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Chapter XI

Contents

CHAPTER XI
 
Therapy and Disposition Overseas

 
    The treatment of trenchfoot has never been really satisfactory. No specific and definitive methods of management were devised in World War II, nor have any been developed since. As was pointed out in the preceding chapter, recovery from cold injury is slow. Rehabilitation is difficult of accomplishment, often psychically as well as physically. Sequelae are frequent and are often permanent.
      
    The final effect of trenchfoot in United States soldiers who fought in World War II has not yet been fully assessed. The residua are now the responsibility of the Veterans' Administration. They are also often encountered by physicians in private practice, whose evaluation of them may be hampered by their unfamiliarity with a condition which has no precise counterpart in civilian life.
       
    In the last year of World War II, the treatment of cold injury was more or less standardized according to the principles set forth in War Department Technical Bulletin (TB MED 81) (appendix A) published 4 August 1944. These principles, which had been formulated chiefly on the basis of the experience in Italy in the winter of 1943-44 1 were modified as was required by expediency, theater practices, local tactical conditions, and the needs of the special patient. As the experience with trenchfoot increased, numerous methods of management reached the literature or were summarized in official reports. Some of these methods were entirely illogical or even bizarre. Those which were of any value revolved around certain general principles.
 
EVACUATION AND TRIAGE
 
    In an overseas theater of operations, evacuation and triage are component parts of therapy. Triage, which is the classification of patients according to the type of medical care which their injuries require, is also determined by the point in the chain of evacuation at which medical care, for tactical and other reasons, can be carried out.
       
    The policy eventually developed in World War II, which proved fairly satisfactory, was as follows: When the man with cold injury reached the battalion aid station or clearing station, either by litter carry, by ambulance, or on foot, it was the duty of the first medical officer who saw him to determine
____________
1 Report, Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, subject: Trenchfoot in the Italian Campaign 1943-45.


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that his injuries had been caused by cold. If they were, it was the officer's further duty to determine whether they were of such a degree as to require evacuation farther to the rear. It was necessary to separate casualties who required definitive care from those who, with a little rest and encouragement, a cup of coffee or other stimulant, a cigarette, a change of socks, and similar simple measures, could promptly return to duty. Similar triage was carried out at each subsequent medical installation, so that, at least theoretically, only men who really required definitive treatment were evacuated to the rear as far as an evacuation hospital or a general hospital in the communications zone.
       
    Triage obviously required careful clinical judgment and practical assessment of the need for, and the possibilities of, treatment. It was usually conducted on the simple plan that all men with objective signs (swelling, edema, blisters, discoloration of the feet) were evacuated farther to the rear, eventually to a general hospital. Men without objective signs were frequently sent to a designated medical facility, where they were kept under close observation for 48 hours or a little longer. In the Third U. S. Army, for instance, one or more medical companies of a medical gas-treatment battalion 2 were utilized for this purpose, in addition to an evacuation hospital. If objective changes were going to occur, they occurred, as a rule, within 24 to 48 hours and were unlikely to occur after this time.
       
    Men who presented objective changes within this period were evacuated to general hospitals. Those who did not were retained in the holding unit, under a 10-day holding policy, after which, if their condition was satisfactory, they were returned to their units. A considerable number of men were thus salvaged who might otherwise have been lost to combat units. On the other hand, it was far better to evacuate a man who might later prove to be suffering merely from cold feet than to return a soldier with an overlooked cold injury to the line, only to have his lesion progress to such a stage that it caused months of disability.
       
    The system of evacuation and triage used in the European Theater of Operations in World War II (chart 5) provided a number of ways in which the individual casualty with trenchfoot who had reached an evacuation or a general hospital could be returned to duty or otherwise disposed of after hospitalization. His disposition, naturally, was related to the severity of his injury.
       
    A man with mild injuries might be sent from an evacuation hospital to a convalescent hospital or a specially designated medical holding unit, such as a medical gas-treatment battalion. If his status after release from the convalescent hospital was still indeterminate, he might be sent to a holding unit for further observation. From this unit, he could either be returned to duty or sent to a general hospital for additional treatment. After treatment at a
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2 The medical gas-treatment battalion was an organization set up for the special treatment of gas casualties in the event that chemical warfare should be employed by the enemy. Since it was well located and was equipped for convalescent and holding medical functions and since it was not needed for the purpose for which it was established, one or more companies were converted to the management of casualties whose cold injuries were minimal and who, it was hoped, could be promptly returned to duty.


