Contents

CHAPTER X
 
Clinical Picture and Diagnosis
 
GENERAL CONSIDERATIONS
 
    The symptoms and signs of cold injury, while they have always been of the same general character in all recorded wars, have varied in degree from area to area and person to person in relation to the severity of weather conditions, the duration of exposure, the extent of tissue damage, the length of time the man has remained in the line after his initial injury, and the kind of treatment he has received between the first point of triage and the first medical installation in which he has received definitive therapy. It has been the universal experience that, if the casualty could not be evacuated by litter or ambulance, the trauma of walking, particularly over rough ground, has increased the severity of symptoms, the extent of tissue damage, and the period of incapacitation.

    In general, the symptoms, signs, and clinical progress of cold injury may be summarized about as follows:
        
    The initial symptoms variously include numbness, tingling, and a feeling that the feet have become wooden. Walking may be impossible, or the man may complain that he is unable to feel his feet moving when they touch the ground as he walks. In other instances, there may be dull or severe drawing pain in the feet and in the back of the legs. There is a universal complaint that the feet are cold. At this time, examination shows the skin mottled and the color light bluish gray. Edema and blister formation may or may not be present. This is the composite picture in the ischemic stage.
       
    In the more severe cases, the next symptom is exquisite pain on touch or on exposure to warmth. The feet are swollen, flushed, dry, hot, tense, and shiny. The edema present is of the pitting variety. Blisters are frequent, and intracutaneous ecchymosis may be pronounced. This is the composite picture of the hyperemic stage. Soldiers in World War II frequently called it the "hot foot" stage.
       
    As edema subsides, hyperthermia decreases. Blisters break. The surface layers of skin begin to desquamate. The ecchymotic areas turn black and become hard and mummified. The appearance of the lesions suggests dry gangrene. This is the composite picture of the posthyperemic stage.

If ecchymosis has involved the deeper areas of the skin, particularly under heavy callous formation, exfoliation may not be complete for a month or more. The nails are sometimes lost, and entire casts of the toes may be shed. As the mummified layers peel off, the underlying skin appears normal but proves to be

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extremely delicate. The soldier is unfit for any kind of duty until the plantar surface of the foot and other areas exposed to friction are covered with cornified skin. It was the universal experience in World War II that when a soldier had lost the superficial skin on the sole of his foot, he was unlikely to return to duty for a considerable period of time, if ever.

    In World War II, the incubation or lag period of cold injury, from the beginning of exposure to the first clinical manifestations of damage, averaged 3 days. It varied, however, from person to person, and was greatly influenced by what had happened during the period of exposure. If the soldier were pinned down in a state of immobility, exposure of even a few hours might give rise to extremely severe injury. If he were fully ambulatory and especially if he had had opportunities to dry his feet, massage them, and change wet socks for dry, his injury was likely to be mild, or he might escape injury altogether. Surprisingly, insignificant factors sometimes weighted the scale in one direction or the other. Experiences are recorded in which the man who left the foxhole daily to secure the rations for his comrades escaped intact while the other soldiers in the same foxhole all sustained cold injury.
       
    Although the clinical picture of trenchfoot was essentially the same wherever the condition was observed, there were certain variables in each theater which influenced the symptoms and signs. It therefore seems worthwhile to present the observations from each area separately, even at the cost of some repetition.
 
THE ALEUTIANS 

    The first clinical description of cold injury sustained in combat in World War II concerned the casualties from the Attu campaign.¹ The men, because of the circumstances of this campaign, were cared for in field hospitals and were then evacuated as soon as possible by hospital ships, chiefly to the 183d Station Hospital and then to general hospitals in the United States. The following description is a composite of the data secured at the 183d Station Hospital, Fort Richardson, Alaska; McCaw General Hospital, Walla Walla, Wash.; McCloskey General Hospital, Temple, Tex.; and Letterman General Hospital, San Francisco, Calif.

    Clinical manifestations were unusually prompt and often very severe in the Attu campaign. Within 12 to 14 hours after exposure to wet cold, many of the men affected began to complain of throbbing, tingling, and cramping pain in the feet. There were also frequent complaints of cramps in the muscles of the calf. Numbness became progressively more troublesome, and many soldiers said that they felt as if they were walking on wooden feet. Some could not walk at all. Only 40 soldiers in a provisional battalion consisting of more than 350 men were
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¹ (1) Annual Report, 183d Station Hospital, 1943. (2) Lesser, A.: Report on Immersion Foot Casualties from the Battle of Attu. Ann. Surg. 121: 257-271, March 1944. (3) Patterson, R. H.: Effect of Prolonged Wet and Cold on the Extremities. Bull. U. S. Army M. Dept. No. 75, pp. 62-70, April 1944. (4) Orr, R. D.: Report on Attu Operations, May 11-June 16,1943.

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able to walk at the end of 5 days; over the same period, the number of killed and wounded in action amounted to only 30. Many of the men presented extensive lacerated, ulcerated lesions of the knees that they had sustained from crawling over the ground because the terrain and the tactical circumstances had made litter evacuation impossible.
    
    When the boots were removed, it was usually impossible to replace them, swelling of some degree being present in practically every case. The appearance of the feet, varied from man to man. Sometimes they were blue, or mottled blue and white, and the soles were waxy white. Sometimes they were red and hot. Sometimes they were blistered; in such cases, swelling was intense.

    McCaw General Hospital.- Twenty-five men received at McCaw General Hospital about 3 weeks after they had been removed from combat presented particularly severe clinical manifestations. Some of them (p.93) had gone to Attu by submarine and had averaged 10 days without a change of shoes or socks. They had been practically without food during their 6 days in action, and they had had no real physical rest or sleep. They became wet almost as soon as they landed, and they were constantly exposed thereafter. Nine of them had battle wounds of varying severity.

    Aside from general fatigue, exhaustion, and numbness and discomfort in their feet, these men had had little actual pain until their shoes were removed. Then there was an immediate onset of pain and swelling, and, within 6 to 12 hours, areas of blackish discoloration were observed, followed by gangrene, which in some instances promptly became infected. When they were received at McGaw General Hospital, all of these men seemed physically exhausted. Both the red blood cell count and the hemoglobin level were lowered, and the white blood cell count was sometimes moderately, and sometimes greatly, increased. The most severe cold injuries were associated with septic temperature elevations. In the other cases, the temperature elevations were low grade.

    When the fingers were affected, numbness was seldom experienced earlier than 3 days after exposure, in contrast to the frequent onset of symptoms within 6 to 12 hours when the feet were affected. The longer timelag was probably to be explained by the opportunities to exercise the hands, even when the men were immobilized by enemy fire, and the consequent maintenance and stimulation of the circulation. Hypesthesia was a usual complaint. Physical findings included desquamation of the fingertips, slight swelling, and hyperesthesia. The coloration was likely to be mottled and cyanotic. Gangrene was exceptional. There was no record in the Aleutians of the type of case reported from other theaters in which there were complaints of transient paresthesia and hypesthesia of the fingertips but, in which edema and color changes did not develop.
       
    McClosky General Hospital.- At this time, there was no standard system of grading cold injuries, and the various hospitals developed their own systems. Some merely divided the cases into early and late groups, depending upon the

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time at which the patients were received. At McCloskey General Hospital, which had received 121 casualties with trenchfoot from Attu by 10 July 1943, four degrees of injury were recognized. First-degree injuries were characterized by small patches of damaged skin, without peeling or blistering. Second-degree injuries were characterized by damage to the superficial cutaneous layers, with associated peeling or blistering. Third-degree injuries were characterized by the loss of thick layers of skin and, occasionally, of subcutaneous tissues also. Fourth-degree injuries were characterized by gangrene of a part or the whole of an extremity.
       
    Letterman General Hospital.- At Letterman General Hospital, three clinicopathologic groups were recognized, in addition to minimal, first-degree injuries, for which hospitalization was not required:
       
    Patients with second-degree injuries suffered from smarting, tingling, and throbbing sensations in the feet rather than true pain. These sensations, while chiefly limited to the toes, were often present in the ball of the foot also. Patients in this group were further classified into three clinical subgroups. About 45 percent had a mild type of injury. The feet were only slightly swollen, or were not swollen at all, and sensory changes were limited to hypesthesia. Pulsations in the feet were good. About a third of the men had cold, sweaty, slightly swollen feet, with areas of anesthesia. One or more of the normal pulsations was absent. The remaining patients, who represented about a quarter of the total number, presented extensive areas of desquamation. The feet were dry, very warm, flushed, and edematous and became congested on dependency. Most of the foot was anesthetic.
       
    Patients with third-degree injuries presented areas of superficial destruction. Thick layers of skin and subcutaneous tissues became necrotic, nails were frequently lost, and, in numerous instances, the tips of the toes were also lost.

    Patients with fourth-degree injuries presented true gangrene, with loss of the greater part of one or more of the toes and, occasionally, loss of the whole foot.
   
    All the patients in the third and fourth groups complained of burning pain, most severe at night and most often located in the toes. They also complained of aching, pulling, or cramping sensations in the foot or in the muscles of the calf. Hypesthesia was invariably present. It began at the ankle and increased to complete anesthesia as the toes were approached. The degree of anesthesia was usually, though not always, proportional to the degree of tissue damage. In two instances of severe gangrene, in both of which the entire foot had to be amputated, sensation was comparatively unaltered almost to the line of demarcation. In contrast, many patients with only moderate degrees of desquamation had almost complete anesthesia of all the toes. How complete the loss of sensation was in these cases is evident from the fact that in most of them it was possible to perform debridement and amputate the gangrenous toes without any anesthetic at all.

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THE MEDITERRANEAN (FORMERLY NORTH AFRICAN) THEATER  <>

    Simeone,² who studied cold injury in the North African theater from the time the first cases appeared in November 1943, recognized three clinical stages, the preinflammatory, the inflammatory, and the postinflammatory. The postinflammatory stage was further divided into an early and a late stage. Edwards and his associates 3 recognized four classifications of injury in the 351 patients whom they observed at a general hospital.  <>

Special Investigation
 
    In the preinflammatory (prehyperemic, ischemic) stage (plate 2A and B), the soldier's first warning of trouble was that his feet felt cold and numb. Then he began to experience aching pain in the ankle and the arch of the foot, with tingling, lancinating pains when he put his weight on his feet. Sometimes these pains radiated to the groin. Later, the only complaint might be stiffness and numbness of the feet, which made him feel as if he were walking on blocks of wood. Ataxia might be severe and incapacitating, and only the soldier who had not been instructed in the dangers of cold injury and whose pain was minimal would be likely to continue on duty for several days longer before lie reported sick. During this time, irreparable damage to tissue might occur, as the following case history indicates:
      
     Case 1.- A 25-year-old soldier, who had lived in New Jersey all his life, had no previous history of frostbite or circulatory disturbance. His company was exposed to wet cold on a hillside in Italy from 4 December through 9 December 1943. The ground was continuously wet and muddy. There was no snow in the immediate vicinity, but the tops of neighboring mountains were snow covered. There was frost on the ground every morning, and, during one night, the water in his canteen became partly frozen. During the daytime, he moved about as much as possible. During the night, he slept in a foxhole, in a cramped position. He subsisted on K rations, with nothing hot to eat or drink, during the 5-day period of exposure. At first, he wore two pairs of light-weight (35 percent) wool socks. They became wet almost immediately, and, when he changed to dry socks on the third day, they also became wet almost as soon as he had put them on.
       
