CHAPTER VII
European Theater of Operations
Statistics collected during World War II indicate that approximately 46,000 cases of cold injury occurred in ETOUSA (European Theater of Operations, United States Army) during the fall and winter of 1944-45. This was about 5 percent of all admissions to medical treatment. The more complete statistics now available, which include not only cases of cold injury without other injuries but cases which occurred in association with other injuries, bring the number of casualties from this cause in the European theater to approximately 71,000 cases (p.494).
Other armies which fought in Europe had no such incidence of cold trauma. Even when British troops fought under co editions very similar to those under which United States Army troops fought, their incidence of cold injury was negligible (p.198).
The purpose of this chapter is twofold: (1) To tell the complete story of cold injury as it was encountered in ETOUSA during World War II, and (2) to attempt, as far as possible, to explain why cold injury occurred in this theater in what was truly an epidemic form.
There are a great many explanations for what happened, some of them more valid than others. If, however, the premise be accepted that cold injury is largely preventable, there is no real excuse for what happened. This is neither a new nor an unreasonable point of view. It was the considered opinion for instance, of the General Board, United States Forces, European theater (p.208), which concluded its study of cold injury in that theater as follows:
29. Cold injury, ground type, is to a great extent preventable.
30. The relatively high incidence of cold injury * * * in the European Theater of Operations was due to inadequacy of clothing and footgear of types suitable for winter operation, unfavorable operational conditions and to the delay of many units in instituting a program with emphasis on and close supervision of the measures to be taken by the individual soldier.
Of the three factors listed by the General Board in their report entitled "Trench Foot" (Medical Section Study No. 94), as responsible for the incidence of cold injury in the European theater in the winter of 1944-45, only one, unfavorable operational conditions, is not susceptible to reasonably complete control, and even this condition is susceptible of some modification (p.425).
If, however, there is no absolute excuse for the epidemics of cold injury which occurred in Europe, there are a number of reasons for them which will be set forth in more detail in the course of this chapter. It might be useful, for orientation purposes, to list and discuss briefly certain of these reasons in this
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introductory section, after stating that the fundamental and all-pervading reason was that the lessons of the past had not been learned or heeded.
There were three major immediate reasons for these epidemics: (1) Operational conditions, (2) inadequacy of clothing and footgear, and (3) delay in instituting a program for the prevention of cold injury, ground type.
As has been pointed out many times in this volume, the experiences of the Aleutians (p.83) and of the Mediterranean Theater of Operations (p.101) either were not understood or were not considered applicable to the European theater. Furthermore, early experience in the European theater was ignored. The high-altitude cold injuries which had originally beset the Eighth Air Force (p.130) were well under control by D-day, but the lessons implicit and explicit in them were not passed on to the Ground Forces, chiefly because there was as yet no general realization that all varieties of cold injury are of the same general etiology and are subject to the same general considerations of prevention and control.
The winter of 1944-45 was the coldest and wettest in years, and the wet cold, combined with the tactical situation (p.136), created precisely the conditions most favorable for the development of trenchfoot and frostbite. Moreover, two points of view prevailed about the possibility of a winter campaign in Europe, neither of them conducive to preparations for the prevention of cold injury. Historically, decisive military campaigns had not been fought in western Europe during the cold winter months. On the other hand, it was the opinion, at least in certain circles, during the summer and early fall of 1944, that the war would end before winter. Thus, staffs were not psychologically attuned to the need for large supplies of special combat clothing, footgear, and other winterizing equipment (p.147), or to the necessity for an extensive program for the prevention and control of cold injury when there was time. A calculated risk also was taken by command decision to bring forward ammunition, gasoline, and other combat requirements to the exclusion of winter clothing and footgear.
For a number of reasons, clothing and footgear, which play an important part in the prevention of cold injury, therefore were not in adequate supply and were of inadequate design, as it turned out. When adequate supplies were finally received, they came too late to be entirely useful, and they were not always used efficiently because troops had not been trained in their use (p.160).
For some of the same reasons, the program of prevention which eventually was instituted comprehensively and effectively in the European theater was instituted too late to be as useful as it should have been (p.169). Troops locked in mortal combat are concerned with saving their lives, not with learning how to take care of their feet.
Other factors inherent in the rapid buildup of strength, the organization of theater and field forces, and the development of operational plans contributed to lack of attention to preparedness for cold trauma. On 31 May 1942, for example, there were only 34,350 United States Army troops in Europe; when the war ended, on 8 May 1945, the United States Army strength in the
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European theater totaled over 3,000,000 men under arms. This tremendous increase in strength involved hundreds of units, both large and small and in both combat and support roles. Efficient command and staff function to direct these units required repeated reorientation and sometimes reorganization of the higher theater headquarters, the integration of the several army headquarters into command structure, and the activation of lesser headquarters of the Communications Zone in the United Kingdom and, later, on the Continent. Inevitably, such expansion brought with it a shifting of key personnel and responsibilities.
The medical organization and personnel staffing understandably and necessarily underwent, in general, the same mushroom growth. As an example, from the meager nucleus of one medical officer who went to England with the Special Observers Group in May 1941, before the United States entered World War II, the total strength of the Medical Department in the European theater increased to 268,798 officers and men present in the theater on 30 April 1945.1 No expansion of such magnitude could fail to have its weaknesses as well as its strengths.
Medical planning for the invasion of the Continent did not include extensive planning for the prevention of cold injuries. The Manual of 'Therapy, issued shortly before D-day, mentioned them only casually, and the precautions suggested after exposure to cold and moisture were somewhat impractical for men in combat or about to be engaged. They included a foot bath with soap and water, massage of the feet for 20 minutes, dry socks, and a change of shoes. The medical officers who were responsible for the medical planning for the invasion and for the preparation of the Manual of Therapy had almost without exception never seen cold injury, and few of them, for that matter, had had any medical combat experience.
It is against this background that the history of cold injury in ETOUSA must be read and evaluated. Other things seemed, and indeed were, far more pressing than possible trauma from cold. As the troop strength of the theater increased, repeated reorganizations of various headquarters were necessary. A multiplicity of staffs were involved. There was constant preoccupation with urgent military and over-all medicomilitary needs, including tactical planning, training, supply, and other matters connected with the normal support of the largest military operation ever to be undertaken. Priorities of effort had to be devoted to day-by-day problems, most of them, or so it then seemed, of far greater urgency than the prevention of trenchfoot. Finally, there was general inexperience, on the part of all concerned, with both the medical and the military aspects of cold trauma.
All of these considerations must be borne in mind in the reading and evaluation of the unfortunate story of trenchfoot and frostbite in ETOUSA in the fall and winter of 1944-45. The lessons then learned greatly influenced the planning and preparations for combat in cold and wet weather in Japan
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I Strength of the Army, 1 May 1945. Prepared for War Department General Staff by Machine Records Branch Office of the Adjutant General, under direction of Statistical Branch.
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and other parts of the Far East (p.216). The European experience should always serve as a meaningful and instructive warning of the responsibility of staff, command, and medical and other technical services in preparation for all future military operations.
HIGH-ALTITUDE COLD INJURY IN THE EIGHTH AIR FORCE
Until the epidemics of cold injury occurred in the European theater in the fall and winter of 1944, frostbite among flying personnel had constituted the only important problem of this kind. Ground troops stationed in Ireland had encountered extremely cold weather, but under noncombat conditions, which in no way paralleled the conditions confronting troops on the Continent in the winter of 1944-45. The dangers which confronted the Army Air Forces were also not parallel to those which ground troops encountered, but certain aspects of the experience are sufficiently instructive to make it worthwhile to tell the story briefly.
Incidence
From the beginning of operations in Europe, in 1942, until the end of the fighting on the Continent, in May 1945, varying proportions of all casualties in airborne personnel of the Eighth Air Force could be attributed to high-altitude frostbite. It was pointed out in the August 1944 issue of Health 2 that, during the fiscal year 1943-44, more crew members returning from operational missions had sustained cold injuries than had sustained wounds from enemy action. These losses were serious. A third of all frostbite casualties required hospitalization, and, even when the injuries were mild, flying personnel had to be grounded for 4 to 14 days. A surgeon, speaking on the subject at a general hospital staff conference, warned that the situation constituted a real emergency, since many of the men hospitalized would not return to duty for months, if ever.
Annual reports for the years 1943, 1944, and 1945, by Col. (later Maj. Gen..) Malcolm C. Grow, MC, Surgeon, Eighth Air Force, contain analyses of the casualties from cold injuries, as follows:
For the 14-month period ending in December 1943, 1,634 men were removed from flying duty because of cold injuries incurred on high-altitude operational missions. Over the same period, 1,207 men were removed from flying duty because of injuries incurred in action against the enemy. In 1943, each casualty from cold injury lost an average of 10.5 days from flying duty, and 7 percent, according to an analysis of a sample of 200 consecutive casualties from this cause, were permanently lost to airborne crewmen.
In 1944, although the numbers of casualties from all causes increased as the rate of combat was stepped up, the situation in respect to cold injury was considerably improved; 1,685 men were lost from this cause in a total of 3,158 men
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2 Monthly Progress Report, Army Service Forces, War Department, 31 Aug. 1944, Section 7: Health.
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removed from flying duty. The average number of days lost from duty because of cold injury fell to 4.7.
In 1945, the situation was still further improved. Between 1 January and the end of the fighting on 8 May, there were only 151 injuries from high-altitude cold in 149 crewmen, compared with 3,852 injuries from combat missiles.
Causes of Cold Injury
The occurrence of high-altitude cold injury was found, on analysis, to be related to a number of considerations. Some of them were obvious, such as the season of the year and the altitude. Most of the missions were carried out about 25,000 feet above sea level, where the free-air temperature, using December 1943 as an illustration, ranged from 22.4? to -45.4? F. (-30.2? to -43.6? C.). In 1944, temperatures as low as -60? F. (-51.1? C.) were encountered.
The position of the crew members in the plane had much to do both with their chances of contracting cold injury and with the location of the injury. In heavy bombers, waist, tail, and ball-turret gunners were particularly vulnerable. The two waist gunners occupied the most exposed position. Injuries from wind blast were frequent for several reasons. The wind entered through openings for gun mounts. The gunners removed the gun-cover assembly because it interfered with the operation of their guns. They left the waist hatch open for the same reason, as well as to reduce chances of surprise by enemy bombers. The radio operator also left the hatch open to avoid surprise.
In 1943, waist gunners and radio operators sustained considerably more frostbite of the face, neck, and ears than men in other positions, though injuries in these locations influenced losses from duty less than did injuries of the hands and feet. The upper-turret and ball-turret gunners were particularly likely to sustain injuries of the feet. Tail gunners suffered heavily from frostbite of the hands and feet but more often sustained frostbite of the face, neck, and ears. Ball-turret gunners suffered equally from frostbite of the hands and face but more heavily from injuries of the feet. Gunners in any position who removed their gloves to clean jammed guns or to change ammunition belts were instantly frostbitten when they touched cold metal with their bare hands.
During 1943, gunners in the waist, tail, ball turret, and upper turret of bombers, together with the radio operator, sustained 75 percent of all injuries from frostbite in the United States Army Air Forces in Europe. Gunners whose position was not stated in the reports sustained another 8 percent of cold injuries.3 Waist gunners and tail gunners sustained 64 percent of all cold injuries. The number of casualties was reduced as time passed, but their proportionate distribution among crewmen (lid not alter materially during the war.
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3 Data on frostbite casualties were secured from the Weekly Care of the Flyer and Statistical Report rendered by group surgeons, who were required, as far as was practical, to state the cause of the injury, the part of the body affected, and the position of the injured man on the plane. Only frostbite severe enough to cause removal from flying duty was considered in these reports.
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In 1945, the waist, tail, and ball-turret gunners sustained 99 of the 151 separate cold injuries which were reported, roughly two-thirds of the total number.
Up to July 1943, injuries of the hands accounted for more than half of all cold injuries in the Eighth Air Force (table 7) and injuries of the face, neck, and ears to less than a fifth. Thereafter, the proportions were reversed, and injuries of the face, neck, and ears accounted for the majority of these injuries. This was a decided improvement, since, as has been pointed out, injuries in these areas were less serious in terms of manpower losses.
TABLE 7.- Changing bodily sites of high-altitude frostbite, 1942-45, Eighth Air Force
The largest single cause of high-altitude frostbite was wind blast, which was responsible for 39 percent of all cases in the 14-month period ending in December 1943 and for almost 55 percent of all cases in 1944. The remaining cases were due chiefly to lack of equipment, failure of equipment, and removal of equipment which should have continued in use. The first few months of aerial warfare in Europe clearly revealed that Air Force personnel, including medical personnel, had not been adequately trained in the prevention of cold injury. They had been fully alerted to such dangers as flak and air collisions, but most of them did not know how to protect themselves against the dangers of cold, nor, because they had not been instructed in its use, did they know the proper use of the equipment supplied to them. The highest incidence of cold injury occurred in new groups and in replacement crews in older groups; these men had not been trained in prevention and did not understand the use and maintenance of protective clothing.
Corrective and Preventive Measures
When once the factors contributing to the severe losses from high-altitude frostbite were understood, corrective measures were promptly instituted. An intensive investigation was carried out in March 1943, after a sharp increase in casualties from this cause had occurred in February. One of the principal causes was found to be shortages of electrically heated boots and gloves. Until additional American equipment could be supplied, the difficulty was tempo-
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rarily relieved by modification of gloves and boots used by British airmen to permit their use with American flying suits. The investigation in March 1943 also revealed that failure of electricity in the planes was responsible for some failures of equipment, that large numbers of injuries were occurring because portions of the face and neck were unprotected, and that casualties in heavy bombardment aircraft were suffering from cold injury after wounding because of lack of warm blankets. It was also found that crewmen who occupied protected positions not infrequently suffered cold injuries from wind blast after damage to the plane by enemy missiles.
After these discoveries, a number of new items of equipment were devised by the Air Surgeon's Office and other service departments, working in cooperation. Among these new items were the following:
1. Protectors for the face and neck, so designed as to cover the oxygen mask. The crewmen had previously complained that the face masks supplied interfered with the use of the new type of oxygen mask and were also impractical because they allowed the goggles to cloud over.
2. A small, mufflike heated unit into which hands and feet could be inserted if the standard gloves and boots became useless because of failure of the plane's electrical system.
3. Electrically heated canvas bags, several of which were supplied to each heavy bomber, to keep the wounded warm, reduce shock, and prevent further cold injury.
4. Electrically heated blankets for the wounded to use if their electrically heated flying suits had to be cut away to control hemorrhage or if the heating system of the plane was destroyed by enemy action.
5. Warm, light, and flexible gloves (devised by the surgeon of the Eighth Air Force), which did not have to be removed to release jammed guns. The men were warned that their hands would be frostbitten if they removed their gloves, and it was demonstrated to them that a locked gun could usually be released just as readily with gloved as with ungloved hands.
During 1944, personal equipment was generally satisfactory, though early in the year there were some shortages in particular sizes, both large and small, of heated gloves and shoes, and not all the items supplied were satisfactory in either design or durability.
The investigation carried out in March 1943 revealed, as has been noted, many shortages, inadequacies, and failures of protective equipment. Originally, the maintenance of protective equipment had been among the numerous duties of the assistant squadron operations officers, who had neither the time nor the training for this task. On 19 March 1943, a directive was issued authorizing the assignment of equipment officers in each combat unit. These officers were trained by the Central Medical Establishment, Eighth Air Force, in 2-week courses. The first class, for 5 officers, was completed on 29 March; by the end of 1943, 275 officers had been trained in 23 classes.
The duties of these officers, who worked in close cooperation with medical officers, were as follows: (1) To provide facilities for drying, testing, and storing
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all flying clothing; (2) to provide means for checking oxygen masks and systems; (3) to assist in all matters pertaining to procurement and alteration of protective flying equipment; and (4) to train airborne personnel in the correct use and maintenance of personal protective equipment.
After each command, division, group, and squadron had appointed equipment officers and these officers had been trained, problems arising from deficiencies and failures of protective equipment promptly decreased. During the latter part of 1944, a demand arose for special training of the enlisted men who assisted the equipment officers. Courses for them were organized at the Central Medical Establishment and were continued until eight enlisted men had been trained in each combat group.
Certain changes were also made in the aircraft themselves. By March 1944, most operational planes had been equipped with a modified closed radio room and modified gun hatches and waist window. Since the number of men who could wear electrically heated suits depended upon the amount of electricity available from the plane generators, the capacity of the generators was increased. The heating systems in bombers were also improved.
Educational training.- Lectures and demonstrations were given on a regular schedule to cover deficiencies in training. The subjects included first aid and methods of preventing cold injuries and anoxia. The proper use of flying clothing, especially electrically heated clothing, was explained and demonstrated. Educational charts to show the various stages of high-altitude frostbite, its symptoms and signs, and methods of management were prepared by the Medical Department and equipment officers under the general direction of the theater senior consultant in neurosurgery, Lt. Col. (later Col.) Loyal Davis, MC. These charts were distributed to all divisions, groups, and squadrons likely to be exposed to cold injury and were given routinely thereafter to all new units as they arrived in the theater.
There was considerable discussion concerning whether or not photographs showing the end results of high-altitude cold injury (that is, gangrene and amputation) should be used in the educational program. Eventually, the distribution of these photographs was limited to medical officers.
Special Investigations
In a memorandum dated 15 February 1943, Colonel Davis called the attention of Brig. Gen. (later Maj. Gen.) Paul R. Hawley, Chief Surgeon, ETOUSA, to a preliminary study of 14 cases of high-altitude frostbite which had been conducted on the neurosurgical service of the 2d General Hospital between 30 January and 9 February 1943. General Hawley sent this report to Colonel Grow, and arrangements were made to assign a neurosurgeon from the 2d General Hospital to temporary duty at one of the airfields, to permit immediate study of cold injuries in returning flying personnel.4
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4 Letter, Lt. Col. Loyal Davis, MC, Senior Consultant in Neurological Surgery, to Brig. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, 15 Fet. 1943, subject: Damage to the Extremities From Cold Among Flying Personnel of United States Army Air Forces.
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Somewhat later, arrangements were made to transfer high-altitude cold injury casualties directly to the 2d General Hospital for special studies.5 It is both interesting and significant that it was necessary to call the attention of all concerned to the fact that Circular Letter No. 12, dated 20 January 1943, Office of the Chief Surgeon, ETOUSA, although it dealt specifically with immersion foot, applied equally to injuries from high-altitude cold to Air Force personnel. Until this concept was appreciated and other details were clarified, transfers of cold injury casualties to the hospital were delayed, and, because of the delay, many of the opportunities for investigation, particularly early investigation, of these injuries were nullified.
By 31 August 1943, studies had been carried out on 93 high-altitude cold injuries in 86 patients; 57 injuries were on the hands and 25, including 6 caused by immersion, were on the feet.6 The investigations covered the circumstances of injury, the factors contributing to the injury, complete clinical details, skin-temperature studies, capillary microscopy, oscillometry, studies of sweating, and sensory reactions to injury.7 A complete photographic record, including colored photographs, was made in each case, and each patient was personally observed by Colonel Davis, who had himself gone on a practice raid mission to study the clinical effects of cold at 13,000 feet.
By 9 May 1943, it was noted that the number of casualties being admitted to the 2d General Hospital for high-altitude frostbite were beginning to decline, presumably because of insistence upon examination of equipment before missions and the enforcement of other preventive measures.
The clinical observations made in the course of this study and other considerations of cold injury sustained at high altitudes are discussed elsewhere (p.13).
Summary
Because of the analysis of the situation and the various preventive and educational measures instituted, the problem of high-altitude cold injuries in the Eighth Air Force was well under control by the time that France was invaded on 6 June 1944. The lessons thus learned, however, were not passed on to the Ground Forces in the European theater, apparently chiefly because of the general failure to appreciate the fact that cold injuries sustained in high-altitude flights could have any relation to cold injuries sustained in ground fighting. The fundamental error was failure to appreciate that all cold injuries are merely separate phases of a single pathologic process, differing from each other in severity and rate of development but in no other way. Both high-altitude frostbite and the ground type of cold injury which occurred later were caused by the same etiologic factors and were brought under control by
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5 Memorandum, Maj. J. E. Scarf], for Chief, Professional Services Division, Office of the Chief Surgeon, ETOUSA, 22 Dec. 1043, subject: Hospitalization of Cases Suffering from High Altitude Frostbite.
6 Memorandum, Lt. Col. Loyal Davis for Chief Surgeon, ETOUSA 31 Aug. 1943, subject: Incidence of Cases of Cold Damage to the Tissues.
7 Letter, Lt. Col. Loyal Davis, NIC, Senior Consultant in Neurological Surgery, to Brig. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, 14 June 1943, subject: Cold Damage to Extremities.
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FIGURE 31.- A. Infantrymen pushing jeep and trailer along muddy road in France, November 1944. B. Infantryman bailing out his dugout.
the application of much the same epidemiologic principles. Hence, had the lessons of the Air Force experience been properly disseminated and utilized, they might have prevented many of the cold injuries which caused such heavy losses during the ground fighting in the winter of 1944-45.
TACTICAL AND ENVIRONMENTAL CONSIDERATIONS
The story of the ground type of cold injury in ETOUSA in 1944-45 begins just about the time that the pursuit of the German armies across France after D-day ended at the Siegfried Line and combat conditions had become more or less static. This was the middle of October 1944. Occasional cases of cold injury had been reported before this time (p.138), but they were sporadic and their possible significance was not generally appreciated.
Up to 8 November, the front was comparatively quiet. On that date, the Third U. S. Army began a heavy drive to the east, in environmental circumstances highly favorable for the development of the ground type of cold injury. The weather on the Continent, which had been almost ideal from the beginning of the invasion until the end of September, then began to change. It proved to be the wettest winter, as well as the coldest, that Europe had experienced in 30 years. The heavy rains which began early in October con-
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tinued throughout the month. On the Third U. S. Army front, it rained 28 of the 31 days.8
The offensive was conducted in large part over wet and flooded terrain (fig.31) and required the crossing of major rivers. The Moselle and other rivers were high because of the immoderate rains. By November, flood conditions had become general in all army areas. Fields and roads were water soaked, and irrigation ditches and small streams as well as rivers were all overflowing. The weather was always cold, and cold injuries, in the form of trench-foot, occurred in great numbers.
A major counterattack was begun in the Ardennes by German forces on 16 December. For the preceding several days, the weather had been extremely cold, and the intense cold, combined with heavy fighting, often under adverse circumstances (fig.32), produced a second major outbreak of cold injury, this time with more injuries in the form of frostbite.
FIGURE 32.-2d Division infantrymen, 9th Regiment, First U. S. Army crouch in a snow-filled ditch, seeking shelter from a German artillery barrage during the Battle of the Bulge.
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6 United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies, September 1944-May 1945, vol. II. [In preparation.]
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With the termination of the Battle of the Bulge, in January 1945, the German threat to the Western Front was, for all practical purposes, at an end. Thereafter, the tactical situation, as the result of an Allied counteroffensive, could best be described as the renewed pursuit of the German armies across Europe into the heart of Germany, the pursuit continuing until V-E Day, 8 May 1945.
Between 19 December 1944 and 31 January 1945, the average maximum temperature on the fighting front in Europe was 33.5? F. (0.83? C.), and the average minimum temperature 22.6? F. (-5.2? C.). The element of wetness, which had been responsible for the initial outbreak of cold injury in November, was absent during this period.
The cold began to moderate during the last days of January, and the thaw which set in on 1. February again altered the environment. Wetness now predominated, and the ground type of cold injury which occurred at this time was, as in the first outbreak, chiefly trenchfoot.
INCIDENCE
As the preceding brief summary of tactical and climatic conditions shows the development and prevalence of cold injury in ETOUSA in the winter of 1944-45 were clearly related to the degree of combat activity and to the environmental circumstances and changed as these conditions changed.
Cold injury did not become epidemic until the middle of November, though sporadic cases had been reported earlier. The first case of trenchfoot appeared on 27 August 1944, in a hospital unit attached to the Third U. S. Army.9 By 12 October, 25 or 30 cases were reported in the 35th Infantry Division, Third U. S. Army.10 Some of them, which were attributed to lack of overshoes, had occurred as early as 6 October. Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA, noted in his official diary on 14 December that there had been no report of cold injury during the week ending on 27 September but that 140 cases had been reported for the week ending on 8 October and 320 had been reported for the following week.
For the week ending on 3 November, 17 cases were reported in the First U. S. Army, 1 in the Ninth U. S. Army, and 184 in the Seventh U. S. Army, the total number recorded for this week being 202.11 Fifty percent of the cases in the Seventh U. S. Army were recurrences in men who had suffered from cold injury in Italy the previous year.
