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Chapter VI

Contents

CHAPTER VI

Mediterranean (Formerly North African) Theater of Operations 1


    Low temperatures and wet cold were no problem to United States Army ground troops in combat in North Africa in the winter of 1942-43, and the occasional cold injuries which occurred therefore attracted no particular attention. Cold injury was also not a problem in the fighting in Sicily in the summer of 1943. It was not until comparatively cold weather, which often was of the wet cold variety, was encountered in the Apennines in the fall of 1943 that United States troops of the Fifth U. S. Army were first subjected to the environmental conditions which constitute the essential, though by no means the entire, basis for the development of cold injuries in appreciable numbers of cases.
           
    When these circumstances arose, the Office of the Surgeon, NATOUSA (North African Theater of Operations), was still without information concerning the cold injuries which United States troops had sustained in Attu in the spring of 1943, although these experiences had been investigated immediately in the Office of the Surgeon General (p.57) . Col. Edward D. Churchill, MC, Consultant in Surgery, Office of the Surgeon, NATOUSA, was, however, sufficiently aware of the possibilities of trouble to write the Surgeon on 31 October 1943 that, with the approach of cold weather during the forthcoming fighting in the Apennines, circulatory disturbances (trenchfoot) were to be anticipated. Even before this date, informal consultations had been held with a number of medical officers with combat units concerning the possible occurrence of cold injury and its dangerous potentialities.

INCIDENCE

    1943-44.- It was only a week after Colonel Churchill had alerted the Surgeon to the possibility of cold injuries that the first patients with trench-foot to be observed in Italy passed through a clearing station south of Cassino. By 12 November, 6 cases are known to have occurred. Not all had been recognized immediately as instances of cold injury. One or two of the first casualties were thought to have suffered sprains and were treated with hot applications.
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1 Unless otherwise indicated, all material in this chapter is based on the cumulative report on trenchfoot in the Italian campaign, by Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, 1945. Data collected during the wartime experience have been modified to utilize the more accurate data available after the war ended.


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    After trenchfoot once began to appear, the incidence increased rapidly, and, over the 6-month period ending on 30 April 1944, there were more than 5,700 casualties from this cause in the Fifth U. S. Army (chart 3, table 3). The all time weekly high of 901 cases was recorded for the week ending on 18 February 1944. During the same 6-month period, casualties wounded in action totaled 27,602. The losses from cold injury occurred in a strength of 4 infantry divisions and 1 armored division.2

    The mere statement of these figures does not, of course, tell the whole story. It does not indicate that losses from cold injury were, case for case, actually as serious as combat losses, because practically all cold injury occurred in combat troops, who are the most difficult to replace in all wars and who were always in extremely short supply during the Italian campaign. Losses from cold injury during the winter of 1943-44 amounted to about 7 percent of division strength,3 and hospital admissions for this cause constituted 9 percent of all admissions for disease. The ratio of trenchfoot cases to battle casualties was 1:5 for the November 1943-April 1944 period. It varied from month to month and was highest in January 1944. Since the impact of cold injury can best be evaluated in comparison with casualties from combat operations, the figures leave no doubt that there was a major loss in effective Fifth U. S. Army fighting strength from trenchfoot during the winter of 1943-44.

CHART 3.-Monthly incidence of trenchfoot in relation to battle casualties; maximum, minimum, and average temperatures; and rainfall, in Fifth U. S. Army in Italy, September 1943 through April 1944


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TABLE 3.- Hospital and quarters cases of trenchfoot and of battle injuries and wounds, and average minimum temperature and average rainfall, by month, Fifth U. S. Army, November 1943 through April 1944 1

    1944-45.- The lessons of the 1943-44 experience in Italy were well learned, as will be pointed out shortly, and the incidence of cold injury during the winter of 1944-45 was far lower than during the preceding winter. The 1,572 injuries which occurred during the 6-month period ending on 31 March 1945 (chart 4, table 4) accounted for an admission rate of 20 per 1,000 men per year, which is a sharp decline from the rate of 54 (table 3) during the preceding winter. The annual rate for wounded in action also fell during the second winter of fighting in Italy because the front was frequently static, but the decrease was much less striking than the decrease in cold injuries.
           
    As a matter of convenience, recurrent trenchfoot, which was a considerable problem during the second winter in Italy, as well as during the latter part of the first winter, is discussed elsewhere, under a single heading (p.381). Precise figures are not available, but it is well established that a definite proportion of the cold injuries observed during the winter of 1944-45 represented recurrent cases. The proportion decreased, however, as medical officers began to realize, from hard experience, that return to full duty is possible in only a limited number of cases of trauma from cold.
           
    The British experience.- A point of major interest in the story of cold injury in Italy is the comparative experiences of British and American troops. During the winter of 1943-44, the British 10 Corps was an integral component of the Fifth U. S. Army. It fought over the same terrain and for the same objectives. It is therefore possible to make valid comparisons of British and


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CHART 4.- Monthly incidence of trenchfoot in relation to battle casualties; maximum, minimum, and average temperatures; and rainfall, in Fifth U. S. Army in Italy, September 19,114 through April 1945

TABLE 4.- Hospital and quarters cases of trench foot and of battle injuries and wounds, and average minimum temperature and average rainfall, by month, Fifth U. S. Army, October 1944 through March 1945 1


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United States experiences. This is in contrast to the situation in the European Theater of Operations, where many comparisons are unsound because the troops of the two nations occupied entirely different positions and their tactical activity and deployment were also different.
           
