The immersion foot syndrome. 1946

1. Prolonged exposure of the extremities to cold insufficient to cause tissue freezing produces a well-defined syndrome. 'Immersion foot' is one of the descriptive but inaccurate terms applied to this syndrome. The clinical features, aetiology, pathology, prevention, and treatment of immersion foot are considered in detail. A discussion on pathogenesis is also included. 2. In the natural history of a typical case of immersion foot there are four stages: the period of exposure and the pre-hyperaemic, hyperaemic, and post-hyperaemic stages. 3. During exposure and immediately after rescue the feet are cold, numb, swollen, and pulseless. Intense vasoconstriction sufficient to arrest blood-flow is believed to be the predominant factor during this phase. 4. This is followed by a period of intense hyperaemia, increased swelling, and severe pain. Hyperaemia is due to the release in chilled and ischaemic tissues of relatively stable vasodilator metabolites; pain may be the result of relative anoxia of sensory nerve-endings. 5. Within 7-10 days of rescue the intense hyperaemia and swelling subside and pain diminishes in intensity. A lesser degree of hyperaemia may persist for several weeks. Objective disturbances of sensation and sweating and muscular atrophy and paralysis now become apparent. These findings are correlated with damage to the peripheral nerves. 6. After several weeks the feet become cold-sensitive; when exposed to low temperature they cool abnormally and may remain cold for several hours. Hyperhidrosis frequently accompanies this cold-sensitivity. The factors responsible for these phenomena are incompletely understood; several possible explanations are considered. 7. Severe cases may develop blisters and gangrene. The latter is usually superficial and massive loss of tissue is rare. 8. The hands may be affected but seldom as severely as the feet. The essential features of immersion hand are the same as those of immersion foot. 9. Prognosis depends upon severity. The extent of anaesthesia at 7-10 days has been found a useful guide to the latter, and has formed a basis of a method of classification. 10. Rapid warming of chilled tissues is condemned. Cold therapy is of value for the relief of pain in the hyperaemic stage, but should not be used in the pre-hyperaemic stage. Sympathectomy and other measures designed to increase the peripheral circulation should not be employed immediately after rescue, but may have a place in the treatment of the later cold-sensitive state. This paper records the results of observations made during 1941 and 1942. Delay in publication has been necessary because of war-time difficulties of maintaining contact between authors. In this respect we have received much help from Surgeon Rear-Admiral J. W. McNee. We wish to thank Professors R. S. Aitken and J. R. Learmonth for much helpful advice during the preparation of the paper. The charts have been prepared by the technical staff of the Wilkie Surgical Research Laboratory, University of Edinburgh. During the period of the study, one of us (R. L. R.) was in receipt of a personal grant from the Medical Research Council.