DEPARTMENT OF THE ARMY COLD INJURIES MEDICAL STATISTICS DIVISION 21 October 1946 MSDC3 MEMORANDUM FQRt LT. COLONEL JOHN W. REGAN Environmental Sanitation Branch Preventive Medicine Division Room 2D283 SUBJECT* Reply to Memorandum of Quartermaster General Concerning Incidence of Foot Conditions. - The attached memorandum is forwarded as a reply to the memor- andum of The Quartermaster General which requested that he be fur- nished with all available statistics on the disposition of Athlete's Foot and Trench Foot aa these conditions occurred among of the Army. The remorandum is in the form of a covering letter with nine appendixes and various attachments. It has been possible, on the basis of the data currently available in this office, to go into some detail with regard to Trench Foot. However, since there was almost no Information on foot conditions such as "Athleiie's Foot", the data in Appendix 9 dealing with the incidence of such conditions during the year 19<»2 will have to suffice for at least the next six to n*ne months. EUGENE L. HAMILTON Chief, Medical Statistics Division 1Aft DKPlRTHUtr qubd no (DLnmm of tlo F*t) 19U6. SUBJECT * Promloaoo of Foot Diseases* 10 i The Surgtoa Mosul, Washington 25* 0*0* !• Request this offieo bo furnished with all aTailablo statistios oa tho ami diotributioa of "Athlete's Foot* ad Hath Foot u pertains to tho Ai—d Forooo of tho Uni tod States* including, if possible* tho wbsr of ■so hoaro loot due to tbooo diooaaoa aad aay aatorlal eonoorniag tho typo aad offooti senses of prophylaotis aoaouroo tahsn. 2* A be to information la required by tho hwlrwiaital Protoe tioa Sootioa of this organisation, whioh, in conjunction with footgear studios* is aairtag a study of tho aioro clients of the foot in Torious parts of the world* FOR TS QUARTKWA5TER QHORALi v. m. mm—it Brigadier Q«mll — Aiiiatait DIR/rak - 73627 MKDCS 18 October 1946 SUBJECTS Incidence of Trauma of the Foot 1. In reply to OQMO memorandum 4MGRD 710 (Dir'taaas of the Foot), 6 July 1946 the following comments and attachments are forwarded* 2. During the war the a nay experienced five periods during which cold injuries of the feet were problems of varying importance. These are considered in detail in the first four appendixes attached to this memorandum. 3. At various tines during the war this office oiblished summary data in ASF Monthly Progress Report HEALTH on the is denoe of cold injury among Amy personnel. Photostatic reproductions of these are included as appendix 5. Statistical data which aopeer in other parts of this memorandum than Appendix 5 are to be cons dt ed more reliable than the'similar data included in this appendix because they are more recent and revised. 4. Appendix 6 is a photostatio copy of a memorandum to The Surgeon General from the Information and Education Division, "Trench Foot Survey." The report sionarises the results of a survey conducted among trench foot patients at Camp Butner, Uorth Carolina in April 1945. The survey was conducted in an attempt to discover some of the factors causing trench foot as seen by personnel who ware effected. 6. Appendix 7, TB Med 81 and Change 1, "Trench Foot". 6. Appendix 8 includes copies of various letters and extracts of unit historiaa dealing with the subject of cold injuries of the feet. 7. No data ara currently available concerning man days lost as the result of cold injuries of the fast. 8. Appendix 9 surma rites those data which are available concerning diseases of the feet such as trichophytosis, bromidrosis, etc. The data pertain to the year 1942. Incidence of these disease in later years will be available in the future. EUGENE L. HAMILTON Chief, Medical Statistics Division APPENDIX 1. Incidence of Cold Injury Durlaf Attu Caapaipi APPENDIX 2. Cold Injury la the Mediterranean Theater APPENDIX 1. Cold Injury In Tho European Theater APPENDIX 4. Cold Injury la Tho Weetem Pacific APPENDIX 8» Fhotoctartio Neproduotione Fro*a !!BALTH APPENDIX 6. photoctctio Copy of Ncnorcndia to The Burgeon Qcnorcl APPENDIX 7. 7D 81 end Change 1# "Trench Foot". APPENDIX 8. coplee of Lettere and Extraote of Unit HI a tori ee APPENDIX •• Data On Diaeaees Of Tho Feet APPENDIX 1. Incidence of Cold Injury During Attu Campaign APPENDIX 2* Cold Injury In tho Mediterranean Theater APPENDIX I. Cold Injury In Tho European Thaater APPENDIX 4* Cold Injury In Tho Woo tom Pacific APPENDIX 5, Photos ta-tlo Wo product! ons Fron HEALTH APPENDIX 6# Photootatio Copy of Monorandua to Tho Surgeon General APPBNDTX 7. TB Hod 81 and Change 1, "Trench Foot", APPENDIX 3« Copioo of Letters and Extracts of Unit Histories APPENDIX 9. On Di a eases Of Tho Post Appendix I. Ineidenee of Cold Injury During Attu Campaign Tho outbreak of oold injury among American troops qgmpaigdng on Attu mi tho first instanoe of oold injury among U.8. porsonnol during World War IX• Tho nuabor of afedsoioas for "exposure", prinolpolly foo teases* was equivalent to obout SI poroont of oil casualties* Tho Attu force consisted of 16,S00 Amy troops oho required tt doyo to complete tho oopturo of tho island* Various operation reports list tho following casualtiest Sunary of Casualties* Attu 11 May IMS through 1 Juno IMS Causa Mdbir of Admissions Rats par i.000 Man par day All aauoaa 8.829 11*4 DlMU«, Total 1.814 5.4 "Bxpoaura" 1.200 8.6 Othsr 614 1.8 Sonbattla Injury 818 •9 Woundad 1,148 8*4 mi«d 549 1.6 The report of the foroe surgeon* dated 10 June 1948 includes tbs following comment pertinent to the oold injury experisno# on Attui Pootgear "It is believed that the leather boots Issued troops of this Landing Pbroe were not properly oonstruoted* The steel heel support was not oarried to prevent the boot breaking against the Aohilles tendon and in napy oases produced a sere