    When he changed his socks on the third day, there was nothing wrong with his feet. On the fourth day, he first noticed numbness in the toes. On the fifth day, the greater part of the foot was affected, and his knees, ankles, and toes were stiff. He noted that he was unable to walk in a straight line.
       
    The company was relieved from duty on 9 December at 0200 hours. When the bivouac area was reached, the man went promptly to the kitchen, where he ate a hot breakfast while seated about 4 feet from a hot gasoline range. When he sat down, he had no complaints except stiffness and numbness. When he rose from his seat to report to the dispensary because of the condition of his feet, he was unable to walk and had to be carried to the medical officer. At this time, the left shoe came off easily and could be replaced readily, but the toes looked dark.
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² Report, Lt. Co1. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, subject: Trenchfoot in the Italian Campaign, 1945.
³ Edwards, J. C., Shapiro, M. A., and Ruffin, J. B.: Trench Foot. Report of 351 Cases. Bull. U. S. Army M. Dept. No. 83, pp. 58-66, December 1944.

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    The patient was removed by ambulance to a clearing station, where both shoes and socks were removed, and thence to an evacuation hospital. Here his feet became progressively more swollen. Within 24 hours, blisters were present on both feet, and the right foot, and leg were red and edematous to the knee.
      
     When the man reached a general hospital, 48 hours after leaving the line, both feet were red, swollen, and blistered, and edema on the left side now extended above the knee. Both feet felt numb. Pulses on both sides were bounding. On this day (11 December), the morning temperature was 102.8^{º .}F. (39^º C.) and the evening temperature 103.2º F (39.6^ºC).  The morning pulse rate was 108 and the evening rate 78.  Sulfadiazine was begun by mouth.

    The following day, both morning and evening temperatures  102.4ºF  (39.1º C.) and the pulse rates were, respectively, 144 and 120. The blood-glucose level was 162 mg. percent. On 13 December, the morning temperature was 102.2º F (37.9 º C) and the afternoon level 102.2º F (39.0º C.); the pulse rate was constant at 92; the blood-glucose level was 125 mg. percent
.
    Edema began to subside on 14 December. The skin over both shins was shiny and wrinkled (fig. 56). There were large blisters on the dorsal and plantar surfaces of both feet (plate 2 C and D). The areas which were not blistered were hot and dry. Both dorsalis pedis pulses were palpable. The toes were anesthetic, and motion in them was feeble. The patient complained of very little pain. The blood-glucose level was 115 mg. percent.
       
    A phenolsulfonphthalein test of renal function on 15 December showed a total excretion for 2 hours of 53.8 percent; no dye was excreted during the first 30 minutes after injection. A glucose-tolerance test showed decreased tolerance (147 mg. percent at the end of 3 hours, as contrasted with a fasting level of 98 mg. percent). The nonprotein nitrogen of the blood was 30.4 mg. percent and the serum-protein concentration 9.8 gm. percent.

    On 16 December, the non-protein-nitrogen level was 45.3 mg. percent. Urinalysis 17 December showed no abnormality. The serum-protein concentration was 8.96 gm. percent. On 18 December, the white blood cell count was 6,200 per cubic millimeter. On 19 December, it was 9,950 per cubic millimeter, and the serum-protein concentration was 8.8 gm. percent. The sulfathiazole blood level on 16 and 17 December was 1.3 mg. percent.
       
    On 22 December, under Pentothal Sodium (thiopental sodium) anesthesia, the right leg was amputated 8 inches below the knee. The wound was sutured, but drainage was instituted. There was no reaction to the operation, and on 27 December, under spinal analgesia, five toes were removed from the left foot, by disarticulation at the metatarsophalangeal joints.
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    PLATE 2.- Various stages of trenchfoot. A. Preinflamrnatory stage of trenchfoot observed in clearing station, after 5 days' exposure to wet and cold near Rapido River, Italy, and directly after removing wet shoes for first time. The feet are still wet and cold, but edema has not yet begun to develop. Note coarse mottling of skin. B. Early inflammatory stage of trenchfoot observed in field hospital near front after 4 days of continuous exposure to wet cold. The trousers and underwear are still wet. The feet are warm and dry. Edema is beginning to develop in the left foot. C. Early inflammatory stage of severe trenchfoot. Detail of blisters and gangrene. In this case, the pulses in both dorsalis pedis arteries were bounding. This soldier had been exposed to wet cold, without snow, between 3 and 9 December 1943. The water in his canteen partly froze during one night. D. Inflammatory stage of severe trenchfoot in same case shown in view C. This photograph was taken after 2 weeks of hospitalization. Blisters are still present, along with gangrene. Only the toes were lost on the left foot, but amputation of the right leg below the knee was required. E. Late postinflammatory stage of trenchfoot without loss of tissue. Note cyanosis, probably resulting from venular dilatation and arteriolar constriction in area affected by cold. Note also suggestive boot pattern. This foot is typical of the postinflammatory stage of trench-foot from 4 to 8 months after injury.

PLATE 2.- (See opposite page for legends.)

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FIGURE 56.- Subsiding inflammatory stage of trenchfoot. Note shriveling of blister over right great toe and wrinkling of skin. In this patient, the dorsalis pedis pulses were bounding, and the skin was red, hot, and dry.
 
    The white blood cell count on 22 December, just before the first operation, was 15,000 per cubic millimeter. The following day, it was 9,950 per cubic millimeter, and the serum-protein concentration was 8.8 gm. percent. On 27 December, just before the second operation, the white blood cell count was 15,000 per cubic millimeter. It was 17,300 on 23 December and at practically the same level on 24 December. Daily urinalyses showed no abnormalities. On 27 December, the sulfathiazole level was 1.5 mg. percent and the serum-protein concentration was 9.2 gm. percent.
       
    On 29 December, when the sutures were removed from the right stump, healing was found to be fairly satisfactory. The heads of the metatarsal bones were exposed in the left foot, and the dorsalis pedis pulse on this side was of greater than normal volume. The patient's physical status and the laboratory data were substantially unchanged when he was evacuated to Africa on 4 January 1944.
       
    This was a typical case of severe trenchfoot, except in one respect, that pain was never a major complaint. There was considerable systemic reaction, as evidenced by fever early in the course of the disease, but leukocytosis was not observed until after amputation of the leg. The evidence of depressed renal function is interesting, but the results of a single test cannot be regarded as significant. The non-protein-nitrogen concentration in the blood was within the upper limits of normal. There is no apparent explanation for two unexpected findings; namely, hyperglycemia early in the illness, with depressed glucose tolerance, and the increased concentration of protein in the serum. It is possible that if amputation had been postponed longer in this case more of the right leg might have been saved.

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    Simeone's first observations on trenchfoot were made in November 1943, in a battalion aid station and in clearing and collecting stations on the Italian Front. All of the men had been exposed to wet cold for periods ranging from 4 to 15 days, with an average of 6 days. The weather at this time was not unduly severe, and the opinion was expressed that, as rain and cold increased, symptoms would ensue within shorter periods of time. This proved true during the following winter, particularly at times when the temperature was near freezing between midnight and sunrise but rose to 50º F. (10º C.) during the day, with consequent thawing of the ground.

    On the initial inspection, the feet of these first casualties were wet, cold, and numb. Variable degrees of pallor and purple mottling were observed. Edema, if it was present at all, was slight. Whether it was or was not present at this time apparently depended, at least in part, upon whether or not the feet had been warmed during the course of the exposure. Questioning of the men revealed that the swelling was most likely to develop during the warmer parts of the day. If the shoes were removed then or if they were removed after swelling had already occurred, it was often impossible to replace them.
       
    Not infrequently, casualties were unaware during the preinflammatory stage of trenchfoot that there was anything wrong with their feet. In 125 cases studied by Boland and his associates ⁴ during one period of the fighting in Italy, 8 percent of the patients stated that they had not known that their feet had been injured by cold until they reported to the aid station for treatment of wounds or other unrelated conditions. This lack of awareness of the injury was sometimes a serious matter, not only because treatment was delayed but also because the man remained on his feet and thus sustained additional trauma.
       
    The ischemic or preinflammatory stage of trenchfoot usually lasted only a few hours after the shoes had been removed and the feet had been dried. In an occasional case, in which there was severe spasm of the larger arteries or in which actual thrombosis had occurred, it lasted considerably longer. In the following (fatal) case, this phase lasted 3 days in one leg and 4 days in the other:
       
    Case 2.- A 22-year-old soldier, on 6 January 1944, was obliged to cross a river that in midstream was over his head. Just as he reached the opposite bank, at 0900 hours, he was felled by shell-fragment wounds of both thighs and a compound comminuted fracture of the right femur. For the next 26 hours, until aidmen could reach him, he lay as he had fallen, wet and cold. At the aid station, his right leg was splinted, and he was given 500 cc. of plasma. When he was received at an evacuation hospital on 7 January at 1500 hours, the diagnosis was recorded as bilateral severe immersion foot, bilateral severe frostbite of the hands, moderately severe penetrating wounds of both thighs due to shell fragments, and severe compound comminuted fracture of the right femur.
       
    Within the first 6 hours after he was admitted to the evacuation hospital, the patient received 1,500 cc. of blood, of which 250 cc. was mismatched; it was type A and he was type 0. There was no noticeable immediate ill effects from the error. Nine hours after admission, the blood pressure was 130/90 mm. Hg and the pulse 110. The hands were cold, cyanotic, and edematous, but both radial pulses were palpable. The feet were cold, numb, and cyanotic, but were not swollen. The dorsalis pedis and posterior tibial pulsations were palpable in both feet.
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⁴ Boland, F. K., Claiborne, T. S., and Parker, F. P.: Trench Foot. Surgery 17: 564-571, April 1945.

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FIGURE 57.- Trenchfoot third day after exposure. Ischemia had persisted up to this time, and the discoloration of the skin suggested impending gangrene, though the foot was warm and dry. A Dorsal view. B. Lateral view. Note blister on plantar surface.

     At 0400 hours on 9 January, the wounds were debrided, and a long hip spica was applied. The patient's condition was excellent after operation.
       
    The following day, the left foot was blue and ice cold, and mottling was present from the toes to the malleoli. Edema extended up to the knee but was most pronounced in the foot, in which no pulsations could be felt. The calf was moderately tense. On the right side, the tips of the toes were blue. The forepart of the foot, to the midtarsal region, was mottled and bluish white. Edema was moderate and did not extend to the leg, which was cool. The dorsalis pedis and posterior tibial pulsations were not palpable on this side.
       
    The left hand was blue, and motion was feeble in the fingers, though they were warm. There were large bullae filled with clear fluid on the dorsal aspect of the hand. The radial pulse was normal. Both cyanosis and edema were more pronounced in the right hand. The fingers, except for the thumb, were cold. There were bullae on the dorsal aspect of the hand. The radial pulse was normal on this side also.
       
    On 11 January, the left foot was warm, except for the toes, but continued to be edematous and cyanotic. Bullae were present on the plantar surface (fig. 57). The patient complained of pain when the foot was covered by blankets. The right foot also continued to be cold, anesthetic, mottled, and cyanotic, and edema was more pronounced. The leg was warm down to the malleoli. The calf still felt slightly tense. Both hands were warm but were moderately edematous, cyanotic, and anesthetic and were covered with huge bullae (fig. 58). The right hand was more extensively involved than the left. Both hands and feet were protected by sterile dressings.
       
