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The chapter on Trench Foot in the official "Medical History of the Great War, Medical Services; Surgery of the War, Vol. I"
TRENCH FOOT
THE effects of cold in the form of frost-bite or gangrene of the feet have been 'recorded in armies from early
historic times. Xenophon makes various references to the effect of cold in producing these conditions during his
perilous march through Armenia. Larrey's description in 1812 of the effects of cold in Napoleon's Russian campaign
shows that it was then a familiar condition. In the medical history of the Crimean War of 1854-6 it is recorded
that cases of frost-bite and gangrene occurred when the temperature was above freezing point, and especially when
there were rain, a cold north-east wind and frost at night. Other factors in this campaign which helped to bring
about the disease were lack of opportunities for changing the clothes, tight boots, fatigue, and defective nutrition.
Diseases such as scurvy or " fever," were factors in the production of trench foot. Owing to the peculiar
conditions of trench warfare, opportunity of movement such as would assist the circulation of the blood was much
restricted, and men in the trenches were compelled to remain under cover in the least exposed positions, most frequently
at the bottom of a trench half filled with snow or with mud and water up to their knees. Similar cases of frostbite
were described by Davys and Powell Connor among the members of the British Mission to Tibet in 1903; in the Russojapanese
War in 1904-5, by Macpherson, and again, in the Balkans in 1912, by Max Page.
On the Western Front, during the war of 1914-18, when carrying out reliefs in the trenches, troops had, in the
first instance, to march several miles frorn their billets along wet and muddy roads, and as they approached nearer
to the firing line the going became heavier and more trying to the soldier equipped in battle order. The troops
arrived thus at the entrance of the communication trench more or less fatigued, and bespattered with mud and wet;
and in the days before trench boards were in general use the effort of marching through a long communication trench,
sometimes half a mile or more in length, was a feat of* endurance which was attended with an immense expenditure
of energy. When the men eventually arrived at their destination, after having waded through mud and water sometimes
reaching the waist, they were already wet through, and had then to remain at their stations with little power of
movement, owing to the depth of the cold semi-liquid mud which often was at a temperature near freezing point.
During the winter of 1914-15 troops might have to stay in the trenches for weeks at a time., as the duration of
the tour of duty varied according to the number of troops available for reliefs. When reinforcements arrived in
increasing numbers it became possible to withdraw divisions from the line to areas ten miles or more from the trenches
for rest and training. It was then possible for reliefs to be carried out more frequently, and an average tour
of duty in the front line would last from 48 to 72 hours, followed by a similar period in support, and another
turn in the front line before returning to billets for five or six days in reserve. The men, however, were almost
invariably given a liberal supply of good food, and they were warmly clad. Also, even in 1914 it was found possible
to provide charcoal fires in braziers in some portions of the line.
As the British front was gradually extended in a southerly direction the nature of the subsoil changed from clay
to chalk, with the result that the hardships due to waterlogged trenches were greatly diminished and a much greater
degree of protection was attained by the provision of dug-outs which could be constructed, comparatively speaking,
without great difficulty in the solid chalk.
In some sectors, owing to the waterlogged state of the soil, the construction of ordinary trenches was impracticable,
the difficulties of drainage were insurmountable and the " trenches " were merely crumbling earthworks.
During the long spells of wet weather in the winter of 1914-15, the parapets in some low-lying sectors would not
stand up and were so flimsy that men were shot through them ; and it was not until sufficient material for revetments
was available that it became possible to move in the trenches in comparative safety. In the waterlogged country
east of Ypres it became necessary to lay down miles of trench-board tracks before it was possible for troops to
reach the trenches reasonably dry shod.
Aetiology and Pathology.
Trench foot is generally considered to be caused by cold, wet and the effects of pressure. Bacterial inyasion,
noted by French Italian and British observers, has been regarded as a secondary infection resulting from the lowered
resistance of the tissues.
As the result of clinical observation and experimental work on animals, Lorrain Smith, Ritchie and Dawson conclude
that the essential change consists in damage to the blood vessels. This damage manifests itself by swellings of
the endothelial cells in the blood vessels and by the vacuolation of the muscle fibre in the arterial walls. These
observers considered it was probable that the aetiological factors concerned in the damaging of the vessels and
tissues were complex. The disease may be due on the one hand to the direct effects of cold, or on the other to
the starvation of the parts resulting from the vascular constriction and the sluggishness of the circulation generally.