re trauma tir tenosynovitis* "The large number of oasualties due to foot trouble were the result of damp feet added to oold and the inability of nan pinned down in fox holes or other oovar to keep up proper circulation by exewoise* A water* proof type of foot gear would probably have prevented the occurrence of disability in many of these oases* "The issue waterproof trousers were not of sufficiently durable ■mterial to remain waterproof more than a few days under the conditions of oowbat in the terrain encountered* "The Alaskan field jacket and o.d. uniform with rain clothing are not considered adequate clothing for operations under the climatic and terrain conditions encountered. "Sleeping Bag - The artio sleeping bag issued is not considered adequate for combat use because of its bulk and the fact that it is not waterproof. It is believed that a'bag constructed as the inner portion of the bag issued but with a waterproof outer covering would be more ' suitable. Such a bag with snail bulk to be carried into combat would permit wans dry rest which would prevent many oases of exposure expeclally the trench foot type. Boots could be removed and socks taken off and dried inside the bag by body heat.” Weather and Terrain "Tundra and steep snow-covered ridges made litter carries slow and exhausting work." Description of Cases "The casualties listed in statistics as exposure are principally foot oases variously diagnosed as immersion foot, trench foot, and frost bite* While all three such conditions did occur, it is believed that the majority properly fall in the trench foot category. Many of the nildor oases hare already returned to duty. - Moderate oases require 18 to 20 days before they are able to walk without pain. The more severe oases which it was believed would require more than three weeks hospital care were evacuated by ship.” Statistics on Exposure Data Admittod to Shoro hospital Braouatod to Ship *5 Duty Homainint; 1Ky 12 7 1 6 13 28 10 24 14 77 9 10 82 IB 84 3 18 145 16 147 - 51 241 17 191 72 10 360 18 32 1 28 •353 19 16 25 344 20 44 24 364 21 86 23 427 22 60 2 25 460 23 62 9 26 487 24 73 43 16 501 26 20 17 20 484 26 66 21 26* 502 27 26 7 IS 508 28 75 2 17 564 20 24 13 575 30 32 18 594 31 31 42 17 666 JUZM 1 20 44 632 fl 7 Total* 1#200 239 419 682 "TFxere" Wrt V f«r oases after 1 June." A special study of a group of exposure oases eracuated to the 183rd Station Hospital mentions constant exposure to wet and snow with tem- peratures ranging between 30° and 40° Fahrenheit for the most part* Men went for days without relief and without haring an opportunity to change their gear* Most men were not prepared for the experience, although some with special training apparently fared better* Constriction of boots was a cession complaint* The high-top, leather, laced boot appears to hare oontribu ted to the derelopment of trenohfoot under the conditions met on Attu* Separate information on trench foot and frost bite is, unfortunately, not arailable, but the fb re going information suffices to re real the general magnitude of the problem* So table is the fact that one-third of the pa- tients had been returned to duty by 1 June, a fairly high proportion sug- gesting that a good many of the oases were mild in degree* The following table summarises the status of the exposure admissions on 1 June* STATUS OF ADMISSIONS FOR EXPOSURE As of 1 June 1943 Status lumber ?oroont Total adaittod by 1 Amo 1,200 100.0 Raturnod to Duty 419 34.9 Sraouatad to Ship 2S9 19.9 Remaining 1 Juno 632 44*8 Unaccounted for 10 •8 Appendix 2a Cold Injury In Tho Mediterranean Theater The outbreak of oold injuriee of the feet which began in the Mediterranean in November 1948 was the firet large eoale epidenio of thie condition. Although «ome attempt wae wade to differentiate be- tween trenoh foot, inner*ion foot, and froet bite (ground type) in reporting, the differential diagnoeie ie perhape wore subjective than for other conditions and was complicated, perhaps to no small extent, by the fact that a diagnosis of frost-bite might entitle the soldier to a "Purple Heart" whereas diagnoses of immersion foot and trenoh foot would not. the data on the incidence of these conditions are derived from the Medical Department current health report, the Statistical Health Report and the counts of admissions must be considered as preliminary. Attachment a - Cold Injury Reported By The Mediterranean Theater* Attachment b - Cold Injury and Wounded-In-Aotion Admissions For Fifth Army in Mediterranean* COLD XMJURT REPORTED BY THE MKDITEHSAMKAM THEATER* Admits loot and Katas Per 1,000 Men Per Tear, By Months Casos Ratos por 1000 Man por year 1948 Rot 68 1 Doo oo 1148 20 1944 Jan 1866 29 Fob 1596 34 Nor oo 867 14 Apr 12 # my — — Jun oo •• — f Jul — ' Aug — — Sop oo — Oot 16 # Not 373 6 Doo oo 372 6 1946 Jtn 448 11 Fob 846 9 Mar oo 133 3 Apr 68 2 May 11 4 Jun oo 8 4 * Frost bito (ground-type), inaorsion foot, and trench foot •• Five-week poriodo. Instarrod months aro porlods # Ratos loss than 0*6 por 1,000 non per year APPBMDZX 2 ATTACHMBMT a COLD INJURT AND WOUHDED-IH-ACTIOM ADMISSIONS FOR FIFTH AJQff IN MEDITERRANEAN Rataa Par 1,000 Man Par Yaar, By Waaka Rataa Tear and FIFTH ARMY 1948-4 leak ending Cold Wounded lnJury in-Action 1948 Wot 6 1.8 224 12 6.8 440 19 86.6 178 26 88.8 156 Deo 8 28.6 191 10 120*0 454 17 60.5 854 24 61*2 161 81 80.0 180 1944 Jen 7 141.0 485 14 99.8 215 21 78.9 185 26 47.6 / Fab 4 29.9 516 11 60.4 508 18 210.8 418 . 25 96.0 306 Mar 8 69.0 126 10 68.0 188 17 82.0 119 24 42.0 154 31 10.0 92 Apr 7 4.1 90 14 8.5 95 21 •88 104 28 2.6 158 May 6 • 90 92.1 13 1.1 284.9 20 8.0 452.6 27 9.7 950.9 Jun 2 8.9 1219.0 9 4.3 507.1 16 .7 267.1 23 •4 151.6 80 .8 258.1 Rates Tear and FIFTH ARM! 1944-5 Week ending Cold Hounded Injury in-Aotion 1944 Oot 6 14*1 835.8 18 86.1 913.1 20 13.3 874.7 27 7.6 605.1 Hot 3 52.6 296.9 10 32.6 166.1 17 24.7 133.8 24 6.0 159.1 Dee 1 19.5 112.7 8 19.2. 