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SECTION I
GENERAL SURGERY
CHAPTER XI
TRENCH FOOT
ETIOLOGY
Trench foot is the name given to the combination of vasomotor, nervous, and trophic conditions arising in the feet of soldiers immobilized in the trenches during the war 1914-18. Since the American Expeditionary Forces had relatively little experience in trench warfare, it obviously follows there could be no great number of such foot conditions in these forces attributable to the peculiar conditions of trench warfare; however, 2,064 admissions to hospital were due to trench foot in our Army.1 The major portion of these admissions arose from conditions other than those connected with trench warfare, and in all probability would have been called by another name, such as chilblain or frostbite, were it not for our knowledge of the subject acquired from the French and the British. As a matter of fact, the British spoke of it as frostbite during the earlier years of the war,2 as did the French,3 the change in name being due to the fact that, though frostbite may have been justified as a name by the appearance of the affected parts, it was not so by the climatic conditions, for trench foot occurred more especially during damp weather when the thermometer did not reach as low as the freezing point.
The causative agencies are almost invariable.4 They are cold, prolonged immersion in water or mud, accompanied by motionlessness, all of which thus tend to affect the circulation in the lower extremities. Such agencies obtained to a greater extent during the earlier years of trench warfare when many of the trenches were of relatively poor construction, without dugouts, and in many places illy drained. And because of the exigencies of service, relief from trench duty was deterred for a longer time than later. For protection against enemy fire, men hugged the bottoms of the trenches, knee deep in water or mud, unable to change their footwear for days at a time. Little or no early attention was paid to the constricting influence of wearing apparel on the legs and feet-a very large contributing factor in the production of trench foot.
PATHOLOGY
The essential pathological feature of trench foot is an ischemia due to damp cold, with or without a contributory external constriction.4 This interruption in the circulation through the capillaries alters the capillary walls, thus leading to greater permeability and causing edema and stagnation,5 either or both of which set up the evolutional stages referred to below under symptoms.
Raymond and Parisot, 3 searching for an infectious agent in cases of trenchfoot, found both the blood and cerobrospinal fluid negative. In studying the lesions, however, they reached the conclusion that certain fungi, which they
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isolated from smears of the liquid of blisters on trench feet, became parasitic and pathogenic under the influence of more or less continuous immersion in cold water, and readily invaded the body through the macerated epidermis. These findings have not been confirmed by other investigators among whom there was a unanimity of opinion that trench foot is not an infectious disease.
SYMPTOMS
Because of the evolutional changes observable in trench foot, unless checked either by removal of cause or by treatment, the clinical picture of the condition as a whole may readily be divided into stages.
First stage.- Primarily the man affected begins to feel a painful cold and numbing sensation, followed by a prickling and burning sensation extending to the legs, frequently ot sufficient intensity as to interfere with walking.4 Usually the pain is severe enough to require morphine. It is a painful anesthesia and one feels as though one is walking on cotton.3
Second stage.- In addition to the painful anesthesia there is now edema. Usually the skin is red; it may be blanched. The blush and its accompanying swelling may extend from the foot to the middle of the thigh.
Third stage.- In this stage bleb formation is superimposed on the swelling. The discoloration--sometimes mottled due to hemorrhage--and painful anesthesia remain. The blebs are irregular in shape and vary in size; they may contain serum or blood, and their floors are of a gelatinous material.
Fourth stage.- Infrequently a case is so severe as to result in more or less deep mortification of the tissues of the foot, with or without a preceding blister formation. When the blebs are present their gelatinous floors become dark, dry, and of a boardy consistency.
PROPHYLAXIS
The occurrence of trench foot among the American Expeditionary Forces was regarded as an indication of a lack of good sanitary discipline,6 because experience had shown that the prevalence of this disease could be precluded by providing proper facilities to units for the care and treatment of the feet and by a strict daily routine within organizations. Organization commanders were made directly responsible for the provision and availability of suitable facilities, and further, for seeing that the men of their commands made full use of them.
The following instructions, published in general orders, General Headquarters, A. E. F.,6 comprise all the essential features of foot hygiene to be observed in the prevention of trench foot:
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3. The chief predisposing and exciting causes of "trench foot" are as follows: 1. Hygienic: (a) The existence of systematic disease. (b) Insufficient nourishment, particularly hot foods, and lack of sleep and comfort. (c) Too infrequent changes of shoes and socks, allowing of accumulation of bacteria-laden secretions, with a consequent maceration of the skin of the feet. 2. Circulatory interference: (a) As the result of the wearing of tight shoes, socks, leggings, puttees, or breeches. (b) As the result of long continued standing or sitting without exercise and with the feet and legs in constrained positions. (c) As the result of prolonged exposures of the feet to the effects of wet and cold.
