use of skin plastics are defined by hl. obr. a condition of fabrics after O.; most often it is undertaken not earlier than in 4 — 5 weeks after the Lake. Closing of defects on the back of foot after amputations and an exarticulation!, on a bottom bearing area of foot and calcaneal area it is necessary to make a full-layer skin rag on a leg.

The best results are observed at plastics by a pedicle graft across Filatov.

Treatment of O. which occurred in water, generally conservative. It is extremely important to warm the patient, to give sedatives for removal of excitement, however it is necessary to remember that the forced warming of extremities at this type of O. causes sharp pain, strengthening of hypostasis of extremities and emergence of bubbles. Anticoagulating therapy lasting 7 — 10 days shall be early included in the general plan of conservative treatment. Extremities cover with water dressings with solution of antiseptic agents (salve dressings cause pain at these patients). Operational treatment at freezing injuries of III and IV degrees — as is described above.

The physical therapy at O. is begun in the doreaktivny (hidden) period when it is directed first of all to recovery of blood circulation in fabrics that is reached by warming of the cooled part of a body. At first-aid treatment if there are bruises of skin, instead of wet heat apply radiation by Minin's lamp, sollyuks, infraruzh, UVCh-therapy in a slaboteplovy dosage.

In the reactive period at freezing injury of the II degree the physical therapy is directed to improvement of blood circulation and fight against pain. Apply currents of VCh, electric field of UVCh and the UVCh-inductothermy on the freezed area to these purposes and on area of nodes of a cervical or lumbar part of vegetative system in weak and sredneteplovy dosages; microwave therapy on the struck zone in a sredneteplovy dosage; UF-radiations of the center of defeat and nearby skin in sub-and small erythema doses, alternating them to radiation by a lamp sollyuks; the electrophoresis of novocaine on area is higher O. and segmented department of a backbone; diadynamic currents on area vegetative gangliyev.

At freezing injury of III and IV degrees the physical therapy is applied to acceleration of rejection of dead fabrics and prevention of development of wet gangrene, rough scarring and formation of contractures. To identification of borders of a necrosis and before an operative measure treatment is carried out as at freezing injury of the II degree. After rejection or operational removal of devitalized fabrics apply UVCh-therapy, UF-radiations in average and hyper erythema doses before emergence of granulations, then pass to small and suberythema doses for stimulation of epithelization (see. Wounds, wounds ).

At once after a wound repair apply ultrasound to prevention of formation of rough hems or fonoforez a hydrocortisone of small intensity (0,2 — 0,4 W/cm 2 ) in pulsed operation (duration of an impulse of 2 or 4 ms) in combination with a paraffin therapy (at a temperature of 45 — 46 °) and to lay down. physical culture. At the developing contracture and keloid cicatrixes fonoforez a hydrocortisone carry out in the pulsed or continuous operation in combination with an electrophoresis of iodine, a lidaza and a thermotherapy (gryaze-, parafino-, an ozoceritotherapy). Apply also diadynamic currents to mitigation of hems (modulation the «long» period).

In the presence of cyanosis and other changes of skin locally apply darsonvalization, at consolidations — an electrophoresis of enzymes (a lidaza, a ronidaza), a paraffinotherapy, a balneoterapiya (sulphidic, radonic bathtubs).

In complex treatment of O. the LFK various forms find application: morning gigabyte. the gymnastics to lay down. gymnastics, individual tasks for independent occupations, gymnastics in water, mechanotherapy, work therapy, massage, etc.

Physical exercises raise the general tone of an organism, promote full recovery of blood supply, a rassasyvaniye of hypostasis and involution of changes in fabrics in O.'s place, prevention of various complications from internals, etc. Occupations to lay down. shall be carried out by physical culture with respect for the principles of the sequence, a regularity and duration of use of physical exercises. The technique of LFK depends on degree, the area and O.'s localization, and also on features of course patol, process. At O. the spasm of blood vessels develops, to-ry can lead to a hypoxia of fabrics therefore to lay down. it is necessary to appoint physical culture in perhaps earlier terms (on 2 — the 4th day). Improvement of the general and local circulation as a result of occupation by physical exercises reduces the phenomena of a hypoxia, promotes recovery of the patient. At O. apply generally the same physical exercises, as at burns (see).