78.8 15 17.6 110.2 22 22.9 80.8 29 36.0 70.2 1945 Jin 8 85.8 75.7 12 26.7 33.9 19 19.6 36.8 26 18.8 44.8 Feb 2 25.1 34.2 9 20.4 212.5 16 88.9 135.7 23 21.6 233.9 Jfer 2 11.8 112.2 9 8.4 228.6 16 8.6 73.6 25 2.7 45.8 30 2.6 36.8 Apr 6 7.1 111.7 13 5,3 168.2 20 1.8 908.6 27 2.1 441,8 May 4 175.4 11 0.3 16..6 APPENDIX 2 ATTACHMENT b Appendix 8* Cold Injury In The European Theater Tho attached tables contain tho best data currently available on the incidence of cold injuries anong ground force personnel in the European Theater* Data on all oases in the theater, suitable for the computation of theater rates are not available* However, the sum of the field armies must be at least 90 to 96 percent of all oases diagnosed in the theater* Attachment a - Cases of Cold Injury Roportod 3y Field Andos la Tho European Iheator Attachment b - Cold Injury and bounded -In-Aotion Adtdssions for First Any in Europe Attachment o - Cold Injury And bounded-In-Aotion Admissions For Third Any In Europe Attaofament d - Cold Injury And Eounded-In-Aotion Admissions For Seventh Any In Europe Attachment o - Cold Injury And Eounded-In-Aotlon Admissions For Ninth Army In Europe CASKS OF COLD IMJURT REPORTED BT FIELD ARMIES IE THE EUROPEAN THEATER Army Waak Ending Total PI rat Third S«T»nth Ninth Fifteenth 1944 Hot 5 202 XT 184 1 • 10 812 322 161 284 46 • 17 5363 1324 3356 586 98 - 24 2922 1062 1027 365 478 - Dao 1 2427 698 908 465 461 - .e 1708 624 609 262 318 - 16 2914 1451 SOI 621 141 - 22 2729 1822 933 434 40 • 29 3141 1269 1060 564 23U - 1946 Jan 6 1682 606 444 556 77 m 12 3384 1487 924 816 64 94 19 8662 1664 1242 667 79 • 26 3318 1291 1016 974 32 - Fab 2 2802 973 567 1188 75 1 9 2861 1622 827 795 107 - 16 1533 482 716 262 26 46 23 660 117 289 178 16 1far 2 701 216 320 83 81 1 9 868 309 410 95 42 2 16 571 168 293 102 8 ■- 23 336 27 68 239 1 - 50 96 4 6 73 - 2 Source« Letter. Office of Chief Surgeon. BTQU8A to SCO Dated 28 March 1946. Subject "Troaoh Foot." APPENDIX 9 ATTACHMENT a COLD INJURY AMD WUUNDBD-IM-ACTION ADMISSIONS FOR FIRST ARMY IN BUROPB Rates per 1,000 Mon Par Year, By Wasks Tear and Waak ending 'told Injury Ratal Woundad in Aotien 1944 Nov 8 8.0 229 10 64.0 410 17 206.6 498 24 170.5 888 Dao 1 97.1 678 8 84.8 444 19 216.1 689 S8 197.2 817 20 211.2 714 1046 Jan 5 99.6 485 12 241.9 481 19 271.2 757 26 205.6 419 Fab 2 167.7 446 9 889.9 862 16 85.2 208 23 19.5 159 Mar 2 36.3 609 9 50.7 C68 16 27.6 556 28 4.5 415 30 0.7 364 APPENDIX 3 ATTACHMENT b COLD INJURY A1ID HOUNDED-IN-AC7ION ADMISSIONS FOR THIRD ARMY IN EUROPE Hates Per 1,000 Men Per Tear, By ileeks Year and Woek • ruling Cold Injury Wounded in Action 1944 Nor 3 91 10 35.2 611 17 752.4 1334 24 222.8 793 Dec 1 186.3 674 8 127.5 508 15 168.8 506 22 190.8 469 29 174.6 671 1945 Jan 5 66.8 704 12 141.9 895 19 164*6 733 26 149.8 462 Feb 2 90.9 297 9 56.8 504 16 124.2 471 23 41.7 513 Mar 2 57.7 836 9 70.1 559 1G 49.4 454 23 11.0 411 30 1.0 350 APPENDIX 8 ATTACHMENT o COLD IIJURT AND WOUHDED-IK-ACTTON ADMISSIONS FOR SEVENTH ARMY IK EU.1QPB Ratos Per 1,000 Hon Per Year, By Keeks TMr and Vtaek ending Cold Injury Woundad in Action 1944 *ov S 83.1 886 10 112.9 669 17 2CG.C 375 24 . 105.7 466 Doc 1 119.6 086 0 cC.Q 671 16 131.6 636 22 104.9 609 29 131.9 219 1946 Jan 5 126.9 363.6 12 179.1 629.7 19 141.4 632.4 2C 187.6 381.6 /•b 2 207.2 418.8 S 132.1 367.7 ie 49.6 & 7.8 23 34.3 276.0 Uar 2 16.6 162.7 9 18.4 205.0 10 17.0 446.8 23 39.8 652.9 30 12.2 266.7 APPENDIX 3 ATTACHMENT d COLD IMJUHT AMD MOL MDBD-IM-ACTIOM ADMISSIONS FOR NINTH ARM! IN MOTOR Rm tea p«p 1,000 Mon Per Y»tr, By Nook* Tear and Week ending Cold Injury Hounded in Action 1944 Jfov 8 0*3 824 10 12*4 179 17 27.8 866 24 180.2 999 Deo 1 125.7 684 3 33.6 310 15 40.4 97 22 10.5 238 29 74.0 221 1945 Jan 8 22.9 182 12 18.6 126 19 22.5 117 26 9.2 85 Fm b 2 12.7 110 9 19.2 154 16 5.5 58 23 2.0 200 Mar 2 18.7 598 9 7.0 204 16 1.8 29 28 0.2 23 80 — 437 APPENDIX 8 ATTACHMENT • Appendix 4* Gold Injury In The Western Paoifis These eases of injuries to the feet whioh oooured in the Western Ifeoifio ere not properly sold injuries because the nsn suffering from the conditions were not exposed to the requisite low temperatures* They are more properly inversion foot, and vers nostly diagnosed during and directly after the latter phases of the campaign on Leyte in the Riilippinss* The oases resulted fron the taotisal situation whioh combined with the weather, foroed many soldiers to spend nuoh tins in we ter-logged foxholes without much ehanee of drying out* DO® RSI 01 FOOT REPORTED HT THE WESTS RE PACIFIC THEATER Admissions and Ratss Psr 1,000 Man Per Tsar, By Months C«SM R*ta« par 1000 Mm par yur 1944 D*o •* 167 2 1945 J*n 25 # Fab 23 # mr •• 7 # Apr 2 # as Fiee-week periods* Unstarred months are four**week periods # Rates less than 0*5 per 1,000 non per year Appendix 6* The attached photostats, which are reproductions of pages of ASF Monthly Progress Report, "Health of The Amy", contain the analyses of oold injuries whish have been prepared in this office* They indicate the type of relationship between oold injury and battle, and contain discussions of possible preventive measures * Attachment: Photostats of articles whioh appeared in ASF MPR, HKALTH. Appendix 0. Copies of letters and extracts of unit histories dealing with cold injuries of the feet. Attachment &. For The Surgeon Gonral dated 9 Deoenber 1944 and signed by Brigadier General ?