    Incidence of cold injury among British troops in Italy during 1943-44 was strikingly lower than among United States troops. Early in the fall of 1943, trenchfoot was apparently of so little consequence in British troops that it was not reported at all. Reports from the week ending on 4 December 1943 through the week ending on 19 February 1944 show a total of only 102 cold injuries in British troops, in contrast to 4,583 battle casualties, a ratio of 1: 45. During the same period, there were 4,560 cold injuries and 17,894 battle casualties in Fifth U. S. Army troops, a ratio of 1: 4.

TABLE 5.- Cases of trenchfoot and battle casualties in British 10 Corps, for weeks ending 4 December 1943 through 19 February 1944

    The explanation of these differences is not entirely clear. Among the obvious reasons for the better British showing were the excellent boots with which British troops were provided; the heavy wool socks which they used, in contrast to the lighter socks provided for American troops; the daily sock exchange which was routine in the British Army; the British practice of keeping troops in the line for shorter periods of time than the American practice; and the very strict foot discipline enforced on British troops. An observer from the Office of the Quartermaster General considered that the British custom of


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classifying cold injury, from the disciplinary point of view, as a self-inflicted wound had much to do with the lower British incidence. 4
           
    Milder cases of trenchfoot among British troops were likely to be treated in quarters and not to appear in formal statistics, whereas among United States troops practically every casualty with trenchfoot was either hospitalized, treated in quarters, or carded for the record, and included in the statistics. Any reasonable allowance for these different practices, however, could explain no more than a minor part of the very considerable difference in the incidence of cold injury in British and United States troops. The opinion was expressed by one corps surgeon (VI Corps) that the discrepancy would have been less notable if there had been taken into account the readiness of United States Army unit surgeons to evacuate all soldiers with cold injury, regardless of its degree.5
              
    These various explanations may or may not be valid. The important fact remains that when the circumstances of combat were precisely the same, as they were on the Anzio beachhead, the disparity between the American and the British incidence of cold injury is very striking, as the Surgeon, VI Corps, pointed out in a report to the Surgeon, Fifth U. S. Army, on 13 April 1944, after a survey of that area: 6
           
    During the months of February and March there was a total of 1,951 cases of "trench foot" reported among the American troops, and 103 in the British forces. The American forces on the beachhead are approximately twice the number of British troops. Thus there was one case of this disability occurring in the British troops to ten cases among the Americans. That is, the incidence of "trench foot" in the American forces was ten times that of the British-climatic and tactical conditions were the same for both forces.

    General Blesse had made essentially the same point in a report to the Commanding General, NATOUSA, on 16 March 1944: 7 During the 10-day period ending on 17 February, 550 American soldiers were hospitalized from the southern sector and 501 from the Anzio beachhead. British troops on the beachhead, fighting under the same conditions as United States troops, had very few cases.
           
    During the winter of 1944-45, recordkeeping practices in the British and American elements of the Fifth U. S. Army were the same, and comparisons of the cold injury rates are therefore valid (table 6). The average annual rate for trenchfoot per 1,000 men was again higher in American than in British troops (20.5 in contrast to 6.3). The average annual rate for battle casualties per 1,000 men was, however, higher in United States troops than in British troops, so that the ratio of cold injury rates to battle-casualty rates was really about the same in both groups (1:10 in United States troops; 1:11 in British troops).
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4 Letter No. 57, Maj. Robert H. Bates, Quartermaster Observer with the Fifth U. S. Army, to General Doriot, Office of the Quartermaster General, 25 Apr. 1945.
5 Annual Report, Surgeon, VI Corps, 1944, annex D.
6 Ibid.
7 Essential Technical Medical Data, Headquarters, NATOUSA, for February 1944. Appendix II, dated 16 Mar. 1944, subject: Health of Command for February 1944.


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TABLE 6.- Incidence rates for trenchfoot cases and battle casualties, United States and British elements, Fifth U. S. Army, for weeks ending 13 October 1944 through 7 April 1945

TACTICAL SITUATION 8
    Although the winter of 1943-44 was not punctuated by the intervals of bitter combat which had occurred earlier, at the time of the Salerno landings, and which were to occur later, with the fall of Rome and the breach of the Gothic Line, combat was nonetheless sufficiently intensive for casualty rates
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8 Fifth Army History, pts. 1I--IV, 7 Oct. 1943-31 Mar. 1944.


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to be high and for the tactical situation to require the exposure of troops to the risk of cold injury. Much of the fighting was in thee mountains and was especially difficult and demanding. After the fall of Naples and the crossing of the Volturno River in October 1943, monthly casualty rates were continuously high; the maximum number of cases (8,378) occurred in February 1944 (table 3).
           
    November and December 1943 found United States troops operating in wet cold over the mountainous terrain before the German winter line. In January, following the breakthrough on the winter line, the Rapido River was crossed, Cassino was approached, and new positions were established before the Gustav Line. Operations of the Fifth U. S. Army during this period can best be described as a continuous assault, over unfavorable terrain, upon prepared positions, with the enemy largely free to make such stands as he chose while he conducted an orderly withdrawal up the peninsula. The individual United States foot soldier, as a result of this type of combat, was often immobilized by enemy fire. The terrain was unfavorable, and dry shelter was almost impossible to find. Moreover, supply was a major problem. Cargo trucks could go only a short distance up the mountains after they had left the main roads, and food and ammunition had to be brought up by mule pack or, very often, by hand carry. As a result, days might pass without supplies of hot rations' being brought up.
           