The total number of cases for the week ending on 10 November was 823 and for the following week 5,386. This was the peak of the epidemic, and for
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s Reported in Annual Report, Medical Activities in the First U. S. Army, 1944.
10 Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley, Surgeon, Third U. S. Army, 12 Oct. 1944.
I1 Administrative and Logistical History of the Medical Service, Communications Zone, ETOUSA, vol. 14, ch 16. [Official record.]
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the next several weeks there was a progressive decline in the number of cases.12 The Third U. S. Army, which had had the largest number of cases, experienced the most precipitous decline. In the First U. S. Army, which had had the second largest number, the curve was also downward, but the decline was more gradual. In the Seventh and Ninth U. S. Armies, the pattern of the curves was similar to that of the other armies but was generally much lower. Early in December, the rates for the theater as a whole were only a fifth of the maximum rates, and it was thought that the situation was under control.13
When the Germans attacked in the middle of December, in what came to be known as the Battle of the Bulge, the number of cases of cold injury again increased sharply. The peak incidence, 3,213 cases, occurred in the week ending on 29 December 1944.14 The maximum number of cases in the December outbreak occurred in the First and Third U. S. Armies, which were most heavily engaged. In the Seventh and Ninth U. S. Armies, the upward swings were less sharp.15 Neither in this epidemic nor in the later outbreak in January did the number of cases per week approximate the 5,386 cases which occurred during the week ending on 17 November.
In contrast; to the November outbreak of cold injury, which had taken the form of trenchfoot, in the December outbreak many cold injuries were in the form of frostbite. The cold was intense and the ground frozen, so that wetness was not a factor. This was a new and different experience, which the troops were not fitted to cope with. The men in all sectors of the battlefield had less time to care for themselves, and particular factors operated to increase the incidence in particular divisions and special smaller units. Even the best trained divisions had trouble during this period.
The decline in incidence which followed the epidemic in December 1944 was followed by another sharp upswing, beginning in the week ending on 12 January, when the weather again became extremely severe, with freezing temperatures and heavy falls of snow.16 Again, many of the cold injuries took the form of frostbite. During this epidemic a new factor entered the situation; namely, the large number of raw and inexperienced replacements (p. 171) who had to be thrown into battle because of the manpower losses which had occurred during this critical period.
The incidence of cold injury continued high, with only minor variations, between the week ending on 12 January and the week ending on 9 February, though, after the thaw that began on 1 February, the character of the epidemic changed and trenchfoot again became predominant. At no time during this period were fewer than 3,000 cases reported each week.
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12 Coded Message CM-IN-E82072, Office of Chief Surgeon, Headquarters, Communications Zone, ETOUSA, to War Department (signed Eisenhower to Kirk from Lee). 3 Jan. 1945.
13 (1) Diary, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, 9 Dec. 1944, subject: Incidence of Trench Foot. (2) Coded Message, CM-IN, Headquarters, Communications Zone, ETOUSA, to War Department (signed Eisenhower to Surles for Houston from Lee), 18 Dec. 1944.
14 See footnote 11, p. 138.
15 Gordon, John E.: A History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45, vol. II, pt. 10, p. 46. [Official record.]
16 See footnote 11. p. 138.
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As the weather began to moderate and combat activity became lighter, the incidence of cold injury again began to decline. This time the decrease was permanent. There were 1,643 cases in the week ending 16 February but only 596 the following week. The peak incidence during March, 888 cases, was in the week ending on 9 March. In the week ending on 30 March, there were only 108 cases, and the total number of cases in April was only 230. Except under special, local circumstances, almost all of the cases which occurred after the middle of February 1945 were instances of trenchfoot.
What happened in the European theater during the winter of 1944-45 has been variously described. It is nowhere better summed up than in a comment in the annual report of the Surgeon, VII Corps, dated 26 January 1945. "Trench foot," he wrote, "appearing sporadically around the first of November, has become like a plague over the First Army front." His description was applicable to the entire frontline.
Variations in incidence.- Although cold injury was always almost exclusively a problem of armies in the field, there was considerable difference at all times during the winter in the incidences reported by armies, divisions, and smaller units. Generally speaking, the Third and First U. S. Armies, which had extremely heavy and difficult combat assignments, had the greatest amount of cold injury. On the other hand, combat activity did not tell the whole story. This was particularly evident when the records of smaller units were examined. Some divisions always had good records; this, however, does not necessarily mean that they were always free from cold injury. The 30th Infantry Division, First U. S. Army, for instance, was an old, seasoned unit, with a well-developed system of foot discipline, and its command had long appreciated the significance of the possible occurrence of cold injury in combat infantrymen.17 Only when tactical circumstances were entirely beyond control did this division have an appreciable amount. Some divisions, in contrast, had records that were almost consistently bad, regardless of the degree of combat activity. Investigation of the situation in these divisions almost invariably brought to light conditions which could be improved. It was in this sort of investigation and counseling that trenchfoot-control teams (p.177) had their greatest field of usefulness.
Variations between units were apparent when the trenchfoot incidence was low as well as when it was high. The Ninth U. S. Army, for instance, had relatively little cold injury because it was less actively engaged than the First and Third U. S. Armies, but its units nonetheless showed the same types of variations as were apparent in those armies.
Incidence according to services.- Because cold injury is so overwhelmingly a disease of frontline infantrymen, it is not always realized that it can also occur in other troops when conditions are favorable for its development. Col. John E. Gordon, MC, Chief, Preventive Medicine Service, Office of the Chief
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17 See footnote 15, p. 139.
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Surgeon, ETOUSA, noted in his report of 22 November 1944 that the bulk of the cases reported up to that time (1,167) had occurred in the Infantry but that cases had occurred also in the Engineer, Field Artillery, Tank Corps, Quartermaster Corps, Cavalry Reconnaissance, Antiaircraft, Tank Destroyer, Ordnance, Antitank, Signal, and Military Police units. On 30 November, cold injury was reported in troops staging in rear areas, presumably because of their lack of overshoes and shoepacs.18 In February 1945, there was an alarming number of cases at a large staging area in the Channel Base Section.19 The outbreak was promptly halted by the provision of proper footgear and other equipment and by strict enforcement of preventive measures.
Cold injury among replacements (reinforcements) furnished a special problem, which is discussed later, under a separate heading (p.171).
Impact of cold injury.- The impact of cold injury in a combat theater is discussed in detail elsewhere, but a few facts may profitably be repeated here because the details are, in many respects, even more overwhelming than the total incidence. The data have been gathered from correspondence, official diaries, and formal and informal memorandums of various kinds.
In November 1944, for instance, the 79th Infantry Division, Seventh U. S. Army, had 1,400 battle casualties and 210 casualties from trenchfoot. For the week ending 25 November, for every 100 battle casualties evacuated from the Third U. S. Army, 60 soldiers were evacuated for cold injury. The medical officer who conveyed this information to Lt. Gen. (later Gen.) George S. Patton, Commanding General, Third U. S. Army, noted that trenchfoot was doing quite as much damage to the Allied cause as was the enemy because of the duration of the disability and its tendency to recur when exposure was again experienced.
Losses of 10 and 15 percent, or more, of the strength of single units were not unusual. During the Lorraine campaign,20 in November 1944, the 328th Infantry Regiment had to evacuate more than 500 men as casualties from trenchfoot and exposure during the first 4 days of one engagement; this number exceeded the number of battle casualties. During the drive into Metz, one company of the 11th Infantry Regiment had only 14 men available for duty chiefly because of losses from trenchfoot. During the 3-day battle to penetrate the Orscholz Line, the mounting toll of trenchfoot casualties, combined with battle casualties, made it impossible for the 358th Infantry Regiment to continue the attack. In all, it lost about 60 percent of its effective strength. The 357th Infantry Regiment was also so weakened from the same causes that it had to be withdrawn. At one time, the 1st Battalion was in such a precarious state that men whose feet were too swollen from trenchfoot to permit them to walk had to be carried by their comrades to forward foxholes.
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18 Essential Technical Medical Data, Headquarters, ETOUSA, for October 1944, P. 17.
19 Semiannual Report, Channel Base Section, Communications Zone, ETOUSA, 1 Jan. 1945-1 July 1945.
20 United States Army in World War II. The European Theater of Operations. The Lorraine Campaign. Washington: U. S. Government Printing Office, 1950.
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During November and December 1944, the total number of cases of cold injury on the Western Front was more than 23,000. In terms of numbers, this was about an infantry division and a half. In terms of combat riflemen (4,000 to the division), the loss amounted to about 5%% divisions.
In his book, a Soldier's Story, Gen. Omar N. Bradley, Commanding General, 12th Army Group, presents the military interpretation of these losses. By the end of January 1945, he wrote, cold injury had seriously crippled the United States fighting strength in Europe. The malady had come upon the armies unawares, partly because the possibility of its occurrence had been ignored. By the time the troops had been disciplined in the care and treatment of wet feet, trenchfoot had the effect of a plague. Previous combat had shown that casualties from this cause occur chiefly in rifle platoons, the handful of troops who must advance under fire and who have less chance of survival than men in any other of the combat arms. Before the invasion, it had been estimated that the infantry would incur 70 percent of the combat losses. By August 1944, that estimate had been raised to 83 percent. Actually, because 3 of every 4 casualties occurred in rifle platoons, the rate of loss in them exceeded 90 percent. Trenchfoot, though listed as a nonbattle loss, exacted its heaviest toll among riflemen in the line, where every casualty sapped assault strength and thus weakened the offensive.
Medical officers had estimated, General Bradley added, that by far the greatest number of the thousands of soldiers with trenchfoot who were evacuated from the frontlines could never return to combat, and they had also predicted that some of these casualties would be incapacitated for life.
The impact of trenchfoot upon hospitals and hospitalization was also extremely serious. Between 10 October and 28 November 1944, 11,348 trenchfoot casualties were admitted to 6 general hospitals in the Paris area from the First, Third, Seventh, and Ninth U. S. Armies.21 For the 4-week period ending 24 November, for every 100 battle casualties admitted to these hospitals the weekly number of trenchfoot admissions was, respectively, 5, 10, 55, and. 54. These admissions represented, over the same period, 1.3 percent, 4 percent, 20 percent, and 24 percent, respectively, of the total hospital admissions. On one occasion, trenchfoot accounted for 602 (38 percent) of 1,581 medical admissions to the 23d General Hospital.22 It is not necessary to point out what such figures mean in terms of bed occupancy, medical attention, and nursing and other care. The situation, in fact, was generally much worse than it seemed on the surface.
A certain proportion of hospital admissions for trenchfoot were incorrect, though ordinarily the diagnostic error was well under 10 percent. Psychogenic causes explained some cases, but malingering, although it sometimes occurred, was surprisingly infrequent.
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21 Essential Technical Medical Data, Headquarters, ETOUSA, for December 1944.
22 Essential Technical Medical Data, Headquarters, ETOUSA, for November 1944.
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CLOTHING AND FOOTWEAR 23
Aside from any other considerations, the protection of the extremities against cold and wet cold depends upon two practices. One of these is general, the use of warm clothing which will keep the entire body warm. The other is local, the use of proper footgear which will keep the feet warm, without constriction. Combat necessities require that all items of clothing and footgear be of such construction that they do not interfere with rapid, unhampered movement of the soldier who is wearing them. These statements concern such elementary principles of protection against cold and wet cold, and thus of protection against cold injury, that they need not be elaborated upon. In addition, these principles are so closely connected with the medical aspects of exposure that they indicate why no apology is needed for the inclusion of a rather detailed discussion of clothing and footgear in a chapter dealing with cold injury in the European Theater of Operations in World War II.
The general situation with respect to clothing and footgear in this theater during the winter of 1944-45 may be summarized about as follows:
1. The clothing which had been introduced into the Mediterranean theater after the trenchfoot experience there in the winter of 1943-44 had been fully combat tested at the Anzio beachhead early in 1944, and a detailed, favorable report on it was available in the European theater by the end of June 1944. Observers from the Office of the Quartermaster General had been in the European theater for several weeks before this time and had the clothing available for demonstration. Their advice that it be adopted for use in the theater, to replace standard types of winter clothing, was not accepted by the theater chief quartermaster (p.145) . Although a change of mind finally occurred, stocks of the new models did not reach the theater until January 1945, and distribution was not accomplished until long after the urgent necessity had passed.
2. Orders for standard types of winter clothing were entirely inadequate because the strength of the field armies had not been correctly anticipated (p. 146).
3. Requisitions on the Zone of Interior for winter clothing were placed too late. The first bulk requisition did not leave the European theater until 15 August 1944. Sufficient consideration was never given to the timelag between submission of requisitions and eventual delivery of articles. A timelag is always inevitable, even in peacetime when the supply and delivery systems can be conducted with the greatest efficiency. It is far more prolonged in wartime when both production and transportation difficulties exist. Transportation difficulties prevailed in 1944 and 1945 not only between the Zone
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23 Except as otherwise indicated, all data concerning clothing and footwear in the European Theater of Operations are derived from the following three sources: (1) United States Army in World War II. The Technical Services. The Quartermaster Corps: Operations in the War Against Germany. [In preparation.] (2) United States Army in World War II. The Technical Services. The Quartermaster Corps: Organization, Supply, and Services. Washington: U. S. Government Printing Office, 1953, vol. I. (3) United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies, September 1944-May 1945, vol. II. [In preparation.]
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of Interior and the European theater but also from area to area on the Continent. where for several months ammunition and gasoline had first priority.
4. The multiplicity of styles and sizes in American battlegear made for difficulties of supply (p.149) . In spite of its complexity, however, the tariff of sizes, which was based on World War I estimates, was inadequate, particularly in the large sizes, in stocks of shoes and overshoes.
5. The belief current in some quarters in the late summer of 1944 that the war would be over before a winter campaign was necessary undoubtedly played a part both in the delay in ordering adequate winter supplies and in the acceptance of the new types of clothing and footgear.
What all of this added up to was that United States soldiers were improperly clothed and shod during the fall and winter of 1944-45 and that the epidemics of cold injury which occurred must be attributed, at least in part, to those deficiencies. The "pipeline obstacles" were numerous, but the shortages themselves "were in large part the result of poor planning and wishful thinking in the ETO and production difficulties in the Zone of Interior."
Clothing
Planning.- The Quartermaster General, as was his routine, sent Capt. (later Lt. Col.) William F. Pounder, Jr., QMC, to the European theater in March 1944 as an observer. Captain Pounder had the additional function of presenting the new winter M-1943 clothing, with a view to its use in the European theater. This clothing had been developed the previous year and had been thoroughly tested in the Mediterranean theater. As already mentioned, the report on the testing of this clothing at the Anzio beachhead was in the hands of the Chief Quartermaster, ETOUSA, by 25 June 1944. This was just about the time active planning was beginning for the provision of winter clothing for troops in the theater.
At this time, the clothing planned for the winter months (exclusive of footgear, which is discussed under a separate heading) was to consist of heavy wool underwear, olive-drab wool trousers and shirt, high-neck sweater, and wool ETO jacket. Service troops in rear areas would be provided with overcoats. Combat troops would wear herringbone-tweed jacket and trousers over the wool uniform. Although this equipment was intended for fighting in France and the Low Countries--areas notably wet, cold, and muddy--it was conspicuously lacking in water-repellent items.24
The uniform and equipment which Captain Pounder proposed, in line with his instructions from the Quartermaster General, consisted of heavy wool undershirt and underdrawers, wool field trousers, cotton field trousers, olive-drab wool shirt, high-neck sweater, wool ETO jacket, M-1943 jacket, olive-drab cotton field cap with visor, gloves consisting of a leather shell with wool insert, synthetic-resin poncho, wool sleeping bag with water-repellent case, and shelter
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24 Letter, Capt. Wm. F. Pounder, Office of the Chief Quartermaster, ETOUSA, to Col. Georges F. Doriot, Military Planning Division, Office of the Quartermaster General, 30 June 1944.
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half tent. In order to use up the large stocks then in the theater, it was recommended that wool overcoats be used if sufficient quantities of the M-1943 field jacket should not become available.
Theater personnel, in refusing these suggestions, stated that available stocks of herringbone trousers would take the place of the proposed cotton field trousers, which would be an additional rather than an essential item, and that the synthetic poncho would take the place of the M-1943 jacket, for which the supply situation was unfavorable. It was decided that the following items would be presented to Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, ETOUSA, for his approval for continental winter operations: Heavy wool undershirt and underdrawers, high-neck wool sweater, ETO wool jacket or olive-drab field jacket, field cotton cap, gloves with leather shell and wool insert, wool sleeping bag with water-repellent case, and wool muffler. Items not then in stock in the theater were to be requisitioned. Combat troops would wear herringbone jacket and trousers over the wool uniform. Service troops in rear areas would be equipped with overcoat or mackinaw.
Captain Pounder's request for permission to go to France to make observations of clothing and footgear in actual use in combat was not granted by General Littlejohn, and Captain Pounder returned to the United States.
The Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, also concerned itself with the question of winter clothing.25 In May 1944, at the suggestion of Colonel Gordon, a conference was held with the chief of the Research and Development Branch, Office of the Theater Chief Quartermaster, at which it was learned that the theater quartermaster considered that the problem of cold injury had been solved, as far as the feet were concerned, by the use of a combination of heavy socks and shoepacs. Both items were in production and would be ready in sufficient time to meet winter needs. The only additional item needed would be windbreaking clothing to wear over the regular winter clothing. The substance of this interview was reported to Colonel Gordon.
In July 1944, in a communication addressed to the theater chief quartermaster, Colonel Gordon pointed out the part which lack of proper winter clothing had played in the trenchfoot epidemic in Italy the previous winter.26 Correct clothing and footgear, he stated, would provide for maximum conservation of natural body warmth; would protect against wetness, which influences the conservation of general and local warmth; and would be without constriction. Immediate action was urged to agree upon details of procurement of the new and superior clothing and footgear which had been developed by the Quartermaster General after the Italian experience and otherwise to get the program under way.
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25 Memorandum for Record, Lt. Col. Paul Padget, MC, Preventive Medicine Division, Office of the Surgeon General, 26 Apr. 1945, subject: Early Interview Concerning Trench Foot Problem and Footwear-Contact With QM.
26 Under date of 6 June 1944, Captain Pounder was informed by the Military Planning Branch, Office of the Quartermaster General, that the Mediterranean theater had already submitted requisitions for the new winter clothing to be used in operations the following winter.
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The reply from the Office of the Chief Quartermaster on 10 August was to the effect that procurement had been initiated to provide clothing designed for maximum conservation of body warmth. There would be a general issue to all troops of the high-neck sweater and the olive-drab wool field jacket to be worn over it. Overcoats, raincoats, and the other usual items of clothing would be available, including wool sleeping bags with water-repellent cases for all personnel. For a typical field army, which then was estimated at 325,000 men, there would also be provided olive-drab cotton field trousers, a windproof and water-repellent garment to be worn outside the wool trousers, ponchos, mittens with inserts, and field caps.
Requisitions.- The first requisition from the European theater was sent to the New York Port of Embarkation on 15 August, the day southern France was invaded. The requirements for the initial issue and 90-day replacement were based on one field army and the attached troops. Half of the requisition was to be delivered in September and half in October. The Chief Quartermaster, ETOUSA, gave definite assurances that no further requirements would be made. On 21 August, the Office of the Quartermaster General questioned the low requirements which had been submitted and stated that, if they were correct, they would force immediate cutback in the production schedules of the supply program. On 5 September, the original requisitions were confirmed.
In Europe, meantime, there had been a growing appreciation of the possibility of cold injury during the forthcoming operations and of its possible consequences. Requests for winter clothing and complaints about deficiencies in supply were beginning to be received from armies in the field. The port of New York was advised of the increasing seriousness of the supply situation. The reply was that half of the 15 August requisition had been approved for immediate shipment but that the items could not be shipped for another 2 weeks, at least. The theater chief quartermaster was requested to review all woolen-clothing requirements, to make as many reductions as possible, and to support all further requirements by complete justification, the data to include lists of all stocks on hand. This request was based on the 1944 policy of the Army Service Forces, which was to cancel contracts for all items of which more than a 60-day supply was on hand.
To understand some of the clothing deficiencies which developed in ETOUSA, it is necessary to go back several months. When the strictly functional M-1943 sateen field jacket, which had been tested in the Mediterranean theater, was exhibited in the European theater, the chief quartermaster was not interested in it for a number of reasons. He doubted that a sufficient number could be produced in 1944. He was anxious to have all troops in the theater uniformly dressed, which would not be possible if his doubts about production were justified. Finally, all echelons in the theater, from high command down, had a strong preference for something like the British battle jacket, which was used for both field and dress purposes and which came to be known as the Eisenhower jacket. It was not the quartermaster's policy "to force these new items down the throat of troops."
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The M-1943 field jacket was therefore accepted in the theater for paratroops only, in spite of the War Department's insistence that this jacket, with the high-neck wool sweater, had been devised to replace the "limited standard field" jacket. The Quartermaster General doubted that without the new M-1943 jacket the troops would be adequately protected against cold weather and supported his statement by a study showing the advantages of this jacket over the wool overcoat for field troops. The commanding generals of the 12th Army Group and the First U. S. Army considered, however, that the overcoat was necessary for adequate warmth and that the Eisenhower field jacket with sweater was preferable to the M-1943 jacket and sweater combination. This decision was concurred in at SHAEF (Supreme Headquarters, Allied Expeditionary Force) .
On 17 March 1944, a requisition was cabled to the War Department for 4,259,000 wool field jackets of the Eisenhower type, to be delivered in the course of 1944. Arrangements were later made for the phased shipments of 2,600,000 in the last quarter of 1944. The theater chief quartermaster and the combat commanders in Europe were all so eager to have this battle jacket that they were reluctant to submit requisitions which would slow down its production. During the summer, they continued to accept substitutes for it, including the old Parsons style of field jacket and the wool-serge service blouse. Many difficulties, however, were encountered in the production of the Eisenhower jacket. Although 500,000 were supposed to leave New York in September, by 13 September only 116,000 had been shipped to the port, and only 14,000 had been dispatched to the European theater. The deficiency in the theater was estimated at more than a million jackets when cold weather began. Large supplies of the Eisenhower jacket eventually reached the theater in January and February 1945, but few of them were issued for combat use.
Even when shortages became apparent in the European theater, General Littlejohn did not, at first, include the M-1943 jacket in his requisitions for substitutes for the Eisenhower jacket. Final arrangements were not made to accept the M-1943 jacket until 10 November 1944, after it had become evident that the overcoat, which field commanders as well as the Office of the Chief Quartermaster had insisted was essential for combat troops, was not satisfactory. It was bulky, it was not water repellent, and troops in combat frequently discarded it in fast-moving situations. The M-1943 jackets which finally reached the theater arrived too late to be useful during the winter.
One reason for the slow pace of planning and requisitioning in the European theater was the belief in some quarters that the war would end before a combat uniform would be needed for winter operations. This feeling of optimism, although it was far from universal, began to develop even before the fall of Paris, and it increased during the late summer. The need, it was felt, would be for a dress uniform for the army of occupation. There seemed to be more concern with the appearance of the troops than with their protection from the weather. It was suggested that the troops of the First and Third U. S. Armies, which would occupy Germany, be outfitted first. Even after trenchfoot had
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appeared on the Continent, instructions were issued by the Supply Division, Office of the Chief Quartermaster, ETOUSA, to store in the United Kingdom the cold-climate clothing which arrived before the end of the year and to use Le Havre for whatever arrived later. As late as 31 October 1944, instructions were to pack light and dark trousers separately, so that they would not be issued indiscriminately, and the million ETO jackets received in the theater by the end of 1944 were held in the United Kingdom because the trousers which matched them (shade 33) were not available.
The situation on the Continent.- The tactical situation during the early stages of the invasion required that troops should carry as little as possible on their persons when they were landed on the far shore; the missing items of personal equipment were to be supplied later. The supply system for clothing and accessory equipment which had been planned was promptly put into operation and operated efficiently, but, while the needs of the troops were met, no surpluses of any consequence could be accumulated. Although clothing and personal equipment had a class II priority, it was not long before, for a number of reasons, difficulties began to develop. Illustrative of such difficulties were the following:
1. Because of the rapidity of the advance, all the attention was originally concentrated on the pressing demands for food, gasoline, and ammunition. What General Bradley described as a calculated risk (p.209) was therefore taken with respect to clothing and other winter equipment. It was not, in fact, until the swift pursuit of the Germans was halted and the weather began to change that demands were made for winterizing items. Earlier, class II priority requisitions had been filled only when they were accompanied by special authorizations.
2. The first requisitions from the theater were far too low. They were based on authorized allowances and replacement factors which proved entirely unrealistic, even though the Quartermaster General considered the later theater estimate-that replacement rates must be 2'/2 times those prescribed by the War Department-to be somewhat exaggerated. Unquestionably, however, nothing lasted as long as had been expected.