    Urinalysis had been negative until 11 January. On this day, two specimens were amber and contained albumin (1 to 3 plus). The concentration of nonprotein nitrogen in the blood was 174.8 mg. percent.
       
    On 12 January, the toes on the right foot were somewhat less cyanotic, but they were cold and motionless. Urinalysis showed 2 plus albumin and 1 to 4 white blood cells per high-power field. The color was clear amber. The following day, two specimens showed 2 plus albumin but were otherwise negative.

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FIGURE 58.- "Trench hands" after 3 days of hospitalization. Merthiolate (sodium ethylmercurithiosalicylate) has been applied to the skin about the blisters.  

    On 14 January, signs of heart failure were apparent, with gallop rhythm and ChevneStokes respiration. Three urine specimens, one of which showed an alkaline reaction, were negative except for albumin (a trace to 1 plus) and 1 to 3 white blood cells per high-power field. The nonprotein nitrogen of the blood was 199.5 mg. percent. Two specimens examined on 15 January showed, respectively, 1 and 2 plus albumin. The following day, both specimens showed 1 plus albumin. Throughout the period of hospitalization, the daily urinary output had ranged from 1,200 to 2,000 cc., and the specific gravity had varied from 1.014 to 1.021.
       
    On 16 January, the patient became progressively drowsier and weaker. Physical examination revealed hepatomegaly and pulmonary congestion. Digitalization was not effective, and death occurred on this day. Autopsy revealed bilateral pulmonary edema, hydrothorax, pneumonia of the left lower lobe, and passive congestion of the liver. Microscopic examination revealed pigment nephropathy. The pheripheral vessels revealed multiple thrombi and acute inflammatory changes, and the anterior tibial muscle showed degenerative changes and necrosis.
       
    This case is of interest for several reasons. The cause of death, uremia without anuria, can most reasonably be attributed to the transfusion of 250 cc. of mismatched blood, even though no untoward clinical reaction seems to have occurred after it. The prolonged period of exposure, however, may have played some part in the development of renal insufficiency, and prolonged shock may also have played a part. The case was additionally complicated by ischemia of the left leg, which was sufficient to cause degeneration and

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necrosis in the anterior tibial muscle, as shown by histologic examination of sections after death. It is possible that the muscle necrosis had the same effect on the kidneys as crushing injuries which cause renal damage. Histologically, it is impossible to differentiate these conditions on the basis of renal changes. Finally, the patient lay on cold, wet ground for 26 hours, and the ischemic stage was unusually prolonged. The feet remained cold on the left side for 3 days and on the right side for 4 days after hospitalization. Although it was then general policy in the North African theater to employ active measures to promote the circulation in the feet in cases such as this, these measures were omitted in this particular instance.
 
Classification

    Inflammatory stage.- In some cases of cold injury observed in Italy, the ischemic stage was mild and transitory, no detectable second or inflammatory stage ensued, and casualties could be promptly returned to duty from the clearing station or evacuation hospital. This was not the usual experience. In most instances, the inflammatory stage was clear cut and lasted at least a week. In many cases, it lasted 2 weeks, and it sometimes lasted as long as a month. In 25 of the 50 cases studied intensively early in the cold injury experience in Italy, the inflammatory stage lasted about a week. Practically all of the 50 patients had passed into the postinflammatory stage by the third week of hospitalization. In no patient in the group did the inflammatory stage last longer than a month.

    Patients in the inflammatory or hyperemic stage of trenchfoot were sometimes seen in clearing stations (fig.59) but were usually first seen in evacuation hospitals. The story was generally the same. Within an hour or two after the shoes had been removed and the feet had become warm and dry, the feet began to swell, even though the patient was recumbent. Within the course of the next few hours, they became hot, dry, red, and painful, thus presenting all the classical signs of acute inflammation. At this time, the dorsalis pedis pulse was easily palpable and was usually increased in volume.

  The patients complained of tingling pain when the feet first became warm. As they became warmer, burning, throbbing pain ensued, and discomfort was extreme. External heat was intolerable, and the feet were most comfortable when they were exposed to cold air. The affected parts were extremely sensitive and tender to palpation except for portions of the toes, particularly the tips and the plantar surfaces, which were likely to show hypesthesia and anesthesia. Often, however, hyperesthesia was present and might be so severe that even light bed coverings could not be tolerated. Small, patchy areas of ecchymosis appeared at pressure points (plate 3A).

    Clinical progression could be correlated with the severity of the injury. In the mildest cases, inflammatory signs reached a maximum during the first 24 hours of hospitalization, then rapidly subsided (plate 3B). Areas of super-

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FIGURE 59.- Inflammatory stage of trenchfoot 2 days after exposure. Swelling was slight in the right foot and moderate in the left. Although this man's combat trousers and underwear were still wet, his feet were dry.

ficial thrombosis were sometimes seen. In the severe cases, symptoms and signs were progressive for 48 to 96 hours. At the height of the inflammatory reaction in the most severe cases, usually between the fourth and sixth days, edema extended to the knee and was sufficient to obscure the pulses in the foot. When regression set in and edema began to disappear, the skin become finely wrinkled. The color, which was originally bright red, first became brownish
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PLATE 3.- Various stages of cold injury. A. Inflammatory stage of mild cold injury, 2 weeks after exposure. The edema has almost entirely disappeared, but areas of ecchymosis remain at points at which the feet and toes were presumably subjected to trauma by rubbing against the shoes or by pressure from them. B. Early cold injury, in which inflammatory stage was practically over by the end of the first week after exposure. Edema had lasted only 2 days. Note superficial gangrene of left fifth toe, rather marked cyanosis over fifth metatarsophalangeal joint, and slighter cyanosis over base of fifth metatarsal bone. These areas of injury to the skin can be attributed to close contact with the shoe, which rendered cold a more effective injurious agent than it was in parts of the skin in less direct contact with the shoe and the environment. Exposure in this case was in the hills about Venafro, Italy; the temperature was never below freezing. C. Early postinflammatory stage of cold injury. Note especially desquamation of superficial layers of skin, with exposure of atrophic skin beneath. D. Late stage of cold injury, about 6 months after exposure to nonfreezing cold. Note sequelae of injury in skin and nail of right fifth toe. The skin is very delicate, soft, warm, and moist. Hyperhidrosis occurs in feet such as this, particularly after marching, and maceration of the skin, with trichophytosis, is a frequent complication. E and F. Plantar and dorsal views of feet during late inflammatory stage of cold injury 1 month after exposure. Gangrenous (partial-thickness) skin has separated, and islands of residual viable skin remain to epithelize the surface. The toes were gangrenous throughout and eventually had to be amputated. The case illustrated, however, that even what appears to be extensive gangrene may be only skindeep and that a major amputation can usually be avoided.

PLATE 3.- (See opposite page for legends.)

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and then faded to normal. The dorsalis pedis pulse became less bounding. Exfoliation usually occurred, revealing delicate underlying skin (plate 3C).
       
    In the most severe cases of trenchfoot, blister formation and signs of circulatory insufficiency became apparent early in the second stage. They were sometimes present when the shoes were removed. The blisters usually contained clear fluid, though it might be hemorrhagic. In some cases, small areas of redness and induration appeared during the first week of the inflammatory stage. Acute tenderness was complained of on palpation, and the whole clinical picture was suggestive of cellulitis. Impending gangrene sometimes progressed to frank gangrene within 48 hours.
       
    The clinical progress of the 50 patients with trenchfoot included in the initial survey can be summarized as follows:
       
    At the end of the first week of hospitalization, 51 of the 100 feet were edematous. The edema was pitting in slightly more than half of the extremities and was slight in the remainder. Initially, it had been slight in nine cases. At the end of the second week, 45 feet were still edematous, but the edema was now slight in 37 of these. At this time, it was unilateral in 7 cases and was of the same degree on both sides in only 8 of the bilateral cases (plate 3D). At the end of 3 weeks, pitting edema was not present in any case, but 18 patients still had slightly edematous extremities. Subsequent observations on much larger numbers of patients showed substantially the same distribution of edema.
       
    After a week of hospitalization, 46 of the 100 feet were warm. In 31 extremities, edema was associated with the warmth; 11 were moist and 20 dry. Of the 15 warm feet without edema, 7 were moist and 8 dry. Of the 54 cold feet, 20 showed edema; 7 of these were moist. Of the 34 cold feet which showed no edema at this time, 14 were moist.
       
    At the end of 3 weeks, 44 of the 100 feet were warm. Of the 14 which still showed edema, 11 were moist. Of the 30 without edema, 23 were moist. Only 4 of the 56 cold feet still showed edema; 3 of the 4 were moist. Of the 52 cold feet without edema, 40 were moist.
      
    In mild cases of cold injury, acute pain often disappeared by the end of the first week, leaving the patient quite comfortable thereafter. Much more often, the burning pain originally present was replaced by a deep-seated ache in the ankle, in the transverse and longitudinal arches, and in the metatarsophalangeal joints, particularly the proximal joint of the great toe. It was frequently observed that the intensity of residual pain was related to the degree of previous edema. Edema almost always disappeared more rapidly than pain.

    Abnormal heat disappeared fairly promptly. At the end of a week, only 2 of the 50 patients first studied had extremely hot feet, and none of the feet, were abnormally hot at the end of 3 weeks. Sometimes, however, there were extraordinary variations in temperature. While the patients were actually under observation, the feet would change in a few minutes from warm and dry to cold and wet, or vice versa. The variability was particularly marked at night, both in the late inflammatory stage and the early postinflammatory

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FIGURE 60.- Postinflammatory stage of trenchfoot. Gangrene in this patient was superficial, and no amputation of tissues was necessary. Note small areas of gangrene on instep and anterior aspect of ankle; they represent points of pressure from shoe.

stage. A patient would complain that he had wakened with his feet "burning up," and, when the nurse or ward officer on night duty investigated, it would be found that feet which had been cool during the day had become hot to palpation.
       
    Gangrene sufficient to require amputation of the toes or of larger areas of the feet was uncommon (figs. 56, 60, 61, 62, 63, 64, 65) (plate 3E and F). It was estimated that gangrenous changes occurred in from 1 to 1.5 percent of the cases of trenchfoot which occurred in Italy during the winter of 1943-44, and in about 0.5 percent of the cases observed the following winter. Six percent of the 125 patients observed by Boland, Claiborne, and Parker presented some degree of dry gangrene, including minor degrees in which loss of tissue was superficial, but this figure must be interpreted in the light of the fact that these patients were part of a selected group returned to a Communications Zone hospital because of the severity of their injuries.
       
    In his personal study of trenchfoot, Simeone observed only one patient who required amputation of more than the toes (case 1), though another (case 2) would probably have required amputation of the leg if lie had survived. Investigation of the proceedings of theater disposition boards for a 5-month
 

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FIGURE 61.- Late inflammatory stage of severe trenchfoot. Edema has almost entirely subsided. The skin was warm, dry, and scaling. Note location of gangrene, in tips of toes and over the prominence of the base of each great toe. It was thought that these particular areas represented areas of frostbite because they were in direct contact with the shoe and might have sustained freezing temperatures. The appearance of the remainder of the foot, however, was entirely typical of trenchfoot.
 
period in 1945 brought to light three other cases in which amputation of more than the foot was required :
       
    Case 3.- A soldier who became separated from his unit just after landing at Anzio beachhead on 22 January 1944 wandered about a swamp for the next 8 days, continuously exposed to cold and wet. When he was finally hospitalized, both feet were seriously damaged. Gangrene affected all the toes and the distal halves of the dorsal surfaces of both feet. Alcohol packs were used to hasten demarcation. The lower third of the right leg was amputated on 25 March, under spinal analgesia, and on 5 April the lower third of the left leg was similarly amputated. Both wounds were sutured primarily. When this man appeared before the disposition board, which recommended evacuation to the Zone of Interior for additional care and final disposition, he had already been hospitalized for 91 days.
       