After O., sometimes despite the seeming wellbeing, serious restrictions of movements of the injured extremities can develop. Therefore for the purpose of formation of motive compensations, and also as preparation for use of prostheses occupations are necessary to lay down. physical culture during a long term.

Stage treatment

the Quantity and frequency of various forms O. in wartime depend on season, meteorological uyet Bini, security of staff with the corresponding clothes, footwear and hot food. At long stay in crude entrenchments and impossibility to systematically dry footwear defeats as trench foot are frequent. At hard frosts in holding time of the equipment as a result of contact with cold metal objects contact Islands are possible.

First aid by the victim is provided on site defeats. It includes protection of the victim of further cooling by means of all available means, warming and massage of the cooled body part, evacuation of the victim on PMP.

The first medical assistance given on PMP, and the qualified medical care provided in MSB, OMO, and in the conditions of GO — in OPM, include: carrying out futlyarny novocainic blockade of the freezed extremity with the subsequent warming and its massaging in tanks with warm water before recovery of blood circulation; processing of an affected area alcohol and imposing of the aseptic warming bandage; preventive introduction of antibiotics, antitetanic serum and tetanic anatoxin. As a result of medical sorting carry out evacuation to destination. At the same time victims with freezing injuries of the I degree after assistance can be returned in a system; victims with freezing injuries of the II degree are left in team recovering or sent to hospital of lightly wounded; victims with freezing injuries of III and IV degrees are directed in all-surgical hospital, and in the conditions of GO — in general and surgical-tsy country hospital base where it appears them specialized medical; the help with the principles described above.

Rehabilitation

Victims of O. need long rehabilitations (see). Various dystrophic processes in fabrics — cyanosis, erythroses of skin, trophic changes of nails, a hyperhidrosis, indurative changes of hypodermic cellulose, neuritis of peripheral nerves can remain many years. Stumps of fingers and other departments of extremities after freezing injury III and IV degrees (tsvetn. fig. 9) begin to live long. Quite often they are very painful, skin on them is sclerosed, easily repeatedly ulcerates that is the basis for reconstructive operations.

The forecast for life at uncomplicated O. most often favorable. Heavy O., according to Yu. S. Vinnik, N. S. Dralyuk, L. B. Zakharova (1978), in 62,4% of cases result in disability owing to amputations of extremities. At the extensive complicated freezing injuries of the III—IV degree the forecast can be serious. The lethality makes 1,5 — 3%ot numbers of victims, including 0,3 — 1,6% of patients perish from sepsis.

Prevention

Use for O.'s prevention the special ointments which are usually representing fats with inclusion in them of the substances causing a dermahemia, not effectively; moreover, experience showed that in some cases use of such ointments promotes O. owing to condensation of moisture under a layer of ointment and moistening of skin.

The most effective methods of prevention is rational equipment well adjusted clothes and footwear. The clothes from synthetic fabrics well protect from wind, however at a low temperature its heat conductivity increases, and the thermolysis of a body through fabrics appears higher, than during the wearing clothes from woolen or cotton. It concerns also rubber footwear: heat conductivity of rubber and skin at t ° 0 ° is approximately identical, but at fall of temperature heat conductivity of rubber increases in many tens of times, causing extremely high thermolysis from the surface of legs. At adjustment of clothes and footwear it is necessary to refuse the hard belts and devices squeezing a body and extremities, their especially distal parts — brushes and feet.

Fight against the use of alcoholic drinks is important. In an ebrietas of people loses ability to feel and analyze cooling of all body and its separate parts, to control the actions.

The large role in O.'s prevention is played by various forms of a hardening of an organism, including daily washings by a cold water, physical exercises on cold, to-rye promote body resistance low temperature (see. Hardening ).

An essential factor is also balanced diet. Nationalities of the North have a tradition at long trips to cold time to eat plentiful food, the cut is a part a significant amount of fat.