• h. Ttankin* Subject* Trenoh Foot* Attach; ent b. Uonorandua For Director Surgical Consultants Division and Director liedioal Consultants Division dated 13 Deoenber 1944, signed by Lt. Col. R. H. Turner and Lt. Col U. K. DeBakey, Subject: Treatnent of Trench Foot. Attachment o. Msanrandisa For ""he Surgeon General dated 19 June 1944 signed by Brigadier General Fred W. .tankin. Subject* French Foot. Attaohxaont d. Cold Injury - 17th Airborne Division, £70. Attachment o. Cold Injury - 26th Infantry Division. Attachment f. Cold Injury - 4ch Armored Division. Attaohaent g. Cold Injury - 94th Infantry Division. Attachment h. Cold Injury - 36th Infantry Division. Attachment 1. Cold Injury - 99th Infantry Division. Attaohaent J. Cold Injury - 33th Infantry Division, 1944. Attaohaent k. Trenoh Foot and Frostbite - 1st U.S. Infantry Division, 1946. Attaohaent 1. Cold Injury - 55th Infantry Division, 1945. Attaohaent n. Trenon Foot - 1st U.S. Infantry Division, 1944. 3PMCP 9 December 1944 MEMORANDUM FORi The Surgeon General SUBJECTi Trench Foot 1* In the report on the "Problem and Control of Tranch Foot" which appeared in tha June, 1944 issue of HEALTH and which waa baaad upon tha Army1 a experience with this condition in Italy last winter, tha statement waa made that, "A winter campaign in northwaatem Europe could areata a trench foot problem of major importance if tha laaaon of Italy ware not headed*" Thia statement now aaaumaa prophetic sig- nificance for a radio just received from E*T*0* it-is reported that up to 28 November 1944 over eleven thousand cases of the condition have occurred among U. S* troops in that theater* Tha early recognition by this o flee of the potential significance of injuries resulting from exposure to wet and cold is indicated in re- peated memoranda on this subject, the first of which is dated 23 August 1943* In all of these memoranda great emphasis waa placed upon the importance and relative efficacy of good prevention* Finally, in a memorandum dated 19 June 1944, in which a detailed analysis of the Any*a unfortunate experience with thia condition during last winter's Italian campaign indicated the inadequacy of our program of prophylaxis, it waa recommended that "a vigorous program directed toward the prevention of trench foot along lines which have proved to be effective be inaugurated y this office" and that this should includes a* The dissemination of information to troops on the hasarda of exposure to wet and cold and the careful instruction APPENDIX 8 ATTACHIJE NT a of personnel in proper methods of prevention. b. the provision of proper equipment end footgear for operation# in net, cold regions. Kffoxt should be directed toward assuring the efficacy of this eqipment. c. the direction of attention to unit oo—lenders of the importance of foot discipline and of the diligent application of the protective ae as urea. d. the dissemination of information to Medical Department personnel concerning the most authoritative knowledge on first aid and definitive treatawnt. 3. In accordance with the Surgeon General's approval and direction all of these recommendations were carried out by this office to the extent possible within the limits of its authority, as indicated by the following! a. A War Department Circular (No. 312, See. IV, 22 July 1944) was prepared, setting forth the essential principles of control and em- phasising the command responsibility for their application. b. Information to Medical Department personnel concerning the most authoritative knowledge on the subject, including the most rational principles of prophylaxis and therepeusis was disseminated through articles published In THE DULLETIN of the 0. S. ARM! MEDICAL DEPARTMENT (page 26, November 1943, and page 46, March 1944) and a Nar Department Technical Bulletin (IB MED 81, 4 August 1944). e. Conferences were held with representatives of the Q.M.C. concerning provision of suitable eqipment for troops when fighting in cold, water-cooked terrain. Recommendations were made to the Q.M.C. on the proper type of heavy woolen socks and water-proof or water- resistant footgear. 4, It is apparent from these considerations that this office has long recognised the military significance of the trench foot problem. Citing the unfortunate experience w1tv this condition last winter, it was strongly urged in June, 1944 that "steps should be taken to prevent its pe etition," Accordingly, all the elements essential to an adequate control program were set forth by this office. However, the most im- portant factor in assuring the success of this program is enforcement of these elements and this lies within the province of command rather then medical authority. F. RANKIN, brigadier General, U. S. Army, Chief Consultant In Surgery Surgical Consultants Division, 13 Dsoembsr 1944* VEMOfURDOIf FORi Director, Surgical Consultant# Division Director, !(edical Consultant# Division STTBJICTf Treatment of Trench Foot 1. In view of the certainty that Trench Foot will, in spite of preventive measures, be a major cause of ineffectiveness in oonbat troops in the F.T.C* during the present winter and may lead to pro- longed invalidism and even permanent crippling in large rashers of soldiers, the undersigned submit the following consents on the treat* nertb of Trench Foot. 2. Responsibility. Trench Foot is a condition for rfcich both nodical and surgical staffs have responsibilities. The experience in VrTTVS: has indicated that the primary responsibility for treatment of Trench Foot may advantageously rest with the Vertical Service. The greatest number of these eases occur under combat conditions that usually give high rates of battle wounds and the surgical service is likely to be more heavily burdened than the medical service. Advice and assistance of surgeons are needed in prevention and treatment of local infection and *hen amputations are required. 