3. Shipping shortages played a large part in deficiencies of clothing and personal equipment. In August, only 29,000 tons of quartermaster supplies were received on the Continent, against an allocation of 55,000 tons. Port discharge deficiencies accounted for additional shortages. At the end of September, with only 14 berths available, 75 ships were offshore. At the end of October, with only 18 berths available, 80 ships were waiting to be unloaded.
4. An additional complication arose from the fact that the clothing was distributed over a number of ships, instead of having been loaded in single ships, as had been requested. Distribution was therefore impossible until balanced loads had been accumulated. During the interval, there was considerable loss from pilferage because warehouse facilities were inadequate, and there were also losses from damage by the elements. The picture, according
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to one account, was "one of vessels lying at anchor and backlogged supplies piled on piers in quantities which could frustrate the best logistical plan."
5. The opening of the Channel ports and of the port of Antwerp improved the situation but did not solve the problem of moving supplies inland. Rail and truck transportation continued in short supply. On 7 September, for instance, one division of the Third U. S. Army was more than a third short in clothing, especially shoes, shirts, trousers, underwear, socks, and overcoats, which were still in duffle bags on the landing beaches.27 It would have required 200 trucks to move these supplies, and the division could not provide the transportation. Up to 13 September, practically 80 percent of issues of clothing and equipment for the Third U. S. Army had been renovated salvage. The army quartermaster was warned by the army surgeon that if these shortages were not rapidly rectified, in view of the recent cold weather and continued rains, "a rapid and explosive increase" in the noneffective rate from trenchfoot and respiratory ailments could be expected.
Even after the port of Antwerp had been in operation for 2 months, the First U. S. Army had to send its own trucks to pick up winter clothing. Vehicles were in short supply, and 50 tons of supplies had to be left behind.
It was not until well into 1945 that these and similar difficulties were completely overcome. An attempt to solve the problem of supplies by airlift from the United Kingdom had not been effective. Of more than a thousand planeloads of emergency supplies brought to the Third U. S. Army airstrip at Briey during August and September 1944, only 44 carried clothing and personal equipment.
6. Still another difficulty had to do with sizing. The tariff provided for shoes in 90 sizes, the M-1943 field jacket in 25 sizes, trousers in 34 sizes, and shirts in 27 sizes. When the Army clothing was issued in November 1940 to the first selectees to be inducted, it was found that, in spite of the apparent liberality of the tariff, there were not enough items of the larger sizes to provide for the present generation of soldiers. The original tariff had been based on the World War I experience. Revisions in August 1941 and July 1942 improved the situation but did not fully correct it. In the fall and early winter of 1944, both high level reports and reports of individual units showed continuing shortages of certain popular sizes. This was particularly true of field jackets, olive-drab wool clothing, herringbone-tweed clothing, and footgear. These errors were not completely corrected until early in February 1945, too late, again, to influence the trenchfoot situation in the European theater.
7. Deficiencies in other cold-weather items paralleled the deficiencies in personal clothing. The authorized issue of four blankets per man, for instance, had been reduced to two, in the expectation that the improved sleeping bag would take the place of the other two. For this reason, no blankets were shipped from the Zone of Interior to the European theater in either August or September 1944. Two million sleeping bags had been expected in the
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27 (1) Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley, Surgeon. Third U. S. Army, 7 Sept. 1944. (2) After Action Report, Third U. S. Army, ETOUSA, 1 Aug. 1944-9 May 1945.
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theater by the end of September. By the middle of the month, only 57,721 had been delivered. On 17 September, when it became evident that requirements for sleeping bags could not be met, General Littlejohn called for every blanket in the United Kingdom to be sent to him by every available vehicle on the ground that lie had 400,000 prisoners of war to supply, as well as field armies. In all, he requested 4,000,000 blankets in September. The New York Port of Embarkation resumed shipments in October, and in the last quarter of 1944 more than 2? million blankets and 2,000,000 sleeping bags reached the European theater, though only after delays at every phase of the supply pipeline and again too late to prevent much of the cold injury which occurred.
The situation in respect to clothing in the European theater in 1944-45 can be summarized in a few sentences. Production snarls and transportation difficulties all along the line accounted for many shortages. The major responsibility, however, must be placed upon delays in planning for and requisitioning necessary items, underestimates of needs, and a refusal to accept new, efficient, field-tested items of winter clothing. If these items had been requisitioned in time, they could have been provided in sufficient quantities. The Quartermaster General repeatedly warned the theater that its requisitions were not adequate either in quantity or in the proper kind of wind-resistant, wet-resistant winter clothing. The mistaken belief that the war would end promptly and that winter clothing would be needed for an army of occupation and not for troops engaged in combat explained some shortages. As a result, when the new clothing became available in adequate quantities, the acute need for it had passed.
The only army in the European theater which was properly equipped for combat in the winter of 1944-45 was the Seventh U. S. Army, which fought in southern France and which had been equipped with the new uniform and with shoepacs through Mediterranean theater supply channels. This army had a great deal of cold injury, it is true, but a large part of it could be explained by recurrences in men who had suffered from cold injury the previous winter (p.382) .
Footgear
The course of events in regard to footgear during the winter of 1944-45 followed the pattern just described for clothing. Neither the combat boot nor the service shoe proved satisfactory. Shoepacs, which were recommended, were not accepted at all in the beginning and were ordered too late in the end. Overshoes (galoshes) were not provided in sufficient quantity nor in sufficiently large sizes and were not made on the proper lasts. Wool socks were not available in sufficient supply.
Boots and shoes.-Combat boots or service shoes were worn by almost all of the troops in the field, except the Seventh U. S. Army, until shoepacs became generally available late in January 1945. The Seventh U. S. Army, as already noted, had been equipped with them in the Mediterranean theater. The Quartermaster General's clothing representative in the European theater had
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written to the chief of the Research and Development Branch, Office of the Quartermaster General, before D-day, of the general dissatisfaction with both the combat boot and the service shoe. It was decided, however, to make no changes until there had been more field experience with these items. In the meantime, action was to be directed toward improving the fitting of the footwear at staging areas in the Zone of Interior.
Among the complaints made about the service shoe, in connection with cold injury, were the following: 28
1. It had to be worn with leggings and was therefore difficult to remove for foot care. In this respect, the combat boot, although it was open to many of the objections raised about the service shoe, was superior to it.
2. It was so constructed that even when it was fitted loosely, as it usually was not, there was very little room in the vamp. Because of the shape of the last, there was pressure across the top of the foot when heavy socks were worn, since there was no space between them and the overlying leather. The uppers were cut so scantily that even shoes which were fitted correctly could not be brought together by lacing without harmful constriction; this defect was exaggerated when extra socks were worn. General Hawley had examined patients with trenchfoot and had found marks of the shoelaces deep in the swollen tissues. This could not have happened with the British field boot, which was cut so generously that the uppers could be brought together from the time the shoe was first put on.
3. Both service shoes and combat boots were fitted too snugly, partly from the general desire to keep the feet trim in appearance, partly because only three widths were available, and partly because of carelessness in fitting. General Hawley remarked in this connection that in 30 years of Army service he had seldom seen shoes fitted with the care and expertness the function deserved.
4. Attempts to improve the situation were not very successful. Additional shoes were usually issued in the same size as the original pair, partly as a matter of routine and partly because of shortages of larger sizes. As with clothing, so with shoes, the tariffs were inadequate for the new generation of soldiers. By the middle of October, the First U. S. Army was complaining of a shortage of wide, large-sized combat boots. The committee appointed by the Chief Quartermaster, ETOUSA, to study the tariff reported that the existing War Department tariff should be revised to provide for more than twice as many E-width shoes and more than three times as many EE-width shoes as were then provided. These deficiencies occurred in spite of the fact that shoes were provided in 90 different size variants.
5. Shortages prevented replacement of shoes originally fitted, and repairs were slow. When the first trenchfoot outbreak occurred, many of the men had only a single pair of shoes, and some were still wearing the ones issued to them before D-day.
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28 (1) Report, General Board, United States Forces, European theater, Medical Section Study No. 94, subject: Trench Foot. (2) Report, Col. A. G. Duncan, QMC, Office of Chief Quartermaster, ETOUSA, to Maj. Gen. Paul R. Hawley, Chief Surgeon, 16 Apr. 1945, subject: Footwear and Socks for Use in the European Theater of Operations.
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6. The fact that shoes were originally fitted too snugly gave rise to a number of other consequences. The soldier's feet spread during combat training, and a shoe which had fitted him in civilian life no longer fitted him now. When the shoes became wet, the fit, because of shrinkage of the leather, was even snugger than it, had been originally. No provision at the original fitting had been made for the wearing of extra socks or heavier socks during cold weather, and the shoes were therefore too tight when these socks were used. When the shoes were removed for foot care and to change the socks, the feet swelled and it was difficult to replace a shoe which had been fitted snugly to begin with. The practical consequence, in the European theater, was that men were unwilling to remove their shoes to care for their feet.
7. Neither the combat boot nor the service shoe was waterproof or water resistant. The welt sole leaked, there was leakage at the seams, and the leather was permeable.
8. Dubbing was no solution to the problem, although it was supplied in lavish quantities. It did not make boots and shoes waterproof, and the men complained that it made their feet perspire because it shut out air and therefore kept their feet cold.
When in February 1945 a special investigation of the whole footgear situation was undertaken in the theater, the observer, who was an official of one of the large shoe companies, made substantially the same criticisms as those just listed.
Socks.- The sock difficulties in the European theater took two chief forms: The socks which were provided did not contain enough wool, and they were not available in sufficient quantities for men in the frontlines to receive clean, dry socks daily, a requirement which implied provision for washing and drying soiled socks, as well as an efficient system of exchange.
In March 1944, Col. (later Brig. Gen.) Georges F. Doriot, QMC, Chief, Research and Development Branch, Office of the Quartermaster General, wrote his observer in the European theater that Table of Equipment 21 then authorized one less pair of woolen socks per man than the experience in the Mediterranean theater had shown to be necessary. Another warning about the type of socks provided for United States troops came in April 1944. The theater chief quartermaster was then notified by the Professional Services Division, Office of the Chief Surgeon, that the chief consultant in surgery for the Norwegian Army in the United Kingdom considered that the socks worn by United States Army troops were fitted too tightly and did not contain a sufficient quantity of wool.
It has been related elsewhere (p.63) that when War Department Circular No. 31.2 was published in July 1944, there were several references to wool socks in it; the soldier was supposed to carry extra pairs on his person and to wear this type of sock in combat. Provision was to be made for a daily supply of clean, dry socks in each unit. It has also been noted (p.65) that the Commanding General, Army Service Forces, at the request of the Quartermaster General, notified all commanding officers at ports of embarkation that this
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circular was not to be construed as justification for an increase in the authorized allowances of wool socks. It is significant, in the light of the events of the following winter, that the European theater did not consider that the terms of the circular would have any effect upon the initial issue of this type of sock.
War Department Technical Bulletin (TB MED) 81 and the circular on foot care published in the European theater in October 1944 (p.164) prescribed that heavy woolen socks be worn, that an extra pair be carried, and that others be made available by daily exchange when troops were on duty for more than a few days in wet, cold regions. Cotton socks were to be used only for garrison duty.
When the footwear representative of the War Production Board surveyed the situation in the theater in February 1945, he was even more specific in his recommendations.29 He thought that neither light wool socks nor cotton socks should be issued at all to combat troops, though he granted that, until shortages of heavy wool socks could be overcome, the light wool socks, which were in oversupply, would have to be used, as a matter of expediency. He recommended that, as soon as it was possible, supplies be limited to heavy wool socks, cushion-sole wool socks, and ski socks. He also stressed the point, already discussed, that the wearing of two pairs of socks was useful only if the shoes were fitted with this in mind. Otherwise, the practice was actually harmful because of the constriction produced and the resulting embarrassment of the circulation in the lower extremity.
Early in October 1944, Colonel Gordon's office and preventive medicine officers who were with field armies began to work with the Quartermaster Corps to establish some system, similar to the British system, whereby clean socks could be supplied regularly to frontline troops.30 The program could not be put into effect immediately because socks were not in sufficient supply and enough laundry units were not available. By the middle of November, these deficiencies had been at least partly corrected and a daily sock exchange had been instituted. It was found that the best plan in all armies was to bring the fresh socks forward with the daily rations (p.182). Each man, when he received his rations and his dry socks, would turn in his wet, soiled socks for exchange. When the tactical situation or other circumstances interfered with the daily sock exchange, the men were instructed to remove their wet socks, wring them out, and dry them inside their shirts or sleeping bags while they were wearing the extra socks which they had been carrying on their persons.
Statistics from the 108th General Hospital, where a special investigation of trenchfoot was conducted, showed how the tactical situation could influence the supply of socks and, in turn, the incidence of trenchfoot. For the week ending 27 November 1944, 96 of each 100 men admitted with a diagnosis of
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29 Memorandum, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, ETOUSA, to Quartermaster General, War Department, 23 Mar. 1945, subject: Footwear and Socks for Use in the European Theater of Operations.
30 Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley, Surgeon, Third U. S. Army, 12 Oct. 1944.
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trenchfoot had adequate supplies of socks (at least 3 pairs per man). For the week ending 21 December, at the beginning of the Battle of the Bulge, only 46 in each 100 men were adequately supplied. By the following week, the number of men adequately supplied in each 100 had fallen to 42.31 These figures, of course, do not tell the whole story. In the stress of combat, many of the men who had dry socks were unable to put them on.
Early in the trenchfoot epidemic, it was found that many of the men seen in the aid stations with apparent cold injuries really needed nothing more than an opportunity to warm their feet and put on dry socks. It was eventually arranged to provide supplies of dry socks in all aid stations, and, as a result, many frontline soldiers who otherwise would have been evacuated and lost for combat duty could be returned directly to duty.
Overshoes (galoshes).- Even before the November epidemic of trenchfoot, there had been warnings by medical and other officers from various units that a high incidence of cold injury could be expected if adequate supplies of galoshes were not available. As early as July, the acting quartermaster of the Advanced Section Communications Zone, ETOUSA, asked that shipments to France from D-day plus 150 should be sufficient by 1 October to equip every soldier with an initial issue of various items of winter clothing and equipment, including arctic overshoes. Maj. Gen. Albert W. Kenner, Chief Medical Officer, SHAEF, after he had visited the 6th Army Group on 12 October 1944, included this matter in his memorandum on the subject to the Chief of Staff, SHAEF. In the report, Essential Technical Medical Data, ETOUSA, for October 1944, it was stated that, in view of the shortage of overshoes, which then affected 60 percent of the total troop strength, and the shortage of shoepacs, the situation was "viewed with apprehension."
In spite of these warnings, by the middle of November only the Seventh U. S. Army, which had been equipped through Mediterranean theater supply channels, was completely equipped with overshoes and shoepacs, and only three divisions from other armies were similarly equipped. At this time, the Third U. S. Army had only one pair for each four men.32 In December, nine divisions were still only partly equipped, and in January seven divisions still did not have overshoes for all personnel
Although there were a number of reasons for these shortages, the over-all explanation was the policy of taking overshoes away from soldiers at ports of embarkation in the Zone of Interior. The plan was that the men would be reequipped upon their arrival overseas. This was War Department policy, founded on the difficulties of effective distribution and the laudable objective of reducing the large amounts of equipment and clothing which the individual soldier necessarily had to carry with him. In practice, the plan of reequipment in the European theater proved thoroughly impractical.33 It worked so badly,
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31 Report, Headquarters, 108th General Hospital, 1944, subject: A Progress Report on the Etiological Factors of Trench Foot.
32 See footnote 30, p. 153.
33 Essential Technical Medical Data, Headquarters, ETOUSA, for October 1944.
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in fact, that some troops developed cold injuries while waiting for their galoshes in staging areas.34
The facts of the matter were repeatedly pointed out to authorities in the United States as follows:
1. Supplies of overshoes in the theater or on current requisition were adequate merely for maintenance of troops already in the theater.
2. The supply lines were by this time spread all over Europe, and the distribution of overshoes after they had been received took weeks because of transportation difficulties.35
3. Large sizes were in short supply.
4. There was a clear-cut relationship between the development of trench-foot and the shortage of overshoes. On 15 November 1944, General Hawley wrote the theater chief quartermaster that hundreds of cases of trenchfoot had already occurred and thousands more could be expected "if something drastic is not done." The War Department was Hot impressed by any of these arguments, and the policy of sending troops overseas without overshoes continued unchanged until the end of the war.
Improper sizing played the same part in the overshoe situation as in the clothing and other situations. There was an undersupply of large sizes, so serious that at one time one corps was short 11,000 overshoes in the larger sizes (from size 10 up).36 Although 90 sizes of boots and shoes were available, only 10 sizes of overshoes had been provided. Enough large sizes were not available until March 1945.37
Another reason why it was difficult to match up shoes and overshoes was that many of the overshoes available had been purchased in trade channels and the lasts on which they were made did not fit the lasts on which boots and shoes procured on military specifications had been made.38
To increase their mobility, troops were occasionally ordered to discard their overshoes before an attack. Armored infantry could have them brought forward later, in halftracks, but regular infantry had no such means of transportation, and their overshoes, once discarded, were usually irretrievably lost and had to be replaced. More often, the troops were not ordered to discard their overshoes. Instead, they simply threw them away because they were difficult or awkward to wear and a nuisance to carry.
When the footgear representative of the War Production Board surveyed the theater in February 1945, he recommended that thereafter (1) all overshoes be made of rubber; (2) all troops be equipped with overshoes except infantrymen, who would wear shoepacs, and troops on garrison duty, who would wear the regulation combat shoe; (3) sizes and lasts conform with sizes
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34 Technical Intelligence Report, Col. B. C. Jones, GSC, Chief, Intelligence and Security Division, Army Service Forces, 17 Feb. 1945, subject: Medical Corps Personnel and Trench Foot.
35 Letter, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, Headquarters, Communications Zone, ETO, to Maj. Gen. R. L. Maxwell, G-4, War Department, 18 Nov. 1944.
36 See footnote 9, p. 138.
37 Report, Maj. Paul A. Siple, QMC, Technical Observer, for Commanding General, ETOUSA, 12 Apr. 1945.
38 See footnote 29, p. 153.
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and lasts of Army service shoes; and (4) all overshoes be plainly stamped with their size, to permit prompt reissue and to avoid the wastage which had occurred during the previous winter for lack of such identification.
Finally, overshoes originally available in the theater were often made with canvas tops because of the rubber shortage. These tops, which were not waterproof, tore readily, and the life of this type of galosh was short.
Supplies flown in from the United Kingdom Base helped to ease the shortage of overshoes in November 1944, when it first became apparent.39 It was not then realized that overshoes should have been provided for the theater on a hundred-percent basis. Priorities were, properly, given to combat troops, but galoshes were also needed by service units, which often had to work continuously in rain and mud, and by such troops as Military Police and antiaircraft units, which had to stand immobile for long hours, regardless of weather and terrain.
The course of events left little doubt of the relationship between the incidence of trenchfoot and the lack of overshoes. During November, for instance, the 9th Infantry Division, 2,426 of whose strength was without overshoes, had 183 cases of trenchfoot. By the end of November, 99 percent of the 28th Infantry Division had secured overshoes, but in the meantime there had been 738 cases of trenchfoot. In the 3d Armored Division, there were 56 cases of trenchfoot in 450 troops without overshoes. In the Ninth U. S. Army, the highest trenchfoot rates in the November epidemic occurred in the 84th and 102d Infantry Divisions, only 35 percent of which had overshoes. 40 These divisions accounted for 62.25 percent of all the cases of trench-foot in this army up to 22 November.
Statistics secured by questioning casualties with trenchfoot admitted to the 108th General Hospital supplied the following significant data about overshoes:41
For the week ending 27 November, 82 of 100 men with trenchfoot had lacked overshoes or had not received them in time to be effective, 52 had not received overshoes, 28 had received them after sustaining cold injuries, and 2 had discarded their overshoes before combat.For the week ending 21 December (the first week of the Battle of the Bulge), 60 of 100 men had lacked overshoes for the reasons just stated. Of this group, 38 had not received overshoes at all, 10 had received them too late, and 12 had discarded them before combat.
For the week ending 28 December, the total number of men without overshoes was 55; of these, 36 men had not received them at all, 4 had received them too late to be useful, and 15 had discarded them before combat. The number of men who discarded their overshoes before combat, while too small to be of any statistical significance, was significant to medical and other officers familiar with the tactical situation and the character of United States troops.
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39 Annual Report, Preventive Medicine Division, Office of Chief Surgeon, ETOUSA, 1944.
40 Annual Report, Surgeon, Ninth U. S. Army, ETOUSA, 1944.
41 See footnote 31, p. 154.
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The troops generally felt that overshoes hampered their mobility in active combat, and the fighting in the last 2 of the 3 weeks included in this survey, during the Battle of the Bulge, was very heavy indeed.
There are, of course, other facts behind these figures. During each of these 3 weeks, a number of men who had been provided with overshoes had wet feet most of the time. The canvas tops, already commented on, leaked and tore. Rain or snow also destroyed the effectiveness of sound protective footgear, or water came over the tops when rivers had to be crossed. Sometimes, all of these causes were effective. Actually, only 18 of the 100 men surveyed the first week had been able to keep their feet dry, only 2 in the second week, and only 11 in the third week. The figures, again, reflect the tactical situation.
Shoepacs.- As already mentioned (p.145), in May 1944, a representative of Colonel Gordon's office was informed by a representative of the theater chief quartermaster that the cold-weather problem in regard to the feet would be solved by a combination of heavy socks and shoepacs and that both items would be in production in time to meet the winter needs. Shoepacs were also discussed at the meeting on winter clothing held in the theater in June 1944 (p.144), at which Captain Pounder had stated the objections of the Quartermaster General to the items of winter clothing proposed. The footgear planned for winter combat was to include service shoes, overshoes, leggings, and light wool socks. Captain Pounder pointed out that this combination of footgear would not be satisfactory in a country which was particularly cold, wet, and muddy in winter. He proposed, instead, that winter footgear consist of shoepacs, with 2 pairs of felt insoles and 4 pairs of ski socks per man. Although it was agreed that, in order to use up stocks presently in the theater, the combination of service shoes, leggings, and overshoes might be issued as a substitute for shoepacs, it was agreed also that shoepacs with felt insoles and ski socks should be included in the list of items recommended to the theater chief quartermaster for use during winter operations on the Continent.
On 10 August 1944, in response to an inquiry made on 23 July concerning footgear (p.145), General Hawley's Preventive Medicine Division was informed by the Supply Branch, Office of the Chief Quartermaster, ETOUSA, that among items of footgear for troops expected to fight in wet-cold conditions on the Continent would be a new type of shoepac, made in three widths, with correct orthopedic support. These shoepacs were to be fitted over a cushion sole or over heavy British woolen socks and ski socks. Allowances would be made for extra socks for each soldier. If this footgear was used correctly, adequate foot protection would thus be provided in the minimum temperatures expected in northern France and southern Germany-10? F. (-12.2? C.)-during the winter.
The Seventh U. S. Army, as already mentioned, had been equipped with shoepacs through Mediterranean theater supply channels. The first requisition for shoepacs from the European theater, on 15 August 1944, was for 446,000 pairs. This was a small number, and the timing was late, in view of the limited shipping available and the low priority for clothing and footgear.
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War Department Circular No. 312 listed criteria for winter footgear but did not specifically mention shoepacs. TB MED 81 stated that shoepacs best met the requirements of insulation and ventilation except on rough, mountainous terrain. When it was distributed in the theater as a circular letter, in place of the circular letter originally planned (p.164), and in the theater medical bulletin (p.164), all mention of shoepacs had been eliminated at the request of General Littlejohn's office, since it was then known that shoepacs would be available only for a limited number of personnel in the theater.
On 8 December, when it had become evident that the footgear provided in the theater (the service shoe and the combat boot) would not furnish adequate protection against trenchfoot, a request was cabled from the theater for 500,000 additional pairs of shoepacs, over and above the 446,000 already shipped and the 90,000 pairs issued to the Seventh U. S. Army. The theater was informed on 16 December that this requirement could not possibly be met because of limitations of production which could not be overcome for 3 or 4 months. An attempt to fill the requisition would disrupt the shoe and wool production of the whole country. It was noted in this reply that the issue of shoepacs, about which the troops themselves had many reservations, would not solve the primary problem, which was strict compliance with the provisions of War Department Circular No. 312 and TB MED 81. In the light of these facts, it was requested that the requisition be reconsidered. On 23 December, the theater repeated the original request, using as justification the fact that extraordinary cold and wet conditions were being encountered at the time. None of the shoepacs requisitioned arrived in the European theater until after the middle of January 1945, and those which were received were not distributed in sufficient numbers until it was too late for them to exert any significant influence on the incidence of cold injury.
