CHAPTER IV
Actions Taken in Zone of Interior
MAY 1942-OCTOBER 1943
The first formal mention of cold injury in the Office of the Surgeon General after the United States entered World War II was contained in a note dated 12 May 1942 and addressed by Col. (later Brig. Gen.) James S. Simmons, MC, Chief, Preventive Medicine Division, to Dr. Lewis H. Weed, Chairman, Division of Medical Sciences, National Research Council. In this note, three points were made: (1) United States troops were already operating in Arctic regions, the chances were that their operations in these areas would be expanded, and it was therefore necessary to institute studies on health and sanitation in a cold environment.
Frostbite was specifically mentioned in this letter, but trenchfoot was not. In view of the circumstances listed, the National Research Council was requested to set up a committee to study these problems. Copies of available field manuals were forwarded with the letter, together with a bibliography on cold injury and a letter and comments from the noted Arctic explorer, Vilhjalmur Stefansson. The activities of the committee set up by the National Research Council in response to this request are reported later in this chapter.
The next recognition of the ground type of cold injury as a medicomilitary problem was early in 1943, in the Surgical Division, Office of the Surgeon General. The essential pathologic process in this type of injury is vascular, and the interest of this division in it stemmed from the fact that several of the surgical consultants had had a wide experience with vascular diseases in civilian practice. At this particular time, unfortunatley, no similar interest was manifested by any of the other divisions which later concerned themselves with the matter, and the opportunity was therefore lost to plan and provide for a coordinated program of prevention before cases1 of cold injury developed.
During the first months of 1943, reports on cases of cold injury in the Air Force in England and on immersion foot in shipwrecked Navy and other personnel began to come into the Office of the Surgeon General. These reports were followed by the reports of a large number of cases of exposure to cold during the Attu campaign in May and June 1943 (p.84). This experience was the subject of extensive correspondence between the Surgical Division, Office of the Surgeon General, and the Surgeon, Alaska Defense Command. Correspondence was
_____________
1 During World War II, it was frequently customary to refer to patients with cold injury as casualties. Current Army regulations (AR 600-400, 23 Aug. 1954) direct that injuries or illnesses due to the elements, exhaustion, or self-inflicted wound or injuries will not be considered casualties.
58
also conducted with the Office of the Base Surgeon, Greenland, and with surgeons in various hospitals which had received patients from the Attu campaign. The implications of the Attu experience, in terms of future military operations in other theaters, caused great concern in the Office of the Surgeon General among the medical officers who had already begun to interest themselves in cold injury.
Survey of official publications.- Among the first activities in this Office was a review of the whole subject of cold injury as it had been reported in the medical and other literature in previous wars (p.29) . This review concerned both the clinical aspects of these injuries and the military responsibility for their prevention. Methods of treatment were also reviewed in an endeavor to bring together whatever authoritative knowledge was then available. At the same time, two other reviews were undertaken. One had to do with the Army equipment available for use in conditions of combat in wet and cold. The other was a review of current official publications, such as training manuals, in which it might be expected that preventive and therapeutic measures would be emphasized.
When these reviews had been completed, a memorandum was addressed by Lt. Col. (later Col.) B. Noland Carter, MC, Chief, Surgery Branch, Surgical Division, to Brig. Gen. Charles C. Hillman, Chief, Professional Service, Office of the Surgeon General. In this memorandum, dated 23 August 1943, it was pointed out that measures currently recommended for the control of cold injury were completely inadequate. It was also emphasized that (1) current military publications dealing with operations under conditions of extreme cold contained a number of contradictions; (2) many of the measures advocated for the treatment of cold injuries were not in accord with current authoritative concepts of rational therapy; and (3) no reference at all was made to immersion foot, trenchfoot, or shelterleg in any of the technical manuals then current except in FM 21-11, First Aid for Soldiers. In view of these findings, it was recommended that the deficiencies listed be brought to the attention of appropriate agencies in the Surgeon General's Office so that data published concerning cold injuries might be corrected and brought up to date.
On the receipt of this memorandum, General Hillman requested the Training Division, Office of the Surgeon General, to confer with the Surgical Division on these various matters. The report of this conference, which was held on 27 August 1943, contained recommendations for the changes necessary to bring the publications dealing with the prophylactic and therapeutic aspects of cold injury into accord with current principles and practices. Changes made in the manuals as the war progressed are discussed elsewhere in this chapter (p.68).
Conferences on exposure to cold.- A conference on exposure to cold, organized by the Division of Medical Sciences, acting for the Committee on Medical Research, Office of Scientific Research and Development, was held on 28 July 1943. It was attended by representatives of the United States Army, the United States Navy, the United States Public Health Service; representatives of the Royal Navy, the Royal Air Force, the Royal Canadian Navy, and
59
the National Research Council of Canada; and a number of physicians and surgeons with civilian experience in the management of vascular diseases. The conference was under the chairmanship of Dr. E. M. Landis, Professor of Physiology, Harvard University Medical School.
At this meeting, three points were especially emphasized: (1) Standard clothing and equipment, particularly footgear, had not been entirely efficient in combat under cold conditions to date; (2) more important, both clothing and equipment had been more satisfactory than the manner in which they had been employed, for the reason that troops had been only poorly trained or not trained at all in the personal precautions necessary under Arctic conditions; and (3) War Department publications, if they mentioned cold injury at all, were universally inadequate and were frequently contradictory.
The conference recommended that military personnel should be trained in the prevention of cold injury. Preventive measures and basic first-aid measures were outlined. Representatives from the Offices of the Surgeons General of the Army and the Navy were appointed to prepare articles on immersion foot, frostbite, and trenchfoot and to draw up instructions for the prevention and treatment of these injuries so that as much information as possible might be disseminated concerning them.
At a second conference on cold injury held on 1 October 1943, the material which had been prepared as recommended by the first conference was reviewed in detail, approved by the whole conference, and recommended to the Surgeons General of the Army and the Navy for publication as the official policy on trenchfoot, immersion foot, and frostbite. The articles were published in the Bulletin of the United States Army Medical Department 2 and in Health.3
OCTOBER 1943-MARCH 1945 4
In a further attempt to emphasize the significance of cold injury and the extreme hazards inherent in military operations in conditions of cold and wet, another memorandum on the subject of frostbite, trenchfoot, and immersion foot was addressed to General Hillman by Colonel Carter, on 16 October 1943, as follows:
1. The Attu experience was outlined, and reports from the Northwest Service Command and the Base Surgeon, Greenland, were cited and commented on.
____________
2 (1) Immersion Foot. Bull. U. S. Army M. Dept. No. 70, pp. 26-33, November 1943. (2) Frostbite. Bull. U. S. Army M. Dept. No. 71, pp.24-27, December 1943.
3 Monthly Progress Report, Army Service Forces, War Department, 31 Dec. 1943, Section 7: Health.
Health was a monthly publication, entirely informative in nature, prepared in the Office of the Surgeon General, chiefly for the benefit of Medical Department personnel. It dealt with certain matters of health, including their statistical aspects. It was not a command publication, and its circulation was necessarily limited. It was not likely to have been widely received or read at lower echelons where the control of trenchfoot had to be initiated and implemented.
4 In addition to the publications mentioned in this section, articles prepared in the Office of the Surgeon General on the subject of trenchfoot appeared in the Bulletin of the United States Army Medical Department for March, June, and December 1944 and for February, April, May, June, September, and October 1945.
60
2. The experience in England with cold injury of the high-altitude type in fliers was reviewed.
3. It was pointed out that, while cold injury was still not a serious problem in United States Army troops from the standpoint of either frequency or morbidity, the solution, as the experience in the Aleutians and in the Army Air Force in England had shown, lay in prevention of this form of trauma. The immediate requirements were the adoption of proper equipment for use in cold weather, training in its efficient use, and the education of military personnel in methods of protecting themselves against the hazards of exposure to cold.
4. The steps being taken to bring official publications into accord with modern principles and practices concerning cold injury were also reviewed.