3. At present the accepted principles of treatment as authorised in TB Ved 81 are conservative and consist essentially of rest, avoid* anee of local trauma and infection, elevation of the feet, and reduction of metabolism in the affected part by local cooling. This form of treatment was used extensively in VATTOSA last winter, but the results cannot be considered very satisfactory. It is generally recognized that a better form of therapy is highly desirable. Um A form of therapy is hereby proposed that has rational basis and offer* a possible aeons of chocking the progression of the under- lying pathologic process at an early stage and befbre tissue damage occurs. It is believed that this method of therapy, by preventing or cutting rfiort the progression of the pathologic process either before it is tally developed or at the time of its inception, could provide a acre rapid return of normal circulation and restoration of function and mipht well prevent the more serious complication* including gangrene. It would thus have the advantages of returning a maximum number of soldiers to doty with a minisun number of days lost and a redietion of ultimate disability and deformity in the more seriously injured. APPENDIX 8 ATTACHMENT b 5* In the of these eons!derat lo ns, it is reoomnsnded that an early trial of the proposed oat hod of therapy, the details of which are presented in the inolosure, be instituted. R. H, TURNER, Lieutenant Colonel, Medical Corps, Medical Consultants UiTislocu V. E. DeBAfST, Lieutenant Colonel, Medical Corps, Turgical Consultants Oirlslon, Incl. PHOrOSKD 3TOUT OF TRKATWOfT Of TOUCH FOOT 1. pathogen—is. The primary pathologic proooM roaponaiblo fbr Trench Foot ievasculap injury duo to oold. Daaynaoo io of imperial)— mainly because it facilitat— boat loss. At low t fra tar— tissu— rel—se a substance which initiat— tha prooaoa of atorilo infla—ition. Snail blood v— oolo ara injured in thlo inflammatory proo—o and transu- dation of plaona through a mall raraal walla tak— place. This tranoudato haa a protaln content of Aron 2.5 to 3*0 pare ant. A feature of the adjustment of the body as a whole to ohilling environment la redaction of blood flow to tho extremities. Vasocon- striction in the sxtrspdtioe induced both reflexly and as a result of the direct action of cold Is accentuated by Inactivity of the individual. The combination of arteriolar vasoconstriction and snail vessel injury and the resulting exudative process tends to cause anoxia aid edema. There is good evidence that the most serious mechanism of local circu- latory failure la blockage of capillaries, venules and larger vessels. This obstruction results from slow movement of blood in snail vessels, rapid transudation of plasma through damaged vessel walls, and formation of columns of red cells of high viscosity, and finally actual clotting of the column of blood. Thile It is not definitely established whether the clump inn of the rod blood cells or "silting’’ is due to loss of plasna into the tissues and stranding of the cells or to chemical colloid changes, it seems reasonable to state that the progression of this phenomenon with eventual clogging of the lumen leads to thrombosis. Once intravascular coagulation begins extension into adjacent channels tends to oocur. Clot- ting of this stagnant oolum of concent rated blood is, therefore, the result of vascular inflammation and stasis. Information is not available concerning the coagulability of the blood of indlvi&als with Trench Foot. Blockage of vessels has been demonstrated to be the cause of gangrene in Trench Foot and frostbite. An excellent experimental study of injury to nerves by cold indicates that injury of vessels in the nerve and sub- sequent anoxia offers the beet explanation for nerve injury. It is not known whether actual vascular obstruction by a clot is an important mode of injury to nerves in Trench Foot or whether more exudation and associated anoxia of the nerve is sufficient to produce the nerve injury seen in the condition. *n>e concept presented here is that Trench Poet is a condition characterised by n diffuse inflammatory process initiated by prolonged cold and in which the natural course of the inflammation is interrupted by occlusion of blood v—sals. One of the clinical features of Trench Foot is the difficulty in prognosis based on observations mads at the time the patient first comes uix!er medical observation. This fact is compatible with the concept that much of the harm may be due to progression of the pathologic process after the indiviriial becomes a patient and therefore might be prevented by proper therapy. 2, Therapy. In accordance with this concept of the pathologic physiology of Foot, three therapeutic measures are proposed that h« to have rational basis and that, if experience Justified, might be combined eventually Into a single regimen. These three aeamires arei 1, Sympathetic Block 2, Pressure Dressings 3, Anticoagulant Therapy These three measures are designed to counteract certain factors, the combined action of which produce the disturbed physiology and con- tribute to the progression of the resultant pathologic process. To be most effective, these measures must be instituted early, i,e,, in the prehypereaic phase while vasoconstriction is still present and before transudation and thrombosis begin. Sympathetic block ”sed with the purpose of counteracting vasoconstriction and thus Inc blood flow. The pressure dressing is employed Just as in bums, in which the pathologic process of a sterile inflammatory reaction is similar. The pressure dressing splints the part and thus diminishes local metabolic activity, increases tissue pressure and thu?eck of January, all ©laments of the Infantry Division moved by