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Certain clinical and experimental investigations of a series of cases allied to frost bite admitted to No. 1 General Hospital British Expeditionary Force since November, 1914

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JohnstonWH_1915redux.pdf (9.585Mb)
Date
1915
Author
Johnston, William H.
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Abstract
 
 
(1). These are briefly as follows: - That the aetiological factors of classical frost bite are by no means identical with those of the allied condition, which for want of a bettor term we have called "Trench Feet ". (2). That two such divergent types of causal factors cannot, and do not, produce the same pathological condition; and, that this present condition is therefore not true classical frost lotto, but a clinical entity allied closely to it, which probably was first diagnosed as such in the Russo - Japanese war, but which, until. the Flanders Campaign of this winter, has never before ranged in line with those great and grave diseases which are inevitable concomitant of every great war. (3). That whilst it is a condition allied to classical frost bite, yet, in its severest type it only approximates to this condition, not only in the destructiveness of its lesions, but also in its depth of pain. (4). That in more detail, the condition of "Trench Foot" differs from that of Classical Frost Bite in being much less destructive, but at the same time capable of producing generally a more wide spread affection, especially of the peripheral nerves of the extremities. The necrosis of "Trench Feet" is more superficial - the lesions are more symmetrical - the pain less excruciating - the prognosis and progress more satisfactory than those of classical "frost bite ". (5). That the essence of the aetiology of the present condition consists in:- A prolonged and intimate exposure on the lower extremities to a medium of stagnant mud and water, in an atmospheric temperature at or near the freezing point. The feet and legs must be in close contact with this chilled medium which by its physical nature continuously induces a radiation of local heat into the surrounding atmosphere. (6)The predisposing factors are: - (i) Absence or great abeyance of those muscular movements which are a natural response of the organism to cold, and which, by stimulating the circulation, tend to remove products of fatigue from the tissues. (ii) Continuous assumption, for periods measured in days, of faulty attitudes and postures of the body, especially of the lower limbs - calculated to induce simultaneously in the distal parts, fatigue in muscle and nerve, and stasis of blood and lymph (7)That certain accessory causal factors do not enter to that extent which as been attributed to them, viz: - (i) That continuous pressure of wet puttees upon the leg has been proved not to exist, in so much that the trained soldier will not wear a tight puttee. (ii) That the theory of tight boots is equally and for a similar reason fallacious; and further, that the increased pressure against the boot is an after effect due to the oedema, which,in its turn,is one of the earlier expressions of an already well developed pathological condition. (iii) That the unavoidable scarcity of hot and stimulating food and drink in the trenches, whilst adding to the suffering, can have but little effect in ameliorating the severity of the factors producing the condition. (iv) That the excessive use of tobacco,with its possible affects upon the vaso-motor nerve terminals, is contraindicated. That from the point of view of service conditions here, and from what we consider justifiable clinical and pathological grounds, and from the stand point of common - sense,and practicability,we have put forward a classification of "Trench feet" into three degrees: - (i). Degree 1. Mild,with defective sensibility. (ii). Degree 2. More severe,with oedema and neuritis. (iii). Degree 3. Dry gangrene superficial in type. (9)That hitherto we have not observed one case of genuine "Trench Feet" which exhibits that preponderance of subjective symptoms of an emotional type over objective symptoms, trivial in character,and associated with slight local lesions,which a recent writer has described as a "neurosis ". (10)Whilst a functional derangement of the nervous system is capable of simulating to a certain extent the defects of sensibility which characterise "Trench Feet", the type of an anaesthesia, however, produced by the latter is similar to that of an organic lesion, - viz,a peripheral neuritis. Frost bite as a neurosis therefore does not exist. (11). While there is abundant evidence to show that the condition is one essentially due to a prolonged local interference with the circulation of the blood and lymph in the distal parts of the limbs, yet,there is also ample evidence for believing that the peripheral nerves of the lower extremities are also the seat of definite lesions. (12). Intense degrees of frost such as have been associated with the production of classical frost bite have not been experienced in Flanders during the present winter, and, therefore cannot enter into the aetiology of the present condition; but, on the other hand, that particular meteorological phase which is associated with "Trench Feet ", consists in a heavy and continuous rainfall, accompanied intermittently by sharp attacks of frost - conditions which have actually occurred in Flanders during the greater part of this winter.
 
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http://hdl.handle.net/1842/34800
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