The Office of the Surgeon General could not, of course, do more than advise concerning either equipment or training. These matters were the responsibility of the Army General Staff, especially the Assistant Chief of Staff, G-3 (operations and training). Clothing was the special responsibility of The Quartermaster General. The situation was admittedly difficult. The Army was expanding rapidly. New types of supplies required time for development, procurement, and distribution. The training load was at a peak, as to both the subjects to be taught and the number of men to be trained. Because of lack of time and space on the program, the introduction of additional required training subjects was not readily achieved. It is not surprising, therefore, that many frustrations were experienced by the medical officers who had quickly grasped the military, as well as the medical, significance of cold injury and the urgent necessity for the training of personnel and for the provision of appropriate protective equipment if costly losses were to be avoided in winter operations.
Impact of Experience in Mediterranean Theater
Less than a month after the memorandum of 16 October 1943 had been prepared, trenchfoot began to be reported from Italy where it rapidly assumed serious proportions (p.101) . The tremendous military significance of this type of injury immediately became apparent, even to those who had not previously considered it of much importance. It was obvious, however, in reports from Italy concerning United States casualties, that the importance of preventive measures was not well understood in that theater, and the lack of appreciation of their importance was further evident, although the comparisons were not always as valid as they seemed, in the contrasting experiences reported by British troops fighting in the same area and under much the same circumstances as United States troops.
As a result of the Italian experience, the whole problem of cold injury was repeatedly surveyed in Health. The first of this series of articles, published in December 1943, discussed trenchfoot, immersion foot, and frostbite, with particular reference to the incidence of this type of injury in previous wars,
61
the incidence in the Aleutians campaign, and the current situation on the Italian front. The article emphasized that the prophylaxis of cold injury is a command responsibility. The results obtained by the British by the use of preventive measures were summarized.
The medical aspects of the Italian campaign were analyzed in the February 1944 issue of Health from the standpoint of comparative battle casualties, neuropsychiatric casualties, and hospitalization for disease. The article closed with the statement that, while the surgical care of battle casualties had been exceptionally good, "the total rates for disease were high and jaundice, trench-foot, malaria, and venereal disease were outstanding medical hazards over which it proved difficult to exercise sufficient control."
In the March 1944 issue of Health, the experience of the 1943-44 winter in Italy was analyzed in considerable detail. The discussion covered etiologic factors of cold injury with particular reference to the influence of terrain, the tactical situation, and climatic conditions; the disappointing results accomplished by the first corrective measures; the serious losses in combat strength because of the long periods of hospitalization usually necessary in trenchfoot; and the frequently poor end results. The United States Army experience was contrasted with the British experience; among British troops, the incidence of trenchfoot was very low, presumably because preventive measures were well established and strictly enforced. The inadequacies of the clothing which had been supplied United States troops for winter use were noted, and preventive measures were reviewed, with emphasis on command responsibilities.
The June 1944 issue of Health carried another analysis of the trenchfoot situation to date. It was pointed out in it that although the number of casualties in the Attu campaign was small, the incidence of cold injury was actually high. The small number of cases could be attributed more to the short period of time covered by the fighting and the small number of troops involved than to any other factor. In addition, certain of the troops engaged were accustomed to cold, wet weather, knew how to take care of themselves in it, and therefore did not develop this form of cold injury.
The article went on to say that, while medical officers were aware of the problem presented by trenchfoot, instruction concerning this type of injury had formed no part of the training for troops going overseas. Their ignorance of the risk helped to explain why they had become patients from cold trauma. The possibilities of prophylactic measures were again related to the British experiences in World War I and on the Italian front the previous winter. The several thousands cases which had occurred from United States Army troops in Italy were chiefly in frontline troops whose replacement was a military necessity. The average time lost from duty per man was in the neighborhood of from 7 to 8 weeks.
A program of control was outlined, in which it was stressed that trenchfoot, like venereal disease and malaria, can be prevented "only by the intelligent behavior of the individual soldier under conditions of exposure." The article
62
closed with the prophetic warning that "A winter campaign in northwestern Europe could create a trenchfoot problem of major importance if the lesson of Italy were not heeded."
Analysis of Reports From Overseas
Meantime, reports and special studies prepared in the Mediterranean theater were evaluated and analyzed in the Office of the Surgeon General with particular reference to methods of therapy and problems of prevention and control.
A memorandum, prepared by Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery, and addressed to The Surgeon General on 17 March 1944, reviewed the experiences in Italy, as well as in the Aleutians, and summarized the activities concerning cold injury which had been undertaken to date in the Office of the Surgeon General. Preventive measures and management were outlined in the light of these experiences. Special emphasis was placed on the fact, that it was not only preventive measures, but the rigidity with which they were enforced, that determined their effectiveness. In the final analysis, it was pointed out, their implementation "is a measure of discipline and is the responsibility of unit commanders."
The Essential Technical Medical Data report from the North African Theater of Operations for February 1944 had included the statement from the Office of the Surgeon, Fifth U. S. Army, that "No solution has been found for the trenchfoot problem." The Surgery Division, Office of the Surgeon General, recommended on 24 May 1944 that the reply to the theater should point out that the experience of previous wars and the British experience in Italy in the winter of 1943-44 had demonstrated that a solution to the problem did exist and that it lay in the bold, vigorous, and diligent application of well-established prophylactic measures. It is unfortunate, and perhaps indicative of the general lack of appreciation of cold injury in military operations, that this plain-spoken comment had been considerably watered down by the time it reached the theater in July.5
The March Essential Technical Medical Data report from the North African theater, which was extensive and comprehensive, revealed that a program of control was by this time well understood in the theater. Responsible theater personnel had concluded, in the light of the low incidence among British troops, that all troops should wear heavy wool socks; that their shoes should be well fitted over these socks; that dry socks should be taken to frontline troops with rations; that laundry facilities for washing socks should be available in divisional areas; that squad leaders should be directly responsible for enforcing proper care of the feet by the individual soldier; and that commanders should arrange for rotation of frontline troops. Requisitions for new winter equipment were placed by the theater in July 1944.
____________
5 Letter, Brig. Gen. R. W. Bliss, Chief, Operations Service, Office of the Surgeon General, to Commanding General, North African Theater of Operations, 16 June 1944, subject: ETMD.
63
In a memorandum addressed to The Surgeon General on 19 June 1944, by General Rankin, the whole experience in Italy during the winter of 1943-44 was reviewed. It was pointed out that inadequate instruction of personnel, failure to provide suitable equipment, especially shoes and socks, and failure to apply preventive measures consistently had been responsible for the heavy losses from cold injury in the Italian campaign. Since prevention was the responsibility of command, it was recommended that a vigorous program be instituted at once to include (1) dissemination of information to troops, with instruction in proper methods of prevention of cold injury, (2) provision of proper equipment and footgear, (3) dissemination of information to Medical Department personnel on first aid and definitive treatment, and (4) emphasis on command responsibility for prevention.
In the annual report of the Surgical Consultants Division, Office of the Surgeon General, for the fiscal year ending on 30 June 1944, trenchfoot was described as "perhaps the most unsatisfactory experience of the war." Much the same feeling had been expressed in General Rankin's memorandum to The surgeon General dated 19 June 1944.
War Department Publications
On 29 May 1944, with the purpose of augmenting existing regulations governing care of the feet, as well as to prevent and control any further outbreaks of trenchfoot such as had occurred on Attu and in the Mediterranean theater, Lt. Gen. Brehon B. Somervell, Commanding General, Army Service Forces, directed The Surgeon General to prepare without delay a circular on the subject of trenchfoot, to include causes, symptoms, prevention, first aid, and treatment. It was desired that this publication be ready by 10 June, but, because of the number of divisions, offices, and special personnel whose assistance and concurrence were required, the date was extended.