motor and train ;envoy to the German "'astern Front from Brittany, France*" "The climatie conditions throughout tre month have been marked with a continuous freoznp. temperature and snow from two (2) to twelve (12) inches deep* Durin- the first r.eok of the month, all elements of the corumand were convoyed to the western Front by rail and motor. This trip was male in crowded conditions and caused numerous esses of fros- bite casualties* Troops that were in contact with the enemy suffered many casualties from frost bite and trend foot. Under severe fire, many troops e:e pinned down for v»riods of thirty-six (36 ) hours with only b&ttls equlpm nt. From these troops the majority cf foot casualties hav b en take-'.. The physical and a- ntal health of the troops has boon excellent. The number of battle fatigue cases has been low, considering the t pe of warfare in whi:h the troops have been engaged. Care of the sick and wounded'has opera ted tvrough normal channels. All casos requiring hospitalisation have been transferred to field and evacuation hospitals servin’ this area. All troops have been provided with sleeping bags. A total of six thousand six hundred (o600) shoepacks have been issued to the front line tr cps during the I'-r -.eek of the month. All other troops, except those requiring non-tariff sizes, have boon provided arctics. Glcth- In and h using cf tr ops .av' een s itisfactcry.’1 Sourcei Monthly Sanitary Report, *Ath Infantry Division, 1 February 1945 APPENDIX 8 * AmcHffiHT r COLD IN'JTRY - 36th lafanUv/ Dlvia^n nTrcn-h foot as caused a serious loss of manpower within the Division iur ng combat operati na in the winter months in Italy and nee due to the cold wet climates en: untered. Tie hi heat incidenta were reported during the months of January with £01 cases, February with 270 cases. No- vember with Z7r> new and recurrent cases and December with 155 new and £5 recurrent cases. During the month of November 77 cases of trench foot were received over a four lay period from one Lagiraent of the Division that was attacking luring a drivin rain. These troops had been issued an e*tra pair of heavy wool socles and an extra light wool pair. Although most of them had shoe pacs they had four times ns much trench foot as the re'-t of the Division. The other two Re*.ments of the Division e e in a holding pcsiticn and had a total of 19 cases of trench foot. Another observation of two adjoining crepanies inder the sane conditions of ex- posure was made *rhen one company Lai 10 cases of trench foot ver a six day period while the oth r company had 3 cases. It was found that the nen of the company having 10 cases had had no change of livht wool socks while those of the other rompany had dry socks exchanged 5 times. Thia was corrected. The marked decrease during the month of December is at- tributed to comparatively dry weather encountered during the month an. to the educational pro Tac conducted Jurin-' the months of October and No- vember on foot hygiene and the prevention of trench foot. Shoo pacs were issued r.o the troops Turin* the month cf November with ins true tics for their propur wear ani the importance of chan ing to iry clean norks and dry inner sol-s d-.il . Approximately 1700 me- of this Division do not have shoe acs cr overshoes because cf the lack of proper sizes in Quarter- master stocks. Every effort is being < ale tc issie combat cots of suf- ficient size nermit wear In of heavy wool socks ani a li *ht wool pair. A system has b* en worked out by whl:h the infantry S-£s replace the dirty socks with clean dr' sockr daily by sending the clean socks forward with the daily ration issue. The high pas:alty rate araonr Con*lssloned and Non-Cornnissi ned Officers, result ng in frequent turnover of the command while in combat bauses the necessary supervision of foot in small units and footgear disci; line to be less efficient than Is iesired, even though constant attention is iven to this matter in Battalio He imental and Division Headquarters. Instructions on prevention of trench foot given at the iire ti n of Seventh Army to personnel of replace nt Depots and Donvales *ent Hospitals is believe! to be an Important aid in the ed- ucational ;rogram agalns the disease.” Sourcet Monthly Sanitary Report, 36th Infantry Division, 1 January 17£5 APPENDIX 8 ATTACHMENT h COLD IHJURT - 99th Infantry Divls-on, 1st Amy "Cliaati; conditions jcntinued aiverre throughout most of the inonth. During the first ralf f the month, wh le the reat r part of the corjaar.i was committed, enow and continuous rain and mud con rioutod largely to the in si lence of trench foot an 1 roetbite. ihe nrw type f winter combat clothing i'-aued to front line troops late in January was not altogether satisfactory under the continuously wet weather conditions which prevailed* The shoe pacs, arctic socks, * and water repellent trousers, failed to keep individuals dry who were cont.nucusly exposed to the v.enther. These deficiencies in clothing undoubtsily contribute! to the hi>-h Incidence of frost bite and trench d r n? the first part of the onth. It was the consensus of opinion of the rocimentnl surgeons that conbat boots with rubber arctic were more satl s factory t* an snoe pacs for tv e Aeathor ani terrain encountered. The main criticisms of the shoe pac were that the arch and counters gave inad- equate su.port or marchinth y not waterproof ani they contributed to *»n .ncrcarad number of nlinter* due to difficulty in obtaining proper fits. Clcttin- was ntirely adequate during the latter part of this month wh«n the division was not in combat." Source * Sanitary he -nrt 99th Inf., 1st Army, February - 1^5 ap:}e?d:x 8 ATTACmnjUT i COLD IHjqRI - 35th Infintry Division. 