    Landings on the Anzio beachhead were undertaken in January 1944 in an effort to draw German strength away from the Gustav Line, which guarded the approaches to Rome. Conditions on the beachhead were simply an exaggeration of the conditions which prevailed throughout the Fifth U. S. Army area at this time. The VI Corps was contained within space roughly 15 miles long and 7 miles wide. Here it was raked by concentrated artillery fire and air attacks throughout the remainder of the winter and until the breakthrough in May, just before the fall of Rome. During this time, there were few quiet intervals. Heavy attacks by armor and infantry were repeatedly delivered by the Germans, under cover of merciless artillery fire from well-placed ground positions, and there were also heavy bombings from the air.
           
    Under these circumstances, infantrymen were often obliged to spend days immobilized in water-filled foxholes, in icy weather, with no chance of relief. Because the beachhead, as just pointed out, was held from the first under very heavy opposition, Allied reverses were serious, and until almost a month after the landings the issue was in doubt. Although it then became clear that the position could be held, it was another 3 months before it could be extended. After 1 March and until the Allied breakthrough in May, the opposing forces maintained a state of no more than active defense of their respective positions, though conditions on the Anzio beachhead could never be described as truly static.
           
    The battle for Cassino was another ordeal in which the individual soldier found himself obliged to take cover in isolated foxholes or other positions in


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which his movement and communications were severely restricted. Here, as elsewhere in Italy, the tactical situation influenced the degree to which troops could be supplied with hot food, dry socks, shoes, clothing, and other necessities. In general, it fostered the type of exposure and other circumstances which would be most conducive to trenchfoot.
           
    Nowhere in Italy during the winter of 1943-44 was controlled, frequent rotation of either units or individuals out of frontlines practiced by United State troops. This was in contrast to the rotation of both units and individuals regularly practiced, for preventive purposes, by British commanders. United States combat commanders in the Fifth U. S. Army explained the policy of nonrotation by the scarcity of combat replacements and the seriousness of the tactical situation. Whatever the causes, the long periods of duty in heavy combat, without relief, which were exacted of United States soldiers during the winter of 1943-44 favored the development of cold injury and helped to explain its high incidence. As an extreme illustration, one division spent 115 of its first 122 days in Italy in combat.
           
    During the winter of 1944-45, the tactical situation was much less favorable to the development of cold injury. After the breach in the Gothic Line in October 1944, the front was comparatively inactive until the end of January 1945, when a large-scale offensive was undertaken by the Allied forces. Casualty rates during this period of inactivity were the lowest for any period of comparable length during the entire Italian campaign. The inactivity from the standpoint of combat was reflected in the decreased incidence of trench-foot. 'Troops could be in relatively comfortable quarters. They had time to take care of themselves. They were more easily supplied. 'They had better food. In short, all the circumstances were far less conducive to trenchfoot than those which had prevailed in the winter of 1943-44. 'Tactical inactivity was, of course, only one of several factors which accounted for the decreased incidence; improvement in clothing and footgear and the institution of preventive measures also played a large part in it.

CLIMATIC FACTORS

    The relationship between weather conditions and the incidence of cold injury was promptly evident in the Mediterranean theater (tables 3 and 4, charts 3 and 4). Cold injury was not reported before November 1943, as might have been expected. Up to that time, the temperature on the front had not fallen below 50 F. (10 C.) and there had been very little rain. In November, temperatures began to fall below this level, and rainfall was heavy. Climatic conditions were promptly reflected in the incidence of cold injury (table 3, chart 3). The average minimum temperatures were 47 F. (8.3 C.) in November, 44 F. (6.7 C.) in December, 36 F. (2.2 C.) in January, and 34 F. (1.1 C.) in February.


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    An average of 10.2 inches of rain fell in the Fifth U. S. Army area in November, and an average of 6.9 inches in December. Between 14 and 19 November, heavy rains flooded the Volturno River and swept away all the bridges except the one at Capua. The environmental hazard was therefore enhanced by the difficulty of getting supplies to the front. On the Anzio beachhead, conditions were even worse. This area has a high water table, and, at the best of times, the ground is marshy and soggy. These naturally unfavorable conditions were made worse by the heavy rainfall. Here, as on other parts of the front, the weather was very cold and ice formation was frequent.
           
    The combination of cold and wet invited trenchfoot. As already pointed out, the soldiers were forced to remain in water-filled foxholes or other ground positions for days, and sometimes for weeks, at a time. Even if they had been trained to care for their feet-as they had not been-foot care would have been extremely difficult under such circumstances. The removal and replacement of mud-caked shoes, boots, and leggings were not easy to accomplish and were frequently not even attempted.
           
    The correlations between the occurrence of trenchfoot and the prevalence of cold, wet weather held all through the winter of 1943-44. The peak of the trenchfoot incidence in February 1944 (table 3, chart 3) followed a period of cold, rainy weather. Combat activity was also heavy at this time, as shown by the peak number of wounded in action, and troops were less able to take proper care of themselves and to practice foot hygiene.
           
    Most of the fighting in the winter of 1943-44 had been south of Cassino. In the winter 1944-45, military operations were conducted in the northern Apennines and on the Ligurian coast, and cold weather came a month earlier than it had come the previous winter. In September 1944, the average minimum temperature in the Fifth U. S. Army sector north of Florence was 62 F. (16.7 C.), and the average rainfall was 2.7 inches. No cases of trenchfoot were reported. In October, when the average minimum temperature was 51 F. (10.6 C.) and the rainfall averaged 6.5 inches, trenchfoot began to reappear (table 4, chart 4), and cases were reported thereafter until the end of the winter, though the number, as already stated, was considerably less than during the preceding winter.