War Department Circular No. 312, section TV, was issued 22 July 1944 as the official policy of the War Department in respect to trenchfoot. It read as follows:
IV. TRENCH FOOT.- l. Trench foot is the name given to a condition which results from--
a. Prolonged standing in water, wet snow, or mud under cold to freezing temperatures.
b. The continuous wearing of wet socks, shoes or boots. Trench foot is promoted by wearing shoes, socks, boots, leggings, or a combination of these which are too tight, and when the individual who is forced to stay in muddy trenches, fox holes, or shell holes for extended periods neglects exercising his feet and legs.
2. Signs and symptoms of trench foot usually develop as follows:
a. Numbness of the feet or toes. The feet feel like heavy blocks of wood and walking becomes difficult.
b. Burning or stinging pain in the feet or toes.
c. Aching of the ankles and bottoms of the feet.
d. Swelling of the feet, and the skin becomes pale and cold.
e. Development of blisters and blebs.
f. Finally, gangrene may occur.
64
3. Trench foot can be prevented by instructing the individual soldier in the proper care of the feet, by providing suitable footgear where conditions promoting trench foot are present, and by insuring that proper measures are carried out through use of disciplinary action, if necessary.
4. When conditions promoting trench foot exist, and in order to minimize the occurrence of trench foot, unit commanders will be held responsible that the following instructions are carried out:
a. Troops will be given the following specific instructions in the care of their feet:
(1) The feet must be kept dry. Damp soles (also, insoles, if worn) will be replaced by dry ones as soon as possible.
(2) An extra pair of heavy woolen socks (also, insoles, if worn) will be carried at all times to permit changing to dry ones once daily.
(3) Shoes will be removed at least once daily and the feet cleaned and dried. Foot powder will be dusted over the feet and into the socks and shoes.
(4) When shoes or leggings feel tight they must be loosened immediately. Tight footgear interferes with the circulation.
(5) If required to stand for long periods, the feet and legs will be exercised frequently. Conditions might require that this be only in the form of wiggling the toes within the shoes and bending the ankle. Positional exercises of the legs such as knee-bending when standing and elevating legs above level of body when sitting or lying down should be accomplished.
(6) Avoid standing in water, wet snow, or mud. Whenever feasible, the water in trenches, fox holes and shell holes should be bailed out, and rocks, pieces of wood, or tree branches used to stand on.
(7) When necessary to sleep while in sitting position, prop feet as high as possible to help blood circulation. Put on dry socks. Place wet or damp socks in trouser pockets or beneath the shirt to dry. Do not sleep wearing wet socks.
b. Before troops enter combat in cold, damp areas, unit commanders will insure that the troops have cleaned and dried their feet and dusted them with foot powder before putting on dry, heavy woolen socks and waterproof or water-resistant boots or shoes.
c. Arrangements will be made to furnish troops with a clean, dry pair of heavy woolen socks (also, insoles, if worn) once daily. This may be accomplished by bringing them up with the daily ration.
d. Proper waterproof or water-resistant footgear will be issued to the troops when fighting in cold, water-soaked terrain. Care will be taken that the footgear fits properly. The footgear should be loose enough to permit wearing heavy woolen socks without constricting circulation.
e. Foot inspections will be held frequently and the necessary corrective measures instituted.
Therapy was not covered in this circular, partly because treatment was regarded as a technical medical procedure and partly because it was to be covered in a technical medical bulletin on trenchfoot then in preparation. Suggestions that instructions be given to massage the feet, unless trenchfoot had already set in, and to use lanolin, were disapproved by The Surgeon General, on the ground that (1) the soldier could not himself determine whether or not he had already contracted trenchfoot; (2) he might do considerable damage to the tissues by massage; and (3) the use of oils and greases on the feet was of questionable value and could be harmful. The suggestion, made by the Quartermaster General, that the shoepac be recommended as the best footgear to prevent trenchfoot, was also disapproved, on the ground that the improper use of shoepacs could result in serious damage to the feet.
65
Revision of War Department Circular No. 312.- Shortly after War Department Circular No. 312 had been published, the Quartermaster General requested that it be revised in order to clarify the reference to heavy woolen socks, since too strict an interpretation of the instructions to use them might result in a sudden depletion of the supply.6 All commanding generals at ports of embarkation had been notified 7 August 1944 that this circular was designed for the prevention of trenchfoot and was not to be construed as justification for an increase in the authorized allowances of socks.7 Theaters served by the various ports were to be informed of this ruling.
The Surgeon General did not concur in the changes requested by the Quartermaster General, and a conference to discuss the matter was held 18 September 1944. Representatives of the Quartermaster General explained why they opposed the circular as it had been issued: If theater commanders should make requisitions for heavy woolen socks, to comply with its terms, the demand could not be met, since at that time these socks amounted to only 10 percent of the total sock procurement. Wool was available for additional supplies of socks, but machinery to make them was not and it could not be constructed in less than 6 or 8 months. It was agreed that before any action was taken in this matter, the Quartermaster General should inquire from the commanders in all theaters how many heavy woolen socks would be needed to comply with the terms of the circular. When it was learned from the European theater that the circular would have no effect upon the initial issue of this type of sock (although it was requested that the maintenance factor for cushion-sole socks be increased from 11 to 25 percent), War Department Circular No. 312 was thereupon modified 8 as follows, at the request of the Quartermaster General:
V. TRENCH FOOT. 1. Reference is made to section IV, Circular 312, WD 1944.
2. The provisions of paragraph 4, section IV, Circular 312, will not be considered as authorization for an increase in allowances of heavy wool socks, authorized in T/E 21, Clothing and Individual Equipment, 1 June 1944, as socks, wool, cushion sole; socks, wool, heavy; or socks, wool, ski. When increased allowances are required to comply with the provisions of Circular 312, requests will be submitted through channels.
War Department Technical Bulletin 81.- The publication of War Department Circular No. 312 on 22 July 1944 was followed by the publication of War Department Technical Bulletin (TB MED) 81, 4 August 1944. This bulletin (appendix A, pp. 509-515), which covered all phases of cold injury, with special emphasis on prophylactic measures, was largely based upon the experience, both in the clinical aspects of the condition and in its prevention, gained in the recent Italian campaign. Minor changes in therapy were suggested in an amended version published 3 October 1944 (appendix A, p.515).
____________
6 (1) Memorandum, Director, Distribution Division, Army Service Forces, for Director, Military Training Division, 23 Aug. 1944, subject: Trench Foot. (2) Memorandum, Headquarters. Army Service Forces, for Quartermaster General, 23 Aug. 1944, subject: Heavy Woolen Socks.
7 Telegram to all commanding generals at ports of embarkation from Lt. Gen. Brehon B. Somervell, dated 7 Aug. 1944.
8 War Department Circular No. 459, 4 Dec. 1944.
66
The Assistant Secretary of War, Mr. John J. McCloy, wrote to The Surgeon General on 16 August 1944 to point out that in polls taken of the Army overseas and published in What the Soldier Thinks, 85 percent of those questioned felt that they had received too little training in how to avoid having trenchfoot and how to take care of it. The only other item in which the percentage was similarly high had to do with the handling of land mines. The Secretary felt that these figures were significant, though he was uninformed as to what The Surgeon General was doing in "training in the avoidance and treatment of trenchfoot."
The Surgeon General replied on 17 August that the soldier was indeed receiving too little instruction in the care of his feet but that prevention of trenchfoot was really a command function, to be carried out with medical advice. He sent the Secretary a copy of War Department Circular No. 312 and also described TB MED 81, then in production, which covered all phases of trenchfoot. A copy of this publication was sent to the Secretary 31 August 1944, just after it had been published and received from The Adjutant General.
Review and Evaluation of European Theater Problem
Either the lesson of the Italian campaign was not heeded in the European Theater of Operations, or appreciation of its significance came too late. The official publications of the War Department on the subject (War Department Circular No. 312 and TB MED 81) were not received in the European theater until after sporadic cases of trenchfoot had already occurred and only shortly before an outbreak of cold injury, of much greater gravity than the outbreak in Italy the previous winter, began in France and Germany.