1944 On 3 November 19-.4 a new drive *aa begun in which th© Division moved Eastward through Chateau Sallna, Morhange, Putelange, Sarroguemines and across the Pleia Mver into Germany. Operations were handicapped during this period by the most adverse weather conditions of almost continuous rain and temperature? near freeaing. The combat troops did not wear over- s oes at the beginning of the offensive because it was felt they would handicap the rifleman and be lost In combat. However, the incidence of "Trench Foot" increased so rspiily that on 15 November 1944 the following preventative measures were instituted* 1. Overshoes were issued to all troops. Ahen speed and nobility ere demanded of infantry companies, the overshoes were stacked in company dumps. They were brought forward and redistributed to the men at the first opportunity. 2. Every effort was mad© by unit command--rs to rotate troops daily, giving them an opportunity to warm their bodies, dry s* oes and other clothing and obtain food and rast. 3. A clean dry pair of socks were issued daily when rations were brought forward. Tha dirty socks «ere returned by the messing detail to the service train area where they were collected by the supply sections and sent to t e launir/. Clean, dry socks *ere pooled a *d from there sent forward daily as previously stated. 4. Soldiers were instructed to masse e their feet for 5 minutes daily, not to wear tight shoes and socks or lace shoes and loggings tightly. 5* All new shoes received an appli- cation of dubbin at the unit supply sections before being issued and dubbin was reapplied by the individual soldier whenever the tactical sit- uation remit.The majority of soldiers shoos fit too snugly to permit the wearing of more than one pair of socks. In view of our expi rienco with Trench Foot in cold, r.et weather from 3 November to 24 December 1944 I believe the following points should be considered wnen troops in combct in cold, wet woathcr. The GI shoe ani combat boot are not adequate protection against Trench Foot regardless of how much dubbin and Ircpredilte are applied. Shoes as routinely fitted are too small to p rmit the wearing of more than one pair of heavy socks without constricting the foot. Shoe? a full siae larger than those ordinarily worn plus an artic for protection a ainstmoisture should be provided in the late fall. If pos/lble footwear such no the shoepac sh uld be issued in preference to the larger shoe and artic. It is also vitally important that troops do rotated in the front line so that men have a chance to warm their bodies, dry foot wear and olothiny and secure food and rest. The 137th Infantry Regiment carried out a policy of troop rota- tion routinely and had as a result a low incidence of Trench Foot. They had a total of 72 cases of Trench Foot as compared to a total of 217 cases for the 134th Infantry Regiment and 22b ca*os for the 320th Infantry Regi- ment durinc the erioi 10 November to 24 December 1944. The results of rotation were so remarkable that the 137th Infantry Regiment was commended by the Commanding General of this Division as well ns the Commanding General, Third US Army. Source* 35th Infantry Division, 1944 Annual Report APPENDIX 5 A ? rACHUENT j TRENCH FOOT AND .-ROSTBITE - 1st 0. S. Infantry Division. 1945 Although winter equipment and clothirgwere an item of issue for combat troops, it was not received 'ey the combst personnel of the divl- 8 on until 23 January 1945* This issue was incom lete in that some individual sizes were unable to be properly filled. Items of issue were Shoe Pace with 2 pairs of heavy wool socks and two pairs of inserts; Ponchos; Mittens vioh inserts; Mufflers; Cotton trousers; Snow Suits; and Snow Capes. Prior to the issue of this clothing and equipment many cases of frostbite especia’ly of the feet occurred and it was not until after the issue of these items that a decrease in the number of cases was evi- dent. During the month of January the division suffered 132 cases of Trench Foot and 212 cases of Frostbite. Only 7 cases of Trench Foot and 41 cases of Frostbite occurrei after the issue of winter clothing and equipment. This same low rate continued during the month of Feb- ruary during which 20 cases of Trench Foot and 32 cases of Frostbite were reported. A’l of these were contracted during the first two weeks of the month and from that point on no c se of Frostbite and onl> one case of Trench Foot developed in the division. During this orioi of extreme cold we-th r and high incidence of foot 'ases maximum effort was made to instruct individuals in the c?re of hy- giene of the feet and the prevention of Frostbite and Trench Foot. Within the combat unite of the division certain facilities were provided for the men (heated tents or buildings) where they could go to change their wet clothing for dry and where their feet could be examined. In keeping with this program of prevention and in 'orapliance with directives from higher headquarters Frostbit Non-commissioned Officers were appointed in the units to exercise ontrol of this problem and a lecture was given to all of these non-commissioned officers cn 23 February 1945 on the care of the feet and prevention of Frostbite and Trench Foot. One criticism to be made of this latter prorrara was that it took place at a time when the problem had disappeared and the Frostbite Non-commissioned Officers as well as the enlisted personnel were not too receptive to a lecture which should have been prevented many weeks earlier when the problem was acute. Sourcet . -at U. S. Infantry Division, APO 1, Semi-annual report of medical department activities 1945 - 23 July 1945 Ar'PENDIX 8 . ATTACHMENT k COLD IK JUKI - 35 th Infantry Diviain. 1945 a. Ardennes Campaign. 