    The course of events left no doubt of the influence of the combination of cold and wet in the production of trenchfoot. The correlation was demonstrated not only by the total figures for the Fifth U. S. Army but also by its daily and monthly incidence in individual combat divisions. In neither winter of fighting, however, did trenchfoot appear until the temperature had fallen to an average minimum of approximately 50 F. (10 C.) and until rainfall had become considerable.


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CLOTHING AND FOOTGEAR
           
    In general, neither clothing nor footgear worn by American troops in Italy during the winter of 1943-44 was entirely satisfactory.9 Many items were in short supply until the winter was well advanced. Others, such as woolen socks, were not forthcoming in adequate quantities until the weather had become warmer and the environmental hazard of cold injury had been greatly reduced. These deficiencies played an important part in the incidence of trenchfoot in the winter of 1943-44, and the improved record in the following winter can be attributed in considerable part to their correction.

Clothing
           
    When the deficiencies of clothing originally supplied to troops in Italy were realized, Maj. (later Lt. Col.) Robert H. Bates, QMC, an observer from the Office of the Quartermaster General, was sent to the theater, by request, to study the situation. His observations upon the clothing worn by the 3d Infantry Division on the Anzio beachhead resulted in the replacement of the unsatisfactory uniform worn the first winter by the M-1943 uniform, which was devised on the layering principle (fig. 24) (p. 430). Major Bates' observations also formed the basis of the requisitions placed for the winter of 1944-45 for both the Fifth and Seventh U. S. Armies. It is significant, in view of the delays which attended the placing of orders for these articles in the European theater (p. 143), that the requisitions for the Mediterranean theater for the winter of 1944-45 were placed in April 1944. The supplies reached the theater in September, and distribution was begun in October.10

    The new items issued in the fall of 1944 included a field jacket with hood and field trousers, which, when worn together, provided a completely windproof and fairly water-repellent outer layer. Underneath this layer, the soldier wore a high-necked sweater and warm pile jacket, in addition to the wool shirt and wool underwear worn the preceding winter. Cotton field trousers worn over regulation wool trousers provided an additional layer of insulation and warmth, as well as additional protection against cold winds. For men in particularly exposed positions, the issue included a warm overcoat parka, with windproof exterior and thick pile lining, and a special rain outfit consisting of a hooded parka and completely waterproofed trousers. The leather gloves supplied had separate woolen linings, and fabric mittens had special wool inserts. Mufflers and down and feather sleeping bags were also issued.
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9 See footnote 8, p. 107.
10 Annual Report, Surgeon, MTOUSA, 1944, vol. II, annex J.


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FIGURE 24.- Cold-weather uniform. A. Utilization of layering principle (note combat boots). B. Field jacket M-1943 (note buttoned collar). C. Same jacket as seen in B, with adjustable tie cord.


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Footgear

    Socks.- When trenchfoot first began to appear in Italy in November 1943, United States troops were wearing the cotton socks or light wool socks which they had worn during the summer and early fall.11 These socks, while satisfactory for warm-weather operations, were totally inadequate for winter fighting in the valleys and on the mountains between the Volturno, Garigliano, and Rapido Rivers (fig.25). Furthermore, even these inadequate socks were in short supply. Only 10 percent of the requests made for them could be filled during October. At one time it was possible to get together only 500 pairs for the 45th Infantry Division, which had requested 16,000 pairs. An investigation of 50 soldiers with trenchfoot in November 1943 showed that only 5 possessed more than 1 pair of socks. One man was wearing cotton socks, forty-eight were wearing light wool socks, and the only man who was wearing heavy wool socks had received them from his family. During periods of exposure, which had averaged 6 days, 45 of the 50 men had been unable to change their socks at all, and the other 5 had changed them only once.

    Dry shoes could not, of course, be supplied in combat. On the other hand, if dry socks had been available and if the importance of substituting them for wet socks, even in wet shoes, had been understood by the soldiers, the dry socks would have provided a period of insulation before they in turn had become wet. Ski socks, which were used only with shoepacs or by moun-

FIGURE 25.- Liri-Garigliano Valley in February 1945. Floods of the same extent played a role in the incidence of trenchfoot in the Fifth U. S. Army the previous winter.
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11See footnote 8, p. 107.


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taro troops, became available late in the winter of 1943-44, when the need for them had almost ended, but they proved extremely useful in the following winter, when the troops had been taught to wear shoepacs efficiently.

    Socks issued to United States troops late in the winter of 1943-44 and in the following winter were more satisfactory than the previous issue. At most, however, they contained only 50 percent wool, and they were never as efficient as the British-issue socks.
           
    Socks were finally in sufficient supply in the theater for each man to carry 2, or even 3, extra pairs upon his person. It is indicative of the general lack of appreciation of the dangers of trenchfoot in an army in combat that as late as April1944 the provision of a pair of socks daily with his ration for every soldier was being described as a luxury which could not be met from present resources.12 The facts were undoubtedly as stated, but the language was unconsciously revealing.
           
    The inner soles tested by an infantry division in January 1944 were thought to be of some benefit, but the impression was that their use would not significantly influence the incidence of cold injury.
           
    Shoes and boots.- During the early winter of 1943-44, American soldiers in Italy wore the regulation enlisted man's service shoes (fig. 26), usually with

FIGURE 26.- Service shoes, wet and covered with mud, removed from feet of soldier who contracted trenchfoot in fighting in Rapido River Valley, February 1944.
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12 Report, Brig. Gen. C. L. Adcock, GSC, Office of Assistant Chief of Staff, G-4, NATOUSA, dated 20 April, 1944, subject: Health of Command Report for February 1944.