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CHART 5.- Flow of cold injury casualties through medical channels, European theater
 
general hospital he might be transferred to a rehabilitation hospital or to a camp whence he would be sent directly to duty after reconditioning.

    A man with moderately severe injuries might be sent to a convalescent hospital from a general hospital, for further observation. From the convalescent hospital, he might be sent to a rehabilitation hospital or to a camp whence he would eventually be assigned to duty. If, however, his injuries were likely to require relatively long treatment, lie would be sent from the general hospital on the Continent to a general hospital in the United Kingdom Base. There his disposition would depend upon the outcome of treatment.
       
    A man with severe injuries, who obviously could not be returned to duty, would be evacuated directly from a general hospital on the Continent to a hospital in the Zone of Interior as soon as he was able to travel.
       
    Effective triage in such a condition as cold injury is necessarily based on some general system of classification. In some areas, the original policy was to send a man with any edema, however slight, to a general hospital but to send a man whose feet were merely white and cold to the medical companies


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of a medical gas-treatment battalion. These and similar systems of differentiation were eventually replaced by the classification of injuries into mild, moderate, and severe types (p. 280), according to the criteria devised at the 108th General Hospital in Paris, which served as a special research center. The limitations of this classification, like those of other classifications, were clearly recognized, and it was advised for use with the understanding that it was to serve merely as a guide and was to be interpreted broadly.  

THE ALEUTIANS  

There was no uniformity of treatment of the cold injuries sustained in the Aleutians campaign either initially or in Zone of Interior hospitals.3  

Initial Treatment  

    For all practical purposes, when the soldier on Attu sustained a cold injury, he did whatever seemed to him best for it. Some men simply rested as best they could, using no active measures. Some massaged the feet, sometimes with oil. They had been warned before the invasion not to rub their feet with snow if they became frostbitten, and medical officers had also been cautioned against vigorous massage. Nearly all the men kept their feet elevated when this was possible. Some found greatest relief by keeping the thighs and legs flexed.
       
    Large numbers of casualties, as noted elsewhere (p.88), were obliged to evacuate themselves by crawling if they could not walk, since litter carries were often impossible.

    Immediate treatment on the hospital ships consisted of general warming measures, warm food and drink, morphine for the control of pain, and plasma infusions when they were indicated. All patients were given sulfanilamide by mouth, and sulfanilamide was applied locally, in the form of cream or repeated sprays. The feet were then wrapped in sterile dressings.
       
    In the Aleutians, as in all other theaters, tetanus toxoid was given routinely to all casualties from cold injury, on the ground that it was impossible to predict the cases in which tetanus might be a risk.
 
Subsequent Treatment  

    No standardized plan of treatment was in effect in the various hospitals to which these casualties were admitted, and treatment therefore varied in some respects from one institution to another.
       
    183d Station Hospital.- At the 183d Station Hospital at Fort Richardson, Alaska, which received the first casualties, the objective of treatment was the
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3 (1) Annual Report, Surgeon, 183d Station Hospital, 1943. (2) Lesser, A.: Report on Immersion Foot Casualties From the Battle of Attu. Ann. Surg. 121: 257-271, March 1944. (3) Patterson, R. H.: Effect of Prolonged Wet and Cold on the Extremities. Bull. U. S. Army M. Dept. No. 75, April 1944.


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control of swelling and transudation and the relief of local heat. This was accomplished by cleansing and elevation of the parts, sterile dressings, and cooling by exposure to temperatures lower than room temperature. Electric fans and icepacks were used in selected cases for the first several days. Lanolin, cocoa butter, or some bland oil was used three times a day to prevent cracking of the skin and subsequent secondary infection. Active and passive exercises were instituted promptly, and walking was resumed as soon as possible.
       
    McCaw General hospital:- At McCaw General Hospital, Walla Walla, Wash.,the patients fell into two groups, 25 who were received soon after injury and 27 who were received later, by transfer from the Northwest Pacific Area.

    The 25 patients received soon after injury included 10 men who went to Attu by submarine (p.93). All 25 had been among the advance scouts of the invasion. Nine were evacuated primarily for battle wounds but also had cold injuries.

