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Recent Cases of Trench Foot A. J. WEBB R. G. HUGHES Further

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Recent Cases of Trench Foot A. J. WEBB R. G. HUGHES Further Postgraduate Medical Journal (December 1980) 56, 879-883 Postgrad Med J: first published as 10.1136/pgmj.56.662.879 on 1 December 1980. Downloaded from Recent cases of trench foot K. D. RAMSTEAD R. G. HUGHES M.B., B.Ch., B.Sc. M.B. B.S., F.R.C.S. A. J. WEBB Ch.M., F.R.C.S., M.I.A.C. Bristol Royal Infirmary Summary Following resuscitation the perforated duodenal Two cases of cold injury to the lower extremities, ulcer was treated by simple oversewing and cime- 'trench foot', are presented. The management is tidine. She made a good postoperative recovery essentially conservative, but in cases of severe although she remained hypotensive throughout and damage, particularly in elderly people, amputation there was no change in the state of her legs. On must be advised. further questioning she denied any pain or loss of function of her feet. She had lived as a recluse for Protected by copyright. Introduction some years in a rat-infested, damp house with 'Trench foot' is the name used to denote a domestic waste covering all floors to a depth of condition produced by prolonged exposure of the 6 inches. She had been wearing a pair of ill-fitting limbs to cold, damp conditions associated with suede boots continuously for as long as she could immobility and constrictive clothing. The majority remember (Fig. 2). Neurological examination of her of cases reported have arisen directly from the feet revealed no sensation over the area of colour exceptional conditions enforced on service personnel changes, but ankle reflexes were present. at times of war (Thompson, 1937; Ungley, Channell Despite an excellent postoperative recovery and Richards, 1946), although there have been there was neither subjective nor objective improve- more recent reports of young civilians with similar ment in her feet and 4 days later bilateral below afflictions following exposure to wet and cold knee amputations were performed. Histological during prolonged sporting activities and adventure examination of the feet showed no evidence of training (Fraser and Loftus, 1979; Marcus, 1979). major arterial disease. There was epidermal necrosis The population of the British Isles is not usually with basal cell degeneration and early vesicle exposed to the conditions required to cause trench formation. The dermal and subcutaneous blood http://pmj.bmj.com/ foot. In this paper, 2 cases are presented where the vessels were prominent and distended with blood, combination of old age and self neglect lead to it. the underlying muscle bundles were microscopically normal although there were small patchy areas of Case 1 interstitial haemorrhage. A 65-year-old widow was admitted following a The stumps healed readily by first intention and collapse at home. She gave a 2-week history of she proved to be exceptionally agile on her pros- and was and theses. Within 6 weeks she was unaided epigastric pain dehydrated, dirty walking on September 28, 2021 by guest. unkempt with a rigid, silent abdomen. Both feet and at the time of writing is awaiting discharge to were 'dusky' in colour with superficial blisters suitable accommodation. containing serous fluid over the dorsal surfaces.No pulses were palpable below the groins, and there was Case 2 a clear line of demarcation of the colour changes at A 65-year-old man was admitted after he had the ankles (Fig. 1). A diagnosis of perforated peptic been found lying in the road early one morning by ulcer and ischaemic feet was made; abdominal the police. He was unable to give a history and was radiographs showed free gas below the diaphragm. disorientated in time, place and person. He was wet It was decided to treat the perforation operatively and hypothermic (32°C) with bilateral scattered and reconsider the condition of the feet when she rhonchi in both lung fields and a raised jugular had fully recovered. vein pulse. Both feet were cold, swollen and 0032-5473/80/1200-0879 $02.00 c 1980 The Fellowship of Postgraduate Medicine 880 Case reports Postgrad Med J: first published as 10.1136/pgmj.56.662.879 on 1 December 1980. Downloaded from .~~~~~ ;',.: . ..' ...:.' EW~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~IvC 0a () co a).2 UI Cd Protected by copyright. ~~~~~~h.~..fal~~.~ ';·?.'..F·~:~;~.'~?:/'ia~.~.? ~ ~ -,,,..,.'-. ..', ~ ~ ~.?'_~ ~, Y,· ~S ~.. ~ pr %*.~. 0 http://pmj.bmj.com/ a) co a) *1~~~~~~~~~~1 : 14 fz6 4. on September 28, 2021 by guest. Case reports 881 Postgrad Med J: first published as 10.1136/pgmj.56.662.879 on 1 December 1980. Downloaded from GA 0 0 0, 0 U .Y6 14C) r2CAcr3 44 *w~~~~~~~~~~~~~~· Protected by copyright. s"~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~L c5 http://pmj.bmj.com/ 0) 0 .2 -i Cd 6 on September 28, 2021 by guest. rZ D~IL ~2 ~ ~ ~2~ ~ ~_~~~ ~ ~ ~ ~ ~ ~ ~ ' ll~1 ~~~~~~~........||~~i!_ 882 Case reports Postgrad Med J: first published as 10.1136/pgmj.56.662.879 on 1 December 1980. Downloaded from discoloured with no foot pulses palpable (Fig. 3). 