The trench foot – Suffering in wetness and mud

With the Austrian declaration of war on Serbia on 28 June 1914, a fight began that developed into a world war. The passage at arms was supposed to be short, according to the military planners, but very fast it developed into a static warfare. A special phenomenon arose here – the trench foot.

 

"Everything is wet and dirty here, you literally go bad here," the soldier Fritz Niebergall wrote to his parents from the Western Front in January of 1915. Socks are top on his wish list in his letters. The young soldier describes a phenomenon that soon turned into a horror scenario for soldiers of all nations: Apart from the so-called "shell shock", the "war scrunched", meaning soldiers extremely disfigured by pieces of shrapnels, the "trench foot", medically "immersion foot" (French "Pied de trancheé), was a greatly feared consequence of the trench fight in the First World War.

Background Single reports about "immersion feet" already existed in the 19th century from wars in Russia. The phenomenon is testified by Dominique Jean Larrey, army doctor of the "Great Army" in the wars of Napoleon and also from the Krim War from 1853 to 1856. Also in the Balkan Wars preceding the First World War the disease was known, often associated with low temperatures in the mentioned war zones by army surgeons. But only in the First World War the immersion foot became a mass phenomenon. Since the fall of 1914 the soldiers in the West dug themselves in from the English Channel to the Swiss border in order to protect themselves at least provisionally against the devastating effect of the artillery, the splints and the machine guns. Especially in Flanders/Belgium they soon hit upon ground water. In other sectors of the front, week-long rain has turned the trenches into a bog. And in this bog hundred thousands of soldiers on both sides stood knee-deep in muddy water. This soon had serious consequences.

Spread

There are no reliable data on the exact spread of the " trench foot", for a simple reason. Military doctors first did not distinguish the immersion foot from other frostbites, as the army doctor Professor Hans Kilian noted after the 2nd World War. It can be deducted from the hospital reports on the German Army of the "Reichskriegsministerium" (German War Ministry) that the peak of the wave of infections was in the years 1914/15. From 1915 the prevention measures were effective in all armies. The phenomenon also spread during the fall and winter months. The hospital report stated "In November 15 people from the XXV. Reserve Brigade had their feet frostbitten from the service in the communication trench. In some of 14 soldiers the lower legs had to be amputated." What worries the doctors is the fact that it is not the sharp frost that brings on the disease: "Further 150 frostbites could be observed in the brigade, although the outer temperatures hardly went below zero degrees." Here we encounter for the first time the typical manifestation of the "trench foot": It is actually the combination of low temperatures and wetness that brings on the "immersion foot". Professor Hans Kilian proves with tests and with the help of the statistics from the First World War that this combination is disastrous for the soldier's foot up to temperatures of 10 – 12 degrees.

Also the French meanwhile suffer from this phenomenon. Here for example 233 soldiers in the front section at the Chemin de Dames in humid April of the mentioned time within a colonial battalion consisting of 2 324 men. Also here they first talk about frostbites. The most detailed statistic is led by the British: Here the military historians recorded as early as in the first war half year 1914 about 20,000 cases. Thus it is clear that at the latest at the turn of the year 1914/15 the "trench foot" has turned into a mass phenomenon.

How does the trench foot develop?

The conductibility of water is 20 times as high as the one of air. This is one essential condition for the development of the "trench foot". Basically you have a humid environment meeting low temperatures. If the soldiers did suffer from the "trench foot" in the end, depended on the conditions of their mission and also of their own preconditions. Usually the front troupes in the trenches had the highest morbidity.

Yet military doctors see the problem also with sharp, dry frost, in which cases frostbites of course are a result. But it was additionally dangerous for the soldiers if wetness was added to the cold. If the soldiers' feet were exposed to a muddy milieu more than 10 days, without being able to wash, dry and warm up their feet, the danger was extremely high. Temperatures above the freezing point were more than sufficient. If mud and snow could get into the boots via the surface of the boots, and if this melted, the skin became soft and additionally bacteria could increase the danger of infections. Those were the conditions in the fall of 1914 along the whole front line in France. If this added to constitutional vascular inflammations, tight boots, a squatting position, scleroses in smokers, lack of hygiene and alimentation that was bad and poor in vitamins in individual soldiers, you had the dangerous combination facilitating the "trench foot".

Stages of the disease

With a combination of wetness and cold the foot first loses its warmth. In the trenches, the soldiers moreover were forced into absolute immobility. Under these conditions, the "natural air-conditioning", our vascular system, fails. Due to the stay in cold mud the foot becomes deeply hypothermic. And here we have the decisive difference between the immersion foot and superficial frostbites. The soldier notices it first by feeling increasing cold pain in the foot. Shoes that often were very tight and the wearing of several layers of socks seemed to be the reason for the soldier for the strangely pulling kind of deep pain. In the beginning some of them tried to fight the phenomenon by moving the toes, but it was in vain. If the soldier stayed in the trench for a longer time, if he was squatting, if the relief did not come, the phenomenon got worse. Additionally the arteries were pinched off. Now paraesthesias occurred, the soldier had the feeling that his legs "fell asleep". After a while the foot and the leg became numb, pale, wrinkled and marmorated. Edema developed.

Photos from the First World War show that the person concerned had to be carried. Walking was often impossible for the victims due to severe pain in the balls and heels.

If the cold and the wetness continued for many hours and days, necroses developed, irreversible tissue changes. If feet and legs were then warmed up suddenly, protein breakdown products were flushed out via the blood and fever developed. The medics now saw taut, tight, shiny and deeply red skin. Sometimes blisters developed. But in the beginning of the war medics and doctors were often still inexperienced: delays and mistakes then led to gangrene in the end.

Countermeasures

In the winter of 1914/1915 the military doctors often had to "amputate the lower leg" of victims with advanced clinical signs, according to the hospital report. The surgeons however were already right when they presumed for their analysis of causes a combination of "immobilized rest position of the feet and wet and tight shoes".

An article of Dr. Dunlap Pearge Penhallow about the "Trench Foot" is from the year 1916. He was in Europe with the American Red Cross and described symptoms and countermeasures from the view of a doctor. His article in "Military Surgery" describes the decisive progress of insight of the time: The "trench foot" here is no longer a "frost problem" but a "wetness problem". How else could it be explained that it also developed with temperatures above the freezing point? This was an insight that led to effective countermeasures.

If diagnosed in time, according to Penhallow, you still could counter the problem with bedrest, pain relief, baths and rubbing with lotions and alcohol.

In order not avoid amputations, he focused on prevention. The boots must not be too tight, according to him, to enable the wearing of two pairs of socks without any problems. Water-repellent treatment of the boots and regularly changing of socks are the most important prophylactic factors for him. Once in 24 hours, the boots should have to be taken off, the feet should be inspected, dried and warmed up by a comrade or medic. Also the trenches itself were something he looked at more closely. Stepping places out of wood, insulations, pumps and straw were supposed to mitigate the wetting and thus fight the cause effectively. The measures were implemented at the Western Front. The "trench foot" did not disappear, but its terrible consequences could be mitigated in the last years of the war.

Epilogue

And after the First World War? The history of the "trench foot" was not finished. From the beaches of Normandy in 1944 over the war in Vietnam ("jungle rot") to the Falkland War this disease remained a sad companion of the soldiers in many wars. But not only there. Even in 1985 the Bundeswehr (German Army) observed impairments when the drills were long. Certainly military doctors nowadays know much more about prevention, but reality does not always allow for the necessary means.

by Stefan Slaby