    Case 4.- A soldier was admitted to an evacuation hospital on 17 February 1944, after having been exposed to cold and wet near Cassino for the preceding week. His feet first became painful on 13 February. When he was received in a general hospital on 23 February, both feet were swollen, blistered, and cyanotic (fig. 65). A definite line of demarcation gradually developed at the level of the malleoli in both legs. A staphylococcic infection of the gangrenous areas, which began to cause temperature elevations on 28 February, was controlled by sulfadiazine. The fever recurred, however, and dead tissue began to slough away as the result of secondary infection. A bilateral guillotine amputation was done at the junction of middle and lower thirds of both legs on 16 March, under ether anesthesia

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FIGURE 62.- Postinflammatory stage of trenchfoot. Note dry, scaly skin and dry gangrene, which was severest at tips of toes and margins of the great toes and the fifth toes. The center of the transverse arch, which is less likely to come into contact with the shoes, was affected less severely.

FIGURE 63.- Early postinflammatory stage of severe trenchfoot. Note delicate skin beneath peeling, gangrenous superficial layer of epidermis, 5 weeks after exposure.

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FIGURE 64.- Subsiding inflammatory stage of trenchfoot. The right foot, on which the process was more severe than on the left, was treated by the local application of ice cold packs for a few days. The left foot was used as a control. A. Appearance of feet immediately after therapy. B. Feet shown in view A 4 weeks later. A better result had been expected, on the basis of the initial appearance of the feet. The wet ice treatment was considered of no value.
 
Skin traction was applied. The postoperative course had been uneventful up to the time the patient was returned to the Zone of Interior for further treatment and disposition.
       
    Case 5.- This patient was admitted to an evacuation hospital on 15 February 1944, after having spent most of the previous week in a foxhole half filled with water. His feet were swollen and painful when he was first seen. Later, he became extremely toxic, and, when he was received in a general hospital, there was wet gangrene of the left foot, with a line of demarcation just below the malleoli, and both wet and dry gangrene of the forepart of the right foot. The lower third of the left leg was amputated on 27 February, and at the same time the right foot was amputated distal to the talus. When the patient appeared before the disposition board, which recommended evacuation to the Zone of Interior for further care and disposition, he had already been hospitalized for 24 days.
       
    Postinflammatory stage.- The postinflammatory (posthyperemic) stage of cold injury began with the disappearance of signs and symptoms of inflammation. The foot, instead of being hot and dry, was now cool or cold and moist. Cyanosis was common when the feet were dependent (plate 2E). The dorsalis pedis pulse, instead of being bounding, was often not palpable at all. Patchy areas of cyanosis frequently remained, suggesting local thrombosis. Occasional patients complained of hyperirritability and spasm of the muscles of the leg, the spasm being either spontaneous or readily invoked by ischemia. Burning pain was replaced by a deep-seated ache, much like the aching pain of rheumatoid arthritis. It was usually worse at night. It was most commonly located in the metatarsophalangeal joints, particularly in the great toe, but

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FIGURE 65.- Subsiding inflammatory stage of trenchfoot 12 days after hospitalization. The gangrene of the skin appeared to be superficial, but the record described the development of staphylococcic infection in gangrenous feet, and bilateral amputations of the lower leg were done 16 days after this photograph was taken. The outcome is surprising, in view of the appearance of the feet in this picture.
 
might also be experienced in the transverse and longitudinal arches. Less often, it was felt in the ankle. Ambulatory patients complained of pain in the weight-bearing parts of the transverse and longitudinal arches. Less often, it was felt in the ankle. Ambulatory patients complained of pain in the weight-bearing parts of the foot. The pain sometimes radiated up to the knee, and, occasionally, into the groin.
       
    Hyperesthesia and paresthesias tended to disappear promptly. Anesthesia did not; it sometimes lasted 6 months or more. In one of the first 50 cases studied intensively, hyperesthesia appeared in the tip of the great toe when sensation first began to return, after 6 weeks of hospitalization.
       
    The pain complained of in the postinflammatory stage was sometimes associated with thickening and stiffness about the joint. More often, the only

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FIGURE 66.- Late postinflammatory stage of trenchfoot. Note the delicate, waxy appearance of the skin, the absence of longitudinal and transverse arches, and the slightly valgus position of the great toes. This soldier was unable to do infantry duty because of hyperhidrosis, maceration of the skin, and pain in the feet.

FIGURE 67.- Postinflammatory stage of trenchfoot. The feet were cold, sweaty, and cyanotic. Note prominence of extensors of toes and dorsiflexion at the metatarsophalangeal joints.

abnormality found on physical examination was deep tenderness. In some cases, there was a general atrophy of the structures of the foot. The arches weakened, the tendons became prominent (figs. 66 and 67), contractures appeared, and the joints stiffened (figs. 67 and 68). Roentgenograms sometimes revealed osteoporosis. In the cases in which the feet were entirely normal on examination after the acute phase had passed, complaints of persistent pain provided major problems of management.
       

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FIGURE 68.- Late postinflammatory stage of trenchfoot. The skin was delicate, and there was marked hidrosis. There is still a trace of edema in the right foot. Note relaxation of both longitudinal and transverse arches and slight dorsiflexion of rnetatarsophalangeal joints.

    As time passed, it became more and more evident that the postinflammatory stage of trenchfoot was not a matter of sharply defined chronologic limits. It seemed likely, instead, that it could last for months and even years. Recovery was very slow. Sequelae were frequent (p.284) . An occasional man malingered, but observations both overseas and in Zone of Interior hospitals clearly showed that many of the men who had suffered from cold injury would be left with genuine disabilities.
 
Other Studies
 
    Edwards, Shapiro, and Ruffin, who observed 351 cases of cold injury in a general hospital in Italy, confirmed Simeone's observations and described much the same clinical picture. The first evidences of cold injury in their cases were numbness and coldness of the feet. As a result, the men hesitated to exercise them. When the feet began to warm up after exposure, the toes tingled and burned or ached. Pain sometimes radiated up to the knee as vasodilatation began to occur in the damaged tissues of the feet. Then a sterile inflammatory reaction became evident, and blebs, some of which contained bloody fluid, might cover the whole plantar surfaces. Sometimes the symptoms and signs of injury were limited to coldness of the feet, perhaps associated with stiffness, for several days. In other instances, the toes were gangrenous and enormous blisters made normal walking impossible for weeks.
      
    Edwards and his associates graded their cases as follows:
  
  Grade 1.- The feet were cool and the great toes numb. The soldier complained of slight aching or stiffness, but there was no evidence of discoloration, blebs, or swelling, and no decrease in the pulsations of the dorsalis pedis and posterior tibial arteries. Return to duty was possible in about 2 weeks. In another group of injuries, also graded as mild, the feet were cool, sometimes

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moist, and slightly cyanotic, but pain was not severe enough to interfere with sleep, stiffness did not develop, and no blebs formed. Pulsations of the regional arteries were normal. When the feet became too warm, there might be mild aching. Return to duty was usually possible within 6 weeks to 3 months.
        
    Grade 2.- The feet were cold, cyanotic, and sometimes moist. Aching pain interfered with sleep for several days. The dorsalis pedis puslation was decreased, or might be absent part of the time. There was tenderness to pressure over the metatarsal pads. Within a week after the onset of symptoms, the feet might become warm, tender, and swollen. Return to duty was possible within 2 to 6 months (4 months on the average), but future combat infantry duty might be impossible.

  Grade 3.- The feet were cold, mottled, and cyanotic, with large blebs or areas of ecchymosis. Pain and aching were continuous, day and night. Pain was always felt on motion of the toes or on pressure over the metatarsal pads. The dorsalis pedis pulse was often absent, and posterior tibial pulsations were feeble. Pulsations might disappear for several days, then reappear for several days before they disappeared again. This phenomenon was particularly likely to occur in the dorsalis pedis. After a few days, the feet might become warm and swollen, with little or no cyanosis. When this happened, the dorsalis pedis pulse became bounding. Desquamation of thick layers of skin always occurred. Return to duty was impossible for 6 months or more, and as a rule only limited duty was possible.
         
    Grade 4.- The clinical picture was similar to that described in grade 3, but, in addition, there were areas of gangrene over the toes. The nail beds were black, and pitting edema was pronounced. Physiologic amputation of the toes sometimes followed, though in a surprising number of instances the blackened dermis peeled off gradually, leaving granulation tissue underneath. Amputation of an entire toe or of the whole foot was necessary in a few instances of gangrene and necrosis.
         
    Edwards and his associates noted that, during the period of hospitalization, the feet became purple or cyanotic when they were dependent and became blanched when they were elevated, which suggested that the subcutaneous circulation was slow in spite of dilatation of arteries in the foot, with increased circulation in the deeper tissues. When the generalized swelling and sterile inflammation had subsided, the foot usually remained tender to pressure over the plantar surface of the metatarsophalangeal area. The great toe was more often affected by numbness, blister formation, and paresthesias than the other toes, but ecchymosis and superficial burning were frequent in all the toes, especially at pressure points in contact with the shoes. These symptoms and signs also occurred over the dorsum of the foot and on the heel. In both moderately severe and severe cases, even after sensation returned, the toes were likely to remain stiff for weeks or months, and 6 months or more might pass before flexions were straightened out.
 
    When hikes were resumed, patients with milder grades of trenchfoot usually ceased to complain of aching pain after the first week, though in both

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grade 1 and grade 2 cases mild aching and tenderness on the plantar surfaces of the metatarsal arch might persist for several months whenever the man walked for any distance. Grade 3 patients usually complained for 6 months or more of tenderness on walking, and few could return to full field duty within the holding period permitted in the theater.
 
Vascular Changes
 
    The vascular changes associated with trenchfoot impressed all observers in the cases studied during the Italian experience. During the ischemic stage, the skin was usually pallid as well as cold. Areas of pallor were mingled with areas of purple mottling and blotching. It was assumed that pallor indicated arteriolar spasm and mottling indicated blood stasis and paralysis of venules. The dorsalis pedis and posterior tibial pulsations were not ordinarily palpable in feet which had this appearance.
       
    In the early inflammatory stage, these pulsations were bounding, and the blood flow, at least superficially, seemed maximal. This was frequently true even when pitting edema was present. After a few days, however, evidences of increased blood flow became fewer and fewer, and later it might be impossible to feel any pulsations at all in the dorsalis pedis. This was the situation in 11 of the first 50 cases of trenchfoot studied intensively. In 3 of the 6 cases in which the pulsations were absent bilaterally, a history of previous frostbite was obtained. The dorsalis pedis of posterior tibial pulsations, or both, were absent in a quarter of the cases studied by Boland and his associates. No relationship was evident between these phenomena and the severity of the injury, though it was observed that pulsations were always stronger in hot feet and weaker in cold feet. In evaluating these figures, it must be remembered that these pulsations are not always present in normal feet (p.387).

