Military Dermatology: Trench Foot

Materials on such pathological processes as "trench foot" and "wet foot" were provided by Tatyana Svyatenko , professor at the Dnipro Medical University, Doctor of Medical Sciences, member of the EAHV. “Thanks to Victoria Kozlovskaya, our colleague from the United States, we have found and started translating the textbook of military dermatology Textbook of Military Medicine from English,” said Tatyana Svyatenko.

CLINICAL OVERVIEW

Damage to the extremities from prolonged immersion in water or exposure to different temperature ranges can be called “wet feet syndrome”. Such lesions, associated with the constant action of cold temperatures and humidity, are divided into "trench" and "wet". An overview describes each condition in order to reduce misunderstandings in nomenclature and to aid in diagnosis and treatment.

Defeat in cool and cold climates

All wet foot syndromes, which will be described below, are characterized by ongoing pain for several weeks. Such a condition can simultaneously affect a large number of soldiers in units due to the general influence of an unfavorable environment.

Consider two syndromes caused by cold, damp conditions.

trench feet

Trench feet refer to lesions resulting from prolonged exposure to wet conditions without getting wet in cold weather. The term originates from World War I, when many warriors were concentrated in the trenches in cold, wet weather for long periods of time. The condition was recognized as the cause of significant loss of human strength during the Greek campaigns, the Napoleonic and Crimean wars. However, these lessons seem to be lost in the newest armies. In Europe, during the Second World War, there were eleven thousand cases of trench stops in November 1944 and more than six thousand cases in the US Third Army alone.

Trench feet are almost identical in presentation with a gradual onset of frostbite, but no maximum temperature has been established at which such a condition can develop. Ice crystals do not form in tissues at temperatures above 0 degrees Celsius, but from 0 to 15 ^° C, clinical signs of trench foot appear when exposed to negative circumstances for 48 hours or longer. Other additional factors include nutritional deficiencies, trauma (rubbing or walking on the affected leg), wind, inadequate clothing type and integrity, circulatory congestion, oxygen starvation of tissues caused by bandaging, lack of movement, hemorrhage or shock, and inadequate technique. .

Clinically, the trench foot is insidious, at first the soldiers feel nothing but a feeling of cold to numbness. Paresthesia and pain may be seen with exercise. With constant exposure, complete anesthesia to touch, pain, and temperatures: a sensation that is described as "walking on a piece of wood." The leg looks pale and swollen, and may show signs of vesiculobulus lesions. The degree of edema in the ischemic or hyper-hyperemic stage depends on whether the leg heats up periodically during the exposure (manifested in a decrease in edema). The foot may appear mottled or purplish, indicating that gangrene is imminent, however this permanent appearance is usually minimal with appropriate care.

The hyperemic or inflammatory stage manifests itself a few hours after removing the shoes and heating the limb. Sensation returns proximally and distally, at first as rapidly progressing tingling to intense heat, throbbing pain. It is difficult for soldiers to endure heat, they are more comfortable when the limb is cooled. Hyperesthesia replaces anesthesia, except for the most remote areas, which may remain insensible for weeks or months. The leg quickly swells and becomes warm, dry, erythematous, throbbing.

In milder cases, this stage reaches its peak within 24 hours. Severe cases can progress from 48 to 96 hours and produce areas of blistering and circulatory disturbance that are more likely to become gangrenous. Bleeding and ecchymosis may occur.

Milder cases of trench leg subside slowly, over 1 to 4 weeks, and are often accompanied by severe flaking of the affected areas. More complex cases progress to the posthyperemic stage. Although patients with trench foot are susceptible to sepsis, the uncomplicated cross-over of these injuries is not systematic.

Post-hyperemic or post-inflammatory stages unbend. At first, a hot, dry leg becomes cold, damp, mottled, or completely bluish with no pulse. Acute pain during the hyperemic stage changes to deep pain, which is usually felt remotely and is often associated with joint pain. Hyperesthesia and parasthesia quickly disappear, although the loss of sensation may remain for months or years. Late changes may include skin atrophy, osteoporosis, atrophy, and muscle deformity (especially of the flared type).