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FIGURE 27.- United States Army field combat boot.

leggings. Later, many wore combat boots (fig.27) without leggings. From the standpoint of prevention of cold injury, the boots had few advantages over the service shoes, and both were open to the same general objections. Both were made on lasts which fitted the foot closely. Both were fitted too small, partly from carelessness and partly because of the habit of wearing tightly fitted shoes. Shoes fitted over cotton or lightweight wool socks were too tight when they were worn over wool socks, particularly after the leather had become wet and had shrunk. Both shoes and boots were usually laced too tightly, and when leggings were worn with service shoes another cause for circulatory insufficiency was provided, as well as another deterrent to removing the shoes to care for the feet.

     The 12-inch blucher boot sometimes used in the first winter in Italy was more efficient than either the service shoe or the combat boot, both because of its construction and because it could be worn with ski socks and inner soles. When the leather became wet, however, whatever advantage the blucher boot might have had originally was promptly lost.
           
    The ski mountain boot, which was issued to mountain troops, had a very high box toe, which made constriction of the foot practically impossible. This boot was designed to be worn with two pairs of heavy ski socks and with an inner sole as well. It was the warmest leather boot known to be in use by any army in World War II, but it was suitable only for mountain troops. It proved extremely satisfactory for mountain use under most dry cold conditions, but


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once the leather became wet some of the original advantages were lost, though the heavy ski socks worn with it still provided some protection against cold injury.

    Dubbing was of no value in winter weather in Italy, and in the opinion of some observers its use made conditions worse.
           
    Galoshes and rubber boots.- In December 1943, galoshes became available, but the quantities were limited and "sufficient to equip no more than a handful of troops." The need, which was estimated at 230,000 pairs, could not be met because of the rubber shortage. Such supplies as became available were issued to combat troops.l3

    Stationary troops found galoshes useful. Combat troops found them awkward, heavy, clumsy, noisy, and hot. They would not wear them on patrol or during combat, and many infantrymen threw them away rather than be burdened with them. Rubber boots were satisfactory for engineering units and other special organizations working in water but were not suitable for troops in combat and on the march.
           
    The first 50 soldiers with trenchfoot who were studied in Italy did not have galoshes or rubber boots.
           
    Shoepacs.- Four hundred pairs of shoepacs were issued on a trial basis to the 34th Infantry Division in January 1944, but they were not found satisfactory for a number of reasons. The model supplied did not grip the ankle, as did the service shoe. After prolonged activity in mild cold, the feet became uncomfortably hot, perspiration was profuse, and the skin eventually became macerated. Sizing was not satisfactory. There was an excess of very large sizes and a shortage of small sizes, so that men with small feet continued to have trenchfoot or developed blisters because the shoepacs they wore were too large. No instructions had been given as to how shoepacs were to be worn (with ski socks and insoles), and, when they were worn incorrectly, trenchfoot continued to occur. The complaint, was general that shoepacs did not support the arch of the foot satisfactorily, although examination revealed no arch troubles among the men who were wearing them.l4

    In spite of the defects of the model provided and the objections raised to them, there was general agreement that shoepacs were preferable to any other type of footwear for use in short operations in cold weather in mud, water, and snow When they were provided in proper sizes and widths, were properly fitted, and were worn with the proper combination of socks and insoles, their popularity increased. They eventually became standard footgear in Italy for all United States troops who had to fight over terrain for which ski boots were not appropriate. They also proved the only really satisfactory type of footgear for climbing in rugged country with heavy loads; under these circumstances, the soldier wearing shoepacs could keep his feet reasonably dry. This was a most important consideration in Italy, in many parts of which the mountain terrain was so rugged that all supplies beyond muleheads had to be brought
__________
13 See footnote 8, p. 107.
14 See footnote 4, p. 106.


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forward by the troops themselves, in loads which often weighed 50 pounds or more.

    Properly fitted shoepacs, worn with socks and insoles as intended, seemed to furnish real protection against cold injury, particularly when temperatures fell to 20 to 30 F. (-6.7 to -1.1 C.). Of 282 patents with trenchfoot observed in Fifth U. S. Army hospitals in November 1944, only 18 percent wore shoepacs. Of 327 observed in December, only 11 percent wore them with the correct socks. Another 27 percent of the December casualties wore shoepacs but did not have correct socks.15 During the entire winter of 1944-45, 4 out of every 5 casualties from cold injury did not wear them.
           
    There were also explanations for the apparent inefficiency of shoepacs in some cases: (1) A considerable number of the men who contracted cold injury while wearing them suffered from recurrences of earlier injuries and (2) another group failed to care for their feet after they had been in water over the tops of their shoepacs.
         
    Training.- A significant result of the study on clothing conducted in Italy by Major Bates was the setting up of training courses on the supply and use of winter clothing and other equipment by the Quartermaster, Fifth U. S. Army. These courses were instituted in November 1944 when it was found that trench-foot was still occurring in spite of the provision of satisfactory clothing and footgear, including shoepacs. The courses were conducted separately for line officers, combat troops, and quartermaster and supply officers and sergeants. Units which could not send representatives to the scheduled courses were visited later for instructional purposes. The lessons which were learned were transmitted through channels down to platoons, and by the end of the year about 50,000 officers and enlisted men had been indoctrinated.