    As the inflammatory stage subsided, there was remarkable variability, as already noted, in the ease with which the dorsalis pedis pulsation could be felt at different times in the same foot. The observations sometimes varied from hour to hour. When this happened, there were always associated variations in the subjective sensation of heat or burning pain in the feet.
 
THE EUROPEAN THEATER
 
    As part of the trenchfoot-study project initiated at the 108th General Hospital in Paris, in November 1944 (p. 186), an intensive study was made of 500 of the 5,000 patients with trenchfoot admitted to this installation. Clinically, the cases were classified into three groups, according to the severity of the injury, the size of all the groups being about equal.
       
    Group 1.- In mild injuries, when the exposed foot was returned to a normal environmental temperature, a bright-red flush developed, the appear-

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ance of the foot suggesting a mild sunburn. Slightly increased pulsations of the large vessels were observed for a brief period. The skin temperature was somewhat increased, and edema made the skin seem thicker than normal. The duration of the edema was from 1 to 6 days and averaged 3 days. The chief complaints were itching, burning, or moderate pain.
       
    Bed rest was necessary for from 1 to 12 days and averaged 6.4 days. In some cases, for as long as 10 days, walking in shoes caused a painful reaction, though in others walking was possible and painless as soon as the patient became ambulatory. The average duration of discomfort from this cause was 4.2 days. Symptoms disappeared completely, and the feet resumed their normal appearance in from 3 to 21 days, or an average of 12.6 days.
       
    Group 2.- When exposure had been more prolonged or the environmental temperature had been lower, edema was fairly severe, blisters formed (figs. 69 and 70), and minute areas of intracutaneous ecchymosis were often present. Exfoliation occurred in varying degrees after edema had subsided. The only serious complaint was deep-seated pain, which was increased by heat and by walking. It was especially severe in the first metatarsophalangeal joint and across the plantar surface of the anterior arch of the foot.
       
    In this group of cases, the edema lasted from 6 to 14 days, or an average of 10 days. Bed rest was necessary for from 11 to 46 days, or an average of 23.2 days. Walking in shoes without pain was possible only after an additional period which varied with the patient from 4 to 15 days and which averaged 8.4 days. After recovery had been sufficient for the man to resume marching, the only sign of abnormality in most cases was profuse hyperhidrosis. Marching in cold weather was likely to cause a recurrence of pain in the feet for a month or more. At the time this report was made, the final disposition of this group of patients was still unknown.
       
    Group 3.- In third-degree cold injury, the initial reaction was intense. All the cardinal signs of inflammation were present, including burning pain, heat, rubor, and marked edema. The peripheral arterial pulsations were bounding. Large blisters appeared on the dorsal and plantar surfaces of the feet. Superficial skin necrosis over areas of intracutaneous ecchymosis produced lesions with the appearance of impending gangrene.
  
    In this group of cases, the duration of edema was usually from 10 to 15 days but might be as long as a month or more. Superficial layers of skin gradually mummified and finally desquamated, leaving underneath normal pink skin, which was extremely sensitive. The extremity assumed a dusky, cyanotic color, on dependency or when placed in a cold environment. Muscular weakness was considerable and was associated with atrophy and stiffness of the joints. None of the casualties in this group were able to walk without great pain and disability during the 3-month period they remained under observation. 
       
    Only 5 of the 500 casualties studied intensively at the 108th General Hospital required amputation of the digits. Bilateral amputation for gangrene

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FIGURE 69.- Second- and third-degree cold injury. A. Early changes. Multiple small blisters are present and in some areas have coalesced to produce bullae. On the right foot, only the great toe is involved, and the process is of moderate severity. On the left foot, the changes are more advanced. B. Appearance of feet shown in view A 28 days later. Gangrenous changes in the first and second toes of the left foot have produced spontaneous amputations. The wounds are still open and unhealed. On the right foot, the changes are superficial, and healing has progressed to scaling of the skin. C. Appearance of feet shown in view B 9 days later. Healing has continued bilaterally. The open wounds on the amputated stumps of the toes on the left foot show beginning epithelization. All blisters have disappeared, and most of the cutaneous lesions on the dorsum of the left foot have healed, leaving only residual changes. D. Appearance of feet shown in view C 4 days later. Healing is now almost complete on the right foot. On the left foot, the open areas are almost completely healed, and only some superficial cutaneous scaling remains.
 
was necessary in one case. This man had been trapped for 5 days behind enemy lines, where he escaped capture by feigning death. He spent the entire time in a snow and water-filled foxhole, in which his feet became encased in ice. At the end of the time, by walking and crawling for several miles, he reached friendly lines, and his shoes were finally cut off his frozen feet.

283
  
FIGURE 70.- Serial changes in trenchfoot. A. Early phase of severe cold injury, with blister formation and beginning gangrenous changes in toes of both feet. Edematous changes have begun to regress, and blister formation on the dorsal aspects of both feet has begun to subside. B. Plantar view of feet on same date as view A. C. Appearance of feet shown in view B 8 days later. Regressive changes are evident on the dorsal aspects of both feet. Blisters have almost disappeared, and the skin is superficially wrinkled and dry. Mummification has begun in the toes. D. Appearance of feet shown in view C 9 days later. Note the cracked, scaly appearance of the skin, following disappearance of blisters, and the slowly progressive dry gangrenous changes in the toes on both sides. E. Plantar aspect of feet shown in view D on same date. The changes present in the dorsal view are also evident in this view. Most of the digits on both feet will inevitably re lost by spontaneous separation.

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OVERSEAS COMPLICATIONS AND SEQUELAE
 
    Trenchfoot, as already pointed out several times, is a type of injury which is likely to continue to give trouble long after acute manifestations have subsided. Experiences in all theaters of operations in World War II bore out this generalization.

The Aleutians Experience
 
    The experiences of casualties from Attu in Zone of Interior hospitals paralleled, in point of time after injury, experiences of other casualties in overseas hospitals. Some of them complained, often for many months after exposure, of pains deep in the foot, superficial burning, and aching, all increased by walking. Pain was particularly likely to occur in the metatarsophalangeal joints, whence it radiated into the ankle and sometimes into the calf muscles. In some cases, hypersensitivity persisted, and the slightest touch or the lightest pressure caused discomfort.
    
    Osteoporosis was observed in 16 of the 93 patients treated at the 183rd Station Hospital,⁵ where it was observed between the 6th and 12th weeks after exposure, in the course of the diagnostic endeavor to find the cause of the deep-seated pain of which these patients complained. The pathologic process, which was moderately advanced in all of these cases, involved the distal half of the metatarsals and the proximal three-quarters of the phalanges, usually in the first and second toes. The changes were particularly marked when there was a preexistent deviation from the normal foot structure, as in two cases of preexistent arthritis, or when there was evidence of faulty weight bearing of longstanding. The immediate factors which produced this complication were probably the result of prolonged disuse of the feet, which, in turn, resulted in nutritional and circulatory changes. It was least in evidence in the cases in which early supervised exercise had been instituted.
       
    At Letterman General Hospital, ⁶ deformities of the feet were observed in the majority of the patients, even those in whom the injury was only of second degree. Most often, the deformity was of a claw-foot type, with varying degrees of pes cavus (fig.71). The great toe was pulled downward into plantar deformity, and the spaces between all the toes were increased. The spread was especially prominent between the great toe and the second toe. A study of available pathologic specimens clearly explained the mechanism of the deformity. Varying degrees of inflammation and degeneration were observed in the nerves and vessels, the supply to the short muscles being more seriously affected. Long muscles usually escaped, probably because they receive their nerve supply farther up the leg, more distant from the involved zone. When smaller muscles of the feet were badly damaged, the large muscles took over their function. Since the long flexor to the great toe is stronger than its long
____________
⁵See footnote 1 (1), p. 260.
⁶ See footnote 1 (3), p. 260.

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FIGURE 71.- Severe flexion contractures of toes, for which amputation was subsequently necessary. On the right foot, amputations have already been performed proximal to the heads of the first and second metatarsals. On the left foot, amputation has been done at the head of the first metatarsal and through the proximal phalanx of the second toe.
 
extensor, the great toe was pulled downward, while the reverse mechanism in the small toes caused them to be pulled upward.
     
    In many of the cases observed at McCaw General Hospital,⁷ the gradual development of claw-toe deformities was a troublesome complication. The explanation was thought to be an exaggerated deposition of collagenous and fibroblastic material in the tissues following injury. Lumbar sympathetic block and surgical lumbar sympathectomy had no effect on the progress of this deformity, and, when rigid contracture occurred, with friction irritation from the shoes, surgery was necessary to straighten the toes.

    The persistence of pain in the toes and feet, which was a principal complaint in many cases, was thought to be related to the extensive perineural fibrosis demonstrable in tissue sections. The delayed onset of pain was probably due to the late, progressive contracture of fibrotic tissues.
       
    Psychoneurosis was observed in many of the patients at the 183d Station Hospital, where it was attributed to the lack of any specific means of therapy and the corresponding slow recovery. Some of the men were seriously concerned about possible permanent damage to their feet. Others were more concerned with their participation in an active engagement, in which they had become casualties, and because of which they felt they had done their share of fighting.
 
The Mediterranean Theater  
       
    Sequelae of trenchfoot became evident in the Mediterranean theater in the course of the 1943-44 experience (plate 3D). They included persistent pain and edema, hypesthesia and anesthesia, and vasospasm. The skin was delicate and
____________
⁷ See footnote 1 (2), p. 260.

286
 
FIGURE 72.- Late postinflammatory stage of trenchfoot. This photograph was taken in June, after the soldier had been unable to remain with his infantry unit because the skin of the feet was so delicate and perspiration was so excessive that maceration ensued. Note absence of calluses on weight-bearing surfaces

FIGURE 73.- Late postinflammatory stage of trenchfoot. Note delicate, waxy skin. This man's transverse arches were relaxed, but the longitudinal arches were within normal limits. This photograph should be compared with figure 66, which shows absence of both transverse and longitudinal arches

waxy after desquamation, and weight bearing was impractical until calluses had formed (fig. 72), a process likely to be long delayed. The patients were sensitive to cold but were also incapacitated by heat. Hyperhidrosis and associated trichophytosis resulted in maceration of the skin (figs. 66, 67, 68, 72, 73, 74, 75, 76).
 

287
 
FIGURE 74.- Late postinflammatory stage of trenchfoot. After 4 months of hospitalization, the feet were still cold and sweaty and were blue on dependency. The patient complained of deep aches in the metatarsophalangeal joints and in the longitudinal arches.
  
FIGURE 75.- Early postinflammatory stage of trenchfoot. After 2 months of hospitalization, edema had subsided. The skin was delicate, and the patient complained of aches in the metatarsophalangeal joints, particularly in the joints of the great toes. Note scanty amount of subcutaneous fat about these toes.
 
    During the summer and early fall of 1944, many patients were admitted to hospitals in the Peninsular Base Section, Mediterranean theater, for what was termed recurrent trenchfoot, though actually the present condition was quite different from the original condition. Most of these men were returned from units which had participated in the drive north of Rome to the Gothic Line, because they could not keep up with the troops. Others were received from

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FIGURE 76.- Late postinflammatory stage of trenchfoot. This patient was unable to do infantry duty during the summer months because of excessive sweating and trichophytosis, with secondary infection, on the insteps.

units undergoing amphibious training for the invasion of southern France. Still others came from replacement depots and rehabilitation centers.
       