Unfortunately, the shoepacs originally issued to the Seventh U. S. Army in Italy and those which went to the European theater were of the old type and were open to many objections. Because of the lack of ventilation, the feet, even in the coldest weather, perspired when the men were active. Later, the felt innersoles froze, and the feet became excessively cold. In warmer weather, excessive perspiration caused maceration of the skin. A cycle was often set up of perspiration, maceration, the development of so-called shoepac foot, hospitalization for 10 to 15 days, return to duty, and a repetition of the cycle.42
The shoepacs issued in the European theater were the 6-inch type, too low to offer much protection in deep mud, swampy ground, and flooded foxholes. They offered no protection at all when streams had to be crossed. They lacked arch supports and heels. The soft rubber soles wore out quickly. It was for these reasons that the theater chief quartermaster had rejected the recommendation of the Quartermaster General that they be substituted for the combat boot (p.157)
The shoepacs supplied were also, for the most part, too large. This made them unsatisfactory for marching, and men had to be evacuated for blisters
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42 Essential Technical Medical Data, ETOUSA, for December 1944.
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on their heels. No provision had been made for the wearing of additional socks with them.43
Finally, shoepacs cannot be worn efficiently unless their use is understood. The supply for the European theater had to be distributed almost literally in the midst of battle, and instructions for their use were often given after they had been worn. As a result, shoepacs in the European theater were seldom as efficient as they should have been.
In spite of these and other objections, men who learned to wear shoepacs correctly came to prefer them to service shoes and combat boots. At the end of the cold season, it was generally agreed that in spite of their deficiencies the shoepacs were the most satisfactory footgear for fighting in cold, wet weather. This was the opinion of the conference on clothing held in March 1945 and the footgear representative of the War Production Board (p.155) . It was also the opinion expressed by the General Board, United States Forces, European Theater of Operations, in its report on trenchfoot (p.208) and of Maj. (later Lt. Col.) Paul A. Siple, QMC, an observer from the Office of the Quartermaster General, who had been in the Antarctic with Admiral Byrd and who studied the whole clothing and footgear situation in the theater in the late winter of 1945.
Improvisations.- When the shortage of adequate footgear first became acute, many units resorted to improvisations to secure additional protection from rain and snow. Some units wore the white plastic powder bags provided with 155-mm. projectiles inside or outside of their shoes. These bags were extremely effective, but they were in short supply. Some units made boots of four thicknesses of blanket and wore them inside their overshoes, without shoes. Some troops which fought in Holland wore felt slippers and overshoes with two pairs of socks. The incidence of trenchfoot was reduced in all the units which used these and similar improvisations, one reason probably being the free movement of the toes and feet possible when constricting footgear was omitted.
Summary
A more detailed account of the clothing and footgear used in the European theater in the winter of 1944-45 does not properly belong in this volume. Enough has been related to show the important role which inadequate clothing and footgear played in the causation of trenchfoot. The items issued were basically unsatisfactory because of deficiencies in insulation or ventilation, or in other respects. The clothing was not windproof or water repellent. The footgear did not protect against cold and wetness and had other defects. Even these unsatisfactory items were in short supply. More efficient clothing and footgear, which had been tested both in and out of combat, were available, but the theater chose not to accept the new models, in spite of repeated warnings from the Quartermaster General and his observer in the theater that the troops would not be properly protected in combat operations during the
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43 See footnote 37, p. 155.
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winter. The director of the Research and Development Branch of the Office of the Quartermaster General had predicted that if the European theater persisted in using a uniform already shown to be inadequate, the Italian experience with cold injury would be repeated. His prediction, unfortunately, was only too correct.
When supplies of the improved clothing and footgear were finally ordered, cold injury was already widely prevalent, and the supplies were not received until it was too late to alter the course of events.
Finally, neither the old nor the new models were correctly worn because the troops had not been trained in their use. The United States soldier, as Major Siple stated after he had surveyed the situation in February 1945 (p.431), was better trained in the care and use of fighting equipment than in the care and use of his clothing.
These conclusions were, in substance, the conclusions of the General Board, United States Forces, European theater, set up later in 1945 to study the whole cold injury situation in the theater.
DEVELOPMENT OF THE TRENCHFOOT-CONTROL PROGRAM
Activities in 1942-43
The first recorded mention of cold injury in the European theater was apparently made in a letter dated 5 August 1942, in which the Chief Surgeon, on the request of the Office of the Surgeon General, transmitted information on the management of frostbite as recommended by the British Medical Research Council, together with some observations on immersion foot.
The first theater publication dealing with cold injury concerned immersion foot. It was Circular Letter No. 12, Office of the Chief Surgeon, 20 January 1943. It was stated in this letter, "A condition which closely resembles the trench foot of the last war may affect the extremities exposed to cold without immersion provided the degree of cold is insufficient to cause frostbite.'
Medical Bulletin No. 1, Office of the Chief Surgeon, 18 March 1943, reproduced the contents of Medical News Letter No. 1, Office of the Surgeon General, which was published 1 January 1943. The material on which this letter was based was assembled under the auspices of the Committee on Information, Division of Medical Sciences, National Research Council, with the cooperation of the American Medical Association and the Surgeons General of the Army and the Navy. The letter also reproduced the substance of the article on frostbite by Raymond Greene, which had appeared in Practitioner in January 1942, and the substance of an article on immersion foot published by Webster, Woolhouse, and Johnson in the Journal of Bone and Joint Surgery for October 1942.
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Activities Before the Outbreak of Cold Injury in 1944
In analyzing the cold injury epidemics in ETOUSA in World War II, it must be borne in mind that there was little official information in the theater concerning the serious losses from this cause in the Mediterranean theater in the winter of 1943-44 and there was no continuous official medical liaison between the two theaters. As one instance of the lack of liaison, the official report on trenchfoot in the Mediterranean theater, which was submitted to the Surgeon, MTOUSA (Mediterranean Theater of Operations, United States Army), in January 1944, did not reach the European theater until a year later, when the urgent need for the data in it was practically over. It seems to have arrived then only because Colonel Cutler requested it directly from the Surgeon of the Mediterranean theater.
There was, of course, considerable informal correspondence between medical officers in the two theaters, though none specifically for the purpose of studying cold injury. Curiously, it was a dermatologist who was most impressed by the potentialities of this condition. On 10 November 1943, Lt. Col. (later Col.) Donald M. Pillsbury, MC, Senior Consultant in Dermatology, Office of the Chief Surgeon, ETOUSA, reported to General Hawley concerning his tour of medical installations in the North African theater. He described the epidemic of what he termed immersion foot in Italy and recounted his discussions of the problem with medical officers in the North African theater, including Maj. Fiorindo A. Simeone, MC, who was then making a special study of this condition (p.101). Colonel Pillsbury stated that the treatment to date was unsatisfactory, but that several approaches toward prevention were practical. It was his opinion that the problem was great enough to warrant the use of every facility of General Hawley's office in its solution and that the Surgeon, MTOUSA, should be informed promptly of the results obtained. Colonel Pillsbury's recommendations concerning dermatologic conditions and venereal disease were duly initialed by the theater venereal disease control officer and the chief of the Professional Services Division, Office of the Chief Surgeon, but no action seems to have been taken on his recommendations concerning an energetic program for the prevention of cold injury.
Colonel Cutler, when he visited Italy in November and December 1943, observed a number of cases of trenchfoot. He was not then impressed with them because of his experience in World War I, in which cold injury took the form of "terrible swollen feet with ulcers and blue color." Major Simeone did not believe that more than a quarter of the men affected would be able to return to duty, but Colonel Cutler was then of the opinion that these soldiers were utilizing the pain very hard as a way out of fighting.
On his return to England, Colonel Cutler discussed cold injury with the chief consultant in surgery to the Norwegian forces in the United Kingdom. This officer, who had also just returned from Italy, had participated in the Russo-Finnish War, and in Colonel Cutler's opinion had had as wide an ex-
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perience in cold wet feet as any medical officer living. As a result of these discussions and after reflection upon his own observations in Italy, Colonel Cutler transmitted the following (summarized) remarks to the theater chief quartermaster, through channels, 9 April 1944:
1. The socks furnished United States Army troops did not have sufficient wool content.
2. Rigid discipline must be enforced within combat companies, so that socks would be changed daily, even if this meant nothing more than wringing them out and putting them on again.
3. United States Army soldiers were invariably fitted with shoes that were too small.
Colonel Cutler added his own impressions of the enormous loss of manpower caused by cold injury in Italy and the importance of its prevention, since no effective method of treatment had been discovered.
This memorandum was forwarded to the theater chief quartermaster from General Hawley's office 11 April 1944, with a notation that his office had in preparation a proposed circular on the proper care of the feet. On the same date, this information was sent to the Chief Surgeon's Professional Services Division, with the request that a draft of the proposed directive be prepared with the least practical delay.
The requested draft, entitled "Prevention of trench foot (immersion foot)," was forwarded to the executive officer of the Office of the Chief Surgeon, 25 April 1944. It emphasized the incapacitating character of the injury, the lack of specific therapy for it, the possibility of prevention, and the preventive measures which could be employed. These measures included keeping the feet warm and dry, wearing properly fitted shoes and two pairs of all-wool socks, removing shoes and socks daily, rubbing the feet lightly with lanolin or petrolatum after they were dried, and making every effort to encourage movement and maintain mobility.
No further action was apparently taken on this proposed circular at this time, other than referring it to the Preventive Medicine Division of the Chief Surgeon's Office.
Preparations for the invasion of the Continent.- Cognizance was taken of the danger of cold injury in the preparations for Operation OVERLORD, the invasion of the Continent. In Standing Operating Procedure 15, Medical Service on the Continent, which was drawn up in March 1944, as part of Policies and Procedures for Mounting the Invasion, and which was published 29 July 1944, paragraph 53 read as follows:
Trench foot (Immersion foot). Emphasis will be given to the care of the feet and to the provision of proper clothing and footwear. Special attention will be given to these details for combat troops operating under wet, cold conditions.
Annex No. 8, which was the medical plan for mounting the invasion, did not mention cold injury. Annex No. 9 to the Operations Plan, Communica-
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tions Zone, for NEPTUNE, the assault phase of OVERLORD, contained the following paragraph:
Section VIII, 40. "Trench Foot"-("Immersion Foot").-The cold wet weather prevailing during the winter season in the area will predispose combat troops to this affection. Supplying seasonal changes of clothing opportunely, giving particular attention to the furnishing of proper footwear, are important measures for preventing casualties due to trench foot.
The Manual of Therapy, issued by the Chief Surgeon, ETOUSA, on 5 May 1944, contained a section on foot hygiene, which emphasized the importance of (1) cleanliness, (2) keeping the feet dry, (3) using foot powder, (4) changing the socks frequently, (5) wearing properly fitted shoes and socks, (6) avoiding trauma, (7) caring for the feet after long marches, and (8) caring for the shoes and socks. It was again advised, as in other publications, that the shoes be laced tightly.
Section XIV, paragraph 7, of the Manual of Therapy read as follows:
The importance of a foot bath with soap and water cleansing, vigorous massage (20 Min.), dry socks, and a change of shoes in the prophylaxis of foot disability resulting from exposure to cold and moisture cannot be overemphasized.
The manual contained a rather extensive description of fungous infections of the feet, but there was no further mention of cold injury.
Preceding letters on the subject of cold injury were rescinded on 10 June 1944,44 and attention was directed to the Manual of Therapy, which, it was stated, contained the principles of therapy to be followed in the theater.
Postinvasion Activities
On 22 June 1944, Colonel Gordon's office recommended publication of a command directive entitled "Care of the Feet" for distribution to army groups, armies, air forces, base sections, and analogous commands. This directive included principles of fitting, care, and use of shoes; the choice and use of socks; and general instructions on foot hygiene. It emphasized that company commanders were responsible for the correct fitting of shoes and that instructions to fit them over light wool socks should be modified, if necessary, to permit them to be fitted over heavy wool socks or two pairs of light wool socks. Instructions were given for the breaking in of new shoes, and tight lacing (contrary to previous advice) was warned against. Specific instructions were given how to lace shoes when the uppers fitted too snugly. Instructions were given for changing of socks regularly and for drying socks by improvised methods if a fresh pair was not available. Finally, instructions were given for the care of the feet, including cleanliness, conditioning, care of the nails, care of blisters and abrasions, avoidance of excessive sweating, and prompt report of infections or other disabilities to the medical officer.
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44 Circular Letter No. 80, Office of the Chief Surgeon, Headquarters, ETOUSA, 10 June 1944. subject: Policies and Procedures Governing Care of Patients in the European Theater of Operations.
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Paragraph (4) read as follows:
External Conditions. The feet are subject to all of the common injuries due to external causes, but there is one type to which they are particularly prone. Slightly different forms of this injury are known as Immersion Foot, Trench Foot, Shelter Foot, etc., but all are fundamentally the same. The condition results from long exposure to a combination of wetting, cold (which need not be extreme) and stagnation of circulation due to inactivity or constricting clothing or boots. Prevention depends upon avoidance of wetting and chilling if possible and where these are unavoidable the preservation of circulation by exercise, relief of constricting clothing and as a last resort general manipulation. After the condition is well established, with numbness, swelling and change of color of the feet, walking and even massage are to be avoided.
This publication was disapproved by the Adjutant General, ETOUSA, on the ground that existing manuals covered the subject and that the problem was the responsibility of subordinate commands. Colonel Gordon thereupon forwarded the content of the proposed publication informally to the surgeons of major commands.
In September 1944, Colonel Gordon's office began work on a circular letter dealing with the care of the feet and intended for publication to all commanding officers, including those of smaller units. After the proposed letter had been concurred in by other divisions of the Chief Surgeon's Office, it was sent to the Adjutant General, ETOUSA, 11 October, with the statement that publication was urgent and should be expedited because of the possibility of trenchfoot in the theater. When it appeared on 24 November as Circular No. 108, Headquarters, ETOUSA (appendix E, p.525), heavy losses from cold injury had already been sustained.
Meantime, as already noted, other publications had become available. War Department Circular No. 312, dated 22 July 1944 (p.63), was distributed in the theater on 2 September 1944. TB MED 81, dated 4 August 1944 (p.65), was received in the theater later that month. When it arrived, a circular letter containing substantially the same material was in process of preparation. TB MED 81 was substituted for the material in preparation and was published 18 October 1944, as Circular Letter No. 126, Office of the Chief Surgeon, ETOUSA. As already mentioned (p. 158), a statement in this bulletin dealing with shoepacs was deleted at the request of the Chief Quartermaster, ETOUSA, because it was now evident that they could be supplied only to a very limited number of personnel in the theater.
In order to give additional and faster circulation to the information contained in TB MED 81, this bulletin was reproduced in the theater medical bulletin for 1 November 1944. It was preceded by a statement by General Hawley to the effect that the Italian experience had shown that cold injury could disable men as suddenly and with as little warning as a severe wound, that many of those affected would remain permanently unfit for duty under conditions of cold and moisture, and that all medical personnel should familiarize themselves with the contents of TB MED 81 because it indicated the possible extent and severity of cold injury and the paramount importance of preventive measures.
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Meantime, there had been numerous informal warnings of the possibilities and potentialities of cold injury. On 4 October 1944, Colonel Cutler informed Col. James K. Kimbrough, MC, Chief, Professional Services Division, Office of the Chief Surgeon, ETOUSA, that Lt. Col. (later Col.) Joseph A. Crisler, Jr., MC, Consultant in Surgery, Office of the Surgeon, First U. S. Army, had sent word to him that lie was fearful of trouble with trenchfoot in the coming weeks and months and that he (Colonel Cutler) shared these apprehensions.45 All experience, the memorandum continued, justified the statement that there is no sound treatment for trenchfoot and that prevention is all important. It further stated that the Medical Department should insist that woolen socks be worn and that shoes be properly fitted, since all Americans wear their shoes too small. Unless these warnings were heeded, Colonel Cutler concluded, "there will be disaster." The memorandum also called attention to the habit of Norwegians, especially Laplanders, of putting straw in their big shoes during the winter, thus providing both ventilation and insulation, and to the Russian custom of changing from leather to felt shoes and binding the feet instead of wearing socks in cold weather. Neither Russians nor Norwegians suffered from cold injury.
In a report, Health of the Command, 12th Army Group, for August 1944, the possible increase of respiratory diseases during cold weather was mentioned, but the report contained no mention of cold injury. In the report for September 1944, dated 11 October, respiratory diseases were again mentioned, and a paragraph was devoted to trenchfoot:
b. Trench Foot. Attention is also directed to the great loss of time and the non-effectiveness of personnel experienced in the Italian Campaign last winter and spring from "trench foot," "immersion foot," and similar injuries due to cold and wetness. Not only should emphasis be placed upon the early issue of winter foot-gear, but also upon fitting of shoes and socks, cleanliness of the feet, and early treatment of foot conditions. The command function of educating and training combat troops in this problem if diligently carried out, will go far toward reducing non-effectiveness from these causes.
This report, which was intended for the 12th Army Group commander, as well as for subordinate commanders, recommended (1) that winter clothing be issued at the earliest practicable date and (2) that commanding officers of all echelons take the necessary steps to insure that all men in their commands were properly instructed in the care of their feet under winter combat conditions and were adequately supplied with properly fitting socks and shoes.
Army publications.- On the army level, the first directive concerning cold injury (Professional Memorandum No. 5, Trench Foot), which was issued before the outbreak, appeared on 1 October 1944, from the Office of the Surgeon, First U. S. Army. All commanding officers and all medical officers assigned or attached to corps, division, and separate medical units were warned of the possibility of cold injury, especially in wet and damp weather and even when the temperature was above freezing. Causes of trenchfoot and meas-
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45 Informal Routing Slip, Chief Consultant in Surgery, to Chief, Professional Services Division, 4 Oct. 1944, subject: Trench Foot, Immersion Foot.
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ures of prevention were outlined, and the importance of teaching troops to protect themselves as individuals was stressed. It was pointed out that the First U. S. Army was then operating in terrain ideal for the development of trenchfoot and in weather that was also ideal for its occurrence.
When Colonel Cutler received this memorandum, he commented that it was an excellent summary of Circular Letter No.126 (p.164) but that he regarded it as unfortunate that two separate memorandums should be issued on this important subject. He hoped proper authorities would advise the First U. S. Army to use Circular Letter No.126 instead of their own publication. Colonel Kimbrough added a note to this comment to the effect that, since the Chief Surgeon's circular letter was entirely adequate, it would be unfortunate if each army were to put out a separate circular on the subject. In effect, that is what each army did and what many lower units also did. Many of these circulars were unduly long, and some of them combined matters, such as how to prevent trenchfoot and how to wash wool socks without shrinkage (p.167), which might better have been handled separately.
On 8 October 1944, the Ninth U. S. Army headquarters issued Memorandum No. 68, entitled "Medical Instructions." In it, the possibility of trenchfoot in the climatic conditions then present and the areas then occupied was stressed, and attention was directed to War Department Circular No. 312. On 3 December, after trenchfoot had already caused thousands of casualties in this and other armies, a second communication was issued by the Ninth U. S. Army in which the effective methods of prevention used by the British were summarized.
In the Seventh U. S. Army, Circular No. 20 was issued as a command directive on 9 October 1944. In it, attention was called to the losses suffered the previous winter in Italy. The causes, symptoms, and treatment of trench-foot were outlined, and methods of prevention in combat as well as in reserve were described. It was emphasized that cold injury is a preventable condition and that its prevention is the function and responsibility of command. This circular also pointed out that commanders must learn how to prevent cold injury and must see that their orders were carried out. The Seventh U. S. Army originally consisted of divisions which had fought in the Mediterranean theater the previous winter. Many of the troops had suffered from cold injury then, and there were numerous recurrences as soon as the weather in France became cold (p.382).
The warning that commanding officers must inform themselves concerning cold injury was very necessary. It was repeatedly found in all armies during the coming weeks that commissioned officers, like noncommissioned officers and enlisted men, did not understand the real nature of cold injury.46 Some of them, in fact, believed that the condition was similar to severe athlete's foot.
The Third U. S. Army issued its first directive on the subject of trenchfoot
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46Letter, Headquarters, Third U. S. Army, Office of the Surgeon, to Commanding General, Third U. S. Army, 19 Apr. 1945, subject: Activities of Third U. S. Army Trench Foot Control Team.
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(Circular No. 76) on 9 November 1944. During the weeks prior to the issuance of this circular, numerous informal discussions between medical and other personnel at army headquarters and in subordinate echelons were held. Although trenchfoot was a serious problem in the army when Circular No. 76 was issued, the directive merely stated officially and in writing, policies and plans which were already in effect.
In this circular, troop commanders were directed to familiarize themselves with War Department Circular No. 312 and to comply with its directions. Commanders were given the direct responsibility of preventing cold injury. The following unequivocal statement was made: "The excessive development of trenchfoot in an organization will be considered as indicative of inadequate supervision and control." This circular also contained numerous details concerning the cause and prevention of cold injury and included a detailed set of instructions for laundering socks and instituting a sock exchange.
Measures Taken During the Epidemics of Cold Injury
On 17 November 1944, by which time thousands of cases of trenchfoot had already occurred, General Kenner addressed a memorandum on the subject to the Chief of Staff, SHAEF. In it, he discussed the incidence of trench-foot and the causes, with particular emphasis upon cold weather, wet feet, and constriction about the feet. He also outlined the action being taken to check the epidemic. The control of cold injury, he stated, had been placed in command channels, since foot discipline was a command responsibility. He emphasized proper footgear, including overshoes, and the use of dubbing. He reported that definitive action had already been taken on his recommendations that the unit issue of heavy wool socks be increased, that high priority be given to forward movement of socks, and that a concise brochure on trenchfoot, for universal distribution, be prepared and published by the Chief Surgeon, ETOUSA.
General Kenner's memorandum was approved at SHAEF and forwarded to the Commanding General, Communications Zone, ETOUSA, for his information and guidance.
On November 17, a field directive on the subject of trenchfoot was prepared by the chief of the Preventive Medicine Section, Office of the Surgeon, 12th Army Group, and was hand carried by Col. Alvin L. Gorby, MC, Surgeon, 12th Army Group, to the commanding general. In this memorandum, the whole situation in the field was surveyed.
General Bradley immediately ordered the material issued as a command directive (Circular No.19). In addition, he sent personal letters to the commanding generals of all field armies in the 12th Army Group. In these letters, he pointed out the heavy loss of manpower caused by cold injury, the permanence of many of these injuries, the particularly heavy losses in the infantry, the fact that cold injury was largely preventable by the proper assumption of responsibility by command, and the apparent absence of all assumption of
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responsibility by command at that time. General Bradley also noted that in many units galoshes had been left behind by direction, spare socks had not been required, and in some instances men had not removed their shoes for 5 to 10 days. He requested that all army commanders give these matters their immediate personal attention.
Immediately upon the receipt of these letters, the commanding generals of the First, Third, and Ninth U. S. Armies prepared and distributed to corps and division commanders letters embodying the information contained in General Bradley's letter and ordering immediate measures to control the trenchfoot epidemic.
The letter from General Patton, dated 21 November 1944 (appendix F, p.529), is typical of the substance of all these letters. In it, attention was called to the gravity of the situation. The causes of cold injury were outlined. Specific control measures were listed, including the use of overshoes, the proper fitting of shoes, the use of dubbing, the provision of extra socks, and daily foot care. It was stated unequivocally that control was a function of command, and a distinction was made between control measures for which the individual soldier was responsible and the support which command could provide. The letter began with the blunt statement, "The most serious menace confronting us today is not the German Army, which we have practically destroyed, but the weather which, if we do not exert ourselves, may well destroy us through the incidence of trench foot." 47
On 23 November 1944, General Hawley sent identical letters to the surgeons of the 12th Army Group, First U. S. Army, Third U. S. Army, and Ninth U. S. Army, pointing out to them that, if ideal methods of prevention of trenchfoot could not be accomplished, simple measures to keep the circulation active in the feet would result in the disappearance of most cases. He recommended removal of the shoes and socks once a day and massage of the feet until the circulation was completely reestablished. He also pointed out that, while dry socks were desirable, wringing water out of wet socks and then replacing them was preferable to leaving the shoes and socks on continuously. The letter concluded:
3. The ratio of trench foot to battle casualties is so high that, by failing to solve this problem, we are doing practically as much damage to our own troops as the enemy-and, by "we," I do not mean the Medical Department. This is a disciplinary problem, particularly one of leadership in small units.