    These patients were evacuated by ship to Barnes General Hospital and then, after a stay of about 4 days, were transferred to McCaw General Hospital. All of them were physically exhausted and almost all had lowered red blood cell counts, lowered hemoglobin levels, and moderate to high leukocytosis.
       
    Six patients were transfused. All were placed on iron-vitamin therapy and were given high-caloric diets.
       
    Suppurative and gangrenous areas on 36 of the 50 feet had to be treated by immediate debridement and drainage, the debridement in some instances including removal of affected bone. The great toes were most frequently involved in the gangrenous processes. Local therapy after debridement consisted of dressings of Azochloramid in triacetin, activated zinc peroxide emulsions, or physiologic salt solution. Intact skin in the region of the wounds was covered with a protective coating of compound tincture of benzoin, over which a mixture of zinc oxide ointment and castor oil was applied, to prevent irritation from drainage and from the antiseptic agents used on the wounds. Large, massive, loose dressings were then applied.
       
    Subsequent revision of the wounds, with closure, was carried out in all the cases in which debridement had been performed. Amputation was necessary in 23 of these 30 feet, as follows: Amputation of the first (great) toes alone just proximal or distal to the first metatarsophalangeal joint, in 8cases; minor partial amputations of the other toes, sometimes alone and sometimes in addition to amputation of the great toes, in 8 cases; amputation and revision through the distal metatarsal area, in 6 cases; tarsometatarsal disarticulation in 1 case. Plastic procedures were also necessary in a number of these cases, and in one instance a pedicle flap from the opposite thigh had to be used to obtain full-thickness skin covering. In two instances, surgery was necessary to straighten rigid, flexed toes, and in another case revision of all the distal phalanges was done for rigid-flexion deformities. Lumbar sympathectomy
____________
4 See footnote 3 (2), p. 310.


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was performed in two cases just before final plastic revision and closure, because of evidence of severe vasomotor disturbances.
       
    When the patients who had been operated on became ambulatory, those who had suffered the loss of distal portions of the feet involving any part of metatarsals were able to walk surprisingly well with the help of prostheses adapted to their special needs. A spring-steel longitudinal strip incorporated in the sole of the shoe, back of the metatarsal heads, proved a very satisfactory substitute for the transverse-arch support usually placed inside the shoe. Pressure points were sought for, and the shoes were modified as necessary to protect them.
       
    All through the period of hospitalization, vascular exercises were conducted three times daily, in organized class fashion. As soon as local conditions permitted, physical therapy was employed, in the form of whirlpool baths, massage, and muscle stimulation.
       
    Soon after they became ambulatory, many of these patients developed dermatophytoses. The condition responded promptly to treatment with potassium permanganate foot soaks and the application of a boric salicylic acid foot powder. Socks and shoes were provided for all the men on the ward.
       
    Two patients had to be separated from service because of their inability to continue infantry duty and their lack of any other training or qualifications for other work. In the other 23 cases in this group, the immediate results were surprisingly good.
       
    The 27 patients received at McCaw General Hospital at intervals of 6 months or more after exposure at Attu had experienced somewhat less severe environmental and battle conditions than the 25 patients admitted soon after injury. Their chief complaints were aching, burning pain in the toes and varying degrees of sweating and clamminess of the feet. Both warmth and cold increased the discomfort. Lumbar sympathetic blocks were performed in all cases, with improvement of the temperature of the feet in all, but with only variable degrees of subjective relief of discomfort.
       
    Fifteen of the twenty-seven patients, whose discomfort was not excessive, could be returned to some form of limited duty, not involving excessive standing or walking, in temperate climates. In three cases, in which lumbar sympathetic block had produced marked relief of symptoms, lumbar sympathectomy was performed. Immediate results were good, but with increasing physical activity, aching of the toes again was experienced, though the feet continued warm and dry. Seven patients were still under observation when the report from McCaw General Hospital was made, and their ultimate disposition is not known.
       
    McCloskey General Hospital.- At McCloskey General Hospital, Temple, Tex., the patients, who were all received late, were divided into three groups for treatment as follows:

    1. Patients whose feet were swollen, congested, warm, and painful were treated by bed rest, elevation of the foot of the bed, cleansing, gentle rubbing with cocoa butter to hasten desquamation, and exposure of the feet to room


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temperature, with no covering at all. A high-protein, high-vitamin diet was given, with supplemental vitamin therapy. The 28 patients in this group became ambulatory on an average of 2 weeks after admission.
       
