This Chapter on Trench Foot was taken from The History of the Great War, Based on Official Documents, Medical Services, Surgery of the War, Volume 1.  Edited by Major General Sir W. G. MacPherson, KCMG. CB. LL.D. 1922

Dr M. G. Miller, Editor.

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 Russo-Japanese 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 from 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."

Etiology 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 may be 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 important 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. 1st 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 hemoglobin, 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 Medecins-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 Scopulariopsis 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," [Not Yet Diagnosed - 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 in the trenches.

According to information supplied by the statistical branch of the Medical Research Council the number of admissions to hospital for frost-bite amongst the British in France and Belgium in 1914 was as follows :-
Month.    No. of Cases
August    •    •    •    •    •    •    •    •     1
September    •        •    •    •    •     •     1
October    •    •    •    •    •    •    •    •   11
November    •       •    •    •    •    •   •  1,555
December    •    •    •    •    •    •    •     4,823
                                                          6,391

In December 1914, eight cases diagnosed " trench foot " were also admitted. In addition to the above, frost-bite was stated to be associated with rheumatism in 306 cases, with myalgia in 69 cases, with bronchitis in 22 cases and with gunshot wounds in 170 cases.   

War diaries also give some indication of the incidence of foot troubles in Gallipoli during the period 25th November to 20th December 1915, but the number of admissions was actually greater than that recorded, as many diaries merely state that  "many" and "several" admissions occurred without quoting figures.

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 issuedby 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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