During November 1944, approximately 11,000 cases of trenchfoot were reported in the European theater, more than 6,000 in the Third U. S. Army alone. The November rates for this theater, which were already in excess of those in January and February 1944 in the Fifth U. S. Army in Italy, were analyzed in the November 1944 issue of Health. The elements of a satisfactory control program, as outlined in War Department Circular No. 312 published in July 1944 and in TB MED 81 published the following month, were reviewed with special emphasis on the provision of suitable equipment, the avoidance of unnecessary risks, and the enforcement of adequate care of the feet. It was pointed out again that the solution of the problem lay in the assumption of the responsibility by commanders.
As described in detail elsewhere (p.146), shortages of winter clothing and other winterizing equipment were at this time compounding the difficulties in the European theater. An urgent cable from Headquarters, Communications Zone, European Theater of Operations, to the War Department 6 December 1944, described the trenchfoot outbreak in detail and urged that the Department make all possible efforts to expedite supplies of shoepacs, socks, and winter clothing.
This cable gave rise to a series of meetings, all held 9 December.
67
The first of these meetings was held in the office of Brig. Gen. (later Maj. Gen.) Raymond W. Bliss, Chief, Operations Service, Office of the Surgeon General, to discuss in detail the situation in the European theater.
At the conclusion of this meeting, General Bliss and General Rankin met with Maj . Gen. Norman T. Kirk, The Surgeon General. General Rankin read a prepared summary of the efforts which had been made in the Surgical Consultants Division, Office of the Surgeon General, to set up an adequate program for the control of cold injury.9 He concluded with the statement: "The most important factor in assuring the success of this program is enforcement of these elements [prevention and foot discipline] and this lies within the province of command rather than medical authority.''
At the conclusion of the second meeting, a meeting was arranged between General Kirk, General Somervell, and Gen. George C. Marshall, Chief of Staff, to provide The Surgeon General with an opportunity to state the seriousness of the cold injury situation in the European theater and t.o emphasize the need for renewed command efforts to bring preventive measures into full implementationat all levels. Special emphasis was to be placed upon indoctrination of the smaller units. The recommended preventive measures also included (1) provision of suitable and properly fitted footgear and heavy woolen socks, (2) daily foot inspections and daily changes of socks, and (3) frequent rotation of troops who were serving under conditions predisposing to cold injury.10 These measures are discussed in detail in the chapter dealing with cold injury in the European Theater of Operations (pp. 167 and 173) .
In the December 1944 issue of Health, the current situation in the European theater was analyzed on the basis of the weekly rates and analyses cabled from it. It was noted that the incidence of cold injury was considerably higher in that theater in certain units than it had ever been during the Italian campaign, and the close parallel between tactical activity and cold injury was pointed out.
The situation in the European theater was again reviewed in the January 1945 issue of Health, and the increasing incidence was commented on. Control measures were being pushed vigorously, it was stated, but the tactical situation and the weather hampered their full implementation. The British experience was analyzed, and it was noted that the British attributed their comparative freedom from trenchfoot to the superior fit of the shoes provided for their troops and to their better foot discipline.
In the March 1945 issue of Health, the entire European experience was reviewed and it was pointed out that about 30 percent of the 45,000 predominantly frontline troops who had contracted cold injury in that theater would require evacuation to the Zone of Interior. Although estimates indicated that 55 percent of the wounded could be returned to frontline duty, it was doubted that this proportion of trenchfoot patients could be returned to combat. The British experience in the European theater was again reviewed.
____________
9 Memorandum, Brig. Gen. F. W. Rankin, Chief Consultant in Surgery, Surgical Consultants Division, for The Surgeon General. 9 Dec. 1944, subject: Trench Foot.
10 Memorandum, The Surgeon General for the Chief of Staff, 9 Dec. 1944, subject: Trench Foot.
68
Among other subjects discussed in this article were the advantages of control teams, the necessity for the allotment of additional time in the training schedule for instructions in the prevention of trenchfoot, the shortages of shoepacs in the European theater, the relationship between tactical activity and exposure to cold, and the necessity for advanced planning whenever there was a remote likelihood of combat under winter conditions.
TRAINING PROGRAM
Manuals
As has already been pointed out (p.58), the various military publications current when the United States entered World War II were neither complete nor satisfactory from the standpoint of the discussion of cold injury, and they were often contradictory as well. For the record, they will be briefly mentioned, together with the revisions which they underwent in the course of the war.
Operations in Snow and Extreme Cold.- This manual (FM 31-15) was published on 18 September 1941 to supplement a training circular of the same title which did not contain full information on the subject. Changes were published on 16 April and on 29 September 1942. Frostbite was briefly discussed in this manual, and it was pointed out that wounded men need special protection against cold injury. Trenchfoot was not mentioned.
First Aid for Soldiers.- This manual (FM 21-11), which was published on 7 April 1943, contained extended discussions of frostbite and freezing, including diagnosis, first aid, treatment, and prevention. Trenchfoot, shelterleg, and immersion foot were briefly discussed. All three conditions, it was stated, resembled mild frostbite but could occur at higher temperatures. The causes were listed as standing or sitting still for long periods in wet trenches or shelters and letting the feet hang for long periods in water after shipwreck. Tight leggings and cramped positions of the legs were listed as contributing causes. The best methods of prevention, it was stated, were keeping the feet dry and exercising the extremities to increase the flow of blood in them. First-aid measures were the same as those recommended for frostbite. No changes were made in these sections when the manual was revised on 20 May 1943.
On 14 September 1944, The Surgeon General requested the Commandant, Medical Field Service School, Carlisle Barracks, Pa., to proceed at once with a complete revision of the text of First Aid for Soldiers, to bring it into accord with most recent doctrine.11In The Surgeon General's request for approval of the revision which went to the Director, Military Training, Army Service Forces, on 16 September 1944, trenchfoot was mentioned as one of the subjects requiring more extended attention. The same necessity was mentioned when The Surgeon General submitted the outline of the proposed revision to the
____________
11An article on the subjects of frostbite, immersion foot, and trenchfoot had been published from this school (Wright, I. S.. and Allen, E. V.: Frostbite, Immersion Foot, and Allied Conditions. Bull. U. S. Army M. Dept. No. 65, pp. 136-150, January 1943). This was a comprehensive article, dealing with all phases of these injuries. including prevention.
69
Commanding General, Army Service Forces, on 31 October 1944. On 29 January 1945, the Surgeon General's Office concurred in the plan to reprint the unrevised manual at this time, on the ground that it would be another 4 months before the revision then in progress could be accomplished.
Actually, the revised manual did not appear until 1 August 1946. In this revision, trenchfoot was described in detail in the light, of the World War II experience, and special emphasis was put upon preventive measures including the care of the feet. It was recommended that the feet be kept clean and dry, that they be exercised and massaged, that constriction be avoided, and that the socks be changed at least once daily. Frostbite was also discussed in detail from the standpoint of prevention.
Field Sanitation.- This manual (FM 8-40), prepared under the direction of The Surgeon General and published by the War Department on 15 August 1940, did not mention either trenchfoot or frostbite in the original issue or in the three changes published in 1942.
Military Sanitation and First Aid.- This manual (FM 21-10), published on 31 July 1940, contained a full clinical discussion of frostbite but did not mention trenchfoot either in the original edition or in the seven changes made between the date of issue and 17 February 1944. Trenchfoot was also not mentioned in any of the correspondence, begun in October 1943, concerning revision of the text.
The revision was not completed until July 1945. Chapter 13, which deals with personal hygiene, contains an extensive discussion of trenchfoot, as well as of immersion foot and frostbite, with emphasis on the care of the feet, the proper use of clothing and footgear, and similar matters. The following paragraph is cited as an illustration that the lessons of the experiences in Italy and Europe had by this time been well learned:
Remember that no single type of footgear or combination of shoes alone will keep the feet dry and warm under the varying conditions met in combat areas. Proper footgear is at best only a help in keeping the feet warm and dry. The prevention of trench foot depends on the care given the feet by constant attention to all the rules outlined above.