In spite of his recognition that the prevention of trenchfoot was a command problem, General Hawley was not entirely satisfied with the activities of the
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47 On 19 November, Col. Charles B. Odom. MC, surgical consultant to the Surgeon, Third U. S. Army, had addressed a memorandum to General Patton in which he outlined the seriousness of casualties from cold injury among United States troops, the far better situation among German troops, and the inadequacies of the footgear supplied to United States soldiers. The shoes, he said, were badly fitted and the quality of the socks was poor. After analyzing the major factors in the causation of trenchfoot and the discouraging outlook for the man who sustained it, the memorandum concluded: "It is apparent from talks with our soldiers that they do not realize the importance of caring for their feet, nor are they properly instructed and disciplined in this regard."
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Medical Department. On 25 November 1944, he wrote to Colonel Gorby, as follows:
* * * I am not sure that the Medical Department has been aggressive enough in this situation. We have published long dissertations on the prevention of trench foot which are too long for anyone to read. Furthermore, they lay down so many requirements that, unless the soldier can fulfill all of them, lie does nothing. Apparently no one has ever told the small unit commander that the very essence of prevention of trench foot is the prevention of stagnation of circulation for periods greater than 24 hours.
General Hawley concluded his letter by again laying down his own conceptof prevention. He stated that he thought that if the shoes were removed once every 24 hours, if the feet were massaged briskly, preferably while they werehigher than the hips, and if the water was wrung out of wet socks before theywere replaced, cold injury could be prevented in 75 percent of all cases.
High command also made it clear, though somewhat belatedly, that control was the responsibility of command and that prevention was both feasible and practical. A letter, dated 24 January 1945,48 stated:
While appreciative of the adverse climatic factors existing in combat areas, he [General Eisenhower] desires to emphasize that this condition [cold injury] may be controlled by the proper exercise of Command, particularly by officers of company grade. It is desired, therefore, that higher unit commanders impress upon all ranks the necessity for unremitting attention to this command responsibility.
There was a similar acceptance of responsibility, though frequently equally belated, in most individual units. The annual report of medical activities in the NIII Corps, Ninth U. S. Army, dated 31 January 1945, read, in part, as follows:
It [trench foot] was the most important and most prevalent condition that could have been prevented * * *. There are several reasons for a high incidence of this disease. First * * * neither the line officer nor the medical officer is sufficiently aware of the condition prior to the time the troops are exposed to the hazards of unfavorable weather and terrain conditions. Second, neither the line officer nor the medical officer stresses sufficiently proper care of the feet. Third, the footgear and clothing issued by the U. S. Army is not adequate for wear under conditions apt to result in trench foot. Fourth, commanding officers often fail to relieve their front-line units sufficiently frequently. Fifth, commanding officers fail to provide facilities for the drying of shoes, socks and clothing; fail to give adequate instructions to their men; * * * fail to realize that the care of the feet of their troops is a command responsibility. All of the above reasons, except the third, could be eliminated by adequate instruction and indoctrination of officers and noncommissioned officers in the training phases.
Individual Instruction and Indoctrination
One of the major problems in the control of trenchfoot in the European theater was the necessity for instructing the individual soldier how to take care of his feet. Almost none of these troops had had any previous training in foot hygiene in cold wet weather. All personnel had to be instructed; line officers, as has already been mentioned several times, knew no more of the matter, for
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48 Letter, SHAEF, to Commanding Generals, 12th Army Group, 6th Army Group, First Allied Airborne Army, and Communications Zone, European theater, 24 Jan. 1945, subject: Control of Trench Foot.
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the most part, than the men for whose well-being they were responsible. The instruction had to be given in highly unfavorable circumstances, in combat, when the soldiers were concerned with other matters that seemed of much more importance than taking care of their feet. One of them was saving their lives. Yet, in some manner, they had to be impressed with the urgent necessity of taking care of their feet. Although they should have been taught these things earlier, it is nonetheless fair to say that the effort, even if made late, was extremely effective.
Formal instruction was obviously impractical under the circumstances, and the facts of the trenchfoot situation and methods of preventing it, particularly in the individual soldier, were conveyed to the men in a variety of ways.
Before the invasion, it had been planned that trenchfoot would be one of the subjects to be considered in a series of articles on health to be published in Stars and Stripes, in which it would be discussed in the article on footgear.
After the first general epidemic of trenchfoot, in November 1944, publicity was intensive. News articles, editorials, and feature notes appeared in Stars and Stripes, including news summaries on 10 November and 29 November and editorials on 6 December 1944 and 19 January 1945. Articles appeared in Ears on 4 and 5 December and in War Week on 9 December. A short article appeared in Combat Tips for 2 December and a 4-page spread (half of the issue) in the 16 December issue. Material was placed in division publications, such as the Invader of the 28th Infantry Division. In these publications, the language of authority was translated into the language of the GI:
1. Keep your feet as dry as possible. With all the mud, this is easier said than done but you gotta do it anyway.
2. Elevate your feet at intervals, every two or three hours, whenever your feet get cold. and wet. Just flop on your derriere and do push-ups with your legs.
3. Modernize your slit trench, if possible, by putting in flooring. Pine boughs make a nice GI color scheme * * * but don't use any floor wax.
4. Wear overshoes. That is, if you have them.
Radio publicity was employed intensively. Mobile broadcasting facilities made it possible for the messages on trenchfoot to reach frontline troops in areas in which printed matter was not practical.
Posters in preparation in the United States (p.72) were not ready in time to be useful in the European theater, but a poster was prepared in the theater for general distribution, and the use of posters prepared in individual units was encouraged. Some of them were very effective.
In his memorandum (p.167) to the Chief of Staff, SHAEF, on 17 November 1944, General Kenner had recommended that the Chief Surgeon, ETOUSA, publish a concise brochure on trenchfoot for distribution to the troops. Colonel Gordon set this project in motion, although his own experience indicated that articles for newspapers, magazines, and periodicals, which could be repeated, were more purposeful.
With the cooperation of the Public Relations Division, ETOUSA, the preparation of a brochure was expedited, and distribution was begun the second
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week in January 1945. Two and a half million copies were printed, so that each soldier in the theater could receive one. Those used in the United King-dom were printed in London and those used on the Continent were printed in Paris, where distribution was delayed because of a strike of printers. When the copy was sent to the Assistant Chief of Staff, G-3 (operations and training), ETOUSA, 6 December, it had been noted that early printing was more important than an elaborate effort delayed beyond the present period of urgent need.
When an inquiry to The Surgeon General produced the information that the film on trenchfoot being prepared in that office was not yet ready, an educational film on the subject was prepared in the First U. S. Army. Clinical material was obtained at First U. S. Army medical installations, medical supervision was supplied by an officer of that army, and the technical work was done by a photographic section from SHAEF. The official film on trenchfoot (FB180, p. 73) did not reach the theater from the Zone of Interior until 24 February 1945.
The clinical pictures of trenchfoot made by the 2d Medical Arts Detachment at the 108th General Hospital were used for instructional purposes, although only after some debate about their value for nonmedical personnel. Still photographs were also made to illustrate preventive measures as practiced by men in the field.
Training of Reinforcements 49
The problem of trenchfoot in reinforcements assumed three forms in the European theater:
1. It occasionally occurred in the Ground Force Reinforcement Command, while the men were still undergoing training. When this happened, it could usually be accounted for by special circumstances, such as the lack of overshoes. In February 1945, 22 of 449 reinforcements received by the 47th Infantry Regiment were found, on inspection by a representative of the G-3 Section, Headquarters, ETOUSA, to be suffering from trenchfoot.50 The explanation was that they had stood in the wet for hours at a time during training.
2. Most of the cold injury which occurred while troops were in the Reinforcement Command was secondary, in the form of recurrences in troops recently released from the hospital after treatment for primary cold injury. In November 1944, there were almost no cases in the Ground Force Reinforcement Command, but in December, for the reason just stated, there was an appreciable number.
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49 The name of the Ground Force Replacement Command was changed on 28 December 1944 to Ground Force Reinforcement Command, the reason being that some officers believed that the British term "reinforcement" was more suitable, because of the morale factor, than the original term "replacement." The implementing letter instructed all concerned to inform new men that they were combat reserves or reinforcements, not replacements for men who had been killed or wounded. As a matter of convenience, the term "reinforcements" is used uniformly throughout this section, regardless of date.
50 Letter, Lt. Col. Richard P. Fisk, AGD, Headquarters, ETOUSA, to Commanding General, Ground Force Reinorcement Command, 23 Feb. 1945, subject: Trench Foot Among Reinforcements.
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3. Most of the cases of cold injury in reinforcements occurred in troops sent into the field without proper training in its prevention. The plan in the European theater provided for a 2- to 3-week period of training for all replacements arriving from the United States before they were assigned to combat units. Military exigencies did not permit the uniform application of this plan. The training period frequently had to be cut short because of the urgent need for manpower in the frontlines. During the Battle of the Bulge, for instance, very little time intervened between the arrival of troops in the theater and their assignment to units in combat.
The program of training in the Reinforcement Command included a course in first aid and field sanitation, in the preparation of which the Surgeon General's Office had participated.51 Foot hygiene was a part of this course. Greater emphasis was placed upon this subject after the distribution of War Department Circular No. 312 and TB MED 81. When the original program proved inadequate and recently arrived reinforcements were found to be suffering heavy casualties from trenchfoot, the program of indoctrination was further intensified, action being initiated both inside and outside the Reinforcement Command.
Colonel Gorby wrote General Hawley on 1 December 1944 that he had asked all army surgeons to take the necessary steps to see that reinforcements were properly indoctrinated in the facts of cold injury before their assignment to combat units. On 7 December, General Patton recommended to the Commanding General, ETOUSA, that before their release from the Ground Force Reinforcement Command each officer and each enlisted man be given intensive individual instruction in measures to prevent cold injury, including the correct fitting of shoes, combat boots, and overshoes. It was also recommended that command responsibility for cold injury be emphasized to officers and that the importance of rotation be particularly stressed. These recommendations were designed to decrease "the probability that they [officers and enlisted men] will become casualties soon after arrival in combat areas."52
Two circulars on the subject of cold injury were issued by the G-round Force Reinforcement Command, No. 55, dated 13 December 1944, and No. 3, dated 10 January 1945. Later, all depots were instructed that no reinforcements were to be reassigned until they had received the proper instruction in cold injury and until that fact had been duly noted on each man's WD AGO Form 20.
As the dates indicate, in this as in other commands, the action taken to prevent cold injury was correct, but it was taken too late to influence the epidemics which occurred in the European theater in the winter of 1944-45.
Training and Schools
It was midsummer of 1944 before the prevention of cold injury came to be regarded as one of the essential considerations in the infantry training
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51Annual Report, Surgeon, Ground Force Reinforcement Command, European theater, dated 30 Sept. 1945.
52 Letter, Headquarters, 12th Army Group, to Commanding General, ETOUSA, 7 Dec. 1944, subject: Training of Replacements in Prevention of Trench Foot and Care of the Feet.
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program in the Zone of Interior (p.74). By the time the program had been fully implemented and the troops trained under it had reached the European theater, the trenchfoot epidemics were practically ended. In other words, except for the divisions of the Seventh U. S. Army which had been trained in the Mediterranean theater, the troops which fought in Europe through the winter of 1944-45 had had only the most casual training in the prevention of cold injury, if, indeed, they had had any at all. This lack of knowledge and training was not limited to enlisted men. With few exceptions, line commanders had equally little understanding and appreciation of the risks of cold injury and of methods of preventing it.
Finally, and again with few exceptions, medical officers were almost equally ignorant and untrained, since cold injury is an entirely unknown condition in most parts of the United States. Even in the coldest portions it is observed only occasionally, practically always in the form of frostbite. Although numerous opportunities existed for instruction of medical officers in the European theater, a study of the record does not indicate that they received any special training in the subject before cold injury began to occur.
The Medical Field Service School was established at Shrivenham, England, as part of the American School Center operated by the Services of Supply, on 27 February 1943 (Circular No.22) for training medical officers in aspects of military practice not ordinarily encountered in civilian practice. Before it discontinued operations on 15 October 1944, about 900 officers had been trained in 21 classes. The field of instruction was wide, but the curriculum apparently did not include cold injury, at least as a special subject; it may have been mentioned incidentally. Cold injury also does not seem to have been included in the instruction in Medical Department training methods provided by a demonstration platoon at the school. Between courses, this platoon toured base sections, putting on demonstrations for the hospitals.
Courses in such subjects as plaster technique, laboratory technique, anesthesia, oxygen therapy, and the making of artificial eyes were given for officers and enlisted technicians at various station and general hospitals in the theater, and selected medical officers attended courses at British hospitals and schools. In all of these courses, as at Shrivenham, the range of interest was wide, but cold injury was apparently not covered in any of them.
OTHER CONSIDERATIONS OF PREVENTION AND CONTROL
Rotation
During the cold injury season in the European theater, fighting was always too desperate and combat manpower was always in too short supply to permit unit rotation to any considerable degree. This was a war of movement, and troops were almost always continuously engaged. Because of the tactical
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situation and the limited manpower available, therefore, major commanders seldom found that any large-scale rotation of troops was possible.
Absence of regular rotation practices was one of the major handicaps of the control program. In spite of the serious difficulties connected with it, however, rotation might still have been accomplished if there had been any stated theater policies concerning it. There were none,53 and, until the end of combat, such unit rotation as was practiced was according to the orders of individual subordinate commanders. This was not a desirable state of affairs.
Individual rotation was difficult and was not practiced uniformly, though it was employed irregularly and to some extent almost everywhere along the front. Since experience has shown that trenchfoot does not, as a rule, develop until after more than 24 to 48 hours of relative immobility, rotation, when it was correctly practiced, had the objective of taking small groups, of squad size or larger, out of the lines for a few hours within these periods.
Many times, conditions in the rear were almost as severe as in forward areas, but usually a tent, a dugout, a ruined building, or some similar protection was available. Here, soldiers could care for their feet, change their socks, and have warm food and drinks. Drying facilities were provided whenever possible.
In spite of the irregular practice of rotation, units which employed it to the limits of the possibilities found it an extremely useful method of preventing trenchfoot. The possibilities, of course, frequently depended, more than anything else, upon the will and resourcefulness of the unit commander.
Tentage and Shelter
In April 1944, when planning for the invasion of the Continent was under way, an elaborate program was outlined (Standing Operating Procedure No. 5, ETOUSA) for the shelter of the invading troops.54 The idea was that all camps and depots should be changed over, in phases, first from canvas coverage to wood and metal huts and then to buildings.
The theater chief quartermaster was not optimistic about the use of existing buildings, because of heavy bombings, and did not regard new construction as practical. It was his idea that tentage should be provided for 2,500,000 troops, about 90 percent of the total number then envisaged, and for their supporting personnel. This planning ran counter to the experience in North Africa, a barren area, where heavy tentage for 50 percent of the troops had proved adequate. No allowances were made in the European theater for barracks and hospital buildings, which would have provided-and later did provide-for a certain proportion of the shelter needed.
The requisitions for tentage made in the summer of 1944 were not filled. Indeed, the requisitions were never more than halfway met, and when the
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53 Report, Office of Chief Surgeon, ETOUSA, to The Surgeon General, 16 May 1945, subject: Trench Foot-Revised Report No. 9.
54 See footnote 23 (1), p. 143.
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field forces called for tentage it was unavailable. At first, the troops did not fully explore the possibilities of houses, barns, and other structures, as European armies had always done, and this omission resulted in a certain amount of unnecessary exposure. Later, as their experience increased, the men began to protect themselves in existing buildings and eventually found them better than tents.
Salves and Ointments
In World War I, British medical officers at first laid much stress upon the use of salves and ointments in the prevention of trenchfoot (p.202). In 1917, this practice was discarded in favor of the use of foot powder, and it, was not reverted to in World War II. Salves and ointments were part of the preventive routine used by American troops in World War I (p. 48), and they were also used by some of the troops who participated in the Attu campaign (p.310).
During the summer of 1944, a number of inquiries concerning the use of salves and ointments were made of the Professional Services Division, Office of the Surgeon General, as well as of the Professional Services Division, Office of the Chief Surgeon, ETOUSA. The substance of the replies, which stated the official policy concerning these agents, was as follows: 55
1. Tests by both ground and air forces had shown salves and ointments to be of no value.
2. The National Research Council had arrived at the same conclusion after studies of work that had been done in Canada. The only exception to this opinion was that oil-impregnated socks might be of some value in the prevention of immersion foot.
3. The use of oils and salves might engender a false sense of security and lead to carelessness in the strict application of such essential preventive measures as cleanliness, frequent changes of socks, and general foot discipline.
4. The application of grease to the feet before the shoes were put on might cause so much sweating, especially in men with a tendency to hyperhydrosis, that a state of chronic local immersion might be produced with vasodilatation and perhaps the formation of small vesicles.
5. The Russians, who had conducted extensive tests with various salves and oils, had also concluded that this was not a useful form of prophylaxis.
The epidemic of trenchfoot in November led to a number of inquiries concerning the preventive value of this practice, but the Professional Services Division, Office of the Chief Surgeon, ETOUSA, invariably replied that the use of these agents had been carefully considered and was not recommended.
Although this was official policy, a number of units in the theater used various agents to massage the feet, some in the hope that the lubricants might have some preventive effect, others frankly for the psychologic effect and to
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55 (1) Memorandum, Lt. Col. A. L. Ahnfeldt, MC, Director, Sanitation and Hygiene Division, Preventive Medicine Service, Office of the Surgeon General, to Major Walker, Preventive Medicine Service, 4 May 1944, subject: Use of Oil as a Preventive in Frostbite, Freezing, and Trench Foot. (2) Informal Routing Slip, Professional Services Division, to Preventive Medicine Division, 4 Aug. 1944, subject: Trench Foot.
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insure massage of the feet. One unit used shaving cream. One division surgeon ran tests on the relative value of massage alone, massage with lanolin, and massage with petrolatum. In another division, aidmen carried a mixture of mineral oil, cod liver oil, and oil of peppermint, which they gave the men to use on their feet. One medical officer had the supply officer make up anhydrous lanolin with 10 percent beeswax for this purpose. So far as is known, none of these practices proved effective and all of them were quietly dropped, though not before a number of men suffered maceration of the feet from the collection of excessive perspiration under the oils and greases which they had used.
EPIDEMIOLOGIC SURVEY AND CONTROL
Even before cold injury had become a serious problem in the European theater, officers representing General Hawley and Colonel Gordon had visited major commands of the 12th Army Group. Their surveys began in October. As a result, they were able to observe the November outbreak of trenchfoot at first hand and to evaluate the efficacy of the various measures taken to control it. On their return to 12th Army Group headquarters at the end of November, they were able to corroborate, from firsthand observation, what experienced observers already knew; that is, that the major means of prevention of cold injury is proper command control. They could also emphasize, from their personal experience, that, even when the tactical situation is most difficult and terrain and environmental conditions most unfavorable, units in which foot care is a correctly supervised command responsibility could maintain reasonably low rates.
The field surveys undertaken in October and November had not been specifically directed toward cold injury. In December, a formal survey of the cold injury situation was undertaken. The observers, all experienced officers who had seen cold injury in the Mediterranean and European theaters, were accompanied by medical inspectors of the various armies. They surveyed the field armies, division by division, collecting accurate data on the incidence and prevalence of trenchfoot in each unit; unit combat experience; weather conditions; terrain; status of clothing supplies; rotation policies and practices; the quality of unit and foot discipline; and whatever other host and environmental factors were known, or were presumed, to influence the development of cold trauma. Conferences were also held with army, corps, and division surgeons and with as many senior commanders as possible. The wealth of material secured in this survey is discussed in detail under the heading of epidemiology (p.363), and only the main points need be summarized here:
1. The winter of 1944-45 was the worst Europe had experienced in years.
2. The terrain which was fought over was chiefly open country, easily flooded, and crossed by many rivers in flood because of heavy precipitation.
3. Clothing and footgear suitable for the environmental situation and the
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terrain were in short supply and were still inadequate at the end of December 1944.
4. The tactical situation could take no account of the unfavorable weather, terrain, and supply situations. The November offensive by United States ground forces and the German counteroffensive in December placed very heavy demands upon combat troops. It was necessary that they expose themselves in the performance of essential duties, and the isolated position of many units, as a result of enemy action, greatly increased the risks of exposure.
5. In spite of these adverse circumstances, a considerable degree of command control was perfectly practical, the proof being that in many units it had been accomplished. Efforts at general indoctrination of troops and at preventive measures by command were increasing and were becoming increasingly effective.
Trenchfoot-Control Teams
The recommendation of the Paris Conference on Trench Foot, that trenchfoot-control teams be established at army level (p.183), was implemented by the directive published on 30 January 1945 (appendix G, p.531). Each control team consisted of a line officer and an officer of the Quartermaster Corps. The function of these teams was to visit corps, division, and regimental headquarters for two chief purposes: (1) To assess the past and present cold injury situation and (2) to teach unit trenchfoot-control officers practical measures for preventing outbreaks of cold injury and for controlling them if they occurred. It was the duty of these unit control officers, in their turn, to train trenchfoot-control officers and noncommissioned officers in battalions, companies, and platoons. The functions of control personnel in the smaller units were to check on individual foot discipline in their units; to encourage obedience to instructions and better performance by means of personal instruction and force of example; to determine shortages of clothing and equipment; and to institute programs of discussions and demonstrations among small groups, so that all personnel would be familiar with the need for, and the details of, the special measures necessary to prevent cold injury.
Trenchfoot-control teams were set up too late to exert any substantial influence on the incidence of cold injury in the European theater during the winter of 1944-45. By the time they had become fully operational, weather conditions were improving, German resistance was deteriorating, and the Allied forces were moving swiftly and victoriously forward toward the Inner Reich.
In spite of the late institution of the program, it was nonetheless the consensus of those who watched the program in operation that it provided an extremely effective means of combating cold injury. This was the opinion of thepersonnel of the teams from all five armies which met at the Office of the Chief Surgeon on 21 April 1945, together with medical inspectors of the various UnitedStates field armies and representatives of Headquarters, 12th Army Group.56
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56 Report, Medical Section, 12th Army Group, to the Adjutant General, 12th Army Group, 7 May 1945, subject Monthly Summary of Medical Section Activities.
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The general feeling was (1) that this was the best method of bringing preventive measures to units of company grade and (2) that squad leaders were essential components of the control program, since they were in close contact, day and night, with their squadmates and could encourage and guide individual foot care and discipline.
It was also the unanimous feeling of those present at this meeting that, should operations be required during the next winter, these control teams should be reorganized and reactivated before the trenchfoot season began. Finally, it was decided that trenchfoot-control officers or teams could profitably be established on divisional as well as army levels.
The full potentialities of the trenchfoot-control program are discussed in the chapter on prevention (p. 484).
CONFERENCES
Regular conferences were held by General Hawley with base section surgeons. The agenda covered a wide range of subjects of both administrative and clinical significance. Other conferences were held with senior consultants, and still others with his division chiefs. Inter-Allied conferences on war medicine were also held during 1942, 1943, 1944, and 1945. Cold injury, however, was scarcely mentioned at any of these conferences until after it had become a serious problem in the theater.
At a conference held in London on 21 July 1944, attended by various professional and administrative personnel, General Hawley stated that The Surgeon General was greatly concerned about the possibility of cold injury during the coming winter. He emphasized that the causes were well known and that prevention was the important consideration. The Surgeon General, General Hawley continued, thought that a sock with a high wool content would prevent cold injury, and Colonel Gordon's division, with assistance from the Professional Services Division, would at once take up the matter with the theater chief quartermaster. Three million pairs of pure-wool socks were on hand in the theater, but the troops did not like them. The alternative might be to request the Quartermaster General to develop an 80-percent-wool sock. At this conference, Colonel Gordon stated that material on the subject of cold injury had been put together and was ready to be published. General Hawley observed that it would not be of much value if the necessary socks were not available.
At a meeting of his division chiefs on 4 October 1944, General Hawley stated that he could not himself think that the end of the war was in sight and that he thought that plans should be made for all eventualities before they developed. Cold injury was not specifically mentioned as one of the eventualities he had in mind.
On 6 October, at another meeting of his division chiefs, General Hawley
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stated that in recent visits to various evacuation hospitals of field armies he had found nurses living in cold tents surrounded by water and mud and that respiratory disease rates were increasing. At the meeting of division chiefs held on 26 October, Col. William S. Middleton, MC, Chief Consultant in Medicine, Office of the Chief Surgeon, ETOUSA, also reported an upward trend in respiratory disease in the First and Third U. S. Armies.
A conference held in Paris from 14 to 16 October was attended by professional consultants to the British, Canadian, and United States Army forces on the Continent. Although cold injury was beginning to be evident by this time, the agenda did not include any mention of it. Other conferences were also held on the Continent, but later, after trenchfoot had already become a serious problem.