1946). These accounts grade the severity of the There was no sign of scalp injury, skull radiography disease either by clinical appearances (Webster was normal and a chest X-ray revealed a right et al., 1942) or, somewhat retrospectively, by the lower lobe pneumonia. neurological damage present (Ungley, 1946). There His general condition improved with a com- are similarities in these 2 grading systems which are bination of antibiotics, physiotherapy and diuretics, summarized in Table 1. Both papers stress that but he remained demented. Over the next week dry excellent results can be achieved by conservative gangrene developed in both feet, with a line of management, using cooling and elevation only. demarcation at the ankle. Examination of his These measures fail in patients with irreversible admission clothing revealed a pair of boots the nerve damage, established gangrene or additional proximal limits of which corresponded to the areas injuries. Few of those patients came to major of gangrene (Fig. 4). His mental state remained amputation. unchanged and, because of the possibility of toxic When one considers the histology of the ampu- absorption, bilateral below knee amputations were tation specimens it is obvious that the pathological performed. Good healing of the stumps occurred change is largely one of disruption of tissue con- by first intention but there was no improvement in tinuity and elevation of skin rather than arterial his dementia. Histological examination revealed occlusion and cellular necrosis. Hence, if elevation similar changes to those of case 1. He is now able to to reduce oedema, and cooling to prevent reactive walk on his prostheses with the aid of sticks and is hyperaemia, can prevent further damage then awaiting a place in a psychogeriatric hospital. debridement, grafting and tissue repair may restore normality. Discussion While histological appearances and the recent Causes ofgangrene ofthe lower limbs are occlusive literature (Fraser and Loftus, 1979; Marcus, 1979) arterial disease, arterial emboli, diabetes mellitus, support conservative therapy for this condition Protected by copyright. it Raynaud's disease and drugs such as ergotamine. may not be valid to extrapolate data from previously None of these were in evidence in the 2 cases, physically and mentally normal people to elderly which appear to have been caused by a combination patients having severe intercurrent disease. The of moderate but not freezing cold, muscular in- priority is to recognize the disease early, and to activity, damp and constrictive clothing: a syndrome differentiate it from cold injury from sub-zero that is commonly referred to as 'trench foot'. temperature, namely frost bite. The latter disease The first descriptions of the condition appeared being associated with more severe climatic con- following the Napoleonic campaigns (Larrey, 1812) ditions and a demarcation that is not clearly associ- but it was in World War I that it began to be seen ated with an item of clothing. In the elderly patient, regularly and from which it derives its name it is naturally preferable to preserve the lower (Lorrain-Smith, Ritchie and Dawson, 1915). At limbs if at all possible because of the problem of the time, soldiers were spendinglong periods standing ultimate function with prostheses. However, this in flooded trenches, wearing tight army boots and must be balanced against the problems of long-term puttees. bed rest in elderly patients such as pressure sores, An upsurge of the disease was seen in World hypostatic pneumonia, urinary infection, constip- http://pmj.bmj.com/ War II, when it was particularly noted in ship- ation and venous thrombosis. The pathological wrecked sailors confined to cramped waterlogged nature of the disease tends to favour healing of lifeboats and termed 'immersion foot' (Webster, amputations by first intention rather than long-term Woolhouse and Johnson, 1942; Ungley et al., problems common with arteriosclerosis and hence TABLE 1. Grades of severity of trench foot on September 28, 2021 by guest. Grade Webster, Woolhouse and Johnson, 1942 Ungley, Channell and Richards, 1946 Minimal Erythema plus slight sensory changes No, or only slight, interference with nerve function Mild Pitting oedema and sensory changes Reversible nerve damage Moderate Pitting oedema, erythema, blebs and ecchymatic spots Irreversible (degenerative) nerve lesions Severe Gross pitting oedema, blebs, massive extravasations of blood, Irreversible (degenerative) nerve lesions and and incipient gangrene gangrene N.B. Both reported cases fall into the severe grade. Postgrad Med J: first published as 10.1136/pgmj.56.662.879 on 1 December 1980. Downloaded from Case reports 883 the level of amputation may be conservative without References prejudicing recovery. Conservative treatment of the FRASER, I.C. & LOFTUS, J.A. (1979) 'Trench foot' caused by damaged limbs also blurs the assessment of other the cold. British Medical Journal, 1, 414. concurrent pathology as it is well known that an LARREY, D.J.
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