In May 1944, while the revision of this manual was in progress, General Bliss recommended that a pamphlet proposed by the Military Training Division, Army Service Forces, should not be published because the material, in substance, was included in this proposed revision and would also appear in Personal Health, a War Department pamphlet then in preparation. It was expected that this revision would also eliminate the need for FM 8-40, Field Sanitation. The request received by radiogram from Headquarters, European Theater of Operations, on 10 January 1945, for 200,000 copies of FM 21-10, Military Sanitation and First Aid, included a request for information concerning the revision which, as noted above, appeared too late to be of value in World War II.
Soldier's Handbook.- This manual (FM 21-100) was first published on 23 July1941. The need for it had been realized much earlier, but funds could not be secured for publication. The distribution was Army-wide. The care of
70
clothing and the cleansing of boots and shoes were described, but the only mention of cold injury concerned the management of individuals exposed to freezing. Trenchfoot was not mentioned in the changes made in May and December 1942. A revision of this manual was planned in the summer of 1943, and several suggestions were made to the effect that the text should be more interesting, more easily comprehended, and more readable. The revision was not carried out, the manual being rescinded on 10 August 1944, because the material in it was either obsolete or was duplicated in other field manuals. Permission was given in War Department Circular No. 375, dated 15 September 1944, to use the handbook, with whatever corrections were necessary, until the pamphlet intended to replace it (War Department Pamphlet 21-13, Army Life) should become available. Army Life was published on 10 August 1944.
Principles of Cold Weather Clothing and Equipment.- This manual (TM 10-275) was prepared by the Office of the Quartermaster General on 26 October 1944. It had been in preparation for almost a year, a large part of the delay being for editorial reasons. Changes were initiated almost as soon as the manual appeared and were issued on 1 February 1945; they had to do with preferred types of footgear, including sock combinations. Excellent advice was given in this publication about the care of the feet, the importance of exercising them, and other preventive measures. Although the military experience had been that dubbing was not useful in the prevention of trench-foot, instructions for its use were given in the changes in the manual issued in February 1945.
Medical Department Soldier's Handbook.- This manual (TM 8-220) replaced the earlier handbook prepared by Maj. Arnold D. Tuttle, MC, and published in 1927.12 Frostbite, freezing, and chilblains were briefly discussed in the earlier text, but trenchfoot was not mentioned.
The Medical Department Soldier's Handbook, which was issued on 5 March 1941, contained clinical descriptions of the effects of prolonged exposure to extreme cold, descriptions of frostbite and chilblains, and instructions for the management of these lesions. Trenchfoot was not mentioned. Directions were given for the proper fitting of shoes and socks and for the care of the feet. In the third set of changes, issued in February 1944, the section on frostbite was considerably expanded and became substantially the same as the similar section in FM 21-11, First Aid for Soldiers. Also included was a section on immersion foot dealing with contributing factors, clinical considerations, preventive measures, and emergency management. Trenchfoot was not mentioned in any of these changes.
Guides to Therapy for Medical Officers.- This manual (TM 8-210), which was published 20 March 1942, contained an extended discussion of frostbite, covering prophylaxis, etiology, and treatment, but did not mention trenchfoot. Athlete's foot was also discussed. Details of foot hygiene were outlined,
____________
12 Tuttle, Arnold D.: Handbook for the Medical Soldier of the Regular Army, National Guard, Organized Reserves, and Enlisted Reserve Corps of the Army of the United States and Others Interested in National Medicomilitary Preparedness. New York: William Wood and Co., 1927.
71
including the care of the feet after long marches. The importance of wearing properly fitted shoes and socks was emphasized. Light wool socks were recommended, and it was specifically stated that the shoes should be laced snugly. This manual was rescinded in 1944, and the material which had previously appeared in it was thereafter published in medical technical bulletins.
Arctic Manual.- This manual (TM 1-240), which was published on 1 April 1942, superseded the two volumes of similar title published on 6 November 1940. It was specifically intended for the use of personnel in the North American Arctic region who were not assigned to permanent posts. Frostbite was described at some length in the 1940 publication, but neither frostbite nor trenchfoot was mentioned in the 1942 edition. When this manual was revised on 17 January 1944, an extensive discussion of all aspects of frostbite was included, but, again, trenchfoot was not mentioned.
Personal Health.- This publication (WD Pamphlet 8-9) was initiated as a manual in the fall of 1943. When it was learned that publication in this form would probably not be permitted, approval was requested for it as a pamphlet in the same format. When the material was sent to the Surgeon General's Office in August 1944 for review before publication, personnel in that office requested that a subtitle, An Eye to Your Future, be added, and that an illustration be provided for the cover.13 The pamphlet, it was stated, contained much valuable material, and it was thought desirable to try to remove it from the category of routine War Department training manuals. The average soldier, the note pointed out, "considers that lie has a sufficient knowledge of personal health without further advice, and often casts aside any document on personal health without reading it" unless it can be made attractive enough to stimulate his interest. In view of the urgent need for this pamphlet in the field, it was requested that its publication be expedited. It is not clear why work on this publication lapsed.
The Fitting of Shoes and Socks.- This manual (TM 10-228) was undertaken shortly before V-J Day but was not completed when the immediate necessity for it ceased.
Comment.- In analyzing the various publications of the War Department dealing with the health of the soldier and his training and equipment for cold weather, one is impressed, as has already been pointed out, with the inadequacy of the instructions for the prevention and management of cold injury, and with the inaccuracy of much of the material that was published. Trenchfoot was entirely ignored in the manuals current when the United States entered the war. When revisions of these manuals were undertaken, trenchfoot continued, for the most part, to be ignored. Revisions were initiated late, and many months usually passed before the concurrence of the various offices and personnel concerned could be secured. Many disagreements concerned trivia. Further delays ensued as the manuals were processed and issued. None of them reached the Mediterranean or the European theater in time to be useful
____________
13 Memorandum, The Surgeon General, for Office of The Adjutant General, 16 Aug. 1941, subject: WD Pamphlet 8-9 "Personal Health."
72
in the prevention and control of trenchfoot. Some of them, in fact, would probably not have been ready in time for cold weather operations in the Pacific had war in that theater continued into the fall and winter.
Posters
The difficulties just outlined, which attended the publication of field and technical manuals, also attended the preparation of posters and films designed to educate troops in the prevention of cold injuries. There would therefore be no point to a rehearsal of the details.
Multiple charts for company-size units were planned and prepared in the Training Division, Surgeon General's Office, on numerous subjects, including trenchfoot. They took time to prepare. Coordination with many offices was necessary. Additional time was required to make the changes required or desired to correct facts, alter emphasis, or change the method of presentation.
For these reasons, when urgent requests were received from the European theater in December 1944 for posters on cold injury for general distribution, the requests could not be filled. On 4 January 1945, General Bliss sent two posters to the Chief Surgeon, European theater, with a request that he order the number desired. One of these posters was an official War Department poster (GTA 8-16) in four colors, designed to drive home the necessity for daily individual foot care. The other had been prepared by units of Army Ground Forces, Fort Benning, Ga. Orders were placed on 19 January for 12,000 copies of each of these posters, half to come by air and half by fast boat shipment.
In the European theater, as in the Zone of Interior, when official posters were not available, many units prepared and displayed their own. Some were excellent, others were not too expert, but most were useful as well as immediately effective.
There was, of course, an element of danger in the local preparation of posters. An official observer from the Surgeon General's Office noted that he had recommended that one such poster which had come to his attention be removed and destroyed at once, on the ground that trenchfoot was not a subject to be treated humorously. Similar advice was given at another camp, where trenchfoot was presented as a form of athlete's foot and as preventable by the methods used for the prevention of that infection. Since the cause of cold injury was presented as a germ, and not as impairment of the blood supply to the feet, the soldier would naturally not understand that it could be prevented by exercise, massage of the feet, warmth, and the unloosing of constricting shoes, socks, and leggings.