At the 10 November meeting of General Hawley and members of his staff, trenchfoot was mentioned for the first time since the 21 July meeting in London. It was now becoming a problem. The shortage of overshoes and the quality of the socks being issued to the troops were discussed. It was brought out that the theater quartermaster had said that the supply of socks was more than ample.
At the 30 December meeting of the Chief Surgeon's consultants committee, in Paris, trenchfoot occupied much of the agenda. The discussion covered both the clinical manifestations of cold injury and its management, with special emphasis on the value of prompt exercise. The idea then prevailed that 50 percent of casualties from this cause could be returned to duty and that anywhere from 5 to 35 percent of the patients hospitalized in the Communications Zone could be returned to duty. The experience in the Mediterranean theater had already shown that the optimism indicated by the figure of 35 percent was unwarranted. Colonel Middleton remarked that the lack of clinical coordination was shown by the fact that every new unit which encountered cold injury had to go over the same therapeutic trials and errors that had already been explored by units farther forward.
The February 1945 Inter-Allied Conference was devoted to cold injury. Papers on the subject were presented by Maj. Leiv Kreyberg, Royal Norwegian Medical Corps, Professor of Pathology, University of Oslo; Col. C. S. Ryles, Professor of Hygiene, Royal Army Medical College; and Raymond Greene, physician, Emergency Medical Service. Cold injury does not seem to have been discussed at any of the earlier meetings of this group.
The other conferences held on cold injury and on cold-weather clothing were not convoked until the problem had become extremely serious.
Conferences on Trenchfoot
In January 1945, just as the epidemiologic survey of trenchfoot in the European theater was nearing completion, cold injury again began to increase in frequency. The disappointing increase, the large numbers of hospital beds
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already occupied by casualties suffering from trenchfoot, and the findings of the epidemiologic survey pointed to the need for a pooling of experiences and a general review of the situation. The Chief Surgeon therefore authorized a conference on trenchfoot, which was held in Paris on 24 January 1945. It was participated in by representatives of the Medical Department, Quartermaster Corps, and G-1 (personnel and administration), ETOUSA, the preventive medicine officers of the several field armies, the officers who had conducted the epidemiologic survey (p.176), and the medical and surgical consultants in the theater. Combat commanders were represented by Col. (later Brig. Gen.) Sterling A. Wood, commanding officer of the 313th Infantry Regiment, 79th Infantry Division, who had shown a particular interest in, and comprehension of, the trenchfoot problem.
The discussions and conclusions of this conference in regard to the pathologic process, clinical manifestations, therapy, and prognosis of trenchfoot are presented elsewhere in this volume, under the appropriate headings. The opening presentation by Colonel Gordon was a comprehensive analysis of the situation from the standpoint of control. The substance of his remarks was as follows:
Epidemic cold injury may be compared with a waterborne epidemic of typhoid fever. In such an epidemic, general measures would first be taken, including the chlorination of water and the institution of a general control program. Then specific measures would be instituted. Focal points of local outbreaks would be sought for and would be eliminated by the application of the general epidemiologic principles of focal attack. This procedure had been followed in the attack on cold injury. Commanding officers in all echelons had made an energetic effort to educate troops and perfect their discipline. The chief quartermaster had invoked all the resources of his office to provide and distribute winter clothing. Finally, the Medical Department had conducted an intensive campaign of instruction in preventive measures for both units and individuals. In this presentation, the epidemiologic similarities between the trenchfoot situation in Europe and the malaria situation in the Southwest Pacific were also pointed out.
The analysis of the epidemic of cold injury had revealed decided variations from unit to unit, whether the unit was an army or a battalion. These variations made it clear that future steps in prevention must be directed toward the smaller units. The small unit did not necessarily require additional general education and indoctrination. It did not even require a more assiduous application of general measures of control. The essential point was that every company, and even lesser units, must understand the special conditions which were producing cold injury within their own ranks. These conditions were not necessarily the same in all units. Frequently, in fact, they were quite different. If the individuality of the special causative factors were realized, rotation, for instance, would not be overemphasized in a unit in which the cause of cold injury was the lack of proper clothing or failure to enforce foot discipline.
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Special experiences.- Of a number of special experiences described in the course of the discussion, the following are of special interest:
1. When it was found in the Seventh U. S. Army that reinforcements coming into one division through regular channels or from hospitals were not acquainted with the facts of cold injury, it was decided, about 1 November 1944, that the convalescent hospital and the replacement depot were good spots in which to initiate preventive training. At this particular time, it was the custom in replacement centers to give the troops a 30-minute lecture on their general health, only 10 minutes of which was devoted to the care of the feet. Trenchfoot was either not mentioned at all or was discussed within 2 minutes. The lecture period was lengthened to 60 minutes, and at least 30 minutes of the time was devoted to cold injury.
The educational program instituted at the convalescent hospital consisted of short, informal discussions; radio programs; and the use of articles on the subject in Stars and Stripes. A representative of the Quartermaster Corps was assigned to the hospital to teach methods of utilizing winter equipment. Among other things, lie demonstrated how easy it was to get out of the sleeping bag, once the trick was known. This officer, together with Medical Corps officers, worked down to battalions, companies, and smaller units. As a result of these efforts, the Seventh U. S. Army had become extremely foot conscious.
The same speaker (Lieutenant Colonel Gowan) who reported this effort in the Seventh U. S. Army also reported the value of individual efforts at instruction. When he visited the 36th Infantry Division, he found that a medical aidman, who was later killed, while serving in a lost battalion, had made the men remove their shoes at intervals, wring out their socks, exercise their feet and toes, and employ other simple measures to prevent trenchfoot. His work paid large dividends. Although the tactical and environmental circumstances were highly favorable for the development of a large number of cases of trench-foot, the number which occurred was very small.
2. The second experience was related by Colonel Wood. In his notes on the conference, Colonel Cutler stated that this officer's remarks were "more effective than any of the professional discussion." Later, General Hawley passed on to the surgeons of the field armies Colonel Wood's suggestion that every regimental commander could profitably be taken on a tour of hospitals caring for trenchfoot casualties, so that they would comprehend the real seriousness of the injury.
Colonel Wood knew nothing of trenchfoot until lie observed it, as a patient with another condition, in the 40th General Hospital. There He saw enough of it to make him very much aware of it. Before he returned to his own regiment, lie was able to have conferences on the subject with the Chief Surgeon and Colonel Cutler.
His remarks concerning his actions thereafter deserve extended quotation:
I went in and asked my division surgeon, "What are you doing about trench foot? * * * He said, "On the 22nd of November we got up a circular." I said, "Let's get it out and see what it is." * * * It had come to my regiment when we were in the middle of fighting
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a battle. There was one copy to the regiment and there had been no follow-up on the part of the higher command to see what had happened to it. The regimental commanders did not know about the dangers of trench foot. * * * I worked * * * to have them [the posters] issued and displayed in every conspicuous place around the area. * * * I had ten basic factors about trench foot printed up and required that every single individual have one and have the company commanders check to see that they have them personally. Then I talked to the division commander and he sent me * * * to tell all the other regiments in the command all that I had seen. At that time we had no trench foot. We did not know what we were going to get into. We were fortunate in that we had the shoepac. [In another connection the speaker said that his own men preferred the shoepac to the combat shoe and could march 18 to 20 miles in it.] We had ski socks, so that we did have basic equipment. There was one thing we immediately found. * * * we had never been trained in this type of foot discipline over here. Colonel Gordon was talking about the original training and education. We never had any training about trench foot. * * * Command control and discipline were also mentioned. Now the difficulty as I see it is that of command control. * * * peaks [of trench foot] are going to happen because during a month's time in our organization the noncommissioned officers and officers are casualties and going back. [They are] the people that will normally handle the supervision to see that the man does what he should do * * *.
I think the commanding officers have to receive some definite orders, not suggestions. One of my objections to all these medical bulletins is that you use too long words and that we don't know what you are talking about, and that they are too lengthy. They should be just as brief as possible. We should get them in quantities, so that we can give them to the man who has to carry them into effect.
Because of the high rate of replacements, in actual practice it means you have to start to educate people all over again. None of the early training we had even two months ago will ensure that the individual man does what he is expected to do. We have broken it down to the noncommissioned officers. Actually I have a more stable rate of noncommissioned officers in my regiment than commissioned officers; often the company commander is a second lieutenant who has recently come in. Each man carries one of the papers and he is checked. They are erased for consideration for a Paris pass if they are caught without one. Then if you can get those leaders to force the men to change their socks, you are doing a great deal in the right direction. That is command responsibility, but in the way we are scattered up there, the company commander is busy planning what he is going to do next. It has to be broken down. The regimental commander has to ask the battalion commander for a report of what he is doing on trench foot, which is exactly the same as he must ask if the men are being fed and supplied. Then he has to insist that the battalion commanders do the same thing with company commanders, but the men who actually made the men put on the dry socks have to see them put on * * *.
One thing we require is that as soon as a man gets into any shelter at all, he is to lie down on his back, elevate his feet and remain there just as long as he can, and wiggle his feet as much as he can. We have tried to convince them that if for a period of thirty minutes time during a twenty-four hour interval, blood can be made to pump into the toes, we can eliminate a great deal of trench foot * * *.
We have drawn extra duffle bags * * * for every company. All the socks are in the duffle bags. It doesn't make much difference in size. * * * All our requisitions are for size twelve socks. The ration detail comes up at night and takes back with it the duffle bags of wet wool socks. They come up then with one dry pair of socks for every man in the company. * * * After a forty-eight hour period we are getting duffle bags and dry socks for every man in the company. That is the rotation system and we are able to use it most of the time. If you can get food to the men, you can also get socks to the men. It can be done if it is ordered, and the same thing applies about wearing socks. When we are ordered to do something, we do it without any question, but if the division surgeon comes up and says, "I think it would be a good idea to get dry socks every day," it just doesn't get done, and I
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would like to recommend that the recommendations from here go down through command channels. By that way the line officer does what he is told automatically without thinking whether it can be done; if we leave it to him, it won't be done. I think it would be much simpler just to tell him to do it.
In reply to questions, the speaker stated that one man, preferably the mess sergeant, should be made responsible for the dry socks. He also recommended that education on trenchfoot be given in the reenforcement depot, to make company officers conscious of the problem before they went forward. Second lieutenants were often company commanders within a few days after they had joined the regiment, and, if they had not been previously instructed concerning cold injury, it was necessary to wait for a break before the matter could be taken up with them.
Conclusions and recommendations.- The general responsibility for trench-foot was particularly emphasized in the discussions at the conference. It was distributed among (1) the individual soldiers, who had to take care of their own feet; (2) command, which bad the responsibility of training the soldiers and seeing that they did what they were told to do; (3) the Quartermaster Corps, which had the responsibility of providing clothing and footgear suitable for winter combat; and (4) the Medical Corps, which had to keep the various command and quartermaster echelons informed about cold injuries, without at the same time letting the individual soldier believe that he was going to lose his legs from this cause.
The most universal fault, the conference concluded, was poor foot discipline, and the time had arrived for firm and definitive action within units in which this deficiency was evident. The similarities between the trenchfoot situation in Europe and the malaria situation in the Southwest Pacific suggested that improvement could be accomplished in Europe by the same approach that had been effective in the Pacific; that is, the use of control teams for individual inspection, education, and discipline.
A recommendation embodying the concept of control teams was supported, and the necessary steps were taken later to form such a team in each of the field armies (p.177 and appendix G) .
After the trenchfoot teams had been appointed in accordance with the directive authorizing their establishment, Col. Tom F. Whayne, MC, preventive medicine officer of the 12th Army Group, suggested that it would be profitable for members of the teams from the various armies to meet with preventive medicine officers from the armies as well as representatives of the theater and the army groups, in order to discuss the functions of the teams and methods of procedure. This conference was held in Paris on 16 February 1945.
Quite properly, because of the command and training implications of the cold injury problem, the conference was opened with a general discussion of the whole problem by a representative of G-3, ETOUSA. The medical aspects of the problem were then discussed by General Hawley. A resume of causative factors, the present status of the cold injury situation, and the principles of the control program were presented by Colonel Gordon. 'This (morning) session
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was concluded by a roundtable discussion in which members of the trenchfootcontrol teams and others participated. Many practical aspects of the problem were covered. The afternoon session, which was entirely clinical, was held at the 108th General Hospital, at which a special study of patients with trench-foot was in progress. After an opening clinical lecture on the nature of cold injury, patients were presented and methods of treatment were demonstrated and discussed.
The over-all effectiveness of the trenchfoot-control program could not be evaluated in the European theater because, at about the time the control teams went into action, the weather ameliorated and, with the thaw that occurred, cold injury began to decrease. It was, however, the consensus of all who had participated in the first conference that a second conference, attended by essentially the same personnel, should be called to review the activities of the teams and of the officers and noncommissioned officers who had been responsible for the implementation of the program. It was hoped that enough information could be brought out to permit some sort of evaluation of the operations of the control teams. This conference was held in Paris on 21 April 1945.
The program of the second conference, after the opening remarks by Colonel Gordon, was devoted to discussions of foot discipline, weather, clothing and equipment, operational conditions, and similar matters. The experience of certain divisions of the Seventh U. S. Army which had previously been exposed to cold injury was compared with that of other divisions which had had no previous experience in winter combat. It was the consensus of those present (1) that the plan of using control teams provided an effective and profitable means for the control of cold injury; (2) that it greatly enhanced the training of the individual soldier and the small unit in their own responsibilities in the matter; and (3) that it also utilized the elements of command, supply, and medical personnel in a well-coordinated and interlocking combination.
It is highly significant that the majority of the members of this second conference (13 of 15), all of whom had observed trenchfoot under combat conditions, concluded that, in the control of trenchfoot, the most important of all considerations was individual foot care, followed, in order of importance, by adequate clothing and equipment and sound rotation policies. Bad weather, although it is the fundamental cause of all cold injury, was given the place of least importance by all the officers voting.
Conferences on Winter Clothing
The conference on winter clothing which the chief quartermaster had planned to call for late December 1944 was necessarily postponed because of the German breakthrough in the Ardennes which occurred at that time. The conference was eventually held in Paris on 29 January 1945, and a followup conference was held in the same city, with much the same personnel in attendance on 17 March.
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A detailed record of these conferences is not the proper concern of this volume, but certain general facts may be stated.57 It had been the hope of the chief quartermaster that the conference would recommend a simple, basic uniform, suitable for all branches of the Army and planned in accordance with limitations of transportation and production. As he pointed out, the United States Army had 70 items of basic winter clothing, against 11 basic items for the British Army. The British Army had made its plans for a simple uniform at the beginning of the war and did not change them; as a result, it did not experience the shortages and inadequacies of various items which constantly plagued the United States Army.
The two conferences did not accomplish the goal which the chief quartermaster had set for them, but they did improve matters by reducing the 70 basic items of clothing by 21, the number of sizes by 29, and the number of fabrics required in the manufacture of the uniform from 10 to 4.
As to clothing, it has been correctly said that the items finally decided upon represented a weighing of preferences rather than a meeting of minds. This was because the clothing recommended by the Quartermaster General had been thoroughly tested only in the Fifth and Seventh U. S. Armies, which had used it with satisfaction for two winters. The 12th Army Group, which expressed a preference for the obsolete armored force uniform, had scarcely tested the new items which it was voting against. On the whole, the conclusions finally arrived at were much the same as those arrived at by members of the trenchfoot-control teams who had observed cold injury at first hand in the field. On one point, at least, there was unanimity, that the shoepac was the most acceptable footgear for frontline troops to wear in winter.
CLINICAL INVESTIGATIONS
Mention has already been made of the study of cold injury in Air Force personnel undertaken in 1943 at the 2d General Hospital in the United Kingdom (p.134). A number of other studies were undertaken when cold injury became prevalent among ground troops in the European theater in November 1944, but most of them were informal and concerned only small series of cases. One of them was a study of therapeutic methods at the 110th Station Hospital. Another was a study of negative pressure therapy at the 7th General Hospital. Still another was an investigation at the 92d Medical Gas Treatment Battalion, Third U. S. Army, to determine what type of casualty could be retained in the army area for treatment with the expectation of return to combat duty. Incidentally, several hundred men were returned to duty under this plan.
In view of the excellent results obtained by the formal study of influenza and empyema undertaken in World War I, it is unfortunate that trained investigators were not sent from the Zone of Interior to the European theater to
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57 Letter, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, ETOUSA, to the Quartermaster General. 9 May 1945, subject: Winter Uniform.
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set up similar studies for cold injury. Not a great deal could be done by personnel in the European theater. All facilities were heavily involved in the care of patients. The clinical material, paradoxical though it may seem, was much too abundant to permit extensive, properly controlled studies to be set up generally.
Early in October 1944, Colonel Crisler of the First U. S. Army had suggested to Colonel Cutler that hospitals for specialized care of trenchfoot should be set up in each army and should be staffed by medical officers experienced in this special field. Colonel Cutler transmitted the suggestion to Colonel Kimbrough, but events, unfortunately, moved too fast for this excellent plan to be carried out. The exchange of information at the trenchfoot conference in Paris in January 1945 (p.179) permitted the evaluation of various diagnostic and therapeutic techniques, but it was then too late to institute formal investigations.
The single formal study of trenchfoot in the European theater was made at the 108th General Hospital, under the direction of Capt. (later Maj.) Octa C. Leigh, Jr., MC. Consultants on the project included Col. Johan C. Hoist, consultant in surgery to the Norwegian Army in the United Kingdom, and Major Kreyberg. The specific objectives of the study were to provide a simple, workable classification for rapid triage; to study various methods of therapy; and to accumulate as much practical data as possible concerning the duration of exposure, the duration of immobilization, the kind of footwear worn at the time of injury, and similar matters. The details of this investigation are cited in appropriate places throughout this volume. The investigation, unfortunately, was not as complete as it might have been because the special equipment required, including skin temperature thermocouples and capillary microscopes, was received too late to be entirely useful.
Plans for a study of anticoagulant therapy (heparin) in cold injury were proposed by the Medical and the Surgical Consultants Division, Office of the Surgeon General, but for a variety of reasons this project could not be carried out. The rationale of this type of therapy is discussed elsewhere (p.326).
REPORTING AND NOMENCLATURE
War Department Technical Bulletin (TB MED) 92, issued 15 September 1944, provided that War Department MD Form 86ab, though intended for use in reporting communicable diseases, should also be used to report trench-foot, immersion foot, and frostbite under a special heading. The reason for the use of this form was that reports made on MD Form 52 would be too late to accomplish one of the most important purposes of the Statistical Health Report; namely, to furnish current information on the incidence of communicable diseases.
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When trenchfoot became epidemic in the European theater, it was found that Form 86ab was not providing statistical data quickly enough to be useful, and Form 323 was substituted for it.
Form 323 was a daily report prepared by all medical units in the theater primarily for use by the Office of the Chief Surgeon; it permitted the reporting of epidemic conditions without loss of time. Reports made on this form, however, were less exact than reports made on Form 86ab. For this reason and as a result of different methods of reporting, the first statistics secured for cold injury contained some inaccuracies, chiefly in the form of overreporting. The errors, which were sometimes substantial, were finally all corrected.
Because of necessary wartime classification of medical casualty reports, higher headquarters at times encountered some difficulty in associating the casualties from trenchfoot with the exact unit in which they occurred and the location of the unit on the battlefront. From the standpoint of Colonel Gordon's office in Paris, the secrecy with which military operations were being carried on delayed the evaluation of the reports of trenchfoot as they were submitted, first weekly and then daily. The condition appeared suddenly, and the number of casualties increased rapidly. Colonel Gordon apparently had difficulty, from the reports which he received at first, in determining the exact units which were most affected and their location. Division, corps, and army surgeons, who were closer to the trouble, of course did not have this difficulty.
Other problems, however, were not settled during the entire war. The first was the category in which cold injury belonged in statistical reports. The second was the nomenclature to be employed for it. The third, which arose out of the confusion in the nomenclature, was the award of the Purple Heart for cold injury (p.189).
Because of lack of clarity in directives, trenchfoot and immersion foot were at one time or another included in medical statistical reports both as nonbattle injuries and as diseases, while frostbite was variously considered as both a battle and a nonbattle injury, depending upon the interpretation of the individual command. As long as cold injury was not a major problem in the theater, the confusion did not make too much difference. In November 1944, with the outbreak of what proved to be a true epidemic, the confusion became serious. It resulted in both underreporting and overreporting, and it added further to the administrative difficulties which arose in connection with the award of the Purple Heart.
As pointed out elsewhere, the terms "high-altitude frostbite," "immersion foot," "trench foot," and "frostbite" were developed as matters of expediency, when the now generally accepted concept of cold injury, that all of these conditions represent varying degrees of the same fundamental pathologic process, did not exist. The distinction between these conditions is not of major importance and is often artificial. In World War I1, in fact, trench-
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foot was often, in effect, immersion foot, and the distinction between trench-foot and frostbite was usually made according to the environmental temperature at the time the injury was sustained. If the temperature was above 32? F. (0? C.), the diagnosis was trenchfoot; if the temperature was below this level, the diagnosis was frostbite. When weather records were lacking or incomplete in any area, as they frequently were, this entirely artificial distinction broke down, and the diagnosis rested with the individual medical officer.
The principal source of the confusion was administrative. Circular Letter No.156, Office of the Chief Surgeon, ETOUSA, dated 20 October 1943, directed that cold injury be designated as (1) high-altitude type, (2) ground type, and (3) immersion foot. When TB MED 81 arrived in the theater the following year, it left the theater Chief Surgeon and The Surgeon General at variance over the nomenclature of cold injury. The opinion was rather freely expressed that the term "trenchfoot" would persist, which it did, although formal recognition was not given to the popular nomenclature until 18 November 1944, when Circular Letter No.156 was rescinded with the issuance of Circular Letter No. 134, Office of the Chief Surgeon, ETOUSA. Nothing seems to have come of the sensible suggestion of the senior consultant in orthopedic surgery, Col. Mather Cleveland, MC, that the term "foxhole foot" would be better than "trenchfoot," since this type of cold injury seldom occurs in large, roomy trenches, in which men can move about, but does develop in foxholes, where they are very often almost completely immobilized.
Circular Letter No.94, Office of the Chief Surgeon, ETOUSA, 31 August 1944, directed that patients admitted for cold injury and retained more than 24 hours (that is, for more than food and rest) should be classified as battle casualties. This regulation was frequently violated, with the result that hospital registrars were confused, and statistical reporting was becoming inaccurate. On 30 November 1944, Col. David E. Liston, MC, Deputy Surgeon, ETOUSA, directed that for the time being all cases of trenchfoot should be classified as nonbattle injuries. Shortly before, Colonel Kimbrough had recommended to General Hawley's executive officer that the relevant portions of Circular Letter No.94 be altered and that disabilities due to exposure be listed as diseases.
Because of the mounting confusion, General Hawley's office requested a War Department ruling on the classification of trenchfoot, immersion foot, and frostbite incurred in combat areas. The reply, dated 3 December 1944, directed that these injuries should not be classified as battle casualties. This ruling was reaffirmed in April 1945.
The reports indicate that trenchfoot and frostbite were both reported as trenchfoot up to the end of 1944. Thereafter, they were reported separately, although the distinction, as already mentioned, was artificial in the extreme. Many medical officers experienced in this type of trauma always thought that the three categories (immersion foot, trenchfoot, and frostbite) would better have been considered under the generic heading of cold injury, if only because
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a more correct concept of the etiologic factors and pathologic process would thus have been obtained. The terms of the award of the Purple Heart, however, made it necessary to continue the separate classifications.
AWARD OF THE PURPLE HEART
One of the byproducts of cold injury, which arose principally in the European theater, was the troublesome, entirely administrative, problem created by the award of the Purple Heart. At least part of the difficulty arose from the confusion in the nomenclature of cold injury, which has just been summarized.
This award, which had been established by Gen. George Washington at Newburgh on 7 August 1782, during the War of the Revolution, and which had lapsed shortly afterward, was revived on 22 February 1932, on the 200th anniversary of his birth, "out of respect to his memory and military achievements," in War Department General Orders No. 3. The award was to be given to members of the United States Armed Forces wounded either in action against an enemy of the United States or as a direct result of an enemy act, provided that the wound thus incurred required treatment by a medical officer. For purposes of the award, a wound was defined as "an injury to any part of the body from an outside force, element or agent sustained as the result of a hostile act of the enemy or while in action in the face of the enemy." The word "element," it was specified, "refers to weather and permits award to personnel severely frostbitten while actually engaged in combat." It was stated, equally specifically and entirely illogically, that trenchfoot did not merit the award.