Histologically, a trench foot is a manifestation of a microvascular lesion. Pietersson and Hugar state that prolonged exposure to cold causes an increase in the viscosity of the blood, the deposition of red blood cells in the vessels. Combined with vasoconstriction and loss of serum proteins due to damaged endothelium, it can cause thrombosis, ischemia, and cell damage. Thrombosed vessels of the dermis and subcutaneous tissues with reflex vasodilation, rupture of capillaries and increased vascular permeability contribute to edema, vesiculation and ecchymosis of the hyperemic stage. The work of Smith et al., in which the condition of trench feet was repeated in rabbits, also showed fibrin deposition on vascular walls and muscle bundles, edema and neutrophilic infiltration of skin and muscle collagen, nerve axonal edema, and vacuolization of muscle fibers. endothelium. Smith and others observed various lesions of the lymphatic tissue.

Post-hyperemic tissue biopsy showed atrophy and thinning of the dermis, fibrosis and collagen deposition around nerve endings and blood vessels, and replacement of muscle bundles and fibrils with scar tissue.

Wet feet

Soaked feet can be seen as a counterbalance to the soldiers' trench feet of sailors. The term "wet feet" was first used during World War II to describe a clinical condition syndrome that occurs in limbs subjected to prolonged immersion in water of varying temperatures, from 0 to 15 ^° C. This was most clearly observed during World War II, as as a rule, a wet foot was found in shipwrecked persons, who were drifting, in water, or in lifeboats partially filled with water. It has also been reported in Vietnam as a result of prolonged submergence in rice fields. Clinical manifestations in soldiers with wet feet: the same stages of pre-hyperemia, hyperemia and post-hyperemia as in classic trench feet. However, in wet feet, the injury may extend higher, including the knees, hips, buttocks, depending on the depth of the dive. Also due to prolonged exposure, the wet foot condition may begin on the first day of exposure, while trench foot usually begins to develop after several days of smaller and possibly intermittent exposure. The histological findings seen with a wet foot are similar to those of a trench foot.

Comparison Table for Trench Foot Symptoms

STATE MANAGEMENT

The treatment of non-hypothermia-related lesions, such as trench and soaked feet, is based on reversing ischemia and, at the same time, preventing increased edema, RBC extravacation, or inflammation in the hyperemic stage. When heated, the affected tissue cells have an increased need for efficient blood circulation to remove necrosis products. Because reflex vasodilation occurs, pre-thrombosis and direct injury to endothelial cells by cold and anoxia cause massive transudation of plasma and red blood cells, leading to varying degrees of edema, vasculature, and hemorrhage.

To reduce metabolism and reflex vasodilation, the physician must raise the patient's body temperature while keeping the affected limb cold. It is usually helpful to elevate the patient's bare legs by blowing cold air from a fan over them while keeping the body warm. The patient feels a decrease in pain, swelling, hyperemia and a decrease in vasculature. Cooling of the extremities continues until the stage of hyperemia subsides and circulation resumes. The practice of rubbing the affected limb with snow or ice leads to further injury to the affected tissues and has no place in modern therapy.

Other general measures include avoidance of exertion, direct injury, aseptic measures, prophylactic antibiotics, smoking cessation, tetanus prophylaxis, analgesics, a high protein diet, and possible plasma transfusions if necessary.

Surgery should be delayed as far as possible to allow natural demarcation of damaged tissue, and amputation should therefore be conservative. Other forms of treatment suggested for frostbite have not been investigated for non-chilblain lesions and are not recommended, such as rapid rewarming, low molecular weight dextran, sympathetic blockade, ultrasound, continuous epidural anesthesia, anticoagulant, local sympathectomy.

Treatment of the posthyperemic stage is mainly symptomatic, including physiotherapy, exercise, and surgical deformity correction. Early sympathectomy in more severe cases may prevent long-term effects such as fibrosis, contractures, and scarring, but such intervention awaits further study.

Trench foot and wet foot prevention is difficult, especially during wartime. The most important thing is the correct choice, use and care of safety footwear. Individual training in first aid and detection of manifestations of lesions, attention to personal hygiene, frequent rotation from wet and cold areas, support for proper nutrition and psychological state, awareness of commanders are necessary to prevent the occurrence of trench foot. Wet feet can be prevented at sea by the use of enclosed lifeboats and protective suits on ships.

P. _ S. _ Several measures available

After the material was translated, the proponents of the publication brainstormed and offered some advice.

• For prevention, use sanitary pads for shoes.
• You can dry shoes or socks by pouring chalk, powdered brick fragments, salt, rice into them.
• You can dry the skin with tooth powder or toothpaste (only without menthol!).
• Brew oak bark and make baths or moisten a rag and wrap the foot for a few minutes.
• Flour, oil can not be used!

We will continue to publish chapters of the book as they are translated.