The official observer just quoted stated in his report on this tour of inspection that the major reason for the difficulty in explaining the concept of trench-foot was the fact that line officers had not read, and would not read and familiarize themselves with, the various directives on the condition. If, as the poster just described indicated, unit officers thought that cold injury was just
73
a severe case of athlete's foot, soldiers under their command would have the same ideas. The knowledge of trenchfoot, in short, was weak because of the average line officer's complete ignorance of the material contained in existing directives.14
Films
The film undertaken in the fall of 1942, under the title "Personal Health in Operations in Snow and Extreme Cold," was approved for release on 28 December 1943.
The Training Division, Office of the Surgeon General, requested authorization on 18 September 1944 for the production of a film bulletin on the cause and prevention of trenchfoot, to be based on the doctrine contained in War Department Circular No. 312. Although the film was put into production promptly, it was not finally approved until 17 February 1945 and was not released until March as Film Bulletin 180, subject: Trench Foot.
This film, which had a running time of 18 minutes, was intended to be shown to all ground troops before they went on maneuvers or into combat, the objective being to focus attention on proper care of the feet immediately before such care would abruptly become of the greatest importance. Troops were shown hiking through mud and snow and living in muddy foxholes. Cold, numb, wet feet, it was shown, could lead to trenchfoot, with cold, numbness, and stiffness the first symptoms, followed by blister formation; these relatively mild symptoms and signs, it was indicated, could lead to gangrene, with amputation the possible end result. Preventive measures were illustrated, such as the use of rocks and branches of trees in the bottom of foxholes, to keep the feet from direct contact with mud and water; daily removal of the shoes and daily changes of socks; vigorous massage of the feet, with the application of foot powder; sleeping with the legs elevated; and methods of drying the wet socks by body heat. It was repeatedly emphasized in the course of the presentation that only by adherence to these cardinal principles could the feet be kept warm and dry, and trenchfoot with its ghastly consequences be prevented. The message was driven home by repeated flashbacks to pictures of gangrenous feet which required amputation.
This vigorous presentation proved both useful and effective in the United States, where the film was widely distributed, and in the training program
____________
14 There were, of course, exceptions to this generalization. An occasional commander was wise before the event. An observer for the Army Ground Forces Board, NATOUSA, quoted the colonel of an infantry regiment as saying "I wrote a monograph at Benning in 1928-29 on the subject of the care of the feet. I thought it was an important subject then, though some other people did not. It is still one of the most important subjects for an infantry officer to know. Trenchfoot is one of the major causes of non-battle casualties. and a non-battle casualty reduces your combat strength just as much as does a battle casualty * * * The remainder of this regiment [he excluded the Japanese-American component, p. 380] has consistently had the lowest trench-foot rate among the infantry of the division. This, I am sure, is largely due to the emphasis we have placed on care of the feet. I have personally conducted a school on care of the feet for the junior officers of the regiment. We require every man to go into combat with a clean, dry pair of socks inside his shirt and we require platoon leaders to see that their men change wet socks for dry ones, and massage their feet, whenever it is at all practicable. If Benning does not already have it in its officer-candidate course, it should include a short course on care of the feet. The instructor should be a competent doughboy who has done a lot of marching and knows how to take care of feet in wet, cold weather. I don't think that anything that Benning can teach its students is of more importance."
74
in the Pacific (p. 231) . It was issued too late to be employed when it was most needed, in the Mediterranean and European Theaters of Operations. Repeated requests for films on the subject of trenchfoot were received from the European theater but could not be filled.
Indoctrination of Troops
Pearl Harbor-July 1944.- Instruction in the risks of cold injury and in methods of preventing it formed no part of the training of combat troops in the early days of the United States participation in World War II. It was not, in fact, until trenchfoot had become a major problem in combat operations in Italy in the winter of 1943-44 that a serious attempt was made to include indoctrination on cold injury as part of the combat training, and the war was almost over before satisfactory courses were set up. This was, of course, an error of the first magnitude, for which a heavy price was paid in loss of manpower and reduced combat efficiency.
On the other hand, it is only fair to point out certain facts in explanation, though not in excuse, for this situation. The United States had been quite as unprepared to enter World War II as it has been to enter World War I. In the space of months after Pearl Harbor, an army of approximately 1.6 million men became an army of several million. New troops had to be taught a great many things, many of them of the utmost importance. There was constant competition for space in the training program. Even after the importance of cold injury was fully realized, instruction in its prevention had to compete for room with other subjects. Furthermore, the Medical Department, which realized the dangerous possibilities of this sort of injury relatively early in the war, and which repeatedly called attention to them, could do no more than advise, and advise only indirectly (p. 81), since the prevention of trenchfoot is primarily a command, not a medical, function.
Cold injury in the training program was first conceived of as relating to combat operations in the Arctic. This is clear from the material contained in the manuals issued early in the war and already discussed (p.68) . The same concept is evident in the training outline prepared in October 1943; it provided only for 12 hours of instruction for training in operations in extreme cold, 8 devoted to sanitation and 4 to first aid.
War Department Circular No. 48, issued on 3 February 1944, provided that training schedules and courses of instruction be so planned as to insure minimum standards of proficiency in the care of the feet, including the prevention of trenchfoot. This circular was amplified on 17 March 1944, in a training directive which specified that unit schedules be revised to include such additional instruction as might be necessary to meet these requirements. 'bests were prescribed to determine achievement of the required proficiency.
July 1944 toV-J Day.- Action in respect to training of troops became much more vigorous in the summer of 1944, as the full realization of the cost of the cold injury experience in Italy in 1943-44 became more general.
75
Weekly Directive No. 31, Headquarters, Army Ground Forces, dated 1 August 1944, pointed out that the alarming number of cases of trenchfoot could be attributed to lack of proper training and command supervision. Immediate and positive steps were to be taken by all commanders to eliminate this deficiency and to comply with current directives, which were listed.
A command letter from Headquarters, Army Ground Forces, was forwarded on 26 August 1944 to all subordinate commands. This letter, which was entitled "Trench Foot and Training in Foot Hygiene," stated that reports received at that headquarters had indicated unsatisfactory ratings in proficiency in the care of the feet and that investigation had showed that sample test questions often did not include this point. Meantime, the rate of trench-foot cases was alarming. The military importance. of such losses was stressed. Attention was called to the various publications available on cold injury, including TB MED 81, which would become available on 31 August. It was directed that "positive and immediate action" be undertaken by all command echelons "to insure adequate training, enforce proper hygiene, and fully indoctrinate all individuals."
Letters to the same effect were sent from Headquarters, Army Ground Forces, to the Commanding General, Second U. S. Army, on 24 October 1944 and to the Commanding General, Fourth U. S. Army, on 30 October 1944. Instruction to date, it was pointed out, had failed to impress the individual enlisted man with basic knowledge concerning cold injury. Additional effort to improve the situation was required. When necessary, further instruction and testing should be carried out on shipboard, en route to theaters of operations.
The information and instructions in this letter were relayed to all commands in the Second Army on 31 October 1944 and followed up the command letter which had been sent from Headquarters, Second Army, on 29 July 1944. In the latter letter, it had been pointed out that reports from overseas and tests conducted by this headquarters had shown a lack of knowledge and appreciation of the prevalence, seriousness, causes, and methods of prevention of trenchfoot. The causes, symptoms, first-aid management, and methods of prevention were briefly outlined, and attention was called to available publications on the subject. Division and separate unit commanders were directed to impress the seriousness of this type of injury upon all officers and noncommissioned officers of their commands.
All units in the Replacement and School Command, Army Ground Forces, received information and instructions concerning cold injury in a letter from Headquarters, Army Ground Forces, on 3 November 1944. The special periods at which this instruction was to be given were listed for the replacement training centers, infantry advanced-replacement training centers, and special-service schools.