Army Air Forces.- The question of awarding the Purple Heart for cold injury first arose in World War II in connection with cold injury in flying personnel. In September 1943, the Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, concurred in the opinion that this type of cold injury justified the award. A few weeks later, however, the inconsistencies of this policy were pointed out to G-1, ETOUSA, by General Hawley in a line of argument to be repeatedly advanced in connection with this award. The Purple Heart, the Chief Surgeon pointed out, was a command, not a medical, problem. Frostbite was a disability produced by the hardships of service, not by enemy action, and it was usually preventable. While it could result from defects in equipment, it was more likely to result from individual carelessness. Protective clothing might be damaged by enemy action, but, if the principle upon which the Purple Heart was being given for cold injury in flying personnel were applied consistently, it was hard to see where the line was to be drawn; the award might as reasonably be made for pneumonia, tonsillitis, and a cold in the head, all of which might develop after exposure. Furthermore, if men in the Eighth Air Force were given awards for frostbite, every soldier on the ground who had sustained a cold injury also deserved it. Awards were not
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given for cold injury in the Royal Air Force. On the contrary, each injury was investigated, to determine whether damage to protective clothing had occurred by enemy action or by negligence.
In May 1944, when changes were made in Army Regulations (AR) 600-45 (Changes No.4) concerning the terms of the award, reference to cold injury in flying personnel was deleted and the term "element" was defined, without restriction, as referring to the weather. It was again specified that, while severe frostbite sustained in combat justified the award of the Purple Heart, trench-foot did not.
Residua of the Aleutians campaign.- The Purple Heart was apparently never a serious administrative problem in the Mediterranean theater either in the winter of 1943-44 or in the following winter. Questions concerning it next arose in June 1944, in connection with the residua of cold injury in the Aleutians campaign. Immersion foot, as cold injury incurred in that area was called, was not mentioned in the regulations for the award, and the commanding general of the 7th Infantry Division, whose troops had suffered heavily from cold injury during that campaign, recommended that the Purple Heart be given for immersion foot.
When the correspondence on the subject was referred to the Surgical Consultants Division, Office of the Surgeon General, the reply sent on 15 September 1944 agreed that the current regulations were unfair for a number of reasons:
1. Many soldiers incur trenchfoot while actually in combat and are more seriously injured than some who incur frostbite, even if it is severe.
2. They may lose one or both lower extremities as a result of their injury.
3. Although immersion foot, trenchfoot, and frostbite develop under different circumstances, the basic pathologic process and the clinical manifestations are similar, the difference being in degree, not in kind.
In view of these facts, it was recommended that, since all three types of injury might be incurred in actual combat, the disputed paragraph (16A) in AR 600-45 should be altered to read: "In connection with the definition of the `wound' above, the word `element' refers to weather and permits award to personnel severely Frostbitten or incurring Immersion Foot or Trench Foot while actually engaged in combat."
In subsequent weeks these arguments were reiterated and expanded in the Surgeon General's Office. On 5 October 1944, the Surgeon General's executive officer wrote to the Decorations and Awards Branch, Office of the Adjutant General, that specifications as to the severity of cold injury were not regarded as practical, partly because injuries without loss of structure might be graver than those in which tissue is not lost.
On 3 October 1944, Brig. Gen. (later Maj. Gen.) Russell B. Reynolds, GSC, Director, Military Personnel Division, Headquarters, Army Service Forces, recommended to G-1, War Department, that the regulations be altered to permit the award to personnel who had incurred trenchfoot or immersion foot as well as frostbite if they were actually engaged in combat, if they required amputation of a part, or if the injury required hospitalization. The changes
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proposed were not made, but, on 21 October 1944, the deputy chief of staff settled the question which had arisen in connection with cold injury in the Aleutians campaign by authorizing the 7th Infantry Division commander, who had raised the question, to make the award to members of his division who had sustained immersion foot during the Attu operation if the injury had been incurred in actual combat and if it had resulted in amputation of a part or in other permanent injury.
European theater.- Meantime, the matter was again coming to a head in the European theater, this time in connection with the ground type of cold injury. As the weather became colder and wetter, and as cold injuries increased in numbers, the situation became more and more confused and unsatisfactory, especially from the administrative standpoint.
On 25 November 1944, Colonel Gorby, the 12th Army Group surgeon and an experienced field medical officer, pointed out to G-3 of the army group that it was not at all fair to limit the award to amputees since more lasting incapacity might be incurred without any loss of tissue. His own opinion, however, was that the award should not be given for any type of cold injury. Trenchfoot was preventable. It was the responsibility of the individual soldier and of his commanding officer to prevent it. Its occurrence usually indicated poor training, poor command, and poor soldiering. The medical officer was in no position to determine whether it was or was not preventable in any given case, and it would be more logical to award it for diseases which could not be prevented. If word got about that the Purple Heart was to be awarded for cold injury, an immediate increase in hospital admissions could be expected; it would be a good way out for potential S.I.W. (self-inflicted wounds). The Russians, although they were fighting in an environment productive of cold injury, had very little of it because in every instance, no matter what the circumstances, disciplinary action was taken against the injured man and his commanding officer. In Colonel Gorby's opinion, disciplinary action rather than awards would reduce the personnel losses due to cold injury. No definitive action resulted from these sound arguments.
Still other complications were arising. Line officers, out of consideration for their men, naturally wanted a liberalization of the regulations, to permit the Purple Heart to be awarded for trenchfoot. On the other hand, just at this time, the concept of command responsibility for cold injury was beginning to be comprehended, and those charged with the prevention of the injury objected, with logic, to making nominations for an award to be presented for the very condition which they were ordered to prevent. The conflict of interests, centering around the criteria for awarding the Purple Heart and complicated by the confusion of nomenclature just described, actually tended to affect the Adjutant General's accounting of battle casualties.
The Purple Heart came in for considerable discussion at the conference on trenchfoot held in Paris in January 1945 (p.179). It was pointed out that in view of the terms of the award, which required a distinction between frostbite and trenchfoot, the nomination of the man for the award really
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rested with the medical officer who first saw the patient, since he was aware of weather conditions and duty status. It was therefore an error, which should not be permitted to continue, to change the diagnosis in evacuation hospitals in any case of cold injury unless there was sound clinical evidence of diagnostic error. If this plan were followed, the award would at least be made consistently, for the diagnosis would be consistently right or consistently wrong. General Hawley said that, over his opposition, the award had been extended to such absurd lengths that it might as well be issued with rations.
No change in Army Regulations was made during the epidemic phase of cold injury in the European theater. The award continued to be a matter of administrative controversy, with the Medical Department, because of its exclusive power to determine diagnoses, squarely in the center. On 4 February 1945, General Hawley wrote The Surgeon General that the wording of the regulation (severely frostbitten) could be interpreted to apply only when the lesion was so extensive that cells were killed and there was an actual loss of a part, or a slough through the whole thickness of the corium. He said that, as a practical matter, it was not possible to distinguish between frostbite and other forms of cold injury. The hospital wards, he said, were full of embittered infantrymen who had sustained trenchfoot, often of a serious degree, but who were not entitled to the Purple Heart. The Medical Department was being required to administer a policy which it had not set up and which it could not administer fairly. Forward units were conferring the Purple Heart and were not being too strict about it, under pressure from frontline commanders who demanded liberality in the award to keep their troops reasonably mollified. As the situation now stood, General Hawley added, men with simple blisters caused by frostbite were receiving the Purple Heart while men with incapacitating lesions from trenchfoot were not getting it.
On 26 February, General Hawley pointed out to the surgeons of the other armies in the European theater that the Third U. S. Army did not authorize the award because of the difficulty of determining the degree of severity of the injury within the period established for holding these casualties in the theater. He felt that the same step could well be taken in other armies in the theater.
The last War Department message on the subject received in the European theater did nothing to resolve the difficulties connected with the award. In April 1945, in response to a second inquiry from the theater concerning the classification of cold injuries, the Adjutant General's Office replied that trenchfoot, immersion foot, frostbite, and injuries similar to them would not be reported for statistical purposes as battle casualties but that the award of the Purple Heart to personnel severely frostbitten while actually engaged in combat would not be affected by this ruling. This meant, in effect, that although cold injuries were not to be classified as battle casualties the Purple Heart, which is an award for an injury sustained in battle, would continue to be given for one type of cold injury but not for the other two.
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The General Board, United States Forces, European theater, trenchfoot (cold injury, ground type).- The General Board which investigated, among other matters, the subject of trenchfoot in the European theater later in 1945 (p.208) stated that a just and equitable award of the Purple Heart for cold injury was possible only if it was authorized for all casualties who sustained cold injuries while actually engaged in combat, and only if the injuries were of sufficient severity to require treatment by a medical officer. The Board recommended that the current policies be reviewed and that the award either be granted for both trenchfoot and frostbite or not be granted for either. Before the award was recommended in any instance, consideration should be given to such factors as combat and weather. It should also be determined whether or not the injury was due to negligence or to deliberate intent or was avoidable and to what degree it was attributable to enemy action.
Action in the Zone of Interior.- When casualties from overseas began to be returned to the United States, the problem of the award of the Purple Heart for cold injuries came to the fore in this country. For example, in February 1945, the commanding officer of the United States Army General Hospital, Camp Carson, Colo., which was a trenchfoot center, wrote to The Adjutant General 58 that the great majority of the patients under his command had received their cold injuries while fighting for their lives, under very unfavorable conditions of combat. Many had been pinned down for days in water-filled foxholes, continuously raked by machinegun fire and periodically subjected to tank assaults. Some had been kept for days on outposts and patrols and could not possibly remove their shoes. Some had been in combat for as long as 30 days without extra socks. There could be no question of personal neglect in such cases. Moreover, many of these casualties were likely to have serious sequelae, ranging from severe paresthesias and hyperhidrosis to gangrene, possibly with amputation of half the foot.
In fairness to these casualties, as well as in the interests of uniformity, the letter proposed that a policy be established whereby the Purple Heart would be given for trenchfoot on two criteria: (1) That the disability be acquired in combat and (2) that it be sufficiently disabling to require evacuation to the Zone of Interior. It was further proposed that the award be accomplished in Zone of Interior hospitals, after thorough investigation of the records in each case. These proposals were concurred in by the commanding general of the Seventh Service Command.
When this communication was referred to The Surgeon General by The Adjutant General for comment and recommendations, The Surgeon General expressed complete accord with the views of the basic communication and reiterated the recommendations made by his office on 5 October 1944 (p. 190). It was specified again that if a soldier was to receive the award, his injury must have been incurred during actual combat and that its severity must have been
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58 Letter, Col. T. E. Harwood, MC, Commanding Officer, U. S. Army General Hospital, Camp Carson, Colo., to The Adjutant General, 12 Feb. 1945, subject: Award of Purple Heart.
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sufficient to require hospitalization. Evaluation of the severity of the injury was considered impractical. It was pointed out again that injuries without loss of tissue might prove to be graver than those in which tissue was lost.
In a memorandum dated 7 April 1945, addressed to Maj. Gen. George F. Lull, Deputy Surgeon General, Lt. Col. Roy H. Turner, MC, acting director of the Medical Consultants Division, Office of the Surgeon General, pointed out that Army Regulations 600-45, Changes No. 5, dated 11 November 1944, permitted the award of the Purple Heart for severe frostbite, while trenchfoot was not considered to merit the award.
At the time this change was made, Colonel Turner pointed out, frostbite was limited almost entirely to flying personnel. In April 1945, however, a large number of patients at the United States Army General Hospital, Camp Butner, N. C., were suffering from trenchfoot, and the clinical picture in these cases could not be differentiated from that of patients in the hospital suffering from frostbite. Existing regulations about the award of the Purple Heart were a cause of impaired morale and unfavorable criticism of the Medical Department, and it was suggested that consideration be given to a change in the regulations, so that severe trenchfoot would also merit award of the Purple Heart.
In the third endorsement of the basic communication, dated 14 April 1945, Maj. Gen. Norman T. Kirk, The Surgeon General, recommended to Gen. Brehon B. Somervell, Commanding General, Army Service Forces, that AR 600-45, paragraph 16a (2), be either amended to include immersion foot and trenchfoot or rescinded insofar as it authorized the award of the Purple Heart for frostbite. In doing so, General Kirk also mentioned the memorandum submitted by his office on 5 October 1944 to The Adjutant General (p.190).
In a memorandum addressed to the Professional Administrative Service of the Surgeon General's Office on 18 May 1945, Brig. Gen. Fred W. Rankin proposed that the regulations governing the award of the Purple Heart be changed either to exclude the award altogether for cold injury or to authorize the award for all nonpreventable cold injuries actually sustained in combat if the injury necessitated hospitalization while in service. It was noted that the unfair regulation differentiating between frostbite, for which the award was authorized, and trenchfoot, for which it was not, had just been perpetuated in Changes No. 6, AR 600-45, dated 2 May 1945.
When the War Department G-1 concurred in this suggested change with the proviso that the award be made only if the cold injury resulted in amputation or partial amputation of a member, the action reopened the question which had already been so warmly debated. The Surgeon General's Office took exception, on the ground that amputation was not a suitable criterion of injury. A soldier severely frostbitten on the cheek, chin, or forehead would not receive the award by this criterion; neither would a casualty with serious and perhaps permanent impairment of the local vascular tree, though he would be left with a major disability. Furthermore, the great emphasis placed by
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the Army upon the preventable nature of cold injury had to be taken into consideration, even while it was remembered that circumstances beyond individual control might be responsible for any gradation of the injury. It was therefore recommended that if the Purple Heart were to be given at all for cold injury, three criteria must be met:
1. The injury must be severe.
2. It must require hospitalization.
3. It must be ascertained that the circumstances of the injury were not preventable and were beyond human control.
The president of the War Department Decorations Board did not look with favor upon a proposal that the whole matter be dropped on the ground that there would probably be few instances of cold injury in the future. He took the position that since the question had been raised it should be settled. He suggested that the criteria of award should include a proviso that the injury had not been incurred as the result of the soldier's own negligence or misconduct. To some extent, this would take care of possible malingerers and would put the responsibility on medical officers. A little later, G-1 of the War Department concurred with the suggested changes, on the ground that if the award was made for one injury it should be made for all.
In July 1945, the Adjutant General, Army Ground Forces, recommended that the award should not be given for frostbite. He wished a wound to be defined as "* * * a physical injury to any part of the body from an outside force, or from a noxious agent used as a weapon, sustained as a result of a hostile act of the enemy or while in action in the face of the enemy." He considered that any substantial departure from this definition was confusing and detracted from the prestige of the Purple Heart, which should be maintained. This letter also repeated the arguments that the award was no more logical for cold injury than for pneumonia, malaria, and other medical conditions; that there was no point at which to stop if any single type of nonbattle casualty were to be considered a basis for the award; and that the problem was complicated by the fact that cold injury might or might not be preventable.
While this correspondence was in progress, Changes No. 7, AR 600-45, was issued on 14 July 1945, with the disputed paragraph as it had appeared on 3 May 1944 (Changes No. 4), before the most recent argument about it had arisen. This meant that personnel severely frostbitten while actually engaged in combat might continue to be awarded the Purple Heart, but that the award would be withheld from soldiers who acquired trenchfoot under precisely the same circumstances. 59
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59 The paragraph in question remained unchanged until May 1951, when the recommendation was revived that the Purple Heart should not be awarded for frostbite. In the notation from (3-1 for the Chief of Staff, United States Army, it was pointed out that the Air Force and Navy had eliminated the award for cold injury, and that the Army, to provide for more uniform standards of awards, should also eliminate it. This recommendation was concurred in on all levels, and the Chief of Staff on 23 August 1951 approved the elimination of frostbite and trenchfoot as reasons for the award of the Purple Heart (Changes No. 4, AR 600-45). The award was therefore not made again during the remainder of the war in Korea.
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PUBLIC AND CONGRESSIONAL REACTIONS TO THE TRENCHFOOT SITUATION IN EUROPE
During the entire period in which trenchfoot was epidemic in the European theater there was intense public interest in the situation in the United States. Full cooperation was given to newsmen working in the theater; they were supplied with as much information as military security permitted. Numerous stories appeared in the lay press. Much of the material was accurate and was fairly presented. Much of it, however, was not, and even the most accurate accounts usually failed to make clear that the trenchfoot problem was a complex one and that it was not possible to simplify it by incriminating any single factor or any single set of circumstances.
How completely the situation could be misunderstood is apparent from the following extracts from a letter which was received by Senator Robert A. Taft from one of his constituents.60 After noting published reports of the widespread incidence of trenchfoot and "frozen feet," the writer continued:
I have also noted the statement attributed by Gen. Lear that the cause was more a question of discipline rather than adequate foot wear. Knowing Gen. Lear's passion for discipline, I suppose he would say the soldiers could fight in their shirt tails as long as they were properly disciplined.
That may be all right on a sunny golf course in the South but would hardly apply to the fighting front during an European winter. Inadequate foot wear may be the reason but a reason is not an excuse for the proper army authorities failure to provide proper foot gear. With the benefit of the knowledge obtained by the experience of our Allies both British and Russian, there appears to be no excuse for overlooking this important matter. Why not hand out a little discipline to the disciplinarian who failed?
Senator Taft sent the letter to General Kirk. In his reply, General Kirk pointed out that trenchfoot was a many-sided problem, with many causative factors, one of which was discipline. The Senator's correspondent had apparently misinterpreted the meaning of the word discipline, which in connection with trenchfoot meant the enforcement of foot care and other measures designed to prevent the soldier from contracting trenchfoot through carelessness. Combat troops were correctly trained in these precautions, but, unless the regulations were rigidly enforced, they would not prevent cold injury.
On 5 March 1945, the Mead Committee, formally known as the Special Committee for the Investigation of the National Defense Program, requested the commanding general of the Army Service Forces to make an inquiry into all phases of trenchfoot in Europe, with special reference to medical reports and the performance of procurement and supply agencies charged with furnishing proper equipment. After several conferences, and the submission on 15 March 1945 of a written report on the activities of the Surgeon General's Office in connection with cold injury, 61 it became evident that to secure all the material
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60 Letter, H. J. Hamlin, to Sen. Robert A. Taft, 3 Feb. 1945.
61 Memorandum, The Surgeon General, for Mr. Julius H. Amberg, Special Assistant for Secretary of war. 15 Mar. 1945, subject: Trench Foot Control-Medical Department Action.
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which the committee had requested would require an on-the-ground investigation in the European theater itself.
The investigation was carried out by Lt. Col. (later Col.) Mason Ladd, JAGD, director of the Legal Division, Office of the Surgeon General. His formal report, which was submitted to The Surgeon General on 9 June 1945,62 covered the following subjects: (1) Action of the Chief Surgeon and surgeons of army groups and armies, European theater, to prevent the development of trenchfoot; (2) factors causing trenchfoot; (3) observations of the British experience with trenchfoot; (4) trenchfoot as a fixed hazard in fighting of the type experienced in the winter of 1944-45; and (5) miscellaneous comments.
The report contained copies of the circular letters and other material issued on the subject of trenchfoot, interviews with various observers in the European theater, extracts from official diaries, statistical data, data on amputations for trenchfoot; and reports of conferences with The Surgeon General and officers of the British Army.
The conclusions arrived at by Colonel Ladd as a result of this investigation were as follows:
1. Efforts in the prevention of trench foot in the Office of the Chief Surgeon, ETO, and in the medical service in this theater, are considered to represent an efficient and thorough dealing with the problem. The work was commenced timely, but became effective only after the initial outbreak of cold weather injuries. When the problem became appreciated generally as a serious threat to military operations, complete cooperation was given by the entire theater command. Although training in foot discipline had been carried on in the ZI and in this theater, its significance in the prosecution of the war on the Continent was not fully appreciated by the troops until the incidence arose. An army-wide education program on the control of trench foot was initiated and successfully carried out.
2. The reduction of trench foot is believed to involve the following controllable factors in order of significance as listed below:
a. Discipline in care of feet.
b. Footgear and clothing.
c. Rotation of troops (short and long term).
3. Among those contacted * * * the shoepac with ski socks, one or two pairs, was regarded as the most suitable footwear for cold, wet weather in combat operations, although the necessity of discipline in its use, and the need for proper fitting were emphasized. For ordinary use, an improved, water-proofed combat boot with the smooth surface of the leather on the exterior was believed desirable. A system by which exchange of types of shoes according to weather conditions, as practiced in some units of the army last winter, was also favored.
4. The subject of supply of winter footwear and winter clothing is a matter pertaining to the Office of the Chief Quartermaster, and is not covered in this report. Based upon opinions expressed by Medical Officers, the matter would appear academic for this theater, as the ordinary winter clothing of the type issued generally during last fall should be fully adequate for ordinary winter conditions and action of the Army of Occupation. The production of new supplies will undoubtedly include improvements realized out of the winter's experiences. The later types of cold weather clothing used in the ETO are regarded as of utmost importance for Pacific operations where many of the wet and cold hazards encountered in combat action in the ETO may be reasonably anticipated to reappear.
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62 Report, Lt. Col. Mason Ladd, JAGD, Director, Legal Division, Office of the Surgeon General, dated 9 June 1945, subject: Report of Study of Records and of Investigation Relative to Incidence of Trench Foot, With Special Reference to its Course and the Activities of Army Medical Service Within ETO in Preventive Measures.
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5. In attempting to evaluate the various factors giving rise to the incidence of trench foot in the ETO during the winter of 1944-45, it was the unanimous opinion of all persons contacted, or groups of persons, that any one cause cannot be designated as the single cause, but that all factors were interrelated, and each of a different force under the varying circumstances under which it operated. It is a practical impossibility to single out any one cause. There is no magic cure or prevention-trench foot control involves a combination of all relevant factors. Under the type of warfare, during the conditions experienced last winter in the ETO by the American Armies, trench foot in a substantial amount is believed to have been an unavoidable hazard of war. The incidence may be reduced but not eliminated under the adverse conditions faced in Europe last winter. Under less severe conditions where fighting is less active, it may be possible, with careful discipline, rotation and suitable supplies, to reduce trench foot to the point of almost complete elimination.
Colonel Ladd's report was presented to General Kirk on 9 June 1945. On 6 August 1945, two copies were delivered to Brig. Gen. Kenneth C. Royall, Special Assistant to the Secretary of War, in accordance with a request from his office that the report be delivered to him directly rather than through channels.63 The understanding was that one of these copies was to be forwarded to the Mead Committee for use in its consideration of the trenchfoot problem in the European theater.
This report, while an excellent summary of the cold injury situation in the European theater, contained little material not already available in the Zone of Interior. When it was presented to General Kirk, the war in Europe had been over for a month. The war in the Pacific ended a week after it was delivered to General Royall, for transmission to the Mead Committee.
The investigation inspired by the Mead Committee unquestionably helped to focus attention upon the whole trenchfoot problem. Any Congressional investigation would demand respect and attention from the agency which was being investigated. On the other hand, by the time the investigation was requested (5 March 1945), cold injury had almost ceased to occur in Europe, and the severity of the epidemics had been so great that the attention of all responsible agencies of the War Department was already focused upon the problem. The dates of the delivery of the report to The Surgeon General and to General Royall for the Mead Committee explain why the investigation exerted no influence upon the planning in the Pacific and had no special impact elsewhere.
EXPERIENCES OF OTHER ARMIES
British Armies
The British and Canadian troops fighting in Europe in the winter of 1944-45 had an extremely low incidence of cold injury, 206 cases as compared with the
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63 Memorandum, The Surgeon General, for Brig. Gen. Kenneth C. Royal], Special Assistant to Secretary of War, 6 Aug. 1945, subject: Report of Study of Records and of Investigation Relative to Incidence of Trench Foot.
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United States Army experience of approximately 46,000 cases.64 The discrepancy was in line with the discrepancy observed between British and United States troops in Italy during the winter of 1943-44 (p.103). On the surface, the circumstances under which British and United States Armies fought on the Western Front seem substantially the same. A closer investigation shows that in a number of respects they were quite different. These facts are best analyzed by presenting summaries of three separate reports made by Maj. William L. Hawley, MC, Major Siple, and Colonel Ladd.
Major Hawley, the epidemiologist from the Preventive Medicine Division of General Hawley's office who observed conditions in the British 21st Army Group, reported that factors responsible for the superior British record were, in order of importance, as follows:
1. The smaller number of divisional combat days engaged in by British and Canadian troops.
2. The tactical handling of troops. On an advancing front, provision was always made in the British and Canadian Armies for periods of alternating activity and reserve. During periods of extreme cold, all elements of forward units were withdrawn from the line every day for rest and warming.
3. Weather, in the sense that the American troops did a greater amount of fighting in the snow than British troops.
4. Clothing and footgear. The British battle dress was warmer, the sock had more insulation when it was wet, and the shoe had slightly more insulation and fitted the foot much more loosely than similar United States footgear.
5. The daily consumption of hot food and drink in forward areas. British and Canadian troops were issued hexamine cookers for use in the frontline and thus were able to indulge their national tea-drinking habits no matter where they were.