    During these courses, all items of clothing and footgear were explained, and their use was demonstrated. The layering principle in clothing and the proper sizing of shoes, shoepacs, and socks were also demonstrated. Demonstrations were given in the use of the sleeping bag and shelter halves, in the drying of wet socks and inner soles inside the sleeping bag or inside the shirt if dry substitutes were not available, in the fitting of shoepacs, and in the combinations of socks and inner soles to be worn with the shoepac. Simple devices were shown for keeping the feet from direct contact with wet ground, such as the use under the feet of food containers, packboards, and branches of trees. The importance of using these materials in foxholes at night was particularly emphasized. It was constantly stressed that the removal of shoes and socks, even for brief periods and even when dry socks were not available, was an essential of foot care.
           
    When formal instruction was concluded, plans were made for continuation of instruction by the use of small mobile training teams. Particular attention was given to the instruction of fresh replacements from the United States.16 These soldiers had had no instruction at all in these matters in the Zone of
__________
15 Essential Technical Medical Data, Headquarters, NATOUSA, for January 1945.
16 See footnote 4, p 106.


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Interior, and they had not yet learned from contact with other troops, or from personal experience, how to protect themselves against exposure to cold and wet.17

    An outgrowth of the courses for supply personnel was a program to correct the initial errors made in the fitting of shoepacs. These mistakes had arisen when distribution had to be effected to organizations already in the line. Each unit commander was directed to check his men and to make such exchanges within the unit as might correct errors of sizing. Sizes not available within the unit were drawn at the training center or were put on order for later issue. 18

INDOCTRINATION AND TRAINING

     When the early trenchfoot experience in Italy was analyzed, it promptly became evident that, while such basic factors as climatic conditions, intensity of combat, and deficiencies in clothing and equipment were responsible for the high incidence of cold injury, ignorance of the disastrous potentialities of this type of trauma and of methods of preventing it played an even more important role in its development.19 In the winter of 1943-44, troops of the Fifth U. S. Army and their commanding officers were almost equally ignorant of cold injury and were almost totally unprepared to combat it.20

    The annual report of the Medical Section, NATOUSA, for 1943 minced no words in setting forth these facts. Present Army regulations and instructional material on the care of the feet, said this report, were inadequate. Troops did not know how to carry out this important precaution. Commanding officers were equally ignorant of foot care and had not been impressed with the essential importance of foot discipline. Troops had not been trained in methods of drying shoes and socks under all conditions. They did not know how to care for minor foot ailments. Instruction in these matters, the report went on, should be a part of all training and should be followed up by frequent foot inspections. The prevention of trenchfoot and of other foot ailments depends primarily upon the care of the feet and only secondarily upon proper footgear and socks. A leaflet on foot care, it was noted, had been prepared in the theater and was being used for instructional purposes, and it was suggested that the War Department should prepare and issue a similar leaflet.
           
    A sample group of 142 men with cold injuries were interviewed between 26 January and 12 February 1944 as they passed through a clearing station.2" Not one of them had had any instruction in the prevention of this type of trauma. Not one of them understood the risk he ran from resting in the cold without removing and changing his wet socks and shoes. Not one of them
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17 Report, Surgeon, 3d Infantry Division, to Surgeon, NATOUSA, 28 Mar. 1944.
18 See footnote 4, p. 106.
19(1) See footnote 5, p. 106. (2) Annual Report, Surgeon, NATOUSA, 1943.
20 See footnotes 4, p. 106, and 19 (2).
21 Essential Technical Medical Data, Headquarters, NATOUSA, for February 1944, and inclosure, dated 8 Apr. 1944, subject: ETMD from Overseas Forces.


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knew how to use overshoes to the best advantage. The few who were wearing heavy wool socks did not change them regularly; one man had changed his socks only 3 times in 6 weeks. The only man who was wearing shoepacs had never been told how to use them. He wore them with light socks, which promptly became soaked with perspiration, and he slept in the cold without changing to dry socks.
           
    Later, in February 1944, an analysis of another group of 320 patients with trenchfoot showed that 59 percent had never received any instruction in how to prevent it. 22 The medical officer responsible for the special surveys on trenchfoot, Maj. (later Col.) Fiorindo A. Simeone, MC, wrote the Surgeon, Fifth U. S. Army, that under such circumstances "the incidence of trench foot will be entirely at the mercy of the weather." 23
           
    Trenchfoot was a particular menace in new, untrained troops. A survey of 129 cases in the 3d Infantry Division showed that 30 percent were in soldiers who had been overseas a month or less, although these new troops made up only 4 percent of the division strength, and that the incidence in this group of cases was 8 times the average division incidence.24 The officer who prepared the basic report stated, "I have never seen a new replacement in this theater who had received instruction in the prevention of trenchfoot prior to joining the division."
           
    A secondary result of the ignorance of trenchfoot was that soldiers who had sustained cold injuries often did not realize what had happened, or the possible consequences of the injury, and did not report to the aid station until the condition was far advanced.
           
    Publications.- The first medical circular published on the subject of trenchfoot in the Mediterranean theater (Medical Circular No. 6) was dated 24 November 1943 (appendix C, p. 521). Although it was chiefly devoted to therapy, it emphasized that the best management of cold injury was prophylactic. It also noted that, of approximately 200 men with trenchfoot hospitalized during the previous 5 days, most had worn wet socks for from 3 to 14 days.
           
    The material on trenchfoot which the Surgeon, NATOUSA, submitted in a memorandum to G-1 (personnel and administration), NATOUSA, on 1 December 1943, was still under discussion on 11 December. G-1 was unwilling to accept the material as a circular, as was proposed, and suggested that it appear as a training memorandum. G-3 (operations and training), NATOUSA, considered a training memorandum an inappropriate vehicle and suggested that the material appear as a circular or memorandum. G-1 then suggested that the material appear as a technical publication by the Surgeon, adding, "The material is largely, if not entirely, already in field manuals, etc."
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22 See footnote 17, p. 118.
23 Letter, Maj. F. A. Simeone, MC, headquarters, Fifth U. S. Army, to Surgeon, Fifth U. S. Army, 14 Feb. 1944. subject: Prevention of Trench Foot.
24 See footnote 17, p. 118.