With regard to the way in which the condition is brought about in man, they direct special attention to the effects
of pressure and constriction ; the latter' which may be due primarily to the boots maybe aggravated by the wearing
of two pairs of socks in boots which are not large enough for more than one pair. They noted that in all the cases
observed, the lesions were confined to the feet and were specially apt to occur in the part where corns and callosities
were common, that is to say, on the inner and outer aspects of the toes, over the joints on the anterior part of
the foot and on the heel.
A study of the literature of trench foot clearly indicates the import-ant part played in the causation of the disease
by conditions which interfere with the circulation in the feet, such as the long hours spent in an upright or crouching
position when on or off duty in the trenches and the want of facilities for rest in the recumbent position. These
conditions were unavoidably present in the early days of the campaign; they occurred also in situations where the
nature of the ground prevented the construction of dug-outs, or when there had been no time to prepare them, as
happened at all times in the case of newly dug trenches.
As an example of the evil effect of cold, wet and conditions affecting the normal circulation of the feet, the
war diary of the D.M.S. Ist Army has the following remark on 7th January 1915:-" Noted during visits to the
C.C.S. the grave condition of men coming in with sore feet and found that in most cases boots had never been off
or even unlaced for days, sometimes weeks at a time, and that no dry socks were carried." Again, it is recorded
that wet boots were worn continuously for periods up to 14 days and the statement is corroborated by others.
A lowering of the haemoglobin, as estimated by Gower's haemoglobinometer, in patients suffering from " chilled
feet," was noted by Major Gray when in charge of No. 2 Mobile Laboratory. In an average of 25 controls he
found the percentage of haemoglobin to be 85.5; whereas, in the case of 25 patients who were suffering from chilled
feet, the percentage worked out at 77.82. Similar investigations were carried out in No. 5 (Canadian) Mobile Laboratory,
but with less definite results.
The universal opinion that trench foot was due to cold and impeded circulation was disputed by Me'decins-majors
V. Reymond and J. Parisot of the French Army. They claimed to have isolated from the lesions a fungus, which has
been identified by Vuillemin as Scopidariopsis koninjii and is found in litter, straw and manure, and they maintained
that cultures of this mould, - inoculated into animals, produced all the symptoms of the condition known as trench
foot. According to them the disease was of a fungoid nature, similar to Madura foot, and was caused by contact
of the foot with the mud of the trenches. They stated that the affection might be fatal, and that autopsies had
shown in some cases alterations in the liver, spleen, lungs, kidneys', and the presence of mycotic germs in the
organs. According to them inoculation of bile obtained aseptically produced in animals the characteristic phlyctenules
and local gangrene of " trench foot." At a meeting of the Inter-Allied Congress of Hygiene in Paris in
November 1919, Dr. Roux, Director of the Pasteur Institute, in opening a discussion on trench foot, stated that
the conclusions of Reymond and Parisot were not generally accepted, and that their observations had not been confirmed.
The consensus of opinion, therefore, is that the disease is caused by cold, wet and conditions which impair or
interfere with the circulation of the blood.
Incidence.
The greatest wastage from trench foot occurred on the Western Front in France and Flanders, and the affection was
also a cause of serious wastage in Gallipoli and Macedonia. In the winter of 1914-15, cases of trench foot were
returned under a variety of names, such as " frost-bite," "chilled feet," "effects of
exposure," " N.Y.D. feet," or simply as "feet cases." The term " trench foot "
does not appear to have been generally adopted until the end of that winter. As might be expected the highest incidence
occurred amongst the rank and file of the infantry, the officers suffering to a less extent than their men. Indian
troops were affected as well as Europeans both in France and in Gallipoli. The greatest number of cases occurred
when troops, with clothing already thoroughly soaked by heavy rains, subsequently experienced a sudden change to
clear weather accompanied by several degrees of frost. New divisions suffered heavily at first through want of
experience in dealing with the conditions of the trenches.
Symptoms.