6. Discipline and morale. The average British soldier was more likely than the United States soldier to do exactly what he was told to do. If, therefore, he was directed to carry a certain number of extra pairs of socks on his person, he carried them. Similarly, he took care of his feet as directed. The United States soldier was frequently careless in such matters. Under direct fire, neither United States nor British troops displayed much interest in their feet.
The most important of the factors just listed, in Major Hawley's opinion, were the smaller number of combat days engaged in by British and Canadian troops and the more favorable climatic conditions under which they fought. On the other hand, the preventive measures practiced in these armies were undeniably better and were better enforced than the United States Army practices, especially in the early fall and winter of 1944-45. When combat situations were parallel, as they were in at least four instances in which United
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64 As has been explained elsewhere, the figure of 46,000 for cold injury in the European theater was later raised to 71,000 when all reports were available and when the cases in which cold injury was not the primary cause of the casualty were included. The figure of 46,000 is retained in this connection because it is the one used in the earlier reports from which much of the discussion in this chapter is taken.
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States and British or Canadian troops occupied adjoining areas in battle, the British and Canadian records were better. "It cannot be denied," said the report, "that where comparisons seem valid the incidence in British-Canadian troops is much less than in the Americans."
Major Siple, who was sent from the Office of the Quartermaster General to the European theater in April 1945 to study various phases of cold injury, arrived at the following conclusions concerning the low incidence of cold injury in British and Canadian troops: 65
1. The constant wet-cold conditions in the British Isles during the winter months, combined with the heavy losses sustained by the British from cold injury during the first winter of World War I (p.43), made the British Army extremely foot conscious. The immediate cessation of losses from this cause in World War I when the proper control measures were instituted showed clearly that cold injury is preventable. The lessons of the earlier experience were therefore incorporated into the training of British soldiers on the Western Front in World War II, just as they had been incorporated into the training of those who fought in Italy. Foot discipline in the British Army was the responsibility of the unit commander; if he failed to carry out the foot inspections and other preventive measures required, he could be subjected to court-martial. The situation in the United States Army was, of course, essentially the same, but American officers did not assume their full responsibility and authority in this matter and did not exercise their full powers of discipline.
2. The British and Canadian Armies fought a holding campaign during most of the winter months and therefore had much less exposure in combat than American troops, who were pushing forward actively during the same period.
3. The areas of Holland and northern Belgium, where the British and Canadian Armies did most of their fighting during the winter of 1944-45, have a good deal of sandy soil, in which drainage is rapid. As a result, these troops did not spend so much time in mud and standing water as did American troops. Furthermore, these areas are somewhat warmer and drier than the more mountainous areas where American troops fought during the winter of 1944-45.
4. When British and Canadian troops were found to be wearing leather boots not adequate for the cold-wet conditions they were encountering, they were provided with completely waterproof boots.
5. The British militia boot had certain advantages over the American combat boot. The range of sizes was greater, and the higher toe and deeper forequarter permitted the use of additional socks during extremely cold weather. It was impossible to lace the boot tightly because the uppers already met when it was first fitted. The British boot was also somewhat more waterproof than the American boot because of the construction of the sole.
6. Throughout the winter fighting, it was British and Canadian policy not to keep any man in the frontlines more than 48 hours at a time if it was at all
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65 See footnote 37, p. 155.
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possible to relieve him. The few cases of trenchfoot which appeared in these armies occurred when this precaution could not be carried out.
7. During the periods British and Canadian troops were out of the line during the winter, they could usually be billeted in buildings, where they were able to dry their clothing and footgear and otherwise care for themselves.
Colonel Ladd, during his investigation of trenchfoot in Europe in the spring of 1945 (p.197), held conferences with the Director General, British Army Medical Services, and certain key officers on his staff. While the emphasis placed upon the importance of various causative factors naturally varied somewhat from officer to officer, the substance of these conferences with British medical officers was as follows:
1. The answer to trenchfoot could be summed up in a single word, "discipline." Assuming that troops had reasonably good equipment and encountered ordinary cold-wet conditions, they would not contract trenchfoot if they took care of their feet. The medical services of the British Army advised upon foot care and discipline, but execution of the advice was the function of line officers, whose personal responsibility it was to see that the men gave their feet proper care.
2. Troops should have a month or more of training, with the care of the feet an important part of the program.
3. All-leather boots and heavy wool socks provided for British troops were important in the program of prevention. Soldiers seldom liked the boots when they first began to wear them, but, by the end of the month of training, they were usually well satisfied with them. Some British officers regarded the British boot as the most important single factor in preventing trenchfoot. It fitted more loosely than the American boot, was made of heavier leather, and could not be laced tightly, since it was so cut that the uppers came together when the soldier first put it on. Its loose fit made movement of the feet possible even when the boot was soaked through, and the circulation of the lower extremities could therefore be maintained.
4. Every British soldier who fought in cold weather was provided with a long, loose, sleeveless leather jerkin, which he wore constantly. In general, British clothing was warmer than American clothing and was more loosely fitted.
5. British soldiers also kept themselves warm by their habit of drinking hot tea. They carried their own equipment and brewed tea many times during the day, even during brief halts in marches.
6. The differences in temperament between British and United States soldiers accounted for the fact that British troops did what they were told to do, without asking questions. Habits of obedience were not deeply ingrained in United States soldiers.
7. All British frontline troops were frequently rotated as individuals. They were given brief rest periods, in places provided behind the lines, where they could take care of their physical needs and care for their feet. This
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practice, while it depended upon the resourcefulness of the individual unit commanders, was almost universally carried out.
8. British and United States troops fought over different terrain, with the differences in favor of the British. Weather and combat activity were also in favor of British troops.
9. United States troops had moved fast and aggressively, and trenchfoot was one of the prices paid for their victory.
At the Inter-Allied Conference on War Medicine held in February 1945, Col. C. S. Ryles, Professor of Hygiene, Royal Army Medical College, said that the magic that had practically eliminated trenchfoot in the British armies in World War I was contained in the General Routine Orders issued 28 November 1915. These orders provided (1) that every man must carry a second pair of socks on his person; (2) that arrangements must be made for drying the socks and reissuing them during tours in the trenches; and (3) that the boots and socks must be taken off in the trenches from time to time, as circumstances permitted, to dry the feet and rub them well, and to put on dry socks.
The only difference between the orders issued in 1915 and those issued in 1917 was that, in the second orders, greases and lubricants were discarded in favor of foot powder. The orders under which the British armies operated in World War II were essentially the same as those issued in 1915 and 1917.
Lt. Col. (later Col.) Theodore L. Badger, MC, Chief Medical Consultant, Normandy Base Section, thought that there was a fundamental difference between British and United States soldiers in regard to their feet. Americans, he said, for the most part walk only when they cannot ride. The British, on the contrary, walk constantly, not only about their business but for recreation. They spend their weekends and vacations on hikes. As a result, they are foot conscious. They take care of their feet. They are careful about the fit of their shoes. These civilian habits were carried over into military life. As a result, British troops understood the necessity for caring for their feet in service, learned promptly from training and experience, and practiced what they already knew about foot care even before they were told what to do.
French Army
Troops of the First French Army fought in the same general territory as the Seventh U. S. Army, engaged in much the same operations, and were exposed to much the same environmental conditions. The bulk of the forces operated in the Vosges Mountains, where rain and snowfall were heavy. Each man had been issued 2 pairs of service shoes, but the allotment of 150,000 pairs of galoshes was not sufficient for the issue of 1 pair per man.66 The program of education was good; it was based on that of the Seventh U. S. Army, and the principle of command responsibility for the care of the feet was the same as the United States Army principle.
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66 Coded Message, Communications Zone, European Theater of Operations, to War Department, signed Eisenhower from Lee to Kirk, 15 Jan. 1945.
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During the week ending 12 October 1944, there were 110 cases of trench-foot reported in the First French Army. Between that week and the week ending 28 December, cold injury was epidemic; 662 cases were reported for the week ending 16 November, and 907 cases for the following week. After a brief period of improvement, there was a second outbreak, in which 574 cases were reported for the week ending 21 December and 582 for the following week. The highest weekly rates per 1,000 men for this period were 3.039 for the week ending 16 November, 4.223 for the following week, 2.648 for the weeks ending 14 December and 21 December, and 2.717 for the week ending 28 December. The smallest number of cases during this period, 105, was reported for the week ending 9 November, and the lowest rate, 0.573, was reported for the week ending 2 November.
German Armies
German troops fought under the same circumstances and in the same areas as United States troops during the winter of 1944-45, and a comparison of their experiences is therefore of some value. The best information concerning the incidence of cold injury among them was derived from the direct testimony of prisoners of war, whose physical condition usually furnished concrete proof of their statements. A great deal of the prisoners' evidence was contradictory, but this could easily be explained by variations in the circumstances of weather and combat. The material is best presented according to the sources from which it was derived, with no further attempt to explain the contradictions.
Records of German units opposing the Third U. S. Army contain no references to trenchfoot, which was apparently no problem among the enemy troops at a time when it was a serious problem in United States troops.67 For this, there were apparently two reasons. The first was that many of the troops facing the Third U. S. Army were seasoned veterans of the previous campaigns on the Eastern Front. German troops had suffered severely from cold injury during the winter of 1941-42, and they had learned their lessons well. The second reason was that German soldiers in late 1944 lacked the mechanized transport (and the freedom to use it when it was available) which characterized the Allied armies. They were, therefore, necessarily inured to long marches on foot and were physically prepared to withstand cold injury.
Up to 15 December 1944, the number of cases of cold injury observed in all German troops was apparently limited. Thereafter, the numbers were larger. Most German noncommissioned officers reported seeing only occasional cases, but a few reported that up to 10 percent of the strength of their units, or more, had been affected in varying degrees. A corporal who had been captured on 14 January 1945 and who had been with a paratroop regiment in the field since 1 January, reported that all 34 men in his platoon suffered from frozen feet, as the Germans called trenchfoot. A battalion surgeon captured on 13
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67 See footnote 20. p. 141.
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January by the Third U. S. Army had seen no trenchfoot in his unit before 1 November 1944; since that time, about 2 percent of the men had contracted it. In the infirmary in the prisoner-of-war enclosure, 150 German soldiers had to be hospitalized because of severe trenchfoot and frostbite; gangrene was sometimes present when they were captured. Lack of bed space did not permit hospitalization of prisoners with milder cold injuries.
A United States medical officer in charge of the dispensary in another prisoner-of-war enclosure in the First U. S. Army area said that, between 4 January and 11 January 1945, 5,061 prisoners had passed through this cage; of the 437 who reported on sick call, at least half were treated for trenchfoot or frozen feet. Of the 44 who were hospitalized for this cause, 21 had serious injuries. Thirty of the 76 prisoners hospitalized between 11 January and 17 January also had cold injuries.
Colonel Cleveland noted in his official diary for the week ending 21 February 1945 that, in a tour of 11 hospitals, he had observed about a thousand German prisoners with frostbite, about a third of it serious because of gangrene of the toes, the forepart of the foot, or the entire foot. He thought that practically all of these men would eventually require amputation of some portion of the foot.
At the 196th General Hospital, Colonel Cleveland saw 127 prisoners, about 20 percent of the prisoner-of-war admissions, with frostbite of various degrees. At the 180th General Hospital, there were 100 cases, many severe, among 622 German prisoners. At least one man was likely to lose the whole foot. At the 168th General Hospital, which was serving as the parent organization of a large prisoner-of-war hospital to be staffed by prisoner-of-war personnel, admissions for cold injury totaled 665; 222 cases were mild, 167 moderately severe, and 276 severe. It was believed that several of the patients in this hospital would probably require amputation of the entire foot.
At the 189th General Hospital, there were 146 cases of cold injury on the medical service, 76 mild and the remainder moderately severe. On the surgical service, 16 prisoners had mild cold injuries, 63 moderately severe injuries with superficial gangrene, and 120 severe injuries, with deep gangrene of the toes or of a portion of the foot. Twenty-seven amputations had already been performed, 6 of the forepart of the foot and 13 of the entire foot.
In all of the other hospitals mentioned, Colonel Cleveland observed German prisoners with cold injuries who had already undergone amputation in forward hospitals. The general practice in the fixed hospitals was to delay amputation until mummification had occurred unless infection required it more promptly, as it did in many instances. At this time (February 1945), it was thought that the frequency of moist gangrene was increasing in prisoners of war.
The prisoners themselves stated that cold injuries had been far more prevalent in the winter of 1943-44 than they were during the winter of 1944-45. Some men who had fought on the Russian front in previous winters had already had one or more of their toes amputated.
The German medical officers, as well as the United States Medical Corps
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FIGURE 33.- Winter footgear used by German troops captured during fighting in Ardennes.
officers who interrogated them, commented on the greater susceptibility to cold of men who had suffered previous cold injuries. A German officer captured in October 1944 thought that cold injury was less likely to occur in younger men, who were well fed. A United States medical officer thought that, on the contrary, it was more likely to occur in younger men because they had not learned to take care of their feet. Some German medical officers emphasized the factor of poor circulation. One regarded the constitutional makeup of the parasympathetic and sympathetic system as a possible predisposing factor. One thought that men who were pale and who tired quickly were more likely to suffer from cold injury. He also thought that heavy smokers were more susceptible.
Interrogation of German medical officers and corpsmen produced fairly consistent statements concerning equipment and discipline. It was apparently not the practice to issue special equipment before the onset of cold weather, though some men reported receiving extra socks, shoes two sizes larger than those worn during the summer, and rags for their feet. A few said that they had received chemical pocket heaters.
German clothing was, on the whole, very good. Every captured prisoner wore an overcoat. The German field boot (fig.33), which had years of development behind it, seemed a very satisfactory item. It was made of excellent quality cowhide and was loosely fitted, without lacings. It extended to just above the calf (just below the head of the fibula). It had no pressure points.
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The leather was thoroughly impregnated with a waxy substance, applied after the use of oil, and was practically water resistant. This was partly because one of the first duties of a German recruit was to spend an hour or more daily in rubbing and polishing his boots. Few of the soldiers had overshoes, but with this type of boot they did not need them.
German socks were of heavy wool. Men who did not wear two pairs were given flannel or other cloths which they wrapped around their feet outside of their socks. The socks were loosely fitted, sometimes so loosely that the toe could be doubled back under the foot.
The preventive program practiced by German troops was similar to that employed in the United States Army, except for the great emphasis placed upon the daily application of salve to the feet. Presumably, the massage implicit in the application was responsible for the apparent good results. Men who had received basic training in the care of the feet stated that the routine was to keep the feet clean, with warm water followed by cold water; to use foot powder regularly; to cut the nails square; to exercise the feet as much as possible; to remove the shoes and rub salve into the feet whenever possible; to take care of calluses; to rub shoe cream into the shoes every day; to carry a pair of dry socks in the pocket; and to dry wet socks inside the shirt.
Men who had received special, additional instructions against cold said that they had been advised to wear American overshoes; to wrap the feet in blankets if the night had to be spent in the open; to select dry foxholes, or to fill wet foxholes with straw or wood, so that it would not be necessary to stand directly in water or mud; to put straw in the shoes, or to wrap paper around the feet inside the shoes; and never to let the metal part of the shoe touch the foot. Men who had served on the Russian front were well aware of the importance of these precautions.
The majority of the prisoners stated that no provisions had been made during the extremely cold, wet weather for issuing dry socks or for rotating personnel to places where heat was available and their clothes could be dried while they rested. Smoking was restricted during cold weather because of its depressant effect on the temperature of the extremities. Alcohol was advocated for its vasodilating effect.
No single person in a unit was responsible for foot discipline. It was only occasionally reported that medical corpsmen examined the soldiers' feet and made suggestions for their care. There was no evidence of any sort of control organization. The individual soldier understood, however, that he was responsible for the condition of his feet and that he must report any trouble with them to the corpsman at once. The soldier who contracted trenchfoot was not punished unless it could be proved that he had deliberately exposed himself, to escape service. Then punishment was severe; a court-martial could mete out prison sentences of 2 or 3 years, or, occasionally, a death sentence. A document, taken from a German prisoner during interrogation and dated 28 December 1944, confirmed these statements. It had been prepared by a battalion
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medical officer, to be read to all members of the unit. Note was taken of two cases of frostbite, the occurrence of which made it necessary to remind the personnel that anyone suffering from this condition could be charged with self-mutilation, an offense subject to court-martial and punishable with imprisonment or the death sentence.
Russian Armies
Russian armies did no fighting on the Western Front at any time during World War II, and their experiences are therefore not comparable to United States Army experiences. Their armies have always operated in regions of extreme cold, and they have long known how to combat these conditions. Furthermore, since the Russian Army is a conscript army, with long and intensive training, they are acclimatized and are trained for combat in cold weather.
Russian clothing during World War II was loose, warm, and efficient. Russian soldiers usually wore fur gloves. Their footgear was usually a very loose-fitting felt boot (the valenki) without a heel and with a single seam. Each man had a pair of felt boots and another pair of leather boots, which were also very soft and pliable and which were to be worn while the felt boots were drying. Both felt and leather boots were free from constriction at any point.
Soviet troops did not wear socks. Instead, they were supplied with linen or woolen cloths, 36 centimeters long and from 16 to 20 centimeters wide, which they wrapped around their feet in a prescribed fashion. When this bandage was properly applied, it was without seams or wrinkles. Each man had 2 or 3 of these cloths; boots were issued in only 3 sizes, and differences in sizing were compensated for by differences in the thickness of the wrappings. If the bandage became wet, it was removed and reversed, the dry portion originally about the leg now being used for the foot. Newspapers were sometimes wrapped around the feet to furnish additional insulation.
The platoon commander routinely inspected the feet at the end of each march. The soldier was not permitted to go to sleep until his feet and footgear had been inspected. In effect, this meant that, unless the combat situation absolutely prevented it, the boots were taken off daily, the wrappings around the feet were reversed, and the feet were dried and rubbed.
The chief reason why the incidence of cold injury was so low in Soviet troops was that it was regarded as a preventable condition, the responsibility for which lay with the individual soldier, the small-unit commander, and the medical officer. The soldier was held accountable for the occurrence of disability, and punishment was meted out according to the neglect presumed to have caused the injury. In severe cases, the offense was looked upon as sabotage, since it deprived the army of man-hours which should have been spent on essential duties, including combat duty.
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STATEMENT BY THE GENERAL BOARD
The definitive statement on trenchfoot in the European Theater of Operations is contained in the report of the General Board, United States Forces, European theater, 68 set up by General Orders No. 128, issued on 17 June 1945, to prepare a factual analysis of the strategy, tactics, and administration employed by the United States Armed Forces in this theater.69 The following points were covered:
1. Between October 1944 and April 1945, 46,107 cases of cold injuries of all, types required hospitalization. This loss of manpower amounted to more than three combat divisions and comprised 9.25 percent of the total hospital admissions for all causes during the entire campaign in western Europe.
2. The causes of cold injury were listed as wet and cold, immobility, lack of shelter, lack of regular warm food and drink, and wet footgear. Contributory factors were listed as impaired peripheral circulation caused by inactivity and constriction, general body cooling from inadequate clothing and exposure to the elements, and lowering of the metabolic rate due to fatigue and lack of warm food and drink.
3. The pathologic process was described.
4. The practical considerations and administrative difficulties of the award of the Purple Heart were discussed (p.189).
5. The specific causes of trench foot in the European theater included extended supply lines and inadequate stocks of proper types of winter clothing and footgear, combined with the onset of wet, cold weather; the footgear worn by the troops, which was unsatisfactory in many respects and which was not waterproof or water resistant; the lack of galoshes for a large proportion of the troops when protection for the feet was most needed; the lack of shoepacs when they were most needed; the lack of proper socks in adequate supply.
6. Operational conditions were regarded as second in importance to inadequacy of clothing and footgear. Weather and terrain were also listed as possible etiologic factors. Infantrymen had been particularly affected, but cold injury had also occurred in reinforcements packed into trucks and railroad cars going forward to combat areas and inn military police who had stood for long periods at traffic intersections.
7. A program of prevention had been employed, beginning with the issuance of Circular No. 312 on 22 July 1944 and the measures of education and prevention which followed. At the onset of the outbreak of cold injury, many men had only a vague idea of its possible seriousness, and practical
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68 This study was prepared by Col. L. Holmes Ginn, Jr., MC, Chief, Medical Section, Chairman; Lt. Col. Edward J. Whiteley, MC, Deputy Chairman; and Col. W. E. Wilkinson, MC. The principal consultants were Col. Horace McP. Woodward, Jr., Commanding Officer, Field Forces Port Detachment; Col. Samuel G. Conley, Commanding Officer, 274th Infantry Regiment, 70 Infantry Division; Lt. Col. John I. Ladd, Assistant G-1, Headquarters, 12th Army Group, and Maj. George T. Aitken, medical member of the trenchfoot control team, Headquarters, Fifteenth IT. S. Army.
69 See footnote 28 (1), P.151.
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methods of preventing it were not understood. After the epidemic had reached serious proportions, a more intensive program was instituted. The various phases of this program included indoctrination, command responsibility, provision of clothing and footgear suitable for intensely cold, wet weather, sock exchange, rotation individually and by units, and the establishment of trench-foot control teams.
The European experience showed that an effective program to combat and control cold injury must be instituted in the War Department and must be based on the premises that a soldier must be provided with clothing and footgear suitable for fighting in cold, wet weather; must be given regular warm meals and hot drinks; and must have opportunities provided to warm and dry himself at least once daily. Supplies must be available when they are needed. Commanders in all echelons must be aware of the seriousness of cold injury and must take the necessary steps to insure the timely application of appropriate preventive measures. Unit surgeons must be thoroughly trained in triage and treatment. Indoctrination and training in preventive measures must be instituted in the Zone of Interior.
There was no doubt of the effectiveness of the control program that was finally instituted, even though the results could not be completely evaluated because the weather moderated just as the program became fully operative. Units which had employed vigorous preventive programs before the institution of the general program had consistently lower rates than units which had not instituted such programs, even when conditions were unfavorable.
9. The incidence of cold injuries in French, British, German, and Russian Armies was summarized.
10. It was recommended that a more effective combat boot be developed; that more adequate socks be developed and that they be provided in sufficient numbers; that the award of the Purple Heart be reviewed and a more consistent policy be developed; and that officers of the Medical Corps be given the same training in trenchfoot as they received in burns.
11. It was concluded by the General Board (1) that cold injury is largely preventable; and (2) that the relatively high incidence of cold injury in the European theater (9.25 percent of all casualties) was the result of inadequacy of clothing and footgear suitable for winter operations, unfavorable operational conditions, and the delay of many units in instituting a program with emphasis on, and close supervision of, measures that must be taken by the individual soldier to protect himself.
THE CALCULATED RISK
A thoughtful reader of this chapter on cold injury in the European Theater of Operations in World War II cannot fail to emerge from it with a number of impressions, such as the following:
1. There was a very heavy loss of manpower from this cause.
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2. The losses chiefly affected the most critically needed of all troops, the combat infantrymen, at the very time in the fighting when their services were most necessary and reinforcements were in shortest supply.
3. The fundamental cause of the epidemics of cold injury was, of course, the wet, cold weather, which could not be altered and which had to be endured.
4. Combat was heavy and could not be postponed or altered.
5. The terrain over which the fighting occurred also could not be altered.
Against this array of facts must be set a number of other factors, including human factors, which could have been controlled and the control of which would have materially modified the factors which could not be altered per Se:
1. Clothing was inadequate and improperly selected.
2. Footgear was inadequate and improperly selected.
3. Troops had not, been trained to care for their feet and to protect themselves against cold, wet weather.
4. Planning for all of these contingencies came too late.
5. An effective program was finally put into operation, but when it became fully operative losses from trencbfoot, had begun to decline and within a matter of weeks had become insignificant.
Unquestionably, one of the reasons for failure to prepare more adequately for the prevention of cold injury in the European theater was the expectation, at least in certain high quarters, that Germany would fall before winter fighting became necessary. This belief developed after the breakthrough in Normandy in July 1944, and it continued for a number of weeks thereafter, during the rapid advance of the First and Third U. S. Armies across France. This belief proved entirely erroneous. What happened with respect to cold injury was therefore, at least in part, the unhappy result of a calculated risk.
General Bradley wrote after the war: 70
When the rains first carne in November with a blast of wintry cold, our troops were ill-prepared for winter-time campaigning. This was traceable in part to the September crisis in supply for, during our race to the Rhine, I had deliberately by-passed shipments of winter clothing in favor of ammunition and gasoline. As a consequence, we now found ourselves caught short, particularly in bad-weather footgear. We had gambled in our choice and now were paying for the bad guess.
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70 Bradley, Omar N.: A Soldier's Story. New York: Henry Holt and Co., 1951.