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    The Surgeon replied to the latter comment on 11 December as follows:
           
    1. Very many cases of trench foot have occurred in troops of the 5th Army. With continued wet weather, this condition can be expected to be prevalent in the 5th Army as well as other commands. The material requested on the prevention of trench foot is not properly covered in existing field manuals. To minimize the occurrence of trench foot, troops must be informed of the cause of this condition and trained in the measures necessary for its prevention. Technical publications by the surgeon can not be expected to be used as a means of individual troop training and inspections required.
            
     2. Since the prevention of disease is a command responsibility, and the medical department only recommends preventive measures, it is our opinion that this information should be disseminated through command channels.

    The communication ended with the renewed request that the material be published in a NATOUSA circular. A communication from G-1 to the adjutant general of the theater on 15 December 1943 directed that it be published as soon as possible. Accordingly, on 21 December 1943, a letter on the subject of trenchfoot was sent from Headquarters, NATOUSA, to the commanding generals, Fifth and Seventh U. S. Armies and the Peninsular Base Section (appendix D, p.523).
           
    Meantime, the Fifth U. S. Army issued information on cold injury in a letter which was distributed to all units of this army on 5 December 1943. In this communication, it was pointed out that trenchfoot was likely to become a major cause of disability among United States troops unless unit commanders and medical officers used all the means at their disposal to prevent it. Unit commands were directed to exercise all possible ingenuity and vigilance to see that the following prophylactic measures were instituted and applied: (1) Rigid enforcement of the rules of foot hygiene with frequent foot inspections; (2) the use of foot powder on the feet and in the socks; (3) the wearing of fresh socks into combat, with at least one extra pair to be carried on the person; (4) loose fitting of shoes whenever possible and, when dry socks were not available, the removal of the shoes and the wringing of water out, of the socks; (5) the use of overshoes in wet weather whenever combat conditions permitted; (6) muscular activity and simple exercises, designed to delay the development of cold injury; and (7) the rotation of frontline troops whenever possible after 48 hours on duty, so that they could wash and dry their feet and change into dry socks and shoes. This letter called the attention of the commanding generals to the increasing incidence of trenchfoot and to the importance of measures of prevention and first aid. Special emphasis was placed upon simple foot exercises, practical under combat conditions, and frequent foot inspections were ordered for troops subjected to exposure, to make certain that they were taking proper care of their feet.
           
    Training Memorandum No. 9, NATOUSA, on the care of the feet was issued on 24 December 1943 from General Eisenhower's headquarters. It repeated the facts about trenchfoot already published in other forms and provided that unit commanders must include in their training programs at least 2 hours of formal instruction covering the care of the feet. Frequent foot inspections were again ordered.


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    The Surgeon, NATOUSA, in a comment on this memorandum, addressed to G-3 and dated 19 December 1943, raised the question of supplementing it with a leaflet on the care of the feet for individual distribution to all United States Army officers. The material was duly prepared, and, on 13 January 1944, publication in the form of a booklet was recommended.25 In the recommendation from G-3 to the deputy theater commander, it was pointed out that the Surgeon considered the subject one of increasing importance and had recommended publication for the additional reason that War Department data were scattered, were difficult to piece together, and did not cover the subject matter satisfactorily.
           
    The theater quartermaster concurred in the publication of the booklet with only minor changes. The Chief of Staff, NATOUSA, did not. He wrote the Surgeon on 19 January 1944 that, in discussions with the deputy theater commander, it had been concluded that "the problem was one which could best be solved by utilizing the services of unit surgeons, at the same time receiving the attention of unit commanders and their staffs." He also remarked: "It would seem that the necessary knowledge of the subject must exist in the Army, Divisions and other Commands, and that possibly better results would be attained by a short communication to Army and base section commanders, pointing out the need for personal attention in the matter." The Surgeon, NATOUSA, replied to this communication on 9 February 1944 that he could not concur with these arguments. The problem was essentially one of unit training and command responsibility, which could not be assumed primarily by the unit surgeon. He also stated that instructional matter presently in existence was incomplete and scattered. Finally, he said that many of the more than 2,000 trenchfoot casualties which had occurred since November of the previous year could have been prevented if troops had known how to care for their feet and if unit commanders had insisted upon proper preventive measures. The Surgeon doubted that a short communication to army and base surgeons would correct the situation and renewed his recommendation for publication of the proposed booklet.
           
    This recommendation was accepted on 12 February 1944, and an issue of 14,000 copies was authorized on 25 February. Distribution was begun on 29 March 1944,26 too late, however, to have any influence on the incidence of trenchfoot during the first winter of fighting in Italy.
           
    Command responsibility.- As many of the facts just stated indicate, command responsibility for trenchfoot had not been realized early in the winter of 1943-44, and preventive measures were late in being put into effect. This error was not made during the following winter. The subject was kept alive, in fact, throughout the late spring and early summer.
           
    A radiogram to the War Department from Headquarters, MTOUSA, on 31 May 1944 pointed out that training in the care of the feet and in foot disci-
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25 Memorandum (intraoffice), Headquarters, NATOUSA, comments 1-9 dated 13, 16, 18, and 19 Jan. 1944 and 9, 12, 15, 16, and 17 Feb. 1944, subject: Printing of Booklet on Care of Feet.
26 Memorandum, Mai. Den. Daniel Noce, GSC, Office of Assistant Chief of Staff, 0-3 to 0-4, 12 June 1944, subject: Trench Foot.


