Shackleton’s ship Endurance, trapped in ice. Image: Frank Hurley/National Library of Australia
Shackleton’s ship Endurance, trapped in ice. Image: Frank Hurley/National Library of Australia
The arrival of Ernest Shackleton and two members of his ill-fated expedition at a whaling station at South Georgia Island in the South Atlantic on May 20, 1916, is usually considered the culmination of a still-unmatched feat of survival. But 22 members of the crew had been left on the uninhabited Elephant Island a month earlier and were still faced with the challenges of surviving the frigid environment with little shelter.
The determination and expertise of the two expedition surgeons played a large part in the ability of those team members to survive until rescue arrived late in August.
In a paper entitled “Of Penguins, Pinnipeds and Poisons,” published in the journal Anesthesiology, Paul Firth, HMS assistant professor of anaesthesia at Massachusetts General Hospital, describes how surgeons Alexander Macklin and James McIlroy treated crew members for the problems and injuries inflicted by the extreme environment, including a June 15, 1916, surgical operation that posed hazards—some that were then unknown—to both the patient and the surgical team.
‘Teamwork, creativity and dedication’
“The story of Shackleton’s doctors has not been told in detail. And while the achievements of the expedition party as a whole are clear to everyone, the specific medical and technical accomplishments benefit from a detailed analysis,” Firth said. “Their story shows how teamwork, creativity and dedication to your fellow human beings were keys to survival.”
In an effort to complete the first land crossing of the entire Antarctic continent, Shackleton and his crew had set off from South Georgia on the appropriately named ship Endurance in December of 1914, traveling south through the Weddell Sea. They soon encountered pack ice, and in January the ship became trapped in frozen sea ice. 
For more than 10 months, the ship was carried north in the ice, until it began breaking up in October, forcing the crew to abandon ship. For another five months the crew camped on ice floes that continued to carry them north, and when the ice began to break up, they launched three lifeboats from the Endurance. Six days later, on April 15, 1916, they arrived at the uninhabited Elephant Island, the first time the crew had stood on solid ground for almost 500 days.
Frostbite
Knowing that rescue from Elephant Island was unlikely, Shackleton and five companions sailed 650 miles to South Georgia in the strongest of the 20-foot lifeboats. Macklin, McIlroy and 20 other crew members remained on Elephant Island for another four months until rescue could arrive.
Among the procedures carried out by the surgeons during that time were tooth extractions for two crew members and drainage of a serious abscess from another, all conducted without general anesthesia. But the greatest challenge was amputating the toes from the left foot of 22-year old Perce Blackborow, the youngest member of the crew.
Many crew members had suffered frostbite, particularly during the voyage to the island when they were almost constantly drenched in cold water, but Blackborow’s case was clearly the worst. After several weeks on the island, in the middle of the Antarctic winter, it had become clear that his toes were necrotic, risking infection and gangrene, and needed to be removed to save his life.
The crew had built a hut from low stone walls covered by the overturned remaining lifeboats. Lined with canvas sails and tents, it provided a cramped shelter that could be used as a temporary operating theater.
Care with chloroform
The only general anesthetic was 8 ounces of chloroform, which was known to require careful administration. Excessive dosage could lead to respiratory failure, and insufficient anesthesia could cause either spasms of the larynx, which could block the patient’s airway, or a potentially lethal irregular heart rhythm. The cold environment would also reduce the rate at which chloroform vaporizes, increasing the risk of an insufficient dose.
Heated with a rudimentary stove fed with penguin skins and seal blubber, the temperature within the hut was raised to around 80 degrees Fahrenheit for the operation. Macklin carefully delivered the anesthetic, which was dripped onto a cloth held over the patient’s face, while McIlroy performed the surgery with instruments sterilized in boiling water.
With the assistance of three other crew members, the operation was completed in less than an hour and required only 1 ounce of chloroform. Blackborow regained consciousness quickly and was able to enjoy a celebratory cigarette.
Improvised operating theater
The imperfect nature of the improvised operating theater actually may have contributed to the success of the procedure. What was not widely appreciated at the time is that chloroform, when exposed to open flame, can break down into the poison gases chlorine and phosgene—which at the same time were being used on the battlefields of World War I. The draftiness of the hut and the chimney that had been installed to vent oily smoke from the burning blubber might have kept both the patient and the surgical team from being poisoned.
Blackborow’s recovery was complicated by infection of the surgical wound. However, after the crew was rescued on August 30th and he was treated at a hospital in Chile, his foot healed completely. He returned to England with only a slight limp.
McIlroy and Macklin both served in the medical corps in World War I and in World War II, with Macklin becoming an anesthetist in the 1920s. Both physicians again joined Shackleton on his last Antarctic expedition in 1922, during which he suffered a fatal heart attack on South Georgia Island. The physicians lived until the 1960s.
Today’s challenges
“These accomplishments show how, with sufficient ingenuity and persistence, you can overcome seemingly insurmountable obstacles,” said Firth. “Perhaps the greatest challenge facing health care today is how to provide surgery and anesthesia to the billions of people in low-income countries who have few financial resources.”
“While this seems at first glance an insurmountable task,” Firth said, “Shackelton’s doctors show how you can overcome huge medical problems with skill, ingenuity and persistence despite very limited resources.”
Adapted from a Mass General news release.