Freezing injury

Freezing injury at children occurs at children rather seldom (2 — 3% of total quantity of patients with O.; 0,5 — 1% of number of children with thermal defeats).

The noncriticality of behavior inherent to children, irrational clothes and defects of leaving can be the factors promoting O. at children's age; the hydrophily of fabrics which was also more expressed at children and the exudative diathesis which is quite often found at them matter.

Are most frequent at children of freezing injury of the I—II degree. Deeper defeats are a rarity and are observed usually at adverse life situations, especially in the conditions of Far North.

As well as at adults, the doreaktivny period at children can proceed asymptomatically. In the reactive period the hyperemia with a cyanochroic shade, hypostasis, a pain syndrome is expressed. At children of younger age the general reaction to cold even is possible at freezing injury of the I degree. At higher extents of defeat bystry infection of the struck part of a body is noted. Freezing injury of the III—IV degree proceeds as wet gangrene more often more often than at adults, is complicated by sepsis with formation of the remote piye-michesky centers.

Diagnosis of a zone and extent of defeat can present certain difficulties. In doreaktiv-number the period indicative data give definition to the area and degree of anesthesia. In the reactive period, as well as at adults, O.'s degree clinically comes to light within the first week; more exact data can be received, applying special researches (a reografiya, an angiography).

Treatment is carried out by the same principles, as at adults.

At suspicion of freezing injury of the II—IV degree with existence of the general reaction carry out therapy as antishock (see. Shock ).

The forecast at easy degrees of O. favorable. At heavy O., as well as at adults — serious.

Freezing injury in the medicolegal relation

O. rather seldom happens an object court. - medical examinations. In court. - medical practice O.'s cases during the leaving of the person are described down and out, as a result of imprudence, at alcoholic intoxication, long stay in cold transport; there is O. at incorrectly given sports activities. Also intentional self-damages by the Lake are possible. O.'s cases in practice court. - medical examinations meet generally in areas frigid, severe climate, but can take place and in a temperate climate with the increased humidity.

Court. - medical survey of the victims or defendants at O. is carried out by the standard methods (see. Survey ). Finding out circumstances of emergence of O., it is necessary to consider, in addition to weather conditions, motive regime of the victim during cooling, compliance of the sizes of footwear to the sizes of his leg and character of clothes — external temperature, to establish whether was alcohol intoxication or other reasons promoting a local circulatory disturbance. At assessment of a ratio between intensity of exposure of cold and O.'s weight take age and the state of health of the victim into account. It is necessary to consider that changes of fabrics at O. generally arise after cancellation of cold, and fully reactive and their necrotic changes are shown only through a certain term. It must be kept in mind a possibility of development at O. of complications as general character (pneumonia, sepsis, tetanus, mephitic gangrene, fatty embolism, acute mioglobinuriyny nephrosis), and local (pyoinflammatory processes, arthritises, focal damage of neurovascular bunches etc.). In this regard there is a need to find out relationship of cause and effect between complications and O.

Harakter of injuries at O. is qualified according to «Rules of medicolegal definition of severity of injuries»; at the same time loss of body or its function, the amount of permanent disability, long or short-term disorder of health are considered.