    In a detailed report by Toone and Williams on these men (p.330), it was pointed out that the feet appeared weak and atrophic and were painful on light pressure. The toes were numb and stiff. The skin was thin, of delicate texture, and bore scars of recently healed excoriations as well as new lesions. Plantar calluses were entirely lacking or were grossly inadequate. The men complained of excessive hyperhidrosis, and many had been incapacitated by recurrent episodes of trichophytosis. Earlier in the summer, Long had observed an apparently increased incidence of epidermophytosis and allied foot disorders in Peninsular Base Section hospitals, and had found that much of it was in patients who had suffered from trenchfoot the previous winter. He considered the complication sufficiently serious to warrant setting up new criteria for the disposition of patients with trenchfoot.
       
    Edwards and his associates believed that this type of complication was preventable. Correspondence with a number of their patients who had returned to full duty showed them to be fully aware of proper foot hygiene and to be following instructions as faithfully as possible under combat conditions. Even when they could not bathe their feet, they removed their shoes, massaged their feet, and applied the foot powder issued by the quartermaster. As a result, they had a minimum of trouble with hyperhidrosis and epidermophytosis.
       
    Ragan and Schecter,⁸ whose study covered only casualties with early trenchfoot, observed them for too brief a period for muscle atrophy or other sequelae to develop. In two cases, however, both instances of moderately severe trenchfoot, the following curious sequence of events was observed:
        The first patient presented nothing out of the ordinary when he was hos-
____________
⁸ C. A., and Schecter, A. E.: Clinical Observations on Early Trench Foot. Bull. U. S. Army M. Dept. 4: 434-440, October 1945.

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pitalized for cold injury. On the 14th day, it was found that all the toes of the right foot, including the great toe, were so firmly held in dorsiflexion that even after considerable force had been exerted the contraction could be overcome only partly. This man stated that, in civilian life, 4 years before his induction into the Army, his feet had been frozen and that a similar contraction of the toes had occurred at that time.
       
    The following day, the patient in the next bed, also on the 14th day of hospitalization, presented the same type of contraction, also on the right side, but without involvement of the great toe.
       
    The circumstances naturally suggested hysterical contraction in both cases, but in each instance the contraction was held so firmly and so constantly throughout the day that the suggestion lost some weight. That night, both patients were heavily sedated and their feet were examined after they were soundly asleep. In each instance, the contracture was still present.
       
    The next day, both patients were given ether anesthesia, under which complete relaxation of the contractures occurred. When Novocain was injected into the belly of the extensor hallucis longus of the first patient, the distal phalanx of the great toe relaxed but the proximal phalanx remained in dorsiflexion. In both patients, similar dorsiflexion could be induced in the unaffected (left) feet by occlusion of the circulation by inflation above arterial pressure of a blood pressure cuff placed around the thigh. The dorsiflexion was relaxed when the cuff was deflated. This phenomenon could not be induced in the first patient when he was under ether anesthesia. Dorsiflexion by the same method was induced in a control patient on the first attempt but could not be induced 48 hours later.
       
    The first patient was kept under observation for 10 days after the appearance of the contracture. When he was evacuated, dorsiflexion was still present but was less firm. The second patient was observed for 23 days. At the end of this time, the contracture, although still present, could be readily overcome by minimal pressure. The phenomenon induced in the left leg by vascular occlusion could no longer be elicited.
       
    A possible complication of trenchfoot or, more accurately, of a measure adopted to prevent trenchfoot was so-called shoepac foot, which was observed in both the Mediterranean and European theaters. This was an irritation of the feet caused by the continuous wearing of damp socks within shoepacs, by the heat generated within the shoepacs as the result of friction of wool socks on the wool inner soles, or by the poor ventilation inherent in a shoe made partly of rubber. The ball of the foot was most often affected, but the irritation also extended to the heel in some cases. Sometimes cleanliness, clean socks, and a brief period of rest cleared up the trouble. Sometimes, however, hospitalization was required for as long as 10 or 15 days. The soldier could usually be returned to full duty, but, if the causative conditions were permitted to recur, recurrence of the trouble could be expected.
       
    Continued observation of patients with trenchfoot in the Mediterranean Theater of Operations showed only slow disappearance of residual complaints

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of pain and tenderness. Complaints were fewer in warm than in cold weather, but long marches were still not possible. During the winter of 1944-45, a year after their injuries had been sustained, many men still complained of spontaneous aching whenever the weather was cold and damp, and the ability to walk and march was decidedly diminished, though the original level of incapacity was not again reached.
       
    In February and March 1945, Paddock ⁹ studied intensively a number of soldiers who had contracted trenchfoot in the Apennines from 4 to 8 weeks earlier. All had injuries of mild to moderate severity, the damage being, on the whole, less severe than in the similar cases observed during the previous winter. At this time, acute edema, gangrene, and pseudogangrene had disappeared, and the chief residual complaint was pain, with tenderness of the soles of the feet. The men could be divided into two main groups, those with complaints of vascular origin, with a tendency to coldness and cyanosis, and those with complaints of neural origin, including pain on firm pressure over the soles, superficial hypalgesia, loss of proprioception, diminution of temperature discrimination, hyperhidrosis, and poor toe-flexion ability.
       
    After employing a variety of tests and making numerous observations, Paddock reached the following conclusions:
       
    1. The capillaries and venules in the injured feet were apparently normal, but there was increased arteriolar tone, apparently secondary to increased sympathetic stimulation. There was no evidence of arteriolar obstruction.
       
    2. In addition to superficial hypalgesia, there was frequently diminution of temperature, vibration, and position sense in the affected feet. Poor toe flexion was not the result of any obvious structural abnormality. Deep-seated sensitivity to cold was usually absent.
       
    3. In trenchfoot of moderate severity, it seemed reasonable to conceive of involvement of all the most superficial tissues of the foot, with a quantitative variation from patient to patient with respect to special tissues affected. The disabilities encountered in the later stages of mild to moderate cold injury were apparently more dependent on neural changes than on vascular changes. Microscopic evidence of damaged tissues tended to confirm this concept.
       
    It was Paddock's opinion that the disabilities from which these men were suffering would persist for years, and that therapy directed at the blood vessels and nonneural tissues would be ineffective. Observations at Mayo General Hospital (p.333) and other vascular centers in the Zone of Interior confirmed this impression.
 
The European Theater  
   
    The end of the fighting in Europe in May 1945 accounts for the fact that most of the residua of cold injury sustained in that theater were observed in hospitals in the United States rather than overseas. As early as April, however, the chief consultant in medicine in the European theater noted that cold
________
⁹ Paddock, F. K.: Chronic Disability in Mild Cases of Trench Foot. New England J. Med. 234: 433-437, 28 Mar. 1946.
 

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injury promised to constitute a continuing problem because of the increased susceptibility of the feet to trichophytosis after it. In Essential Technical Medical Data for the month ending 30 April 1945, the same observation was made. It was also noted that a number of men with neglected cold injuries were now presenting themselves for treatment. They had resisted evacuation when they sustained their injuries during the hard fighting in December and January of the previous winter, but now they were appearing with extreme vascular changes, usually in the form of cold, clammy, blue feet, frequently associated with edema.  

OBSERVATIONS IN THE ZONE OF INTERIOR  

    The observations made on the 656 patients with trenchfoot treated at Mayo General Hospital in 1944 and 1945 may be taken as typical of the late clinical picture of cold injury of moderate to serious degree.  

Exposure to Cold (Wet Cold)  

    Five hundred and eighty-six of these six hundred and fifty-six patients sustained their cold injuries after a single exposure in combat, the duration varying from 3 to 54 days and averaging 14 days. The injuries occurred between November 1943 and March 1944, at Cassino or on the Anzio beachhead, and between October 1944 and January 1945 in France, Germany, Luxembourg, Holland, and Belgium. In practically all instances, the environmental temperature had been in the neighborhood of freezing or only slightly higher, and rain had been almost continuous for long periods. For the most part, the men had lived in mud and water and had seldom been able to change their shoes and socks.
       
    Sixty of the six hundred and fifty-six patients had suffered two attacks of cold injury. The first exposure, which lasted from 1 to 60 days and averaged 15 days, occurred between November 1943 and March 1944 at Cassino, Venafro, or the Anzio beachhead. The men were hospitalized for an average of 9 weeks each, then were sent to convalescent or reconditioning centers before they were returned to duty. The second exposure occurred between August 1944 and February 1945 in France, Holland, or Germany. All the patients had been hospitalized overseas for a second time before being evacuated.
       
    Ten men had suffered three exposures each, the first at Cassino, the second at the Anzio beachhead, and the third in France, Germany, or Holland. They were returned to duty after the first and second attacks, after varying periods of hospitalization, and all reached the Zone of Interior about 2 months after the third exposure.
       
    Some men who had suffered single exposures had remained on a patient status until they were received in general hospitals in the United States. Others had been returned to full duty after varying periods of hospitalization

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but had been unable to perform their duties. Some men who had sustained their injuries in Italy in the winter of 1943-44 had had the first evidence of recurrent trouble during the march on Rome in July 1944 (p.287). They complained of their feet almost at once, and pain, swelling, and blister formation eventually made them unable to keep up with their comrades in any kind of physical endeavor.
       
    The patients with trenchfoot observed at Mayo General Hospital and other vascular centers in the United States were seen between 2 and 13 months after exposure. The average timelag was 4 months.
       
    No correlation could be demonstrated between the duration of exposure and the degree of resulting damage to the tissues in 633 patients with cold injury treated at Mayo General Hospital (table 8). There was also nothing in the histories to suggest that men who had suffered previously from trench-foot or frostbite were any more likely to suffer from gangrene than were men who had been exposed only once, though they were, obviously, more susceptible to cold injury.
 
TABLE 8.- Tissue damage in relation to duration of exposure in 633 patients with trenchfoot, Mayo General Hospital¹

Classification  

    Signs and symptoms of the later stages of trenchfoot observed in vascular centers in the Zone of Interior fell into three general categories:
       
    Predominance of excessive sympathetic activity.- One hundred and forty-five (22.1 percent) of the six hundred and fifty-six patients observed at Mayo General Hospital presented symptoms and signs which seemed primarily the result of excessive sympathetic activity. The skin temperature of the toes was low, frequently lower than the environmental temperature. Hyperhidrosis was invariably present. It ranged from slightly more than the usual amount of perspiration to an almost continuous flow of sweat which rolled off the foot

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in perceptible quantities. The amount was definitely increased by emotional disturbances. The cooling effect produced by the evaporation of perspiration was one explanation of why the skin temperature was often lower than the environmental temperature.
       
    Cyanosis, particularly when the feet were dependent, was another prominent observation. Changes of color and temperature were often observed. A blue, cold foot would become red and hot after exposure in a warm room or after the man had walked a short distance in shoes. At other times, for no apparent reason, a blue, cold foot would become red and hot, and then would revert to its original status. Mottling was fairly common, sometimes as a transient phenomenon and sometimes for longer periods. It assumed varying patterns, sometimes in the same individual. For the most part, it took the form of sharply demarcated areas of rubor interspersed with numerous areas of pallor on a background of cyanosis.
       