    2. Patients whose feet showed moderate blanching on elevation, congestion on dependency, slight edema, reduced temperature, and residual hypesthesia or anesthesia, were treated by essentially the same measures just described, supplemented, in 14 of the 36 cases in the group, by paravertebral block with Metycaine Hydrochloride. In two cases the block was repeated. Two or three of the fourteen men who were treated in this manner felt that there had been some improvement ire their condition, but, as a whole, the patients treated by block recovered no more rapidly than those who were treated by general measures only. It was the conclusion of the staff that lumbar sympathetic block is likely to be useful in cold injury only when edema is present and only if it can be performed during the initial stage, a requirement which can scarcely be met in combat conditions. All the patients in the second group of cases became ambulatory in 7 to 10 days.
       
    3. The remaining 47 patients, who were well on the way to recovery when they were admitted, were treated conservatively, were promptly allowed out of bed for graduated periods, and were given systematic exercises.
       
    The experience at McCloskey General Hospital indicated that the essence of treatment in these cases was the rehabilitation of the patients by conservative medical measures, including gradually increasing, carefully supervised muscular activity. It had been originally planned at this hospital to use pavex machines in cold injury, with the objective of preventing gangrene, but the plan was discarded, because of the length of time which had elapsed since the original injury, on the advice of the Surgical Consultants Division, Office of the Surgeon General, after consultation with the inventor of the pavex machine, Louis Herrman, M. D.     
   
    Letterman General Hospital.- At Letterman General Hospital, San Francisco, Calif.,5 treatment was also based upon the classification of the patient according to the degree of his injury, as follows:

    1. Patients with first-degree injuries were not hospitalized.
       
    2. Patients with second-degree injuries were kept at bed rest, with the feet slightly elevated, under unheated, hooded, wooden cradles. Lanolin or petrolatum was applied once daily, with light massage. As soon as practical, tepid whirlpool baths and foot exercises, without weight bearing, were instituted. Patients who presented vascular spasm and whose feet were cold and sweaty received one or more lumbar sympathetic blocks with procaine. That these blocks hastened convalescence is doubtful, but they were usually followed by transient improvement, in the form of increased pulsations in the regional arteries, moderate reduction of perspiration, and a lessened tendency toward edema.
       
    3. The patients in this group were eventually given woolen socks and soft shoes and were permitted to be ambulatory while exercises and physical
____________
5 See footnote 3 (3), p. 310.


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therapy were continued. In numerous instances the results of treatment were not satisfactory. As long as 5 months after injury, some of the patients were still complaining of superficial burning and aching and of pains deep within the foot, which were worse on walking.
       
    Patients with third- and fourth-degree injuries were dressed in the operating room, under aseptic precautions, on the day of admission to the hospital. Superficial necrotic tissue was removed to establish free drainage; anesthesia was not required. At the same time, material for aerobic and anaerobic cultures was obtained from moist or infected areas, especially at the line of demarcation. Sulfathiazole powder was sprinkled over all raw areas, which were then covered with petrolatum-impregnated gauze and dry sterile dressings. When trichophytosis was present, as it was in about 80 percent of both these groups, tincture of Merthiolate was applied to the webs of the toes. Padded plaster or Cabot's splints were used to maintain the feet in neutral position. The feet were kept slightly elevated, at room temperature, under hooded wooden cradles. Dressings were changed as infrequently as possible.
       
    Lumbar sympathetic block was carried out in 13 patients who complained of pain, hyperhidrosis, and cold feet. In 10 of the 13 cases, the dorsalis pedis pulsations were diminished or absent. The posterior tibial pulsations were diminished in two cases and absent in one. When the pulsations were present, they varied widely from day to day. Sometimes they were fairly strong, sometimes they were weak, and sometimes they were totally absent. In all cases in which sympathetic block was done, the pulses were thought to improve more rapidly than in the cases in which it was omitted. In one case in which both dorsalis pedis pulses were absent, there was permanent bilateral return of good pulsations after the third block.
       