At about this time, each division surgeon in the Zone of Interior also received a letter from Brig. Gen. Frederick A. Blesse, Surgeon, Army Ground Forces, emphasizing that instruction in trenchfoot must. be given accurately,
76
must be clearly understood, and must be followed by application of the information, inspections, quizzes, and continuous correction of errors.
After the issuance of these letters, upon instructions of Lt. Gen. (later Gen.) Ben Lear, Commanding General, Army Ground Forces, staff officers from his headquarters, in their inspections of Ground Forces installations and replacement training centers, always put particular emphasis upon proficiency in the care of the feet and in knowledge of trenchfoot. General Lear's stated policy was that each company be given two foot inspections weekly, one by a commissioned officer and one by a noncommissioned officer. Inspecting officers from his headquarters were instructed to assure themselves that this policy was being carried out. They also made spot checks of the condition of the men's feet and of their knowledge of trenchfoot. Special emphasis was placed upon trenchfoot when a surgeon was added to the staff of each replacement center in December 1944, and instruction on medical subjects was increased.
In December 1944, the Office of the Surgeon General prepared an outline for a 15-hour program in military sanitation and hygiene, for a proposed revision of the courses in these subjects in the Army Service Forces officers candidate schools. Lesson No. 2, dealing with personal hygiene, laid special emphasis on foot care and the prevention of athlete's foot and trenchfoot.
An outline of the training program instituted in the European theater after the November 1944 outbreak of trenchfoot contained full information about the prevention of the condition, including both the proper use of clothing and the proper care of the feet. This outline was distributed by Headquarters, Army Ground Forces, as inclosure 1 to a letter dated 20 January 1945, on the subject of prevention of trenchfoot and frostbite (appendix B). A team of three specially qualified officers, one from G-4 (logistics), Army Ground Forces, and two from the Office of the Quartermaster General, was appointed to train instructors at each port of embarkation. The mission of these instructors was to insure that all military personnel passing through ports for overseas assignment received the indoctrination contained in this directive. No man was supposed to leave the port of embarkation for a combat area until his AG Form 20 or 66-1 bore the notation that he had received 2 hours of training in the prevention of cold injury and in the use of the winter combat uniform and other equipment, just as he could not leave without a record of the inoculations required in the area to which he was going.
When a sufficient number of instructors had been trained to cover the various ports of embarkation, similar training programs were set up at the large camps and training centers throughout the country. Courses were also conducted at both embarkation points and training centers for supply personnel, who were instructed how to requisition, fit, and issue the new clothing.
This program was continued until the end of the war. In all, more than 100,000 officers and men were trained by the original team and by the instructors who had been trained by this team. The need for the program was evident
77
in a single fact, that at no time did any team of instructors encounter units which had already been 100-percent trained.
In the meantime, training was continuing in Army installations throughout the country. A request was made 4 April 1945 by Brig. Gen. Stanhope Bayne-Jones, Acting Chief, Preventive Medicine Division, Office of the Surgeon General, to the Training Division to increase the time allotted to the teaching of sanitation in War Department Circular No. 48, 1944, from 20 hours to 22 hours, to permit increased emphasis upon certain subjects, including fungous infections of the feet and trenchfoot.
Training Memorandum No. 1, Headquarters, Army Ground Forces, 1 June 1945, reiterated the requirements specified in War Department Circular No. 48, 1944. Training Memorandum No. 5, issued from the same headquarters on 16 July 1945, directed that all personnel be given instruction in the capabilities, limitations, use, care, and preservation of clothing and equipment and in the principles of living in the cold. Instructional kits included a wet-cold kit, which contained a complete wet-cold uniform assembly (p.222), as well as training aids. All of this information, it was stressed, was intimately related to the prevention of trenchfoot. Instruction was to consist of 2 hours for enlisted men and 4 hours for officers. A detailed question-and-answer guide was prepared by Headquarters, Army Ground Forces, and made available to Headquarters, Replacement and School Command, on 17 July 1945. This guide presented the minimum knowledge considered essential for proficiency in basic medical subjects, including trenchfoot.
Mobile Intelligence Training Units, whose function was to aid in the training of redeployed units in subjects of special importance in the Pacific, were set up and supervised by a specially qualified medical officer from Headquarters, Army Ground Forces. These units were trained to put particular emphasis upon the prevention and control of trenchfoot. It was contemplated that a team would be made available to each Army post at which Ground Forces units were receiving redeployment training, but the ending of the war terminated the necessity. At the end of the fighting, 7 teams had been trained and were ready to function, 10 more were in training, and arrangements were under way for the training of 13 others.
In a memorandum, dated 27 July 1945, to the Chief of Staff, Army Ground Forces, General Blesse summarized the steps which had been taken for the training of ground troops in the prevention of trenchfoot from February 1944 to 27 July 1945, as follows:
1. All War Department publications relative to the subject of cold injury and foot care were listed, including War Department Circulars No. 48, 1944, and No. 312, 1944; TB MED 81, 1944; publications in the Bulletin of the United States Army Medical Department; and publication in Health.
2. Measures taken by Headquarters, Army Ground Forces, to implement these publications and assure effective training were also listed. These measures included the training directives described earlier in this chapter, training aids,
78
posters, clinical photographs and models, letters to various divisions and other commands, inspection trips, and a proposed course of instruction in diseases likely to be encountered in the Pacific theater.
This memorandum to the Chief of Staff, Army Ground Forces, was accompanied by the draft of a letter which it was proposed should be sent by Gen. Jacob L. Devers, Commanding General, Army Ground Forces, to each of his major subordinate commanders. The letter reiterated the various points of importance concerning trenchfoot and stressed command and individual responsibility. Attached to it was an enclosure covering all of these points in detail.
General Devers approved the proposed letter and directed General Blesse to prepare a summary embodying the latest information on trenchfoot, to cover concepts and measures necessary for prevention. This was accomplished on 7 August 1945. The summary outlined the causes of trenchfoot, its clinical aspects, individual measures of prevention (clothing, footgear, and care of the feet), and a control program. In the directions for formal training, provision was made for trenchfoot control teams and control noncommissioned officers, in line with the system which had proved so effective in the European theater (p.177). The facilities and training aids available for this program were listed. Command responsibility for trenchfoot, discipline, clothing, and rotation of troops was unequivocally stated.
The course of instruction mentioned in the correspondence with the Chief of Staff, Army Ground Forces, was to deal with diseases prevalent in the Pacific and was to be given to selected Medical Department officers. The allotment for trenchfoot was 4 hours. The plan was that student officers would indoctrinate their own organizations after they had completed the course. It was proposed that the course should begin on 13 August 1945 and that each course would last for 2 weeks. The plans were cancelled when the war ended on 14 August, and the text being prepared for use in the course in the Office of the Surgeon General was not completed.
HOSPITALIZATION OF TRENCHFOOT CASUALTIES
In the fall of 1944, the vascular center at Letterman General Hospital, San Francisco, Calif., Mayo General Hospital, Galesburg, Ill., and Ashford General Hospital, White Sulphur Springs, W. Va., were designated to receive trenchfoot cases. In January 1945, Brooke General Hospital, San Antonio, Tex., and the Army Service Forces hospitals at Camp Butner, N. C., and Camp Carson, Colo., were designated for the same purpose, with the expectation that one or two additional hospitals might be designated later. During the peak load, in the late winter and spring of 1945, trenchfoot patients were necessarily sent to other hospitals, but no others were formally designated as trenchfoot centers. The original plan was to handle all these patients on medical wards. Later it became evident that surgical wards would also have to be provided.
79
In planning for the management of trenchfoot cases received in the Zone of Interior, the Ashford experience was used as a sample.15 Of 135 patients under treatment for cold injury in January 1945, 3 percent had gangrene and would probably require surgery. Sixty-two percent had moderately severe injuries which would require specialized treatment, probably including sympathectomy. The other 35 percent had mild injuries and could be managed in a convalescent hospital.