    Palpation of the large peripheral arteries in patients with signs of excessive sympathetic activity and without gangrene revealed absence of the dorsalis pedis pulsation on one side or both in about 6 percent of all cases (table 9). The significance of this observation, if there was any, could not be determined, since comparable observations were not made in normal subjects. There was no evidence of arteriosclerosis in any patient in this group. Impairment of the blood supply to the muscles of the leg seemed extremely unusual, a history of intermittent claudication being very seldom obtained.
 
TABLE 9.- Residual manifestations of trenchfoot 4 to 13 months after exposure in 619 patients without gangrene, Mayo General Hospital 

    Tests of the efficiency of the circulation substantiated the view that the symptoms and signs in this group of cases were caused primarily by excessive sympathetic activity and not by organic involvement of the vascular supply of the lower extremities. Oscillometric readings were carried out on the first 40 patients admitted but were discontinued when they revealed no significant departures from normal. Indirect vasodilatation, accomplished by applying hot-water bags to the abdomen and chest and covering the patient with several

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wool blankets, was carried out in 25 cases. In all instances, the skin temperature of the feet, which was lower than normal at the beginning of the test, rose to a level considered normal under the circumstances.
       
    The reactive hyperemia test was performed on 10 patients with marked cyanosis. In all instances, the flush, which appeared within 10 seconds, faded out in 1 to 2 minutes. This type of reaction, which was interpreted as a normal response to a period of anoxia of the cutaneous arterioles and small vessels (capillaries and subpapillary venous plexuses), helped to rule out occlusive disease of the blood vessels. Paravertebral lumbar sympathetic block with procaine was carried out in 11 cases. In all instances, a normal skin temperature response was obtained, while, at the same time, cyanosis was replaced by a pink coloration of the feet. Hyperhidrosis also disappeared transiently.
       
    Predominance of peripheral-nerve involvement.- Sixty-three (9.6 percent) of the six hundred and fifty-six patients with trenchfoot observed at the Mayo General Hospital Vascular Center presented symptoms and signs indicative of some type of peripheral-nerve involvement. Few objective abnormalities were noted in this group of cases, except that the feet, at rest, appeared pale. The chief complaint was tenderness in the sole of the foot, at times so severe that even the slightest pressure on the part could not be tolerated. Some men could not walk at all, or could walk only by putting the weight on the heel or along the lateral aspect of the foot.
       
    Anesthesia was infrequent. Many patients had areas of hyperesthesia to cotton wool and pinpricks, corresponding closely to the sites sensitive to deep pressure. These areas also included the dorsal surfaces of the toes and the dorsum of the foot. There were frequent complaints of various types of paresthesias, such as burning and stinging sensations, shooting pains, sensations of numbness in the toes, and a feeling of pins and needles in the toes.
       
    Combined sympathetic activity and peripheral-nerve involvement.- Four hundred and forty-eight (68.3 percent) of the six hundred and fifty-six patients observed at Mayo General Hospital presented symptoms or signs of both excessive sympathetic activity and some type of peripheral-nerve involvement. Many in this category (as well as in the other categories) entered the hospital still showing considerable desquamation of thick epidermis on the plantar surfaces of the feet (fig.77). As the process of desquamation was completed, thin, new skin was revealed. Twenty-eight patients had prominent swelling of the toes and somewhat less marked swelling of the feet (fig. 78). This swelling did not disappear with rest in bed and elevation of the extremities but sometimes responded to treatment with typhoid vaccine (p.337).
       
    Most of the men presented varying degrees of atrophy of the small muscles. As a result, the arches of the feet seemed abnormally high (figs.79 and 80). This phenomenon was particularly conspicuous in 11 cases. It was not possible to determine whether it was a nonspecific response to disuse or was part of the pathologic change in the syndrome of trenchfoot. The latter theory seems

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FIGURE 77.- Typical hyperkeratosis of skin observed in late trenchfoot. Note wrinkling, fissuring, and maceration, similar to findings observed after long immersion of feet in water. Note also dry gangrene at tips of toes. There was marked cyanosis on dependency. The patient complained of severe, throbbing pain in the right foot. Examination showed normal pulsations in the peripheral arteries on both sides.

     This infantryman sustained his cold injury in Luxembourg, in November 1944, after 3 days' exposure to very cold, wet weather, with snow. In the battalion aid station, he complained of considerable burning and pain. Both feet were swollen. Multiple blisters, filled with blood, appeared on both feet after 2 hours' exposure to a hot stove.  

more reasonable in the light of the histologic alterations in the muscles and nerves described by Friedman (p. 250) as part of the initial pathologic change in trenchfoot. Whether or not this atrophy is reversible can be determined only by long-term followup studies. Some patients at Mayo General Hospital showed no beneficial effects from the intensive and prolonged program of exercises designed to utilize the small muscles of the foot and still presented considerable atrophy at the time of disposition.  

Other Observations 

    At the time they were admitted to Mayo General Hospital, an average of 4 months after injury had been sustained, occasional patients still presented vesicle formation. Frequently, one or more toenails had fallen off, leaving the nail bed exposed (fig.81) . In other instances, the nails were distorted,

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FIGURE 78.- Persistent swelling of feet in late trenchfoot. A. Appearance of feet 4 months after injury, showing granulating wounds of both great toes, with infection and osteomyelitis. Note persistent swelling of toes and dorsum of foot. B. Appearance of feet after revision of amputation stumps.
       
    This infantryman sustained his cold injury in Germany, in November 1944, after 8 days' exposure to cold, wet weather, with snow. The first note on the record mentions bilateral swelling of the feet, with deep gangrene of the tips of all the toes. Treatment consisted of bilateral lumbar sympathectomy, amputation of toes, and the application of split-thickness skin grafts to both great toes. The grafts did not take, and revision of the stumps was necessary.
 
and there was considerable debris beneath them. Dermatophytosis was a common finding.
       
    In 34 cases, there was great stiffness of the toes, and the skin was shiny and seemed firmly attached to the underlying tissues. Sometimes the great toe was widely separated from the others and was either flexed (fig.79) or was hyperextended in the form of a pseudo-Babinski sign. This phenomenon could probably be explained by disuse. There was no correlation between the degree of stiffness present and the severity of the original injury.
       
    Osteoporosis was a fairly common observation in the more severe cases. It sometimes disappeared after 3 or 4 months of physical activity, but as a rule there was not much difference between the roentgenograms taken on admission and the final roentgenograms taken before disposition. The bone changes, like muscle atrophy, could be explained either as the response to a long period of inactivity or as an integral part of the trenchfoot syndrome. As with atrophy, whether or not osteoporosis represents an irreversible change in cold injury can be determined only by long-term followup studies.
 
Superficial and Deep Gangrene  

    A study of the early records of patients admitted to the trenchfoot centers suggested that by the time a man with trenchfoot had reached a fixed installation it could usually be determined whether or not he would eventually lose

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FIGURE 79.- Atrophy of small muscles of feet, characteristic separation of great toe from others (pseudo-Babinski sign), and moderate heel walking, 9 months after injury.

    This patient sustained his cold injury in France, in October 1944, after 7 days' exposure to cold, wet weather, but not to freezing temperatures. The clinical course was characterized by excessive coldness of the feet, cyanosis, hyperhidrosis, stiffness and numbness of the toes, and pain in both feet. Cyanosis and hyperhidrosis were still present 9 months after injury but ability to flex the toes on the right foot had returned. <> 

any significant amount of tissue. Fifty-three of the patients admitted to Mayo General Hospital still presented small areas of superficial gangrene, usually on the medial aspect of the foot (fig.81) or the tips of the toes. The heels were affected much less often. For the most part, these gangrenous tissues separated spontaneously, revealing normal tissues beneath (fig.81C and D). In a number of cases, the original lesions suggested the presence of a much more severe type of involvement than subsequent events proved to exist. These observations supported the general opinion that conservatism should be practiced in the early management of trenchfoot complicated by gangrene.

    Observations from other vascular centers and from Camp Carson (p.193) were to the same effect. At Camp Carson, 400 patients, about 8 percent of the total number admitted, had gangrenous areas of some degree when they arrived. It was regarded as significant, however, and the data were utilized in outlining the plan of management in these cases, that about half of the other patients received also had had areas of gangrene, which had healed spontaneously, earlier in the course of the injury. In 50 of the 400 patients

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FIGURE 80.- Atrophy of small muscles of feet and peripheral neuritis in late trenchfoot. Note marked atrophy of small muscles of both feet 8 months after injury.

    This infantryman sustained his cold injury in Italy, in December 1943, after 7 days' exposure to cold, wet weather but not to freezing temperatures. The clinical course was characterized by bilateral swelling of the feet, cyanosis, and elevated cutaneous temperatures. Gangrene did not develop. The patient complained of aching, painful sensations, and numbness. He was returned to duty 5 months after exposure but had to be rehospitalized after 3 months of duty because of aggravation of all symptoms. At this time, he complained of tingling and burning sensations and great tenderness on the plantar surfaces of the feet; all symptoms were increased by extremes of temperature. Areas of hypesthesia and anesthesia were present on both feet. <> 

who arrived with gangrene, healing progressed so satisfactorily that spontaneous separation of the nonviable tissues occurred, and plastic revision of the scars was not necessary. Gangrene of a degree requiring amputation above the ankle was encountered in only three patients, all of whom were transferred to amputation centers. The remaining 347 patients required only amputation of localized gangrenous parts or some type of surgical revision of the scar left after spontaneous separation of the gangrenous areas.
       
    The 37 patients with deep gangrene and subsequent extensive loss of tissue, observed at Mayo General Hospital, may be considered as being typical of all patients in this category. They had suffered only a single exposure, ranging from 1 to 34 days and averaging 8 days, either in Italy, between November 1943 and March 1944, or on the Western Front, between October 1944 and January 1945. In some instances, according to the records, gangrene had been present when the patients reached the battalion aid station. More often, it appeared after 6 to 10 days of hospitalization. Sometimes ulceration and infection had also occurred before the men received any medical aid. The development of gangrene had sometimes been preceded by the appearance of large hemorrhagic blisters, after which the involved areas quickly became black and mummified.

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FIGURE 81.- Superficial gangrene in late trenchfoot. A. Appearance of feet 2 months after injury, when areas of superficial gangrene on the medial aspect of the right foot were becoming demarcated from normal tissue. At this time, the patient complained of stiffness of the toes and tenderness in the sole on the application of pressure. Cyanosis was conspicuous. Pulsations in the peripheral arteries of both feet were normal. B. Plantar view of feet 2 months after injury. Note gangrene of plantar surface of tips of toes of both feet and scaly appearance of skin before desquamation. C. Appearance of feet 2 months later. The superficial areas of gangrene on the medial aspect of the right foot are completely healed, and only areas of pigmentation indicate their sites. A number of nails have been lost. The feet were now less cyanotic, and the toes, less stiff. D. Plantar view of feet at same time as view C. The areas of superficial gangrene on the tips of the toes are completely healed, and the dead epidermis has separated, leaving normal skin.
       
    This patient sustained his injury in France, in October 1944, after 6 days' exposure to cold, wet weather but not to freezing temperatures.
 
    All of the patients with deep gangrene seem to have presented the same general clinical picture in the first stages of their injury as did the men who did not develop gangrene, the only difference being that all their symptoms and signs had apparently been severe. Swelling, cyanosis or pallor, blister formation, severe pain, and numbness of the feet were invariably observed.
       