In slight cases the foot may present no abnormal appearance, but is the seat of severe pain and of acute cutaneous
hyperaesthesia, which may persist for several weeks ; or the whole foot may be swollen, and, although at first
cold and so numb as to be practically anaesthetic, it soon becomes very red and hot, presenting the appearance
of a large chilblain, to which affection trench foot of this degree is very closely allied. The D.M.S. of the First
Army, on first observing cases of trench foot, described it as " a peculiar form of aggravated chilblain with
a painful condition of the feet apparently due to an inflammatory condition of the plantar fascia."
In severe cases the foot is always swollen and the swelling may extend nearly as far as the knee. In these cases
the whole foot is absolutely numb at first, but becomes very painful after rest of a day or more in a billet or
field ambulance. It was quite common for men to have no feeling of anything wrong with the feet while they were
in the trenches, even though the toes were already dead. In many cases of the swollen type blisters occur, and
in severe cases these are both large and numerous. In still worse cases the toes may be purple or black, and the
same colouring may extend to half or to the whole of the foot. In many such cases, however, the blackness did not
indicate deep gangrene, and the great majority of blackened toes could not be regarded as wholly gangrenous ; most
of them in fact recovered. In the minority of cases one or more of the toes died, and in a few cases half or the
whole of the foot became completely gangrenous. When the toes were dead they often remained dry and shrivelled,
but when the foot died the condition was more frequently moist and very foul.
Subjects of trench foot often suffered from tetanus. Bruce drew attention to the importance of the early prophylactic
injection of anti-tetanus serum in trench foot, and, when referring to the onset of tetanus in these cases, states,
" the disease wastes no time in local manifestations, but bursts out as generalized tetanus and runs an acute
and fatal course in 24 to 48 hours." [Instructions were issued in December 1916, by the D.G.M.S. on the Western
Front for anti-tetanus serum to be given in all cases of trench foot, irrespective of rupture of the. skin. Similar
instructions were issued by the D.M.S., Macedonia, in the winter of 1915-16.]
Treatment.
In slight cases the only course necessary is to allow the patient to lie down so as to keep the feet elevated.
In all cases the feet should be carefully and thoroughly washed with soap and water, followed by an antiseptic
lotion, and an injection of anti-tetanus serum must always be given. After being washed the skin should be painted
with a 1 per cent. solution of picric acid in spirit. When the feet remain cold and numb they should be frequently
rubbed, and in the interval wrapped in cotton wool. If they are red and hot they are often best left exposed, for
wrapping in wool only aggravates
the pain. Bullae should be punctured and dressed with some antiseptic. The foot may be enveloped in "ambrine,"
or other preparations of paraffin wax, if blistering is extensive. Pain is often relieved by aspirin or by salicylates
in large doses. In later stages slight cases are much benefited by a course of electrical treatment, especially
of the high frequency current, and massage.
Gangrene of toes is best treated by amputation of the toe or toes, after a week or more has been allowed for the
circulation of the foot to improve.
In cases of apparent gangrene of the foot it is never right to amputate at once, for in the majority of such cases
most of the foot recovers. If the gangrene is dry, it is well to wait for a " line of demarcation.,"
but if moist it is often necessary to amputate earlier. In very few cases is an amputation through the leg required.
Syme's amputation can generally be performed, even in the worst cases.
In general, prevention consists in maintaining the men in as fit a condition as possible and in exercising as wide
a hygienic control over them as is compatible with the conditions of trench warfare. The particular measures of
prevention are summed up in the protection of the feet and legs from mud and wet; keeping them dry, warm and clean
; making, in fact, a fine art of the " toilet " of the feet ; improving the condition of the trenches,
and providing the men in them with hot food. The application of foot powders and foot grease, a variety of which
was recommended was, after all, only an accessory to the toilet of the feet and not essential. The preventive
treatment on the above lines are described in detail in the volumes on the " Hygiene of the War," but
it may be noted here that the use of rubber boots extending to the top of the thigh was of the greatest value,
and also that whatever other precautions might be taken, it was essential not to keep the men too long in deep
mud or water at a low temperature.
One of the most important facts established was that even comparatively slight cases, without either blisters or
gangrene, took many weeks or months to recover, and it was also noted on many occasions that after an attack of
trench foot a man was much more susceptible to a second attack.
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