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pline had not yet reached required standards. It was therefore recommended that the handbook prepared in NATOUSA be used as a basis for all unit training programs, which should include at least 4 hours of instruction in the care of the feet; that unit commanders and noncommissioned officers be given special training in foot care and be taught the fundamentals of foot inspection by unit medical officers; that a high incidence of cold injury be regarded as an indication of faulty leadership; that all replacement depots conduct schools in the care of the feet and certify that all men furnished to combat units had completed this course; that dry socks be brought up with individual rations; that laundry facilities for socks be provided for combat troops during wet, cold weather; and that commanders arrange, during cold weather, for men in frontlines to be released at frequent intervals, on the ground that without this precaution they could expect to lose 1 man with cold injury for every 3 or 4 battle casualties.
           
    The Surgeon, NATOUSA, on 6 June 1944, sent the theater commander a letter in which he made the following points:
           
    1. Trenchfoot during the previous winter accounted for 5,670 hospital admissions, or 9 percent of all admissions for disease to Fifth U. S. Army hospitals over this period. The ratio of trenchfoot to battle casualties was 1:3.8.
           
    2. It was not likely that more than 60 percent of these men could return to duty, and a high rate of recurrence could be anticipated in those who did return.
           
    3. Trenchfoot is primarily a training problem which involves the education and discipline of the individual soldier. Indoctrination and training are made more difficult by the fact that the infantry, which is the most susceptible group, has a high turnover and that the recruit must be taught to save himself from becoming a casualty from trenchfoot at the most tense moment of his life, when lie is about to engage in combat for the first time. Experience during the previous winter had showed that replacements had not been properly trained in the prevention of cold injuries.
           
    4. British troops in the theater had had less trenchfoot than United States troops, probably because of more efficient equipment, including better fitting shoes, a more effective sock exchange, and frequent rotation of troops in the line.
           
    Medical Circular No. 14, which was issued by the Surgeon, Fifth U. S. Army, on 7 September 1944, contained one section (II) in which the facts of trenchfoot were reviewed in respect to etiology, clinical considerations, therapy, and disposition.
           
    Training Memorandum No. 2, Headquarters, NATOUSA, 29 September 1944, was based on War Department Circular No. 312. section IV, dated 22 July 1944 (p. 63). This memorandum directed that the instruction of troops in preventive measures against cold injury should begin immediately upon the receipt of the communication. It stated unequivocally that the enforcement of precautions against trenchfoot was a command responsibility and that commanders would be held responsible for unreasonably high incidences.


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FIGURE 28.- Drawings used to instruct troops how to keep their feet dry and care for their shoes.
          

    This warning meant just what it said. As the winter progressed, commanding officers of various units were required to explain to higher authority why the incidence of trenchfoot in their units had exceeded certain levels and were informed that additional cases resulting from failure to carry out prescribed preventive measures would be considered to reflect a lack of discipline and training for which the unit commander would be held responsible.
           
    In addition to the formal program of training in the prevention of cold injury, all possible devices were employed to make the soldier foot conscious. The effects of poor foot hygiene were illustrated by photographs of disabling early and late lesions. These pictures were furnished to battalions surgeons, who demonstrated them in classes held for enlisted men in their intervals out of the line. Spot radio announcements were made. Posters were displayed in the bathing facilities provided (figs. 28, 29, and 30). Small pamphlets of instructions listing "Cold Weather Don'ts" and "Cold Weather Do's" were distributed among the men to carry on their persons. No opportunity was spared to alert the soldier to the consequences of neglect of his feet and to school him in the precautions by which he could protect himself against cold injury.
           
    Specifically, the training of the individual soldier was directed toward the following considerations:
           
    1. Conserving body heat.
           
    2. Keeping the feet warm'and dry. This was to be accomplished by the avoidance of any form of constriction, immobility, dependency, and cramped


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FIGURE 29.-Drawings used to instruct troops in care of wet shoes and socks.

position; by the promotion of circulation through exercises; and by periodic removal of the shoes and socks, and massage of the feet.

    3. Using equipment to the best possible advantage, with particular emphasis on the correct use of overshoes and shoepacs.


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FIGURE 30.- Drawing used to instruct troops in causes of trenchfoot.

    4. Changing shoes and socks frequently, particularly when they had become wet from rain, mud, or perspiration.

SUMMARY
           
    The heavy losses from trenchfoot which occurred during the winter of 1943-44 in Italy were greatly reduced during the succeeding winter. It is quite true that during the second winter the front was frequently static, troops were not kept in the front lines for overlong periods, exposure to cold was therefore briefer, and men were evacuated promptly when they first complained of their feet. When, however, all due allowance is made for these considerations, there is still no doubt that the preventive measures devised and put into practice were fundamentally responsible for the improvement evident in the winter of 1944-45.
           
    Between October 1944 and January 1945, inclusive, total trenchfoot casualties in infantry divisions amounted to only 1.3 percent of total infantry strength, as compared with 4 percent for the same period in the preceding winter.27 Over this period, surveys had showed steady improvement, from month to month, in the use of preventive measures by the troops, and it was to the use of these measures, even more than to the provision of better clothing and footgear, that the decrease in trenchfoot was attributed. The schooling had been expensive, but the lessons of 1943-44, as the experience of the succeeding winter showed, had been well learned in the Mediterranean theater.
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27Progress on the Trench Foot Problem. U. S. Army M. Dept. Bull. No. 88, May 1945, p. 3.