    Although the gangrene which was present in some cases of cold injury resembled the gangrene present in other vascular disorders, gangrene associated with trenchfoot presented certain features peculiar to the original injury. It

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varied widely in extent. Pain was not associated either with the gangrenous process itself or with the resulting ulceration. Intense vasospasm was a frequent observation. Extensive arterial obliteration proximal to the gangrenous areas was not observed. Finally, the incidence of infection was extremely high.
       
    In the 37 cases of deep gangrene observed at Mayo General Hospital, as in other, similar cases, the process differed from the gangrene observed in thromboangiitis obliterans, arteriosclerosis, and other obliterative vascular diseases, chiefly because the reduction in the circulation of the foot regularly present in those diseases as the result of obliterative vascular changes was generally absent in trenchfoot. Relatively normal circulation was observed in trenchfoot when vasoconstrictor impulses were eliminated, which is contrary to the usual course of events in the obliterative disorders. When the gangrenous process had extended into the dorsum of the foot, the dorsalis pedis pulsation was not palpable, and the pulsation of the posterior tibial artery was likely to be absent also.
       
    Rest pain, which is characteristic of the obliterative diseases, seldom occurred in the late stages of trenchfoot, even when ulceration was present. Initially, rest pain might be very distressing in patients with trenchfoot (p.271), regardless of whether or not gangrene had developed, but after an interval of weeks or months it usually disappeared completely or almost completely.
   
    Infection does not usually complicate gangrene in the obliterative diseases, but it was frequently in trenchfoot associated with deep gangrene. Skin defects can only occasionally be repaired by grafts in the obliterative vascular diseases, but they could often be successfully covered by this method in cases of deep gangrene following cold injury.
       
    The deep gangrene observed in trenchfoot also differed from that seen in Raynaud's disease and similar disorders, in which the process, even when associated with ulceration, is generally superficial and limited. All of these disorders are alike in that obliterative arterial changes are usually limited to the actual gangrenous areas or, perhaps, to the areas immediately proximal. Patients with Raynaud-like disorders and with frostbite tend to have few symptoms connected with gangrene other than cold sensitivity and hyperhidrosis, which are the rule in the former group of diseases and are very common in frostbite also. In trenchfoot and immersion foot, on the other hand, the most distressing symptoms observed were the result of damage to nerves and muscles in the foot proximal to the area of gangrene. Areas of hypesthesia or hyperesthesia, muscle atrophies, and contractures were relatively common in gangrene associated with trenchfoot. Almost all patients had pain on weight bearing. However, these symptoms, as well as hyperhidrosis, coldness and cyanosis, were also prevalent in patients without gangrene and therefore could not be attributed to postural difficulties resulting from ischemic loss of tissue.
       
    The infection associated with superficial gangrene in cold injury was usually minimal. In deep gangrene, it was usually extensive and therefore

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FIGURE 82.- Deep gangrene of toes of both feet in late stage of trenchfoot. A. Appearance of feet 2 months after injury, when areas of dry gangrene were becoming demarcated from normal tissue. The line of demarcation was bathed in foul-smelling, purulent discharge. At this time, the patient complained of burning, tingling, and numbness of the toes and excessive sweating. There were areas of hypesthesia on the dorsal and medial surfaces of the right foot. Both feet were extremely cyanotic on dependency. Oscillometric readings and pulsations in the peripheral arteries were normal on both sides. B. Appearance of feet 5 months after injury, after bilateral lumbar sympathectomy, amputation of gangrenous toes, and pedicle graft to left foot. The patient was walking well when he was discharged a month later
This infantryman sustained his injury in Aachen, Germany, in November 1944, after 6 days' exposure to cold, wet weather, with snow.

  was a serious problem. Though infection was not a part of the primary pathologic process, the circumstances under which cold injury occurred naturally favored its development. The hygiene of the feet was often necessarily neglected under conditions of combat. At the time of exposure, the shoes and socks were often wet and sometimes had not been changed for days or even weeks. Bleb formation, maceration and desquamation of the skin, and loss of the nails were favored by the constant wetness of the feet and the ischemia which resulted from exposure. These lesions, though minor in themselves, served as portals of entry for pathogenic organisms.
       
    When patients with deep gangrene were first seen in Zone of Interior hospitals, the gangrenous parts were often partially separated by a line of demarcation bathed in foul-smelling purulent exudate. Blebs were often present. Sometimes there was evidence of extensive bleb formation throughout all the gangrenous area. The infection was invariably mixed, with penicillin-resistant and sulfonamide-resistant Bacillus proteus and Bacillus pyocyaneas present in addition to other organisms.       

    Often, when the gangrene appeared to be of the dry type, removal of the gangrenous tissue at the line of demarcation would reveal underlying pools of purulent exudate (fig. 82). Osteomyelitis was frequently present in this type

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of case, as well as in cases of wet gangrene, and showed a tendency to proximal spread, in contrast to soft tissue infection, which showed little tendency to invade adjacent intact soft tissues.  

DIAGNOSIS OVERSEAS  

    Accurate diagnosis in the battalion aid station and other forward installations is of the greatest importance in cold injury. If the soldier is really suffering from cold trauma, unless it is of the mildest and most superficial type, he must be evacuated to a general hospital for definitive treatment, which is usually prolonged. If he is suffering merely from cold feet, a fungous infection, trauma from improperly fitted footgear or some such cause, poor pedal hygiene, or an orthopedic condition, he can usually be treated in the division clearing station or the evacuation hospital, depending upon the evacuation policy in force at the time, and can be promptly returned to his unit. The details of triage are discussed elsewhere (p.307).

    The diagnosis of trenchfoot, when once the possibility of the condition was realized, seldom offered much difficulty in World War II, especially when objective findings were present. It was sometimes a serious problem in cases seen late, in which objective findings had been minimal throughout or in which they had completely disappeared. Patients in the latter group complained of aches and pains in their feet, often to the point of incapacitation, and admitted no relief from any kind of treatment. No satisfactory objective tests were available to aid in diagnosis, and even neuropyschiatric consultation frequently failed to solve the problem. The question of possible malingering was, of course, always a factor in such cases.
       
    Useful points in the diagnosis of cold injury in forward installations included the following considerations:
       
    1. The history.- A casualty who had been exposed to cold and wet for a prolonged period of time and who complained of pain or loss of sensation in the feet presumably was suffering from trenchfoot. On the other hand, there was no definite correlation between the length and severity of the exposure and the severity, or even the existence, of cold injury. Seventy-two hours was the average period of incubation, but some men suffered their injuries after an exposure of 12 hours or even less, and some did not begin to complain for many days.
       
    2. The branch of service.- Trenchfoot is so predominately a disease of frontline combat infantrymen that many medical officers in World War II thought the diagnosis questionable when it was made in noncombat troops and would not accept it without corroboration of the circumstances of injury.
       
    3. Symptoms.- The most constant symptom of cold injury was pain, worse at night. Areas of hypesthesia or true anesthesia were also corroborative. An important differential point, in the absence of objective findings, was that patients suffering from cold injury almost universally stated that they were most comfortable when they were cool and when their feet were exposed

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to the air at room temperature. Men whose feet were merely cold, or whose complaints were entirely imaginary, were always eager to warm their feet.
       
    4. Signs.- In the forward installations, the appearance of the feet varied, the findings depending upon the timelag between the injury and the first examination by a medical officer. The feet might be red and extremely tender or blanched. Swelling might or might not be present. Blebs might be present or absent. Gangrene and ulceration might already have set in.
       
    One point to be borne in mind in forward installations was the possibility of the occurrence of cold injuries in association with other injuries. It was pointed out at the Paris Conference on Trench Foot in January 1945 (p.179) that, if a casualty was brought into a field hospital with wounds in the chest or abdomen, it might be a long time before his boots were removed and it was discovered that he was also suffering from trenchfoot. This was a particularly unfortunate error. It was often observed that men with other injuries, particularly abdominal injuries, tolerated cold poorly, and serious damage to the feet might occur while all the attention was concentrated on the battle wound. Ariev ¹⁰ pointed out that the cold injury in such cases might be sustained after the other injury, while the man was still lying in the field, or in the course of his transportation to a hospital.
       
    It was also found to be important to examine the feet for possible cold injury before an injury of the extremity was splinted. It was pointed out at the Paris conference that much damage could be done to a man suffering from cold injury as well as from a compound fracture of the femur if a traction strap were put over the instep before the shoe had been removed and the foot examined. The risk of damage of this origin could be avoided by the use in the field of skin traction with adhesive instead of a traction strap.
       
    Differential diagnosis.- The differential diagnosis of trenchfoot and frostbite was not very important. The all-inclusive diagnosis of cold injury would have been better from every standpoint. The differentiation in World War II rested upon the arbitrary distinction that the former occurred when the temperature was above freezing and the latter when the temperature was 32º F.(0º C.) or lower. This distinction was readily made early in the winter, when the temperatures were generally mild, and later in the winter, when they were generally severe. When temperatures were borderline, particularly when they were above freezing during the day and were freezing or lower during the night, there was often considerable confusion. Clinically, the feet looked much the same in both conditions, and about the only subjective distinction possible was that the patient was frequently aware of the precise time that lie had been frostbitten, whereas the onset of trenchfoot was always insidious. High-altitude frostbite, for obvious reasons, was not a consideration in forward installations of the Army.

    The difficulties of the differential diagnosis of trenchfoot and frostbite and the associated problems which arose in the award of the Purple Heart
____________
¹⁰ Ariev, T. V.: Fundamental Outlines of Present Day Knowledge on Frostbite. Medgiz, Moscow, 1943.

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came down, in the end, to purely administrative considerations. They are discussed in detail elsewhere (p.191). <> 

Special Tests  

    The development of clinical criteria and of simple objective tests which could be applied under military conditions would be of inestimable value for purposes of triage at various levels of medical care and for determining when the soldier who had been hospitalized with a cold injury could be returned to
 
TABLE 10.- Classification and disposition of trenchfoot cases used at the 108th General Hospital, European theater
 

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full or limited duty. No such criteria or tests were developed during World War II. The classification scheme devised during the special study of trench-foot at the 108th General Hospital in the European theater (table 10) remained about as useful as any.
       
    The special tests employed overseas in World War II did not prove useful. Boland and his associates, who made skin temperature studies in patients seen 1 to 4 weeks after injury, concluded that this method might be of value in determining the severity of injury early in the course of trenchfoot but that it was of little help in later cases associated with cold sensitivity. The ischemic-pain test devised at the 15th General Hospital ¹¹ as a diagnostic and prognostic aid had rather extensive testing, but it proved too variable to be of any value in determining progress of the condition. It also had the basic disadvantage that the results were essentially an interpretation by the patient of his own complaints, which made it a priori of questionable usefulness. Furthermore, as Paddock noted in his studies with it, complaints were likely to become intensified as hospitalization continued. It was found, in fact, that only soldiers of "undeviating character and morale" could resist the temptation, when furnished the opportunity, to enlarge upon their foot troubles. This test did not prove reliable when it was employed in Zone of Interior vascular centers.

NOTE.- The clinical details of high-altitude frostbite are reported elsewhere (p.13). The tropical type of cold injury experienced on Leyte is also reported elsewhere (p.211), since it was a unique and limited experience. Finally, as a matter of convenience, all details of recurrent trenchfoot are discussed under the heading of epidemiology (p.381).
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¹¹ Schecter, A. E., and Ragan, C. A.: Trench Foot: The Diagnostic Value of "Ischemic Pain." Bull. U. S. Army M. Dept. No. 89, pp. 98-100, June 1945.