Bibliography: Aryev T. Ya. Burns and freezing injuries, JI., 1971; B and to y h and r about in Ya. P., etc. An acute renal failure at a cold injury, Vestn, hir., t. 121, No. 9, page 78, 1978; Barton A. and E d - the hill O. Chelovek in cold, the lane with English, M., 1957; B of e and e in G. A. Concerning classification of freezing injuries, Klin, hir., No. 5, page 65, 1967; Burdenko H. N. O of a role of a sympathetic nervous system at freezing injury, Surgery, No. 5 — 6, page 3, 1942; Vinnik Yu. S., Dralyuk N. S. and Zakharova JI. B. K to a question of pathogenetic therapy of freezing injuries of heavy degrees, Ortop, and travmat., No. 2, page 27, 1978; Questions of vascular surgery, under the editorship of V. V. Kovanov, page 9, M., 1958; Gavrilova K. M. and the Bale and on A. P. O bone changes in extremities at long influence of low temperatures in the conditions of the wet environment, Klin, medical, t. 42, No. 7, page 112, 1964; And m about in V. S. Klinik and treatment high (III and IV) degrees of freezing injury, JI., 1946; Doletsky S. Ya. and d river. Diagnosis and treatment of medical emergencies at children, page 515, M., 1977; To l and N of c of e in and the p G. N. Defeats by cold, JI., 1973, bibliogr.; Kotelnikovv.P. About a toxaemia at freezing injuries, Klin, hir., No. 6, page 16, 1976; Likhoded V. I. An angiography in diagnosis of freezing injuries, Vestn, hir., t. 110, No. 3, page 90, 1973, bibliogr.; JI and x odes of e d V. I. and With ok ov JI. P. Treatment of freezing injuries of extremities, Surgery, No. 12, page 32, 1974; Mai E. V fear. Pathological physiology of cooling of the person, L., 1975; M at r and z I am a N R. I., Smir-novs.v.i Panchenkov N. R. About diagnosis and treatment of freezing injuries of extremities, Vestn, hir., t. 121, No. 9, page 74, 1978; Eagles And. B. General cooling and its emergency treatment, Norilsk, 1946; 0 r l about in G. A., Freezing injury in the wet environment («a wet extremity»), Arkhangelsk, 1951; it, Chronic defeat cold, in L., 1978, bibliogr.; About r-l about in G. A., Pyankovs. M of ityuki-N and A. P. Neyrovaskulita of extremities after cooling in the wet environment, M., 1977; Pathological physiology of extreme states, under the editorship of P. D. Gori-zontov and H. N. Sirotinina, M., 1973; Rozin L. B., Katrushenko R. N. and B atkin A. A. Treatment of burns and freezing injuries, L., 1978; The Guide to physical therapy and physioprevention of children's diseases, under the editorship of A. N. Obrosov and T. V. Karachevtseva, page 348, M., 1976; V. I. Pods, T about l with t y x P. I. and Struchkov Yu. V. Treatment of wounds, Surgery, No. 3, page 20, 1979; With yzd y-to about in K. Zh. Treatment of freezing injuries, Ortop. and travmat., No. 2, page 31, 1978; In and-n of e s R. Century of Thermography, Ann. N. Y. Acad. Sci., v. 121, p. 34, 1964; B o s w i with k J. A. a. Thompson J. D. The epidemiology of cold injuries, Surg. Gynec. Obstet, y. 49, p. 326, 1979; Dalgaard J. B. Burns and freezing as a causg ulceration, J. forens. Med., v. 5, p. 16, 1958; F r i e d m a n N. B. The reactions of tissue to cold, Amer. J. clin. Path., v. 16, p. 634, 1946; G r o s C. o. Thermography of breast diseases, Bibl. radiol. (Basel), v. 5, p. 68, 1969; Hardy J. D. Physiology of temperature regulation, Physiol. Rev., v. 41, p. 521, 1961; K e a t i n g e W. R. Survival in cold water, Oxford, 1969; Shafer J. Page of a. Thompson And. W. Local cold injury, Arch. Derm., v. 72, p. 335, 1955; T i s h-1 e r J. M. The soft-tissue and bone changes in frostbite injuries, Radiology, v. 102, p. 511, 1972; U n g 1 e at S. S. of Immersion foot and immersion hand, Bull. War Med., v. 4, p. 61, 1943; Ward M. Frostbite, Brit, med. J., v. 1, p. 67, 1974; WhayneT. F. a. D e B a k e at M. of E. Cold injury, Washington, 1958; W inslo w of Page E. And. and. Herrington L. P. Temperature and human life, Princeton, 1949.


G. A. Orlov; M. I. Antropova (fizioter.), A. A. Balyabin (stalemate. An.), B. S. Vikhriyev (soldier.), V. P. Illarionov (to lay down. physical.), A. N. Kishkovsky (rents.), H. N. Prutov (it is put. hir.), P. P. Shirinsky (court.).

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