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4. The commanditig officers of all units will be held personally responsible that the following instructions are carried out under the personal supervision of a commissioned officer: (a) That there is available a sufficient supply of dry, clean, well-fitting, woolen socks. All men will be instructed to habitually wear socks without garters. The tendency of the sock to creep down is prevented by fastening to the breeches by means of safety pins. (b) That there is available for each man present not less than one change of shoes or boots, and that all boots and shoes are in serviceable condition, well fitted, thoroughly greased, and of sufficient size to permit of wearing woolen socks. (c) That the wearing of rubber boots for periods longer than a few hours be discouraged. Troops should be warned of the disadvantages of this form of footgear. Rubber boots always ventilate badly and remain moist after removal. In drying, they should be wiped out upon the inside after removal of the inner sole, and then hung by the inside straps suspended with the feet down. Neither puttees nor leggings will be worn under boots. (d) That there are available at all times suitable rooms set aside for use as drying chambers and that this space be of such arrangement and size as to adequately provide for the drying of all footwear or other clothing. (e) That the feet of all are vigorously rubbed at least once each day, and preferably with some animal fat, such as tallow or whale oil. (f) That active foot exercises be indulged in at frequent intervals, and from time to time that this be supplemented by removal of shoes and socks, with subsequent drying and massaging of the feet. (g) That special efforts be made to discover men who are suffering from corns, ingrown nails, blistered, or inflamed feet. Any one of these conditions alters the gait and thereby decreases efficiency and increases the tendency to "trench foot." All such cases should be placed under the surgeon's care without delay. (h) That every effort be made to reduce to the lowest possible minimum the necessity of the men performing duty with their feet in mud anad water; this is frequently only a question of trench drainage and the elevation of "duck boards."
5. Since an ample supply of woolen socks is a primary need, arrangements will be made for the delivery of dry socks to the men at the front and for the return of wet ones to the dry socks to each man at least one change a day.
6. Before marching into a forward area, company commanders will make the necessary inspections of their command to see that all shoes are well fitting, in good repair, and properly"dubbined," and that each man has at least three pairs of serviceable woolen socks upon his person. At this time all members of the command will be warned against too tightly applied puttees. This danger is particularly prominent during wet weather, since dry puttees properly applied, which subsequently become wet, shrink 3 percent of their length.
7. Since the lack of nourishment in general, and hot foods in particular, strongly predisposes to "trench foot," the responsible commanders will make suitable arrangements for the supply of hot food to the men. Food containers for bringing up hot food will be provided, and cookers and kitchens will be placed in localities suitable for supplying food and drinks. There will be served each day to all men in the forward areas not less than two hot meals, preferably one at midday and one between midnight and 5 a. m.
8. Plans for improvising and constructing field cookers, kitchens, clothes driers, or other special arrangements found necessary to properly carry this order into effect will be furnished upon application to these headquarters.
9. Foot powders and the various oils, greases, or ointments to be used in the prevention and treatment of " trench foot " and other diseases of the foot will be furnished by the Medical Department. The necessary supplies for application to boots, shoes, etc., will be supplied by the Quartermaster Corps.
10. The proper requisitions to meet the needs of this situation will be prepared and forwarded without delay to the various supply department depots for filing.
Subsequent to the promulgation of this order whale oil and grease in general caine to be looked upon with disfavor; they made a coating which prevented the moisture from getting away from the skin.7 It was thought that oil should be used only when gum boots are not available or when it is impossible to remove the gum boots for long periods at a time.
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TREATMENT
The treatment of trench foot as practiced in the American Expeditionary Forces was based largely upon the work of Raymond and Parisot, of the French Army. The methods to be followed were published in Memorandum No. 4, Army Sanitary School, A. E. F., in the fall of 1917, the essentials of which were as follows:7
Edematous stage.- Foot baths with green soap and water. Large hot formentations consisting of camphor 1 part, sodium borate 15 parts, boiled water 1,000 parts. The gauze compresses should be covered with an impermeable material (oiled silk or oiled paper) and should extend well above the upper limits of the edema. The most strikingly early effect of this treatment is the relief from pain, permitting men who have been unable to rest because of the pain to drop promptly off to sleep.
Blister stage.- Blisters larger than one-half inch in diameter should be excised and their gelatinous floors wiped away with a pledge t of sterile cotton. On the bare surface thus produced place aseptic compresses of camphor 30 parts and ether 1,000 parts. Over these compresses the fomentations used for the edematous stage are placed and continued in use until after the disappearance of the edema, when the camphorated ether will suffice.
Slough stage.- The treatment outlined above will be adequate usually to prevent the formation of sloughs. When sloughs are present, however, loosen them by the camphor-ether compresses and alkaline camphor fomentations for the purpose of gaining access to the affected tissues beneath. Surgery is to be avoided except when the sloughs are hard, whereupon incise through them down to the grumous layer beneath, avoiding blood letting, then apply the compresses. The cautery should not be used.
The use of potassium iodide gave surprisingly good results in the elimination of pain in trench feet,7 its action being almost specific.
Trench foot strongly predisposes to tetanus; consequently each patient suffering from trench foot should receive a dose of antitoxic serum that should be repeated at weekly intervals until the lesions become healthy in appearance.
REFERENCES
(1) Sick and Wounded Reports. Historical Division S. G. O.
(2) Munroe, H. E.: The Character and Treatment of Frostbite. British Medical Journal. London, December 25, 1915, ii, 926.
(3) Raymond, Victor and Parisot, Jacques: Étiologie, prophylaxies et thérapeutique de l’affection dite gélure des pieds. Comples rendus des séances de l'académie des sciences, Paris, May 1, 1916, clxii, 694.
(4) Cottet, J.: Trench Foot; Etiology-Pathology--Symptomatology. War Medicine, Paris, 1918, ii, No. 5, 707-11.
(5) Cannon, W. B.: In discussion of Ashford's article on Trench Foot. War Medicine, Paris, 1918, ii, No. 5, 723.
(6) General Orders No. 11, G. H. Q., A. E. F., January 17, 1918.
(7) Ashford, Bailey K.: Trench Foot; Its Treatment. War Medicine, Paris, 1918, ii, No. 5, 717.