11m 35th Infantry Division on 1 January 1945 remained heavily engaged with German For:es on the Southern flank of Ve German salient in the Ardennes Se tor, generally in the vicinity cf Marvie, Viilers-La-3onne-Eau and Suree. -ur mission was to attack to the Wort* and protect the East flank of the Southern corridor to Bastogne. Heavy casual tier? were incurred because of the intensity of combat, snow covered mountainous terrain and temperatures wh ch ranged between 10° F to 20° F. Of particular interest was the number of cases of Frost Bite the Casualties. Ey- ry effort was made to prevent Frost Bite by frequent rotation of troops, providing warning stations in defiladed a.eas Immediately back of the front lines, wearing of adequate :lothing# massa e ar.d exercise of the lower extremities, drying of seeks a d shoes and avoidan e of :onatri?ting foot wear and clothing. We had beer, unable to secure for our personnel. The Comb t boots a~d overshoes being worn were inade- quate protection against the cold for those in the front line whose movements were restricted, sc a series of tests were rade with avail- able clothing and foot ear t let rralrei the t)est means cf protection against Frost Bite. Paper w-rn between two (2) pair of socks or over 1 or 2 pair f sc'ks was ineffective In keeping feet warm. Com- bat boots were not large enough to permit the wearing of more than two pair cf thin wool sc:ks wit..o:t constriction of the feet. Overshoes worn over combat boots provide! slight protection but were inadequate as proven by the fact that 60* of the Froet Bite casualties wore over- shoes. The most satisfactory protection was obtained by wearing 6 or 3 pair cf socks or a boot made out of 2 thicknesses of GI blanket inside of the overshoes. A foot so protected was kept warm, but it was difficult for soldiers tc walk long distances. Out total losses in this Division from Frost cite during the period 23 December to 17 January 1945 inclusive was 479. These casualties were incurred wh le the troops were heavily engaged With the enemy and frequently nablo tc m ve because of heavy enemy fire. Sourcet 35th Infantry Division, ETO Gemi Annual Report, 22 J-ne 1945 APPEWDIX 8 attackmest 1 TRENCH FOOT ■ lit 0. I, Infantry Division* 1944 Ths first oasss of Trenoh Foot In ths division were roportod tho later part of October 1944* As mentioned a bo to tho alias to at this time was sold and woti bivouac areas vers wuddy and rainfall was very heavy• Overshoes wore not available and non were unable in seme oases to take proper oars of their feet* It was not until the start of the attack toward the Roer River that Trench Foot began to ooour/4*efularly and show a gradual increase* Those conditions which predisposed to Trench Foot were present during this campaign. For the month of November, one hundred forty-nine (149) oases of Trench Foot were reported* In order to prevent its ooourreno e certain preventive measures w're instituted and overshoes w«.re requisitioned for the combat troops* Un- fortunately, the iseue of overshoes was unsatisfaotoiy in that all isrgs sixes were not available and at a much later date when overshoes did become available, they were of the canvas type which experience has shown were permeable to water* However, each man was instructed in the proper daily oare of his feet, and made to understand how important this preventive oare was* Kaoh soldier was supplied with a minimum of five (5) pairs of sooksi laundry service for socks was pro- vided by the division quarts mas ter i "drying tents" wars established at company level* The following is a directive issued to the troops on this subject* Sourcei Annual .Report of 1st 0. 8* Infantry Division, 1944 APPENDIX 8 ATTAC2M5HT at Total *3L P.8. Total foralgn L.A. B.A. ET0 lorth Africa H.E. GDI Cl’ A SP SHP At Saa Broad droala 125 118 7 % 2 2 1 m 2 Calloaitaa 2374 1961 413 77 128 54 9 3 2 71 66 3 C la bus 413 840 73 13 23 15 . 1 1 14 5 1 Orar-riding toaa 90 79 11 2 2 m 7 Hallux Tal*ua 933 839 94 21 22 15 - - 1 50 6 m Sanaa r toa 913 839 74 13 13 11 1 - ■ . 21 15 m Hyparhidroala 372 824 48 10 9 10 - 2 . 11 6 • Batataraolgia 1025 1410 206 40 S3 63 4 1 1 31 32 1 Tri ohophytoa1a of foot 25471 18127 7344 2544 661 899 89 117 201 2224 956 158 Paa Canua 729 670 59 8 11 16 • 1 20 8 m Paa Planua 7764 6900 784 96 175 181 11 2 6 177 129 5 Tallpaa 192 181 11 - - 1 1 _ - 8 1 m Loaa of Part of foot 21 21 m m m m Dafondty of foot 661 680 81 5 7 1 IS 5 Prooatad foot 82 70 12 1 - 2 - - - 1 6 - TOTAL 41766 82598 9167 2829 1084 771 115 126 218 2628 1238 168 Appendix 9 IK IDS ICE OF SELECTED DISEASES 0? THE FEET AUOVQ U.S. ARKT PS3S0HEL lumber of Adnissiona curing 1942 Total Army U.S. Total Foral gjx L.A* I. A. ETO North Africa F.S. CBI CP A SP SHP At 8aa Rrwldroila •04 •04 •01 .02 .02 .01 •03 Calloaitaa .73 • 74 .71 .76 1.27 .65 •39 .50 •23 .47 • 93 .07 Clanua •13 • 13 .12 • 18 .23 CD • - .17 .11 •09 .07 •02 0?tr-fl4lBf toaa •08 •OS .02 •02 .02 m .06 Hallux Valfua •29 • 32 .16 •21 •22 • 18 - - • 11 .20 .07 - Hiir toa •28 •32 • 18 • IS • 13 • 18 .04 - - .14 •21 • typarhldroaia •11 .12 .08 .10 .09 .12 • •33 • .07 .08 • Matataraolgia •60 •63 •35 .39 •33 .76 .17 .17 .11 •21 •45 •02 Triohophytoala of foot 7,86 6.81 12.54 24.96 6.56 4.68 3.90 19.34 g • CM CM 14.78 13.43 3.81 Pa* Canua •22 •25 .10 •08 .11 • 19 . • .11 • 13 • 11 - Paa Planua 2.89 2.83 1.84 • 96 1.74 2.18 •46 •33 •69 1.17 1.81 • 12 Talipa* •06 .07 •02 • • .01 .04 • • •05 •01 Loaa of Part of Foot •01 •01 . . . . m Deformity of foot •20 •24 •05 •05 .07 •01 . . •09 .07 Pronetad Foot •03 •03 •02 •01 - •02 - - - •01 •11 TOTAL 12.88 12*27 15.65 27.76 10.77 9.29 5.02 20.84 24.86 17.41 17.38 4.04 INCIDENCE OF SELECTED DISEASES OF THE FEET AUDIO U.S. Aft* PERSONNEL Ratmu par 1,000 Man Par Yaar0 1942