Now all roads lead to France and heavy is the tread
Of the living; but the dead returning lightly dance.
Edward Thomas, Roads

Sunday, March 23, 2014

The Britsh Army's War on Trench Foot


The conditions of trench warfare included nervous strain and long hours of inactivity, with men remaining almost motionless and in cramped positions, immersed in mud or cold water at near-freezing temperatures. As the temperatures fell, those standing knee deep in ditches faced actual freezing, and field ambulances reported treating cases of frostbite. Even with improved weather conditions, physicians found themselves not treating actual frostbite but characteristics that were clinically indistinguishable from frostbite and which they initially called "chilled feet" or "trench foot."

This Can't Possibly Be Good for One's Feet

The typical medical history of trench foot began with soldiers feeling their feet becoming cold and then ultimately losing all feeling. Beyond the initial discomfort associated with cold feet, there was no other complaint until the feet swelled around the ankles, the swelling sometimes extending up the calves. At this stage, soldiers could not replace their boots once they had been removed. It was thus not unusual to see men in a battalion hobbling along in their bare feet or in boots that were too tight to lace. In moderate cases, the condition lasted two to three weeks, but the more severe cases lasted from six weeks to three months or more.

Among soldiers diagnosed with trench foot, many had worn their boots and puttees for periods from 72 hours to 14 days without taking them off. Often, boots that were large when dry had shrunk under the wetness. "Within a few minutes  or even before entering the trenches for their spell of days and nights of fighting," wrote one medical observer, "the boots of the majority of my patients had been soaked, and so they remained until, on their removal, the gangrene or other manifestations were discovered."

A Minor Case of Trench Foot

In studies undertaken by the British Medical Department, physicians not surprisingly found that the instances of trench foot coincided with cold and wet weather. Of interest, however, the highest number of cases occurred during October and November, falling off in December and January during the freezing weather and rising again after the thaw. During the first year of the war, one battalion lost 400 men in two days to trench foot, and many of these men suffered subsequent amputations. Physicians treating these cases soon began dividing them into three different groups: the first type they characterized as functional anesthesia with impairment of movement; a second type showed slight edema, functional anesthesia, and impairment of movement; the third type exhibited well-marked edema, bleb formation [bulges], and ecchymoses.

Further research discovered that the predisposing factor was fatigue, but the exciting factor was purely mechanical, namely, "venous stagnation and consequent exudation of material into the tissues of the foot." Accordingly, one researcher, Capt. Basil Hughes, insisted that men in the trenches rest with their legs elevated, that they use blankets when resting on the fire-step, that they change socks frequently, and that they take hot soup and rum to keep up vitality.

A Gruesome Case of Trench Foot

Ideally, dry weather and good drainage in the trenches eliminated the problem of trench foot. Such an environment, however, seldom prevailed under battle conditions. Constant bombardment and the need for readiness often precluded efforts to pump out saps, fire bays, traverses, and communicating trenches. The military initiated efforts to drain the trenches and provide them with boards — known as "duckboards" — placed at the base of the trench. By 1915, miles of duckboards were laid in the trenches, many of which either floated away with the heavy rains or were trodden into the mud.

More effective prophylaxis involved thorough foot and boot inspection of soldiers before they entered the trenches, the systematic use of soap, water, and "French powder" (borated talc and camphor), oiling the feet, and insisting that boots be well greased and of ample size so as to ease pressure on the feet when wet. Additional precautions included loose lacing of the boots as well as loose binding of the puttees to ensure adequate circulation.

Eventually, officers across the Western Front developed elaborate organizational arrangements to ensure fresh supplies of socks to men in the trenches. Waterproof bags full of clean dry socks were sent every night to the trenches along with the rations. This enabled every soldier to receive a fresh pair of socks every 24 hours. To maintain circulation and avoid any form of constriction of the feet and legs, officers prohibited the wearing of puttees in the trenches and encouraged the men to move about as much as possible. Some even instituted a regular removal of the boots, followed by foot rubbing drills and massage. Officers also insisted on correct posture when sitting on the fire step or crouching against the wet side of a trench. Other changes included the rule that trench duty in a waterlogged sector should not exceed 24 to 36 hours; the institution of "foot-ashing centres"; a liberal ration of hot food in the trenches; removing boots and socks at least twice a day while in the trenches; the more extensive use of gum boots; and the gradual abandoning of greasy preparations for the use of dry foot powder. Nevertheless, British soldiers never completely gave up using their whale oil. When in the line, a battalion received ten gallons of the oil as its daily issue.

Foot Inspection in the Trenches

Most important, the Army placed the responsibility for the proper care of the men's feet on company and platoon officers rather than on the medical corps. The Fourth Army's Standing Order No. 595, issued 20 June 1917, stated that "CO's [company officers] will be reminded that the loss of effective strength due to the prevalence of this trouble is an indication of faulty discipline and faulty interior economy, and they will, therefore, be held responsible that the instructions laid down are carried out under the strictest supervision by company officers." The real secret to preventing trench foot was perhaps best revealed in the comment of A. G. Butler in The Australian Army Medical Services in the War of 1914-1918: "The CO and all officers entered enthusiastically into the spirit of the game.   In other words, the successful elimination of trench foot as a major source of attrition turned out to be little more than good morale, common-sense hygiene, and strict military discipline.

Source:  THE WESTERN JOURNAL OF MEDICINE, JUNE 1990

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