On the assumption that possibly half of the 18,000 cases of cold injury which had occurred in the European theater in December 1944 would require evacuation, it was estimated that facilities must be provided for from 7,000 to 9,000 casualties from this cause in Zone of Interior hospitals during the first 3 months of 1945. It was further estimated that 5,850 of these injuries would be severe or moderately severe. Since this would be an undesirable and impractical load for the vascular centers designated for the care of trenchfoot, it was suggested that the best plan might be to send all returning trenchfoot patients to the convalescent centers set up at Camp Butner and Camp Carson and to route them from there as beds become available, to the vascular centers for such specialized care as might be necessary.
Later, on 17 January 1945, it was proposed in a memorandum to the Resources and Planning Division, Office of the Surgeon General, from the chief consultants in surgery and medicine that the best plan of management for the minimum of 2,000 trenchfoot patients to be expected each month for the next 3 months would be, after triage at ports of embarkation, (1) to send all patients with gangrene and any loss of tissue, as well as those unable to walk or with serious subjective complaints, to vascular centers, and (2) to send all others to convalescent centers, preferably in a mild climate. This plan was, in effect, finally adopted.
INVESTIGATIONS
The Climatic Research Laboratory at Lawrence, Mass., had as one of its purposes the study of the physiologic effects of clothing and the influence of meteorologic conditions on health in cold climates. In January 1943, representatives of the Preventive Medicine Division, Office of the Surgeon General, began to work with the Research Clothing Board appointed from the Office of the Quartermaster General and already at work in this laboratory.
The Surgeon General, after a visit to the laboratory in December 1944, wrote to congratulate those in charge upon what was being accomplished. 16 He could not, however, agree with the investigations being conducted on trenchfoot. The place to study that condition, he emphasized, was in the field, where it could be determined whether foot discipline was being correctly carried out and whether the clothing recommended "is available to the doughboy in the trench
____________
15 Memorandum, Lt. Col. 11. H. Turner, Medical Consultants Division, for Brig. Gen. Hugh J. Morgan, 13 Jan. 1945, subject: Hospitalization of Trench Foot Cases.
16 Letter, The Surgeon General, to Col. J. H. Talbott, Climatic Research Laboratory, Lawrence, Mass., 9 Dec. 1944.
80
or whether it is on the shelves in the depots or in the dumps far to the rear." Trenchfoot was then epidemic in the European theater, The Surgeon General pointed out, in spite of the directives issued for its prevention.
Medical officers were eventually assigned to this laboratory, but the work accomplished there was of little practical value in the control of trenchfoot and came too late, anyway, to influence the situation in Europe.
In March 1945, plans were made for the investigation of certain phases of trenchfoot at the trenchfoot center at Camp Butner, particularly the extent and character of the lesion, the resulting disability, and the determination of objective criteria upon which to base the decision as to fitness for duty.17 The following techniques were thought to be most promising: Lange's fluorescein procedures, both visual and instrumental; measurements of foot volume by the water-displacement technique, both before and after the foot had been subjected to heat, cold, and the stress of physical activity; changes in the temperature and color of the skin of the extremities in response to posture and environmental temperature as measured by the electric skin thermometer; capillary microscopy, in spite of the known limitations of this technique; foot-pattern studies by the technique of Silverman and Howell, to trace the relation between nerve injury and abnormal sweating; plethysmography, with special reference to the toes; and the histamine wheal.
Since it was obviously impossible for the staff of a single center to undertake all of these studies, it was decided that the investigations at Camp Butner should be limited to the fluorescein technique in severe trenchfoot; foot volume studies in milder trenchfoot; and studies in sweating, including plethysmographic studies, in an attempt to throw light upon the nerve and vascular lesions of trenchfoot. The war ended before any of these special studies were set up.
CONCLUSION
The annual report of the Surgical Consultants Division to The Surgeon General for the fiscal year ending 30 June 1945 read, in part, as follows:
During the two winters when American forces were suffering heavy casualties from trench foot much was written, said, and done about this condition. In fact, an uncritical observer might readily conclude that despite all that was done a high incidence of the condition resulted and that trench foot, after all, is not preventable. Any historian or student of the subject who in the future may be reviewing the trench foot experiences of American Armies during this war in order to maintain a proper perspective must constantly ask himself two questions:
(1) What was the situation at the time this publication was printed or this action taken?
(2) Was the information in this publication or this action felt by line officers and soldiers in the field at a time when it would be effective?
Trench foot does not occur during summer months. It is a condition which occurs as a result of prolonged uninterrupted exposure to cold and wetness. In order for troops to pro-
____________
17Memorandum, Medical Consultants Div ision for Brig. Gen. Hugh J. Morgan, 31 Mar. 1945, subject: Trench Foot Studies.
81
tect themselves, they must be thoroughly educated and informed on the subject before these weather conditions are encountered. Training troops on a subject of this type after they are engaged in intensive combat is less effective than training them during a period prior to such action. The main concern of men engaged in combat is the preservation of their lives. Attempts to teach men under such conditions measures for preventing trench foot, which to them is seemingly unimportant at the moment, are not likely to meet with any great degree of success.
For all practical purposes, this quotation summarizes the experience of the United States Army with cold injury in World War II and points the way to its prevention in any future war. No one realized the significance of this type of injury early in the war. Many did not appreciate it until very late. The Surgical Consultants Division, in the Office of the Surgeon General, first appreciated the danger and for some time was the only division of that office to study and report cold injury and to recommend the appropriate command and staff action.
The prevention of trenchfoot, as has been repeatedly stated, is primarily a command, not a medical, responsibility. Higher command and staff echelons were in the beginning almost totally unaware of the medicomilitary dangers of cold injury. Until losses from it became serious, they did not fully accept their responsibilities for it.
The Surgeon General had the responsibility for the health and medical care of the Army, but he could normally convey his recommendations to the highest echelons of the War Department only through what were, in effect, command and logistic channels. By virtue of his position on the staff of the Commanding General, Army Services Forces, he was responsible to, and reported to, that officer. As a consequence, he had, as a rule, little direct access to the Chief of Staff or to the Secretary of War.
An additional difficulty arose from the fact that the activities of The Surgeon General and, indeed of the entire Medical Department, were, of necessity, closely allied with logistics. Frequently, and for obvious reasons, logistic personnel without medical knowledge failed to realize that medical care, in its broadest definition, cannot be placed in the same status, or administered in the same fashion, as rations or ammunition.
In the opinion of many observers, the situation just described considerably reduced The Surgeon General's authority and diminished the effectiveness of such actions as he could take or recommend. This fact unquestionably played a part in the cold injury epidemics which occurred in World War II. Close liaison did not exist between his office and that of the Chief of Staff. When The Surgeon General made recommendations pertaining to the prevention of cold injury, they normally reached the Chief of Staff or the Secretary of War only through command channels, that is, through the Commanding General, Army Service Forces. Considerable evidence exists to show that until planning for the final operations in the Pacific was begun The Surgeon General's numerous warnings did not reach higher authority and that none of them reached the theaters of operations. It is quite conceivable that,, if these plainly worded
82
warnings, many of which antedated the official publications (WD Circular No. 312 and TB MED 81), had fulfilled their purpose, the incidence of cold injury might have been a great deal lower than it was.
Many of the medical lessons of World War I, like many of the strictly military lessons, had to be relearned in World War II because the experiences of the First World War were ignored. That was true of cold injury. Eventually, but only after grave losses had been suffered in the Aleutian Islands campaign and in the Mediterranean and European theaters, measures of prevention and control were instituted, and training in trenchfoot prevention became part of the training program of Army Ground Forces. All concerned must accept the responsibility for failure to institute them early enough to prevent most of the thousands of casualties which occurred from this cause during World War II. The influence of the Medical Department was exerted toward this end earlier than that of any other branch of service and was also exerted more continuously. The Surgeon General, however, was handicapped by the anomalous position which he occupied in respect to higher authority. Whether a greater effort should have been made to exert such influence as he possessed is a matter for debate. In retrospect, it seems that a more vigorous effort probably should have been made.