    Five patients who complained of severe pain were treated by unilateral sympathetic blocks. All stated that pain was less afterward on the treated than on the untreated (control) side. Numbness was also decreased in all five cases. The improvement, however, persisted only for the duration of the block. Four patients with severe hyperhidrosis were transiently benefited by bilateral block, but no permanent results were observed.
       
    Twenty-one patients at Letterman General Hospital were treated by mechanical respiration, produced by alternating in a positive-negative respirator. Oxygen was administered simultaneously, in a further effort to relieve local tissue anoxia. In a number of cases, the coloration of the feet was improved and congestion and edema were reduced, but it was concluded that, by the time patients with trenchfoot were received in a general hospital, the optimum time for measures of this kind had already passed. Improved venous drainage and better oxygenation of tissues might, it was thought, have reduced tissue necrosis appreciably if these objectives could have been accomplished immediately after trauma.
       
    Prophylactic X-ray therapy was used locally in all cases in which it was feared that gas bacillus infection might occur. That this treatment played


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any part in the absence of this complication seems unlikely. The infection (lid not occur in other theaters, in none of which X-ray therapy was used.
       
    Amputation was required in 23 cases at Letterman General Hospital, as follows: Both feet, through the lower third of the tibia, in 3 cases; 1 foot, in 2 cases, through the upper and the lower third of the tibia, respectively; half of 1 foot, in 1 case; all the toes of both feet, in 4 cases; 1 to 9 toes, in 13 cases. In none of these cases did gangrene terminate in mummification and a circumscribed line of demarcation. Instead, an edematous and inflammatory zone persisted in the affected area. At the same time, there was a tendency toward slow extension of infection, especially along fascial planes and into neighboring small joints.
    
    All the amputations were performed within 5 to 8 weeks after injury, as soon as a fairly definite zone of demarcation was demonstrable. They could well have been performed even earlier. When the whole foot was involved, and a useful member obviously could not be preserved, much time was saved by performing a guillotine amputation well above the infected demarcating zone. The stump was left open, and compression bandages and skin traction were applied.
       
    Reamputation or plastic revision was carried out later in these cases. Skin grafting was sometimes resorted to, in an attempt to cover exposed areas as promptly as possible. Penicillin solution and Dakin's solution were both tested, but it was eventually found that dressings saturated with physiologic salt solution and changed every 3 or 4 hours provided the simplest and promptest way of preparing granulating areas for skin grafting.
 
MEDITERRANEAN THEATER OF OPERATIONS
 
    It would serve no useful purpose to describe the various methods of treatment used in the Mediterranean theater during the early months of the trenchfoot experience. As in the experience in the Aleutians, therapy was not standardized. Most of the methods employed were tentative, and many of them were illogical and sometimes actually harmful. Eventually, a routine of treatment, dependent upon the stage at which the casualty was seen, was adopted in all Fifth Army hospitals, the experience in which, as already noted, formed the basis for the official policies on treatment set forth a little later in TB MED 81 (appendix A) 
    
    Three considerations of therapy were fundamental:

  1. Great care was taken to avoid further trauma and to guard against secondary infection, particularly in the early stages of the injury.
    
    2. Heat was never applied to the feet.
 
  3. The strong psychogenic factor in trenchfoot was recognized early and was dealt with promptly. All patients, with the exception of the few casualties whose injuries were severe enough to suggest that amputation would eventually


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be necessary, were impressed from the beginning of treatment with the fact that they were suffering from a curable condition which would permit their return to full duty and that treatment of their injuries was being carried out with this objective in view. Even when it became evident, as it soon did, that only a relatively small number of casualties from trenchfoot could be returned to full duty, this point of view continued to be stressed. <> 

Preinflammatory Stage
 
    In the preinflammatory or ischemic stage of trenchfoot, the patient was transported by litter unless this was absolutely impractical. Special care was taken not to set him down near a stove at any of the halts in the chain of evacuation, though blankets were used under and over the body to keep him comfortably warm. The feet were dried gently and then were kept exposed to cool air, preferably about 65 F. (18.3 C.). They were never rubbed or massaged. Treatment was usually limited to these simple measures until the patient reached an evacuation hospital.

   In 13 cases of severe trenchfoot observed by Simeone in a clearing station in Italy, one foot was powdered, the toes were separated by cotton, and uniform pressure dressings were applied (figs. 83 and 84). The untreated feet served as controls. These patients, without exception, stated that discomfort and pain were promptly relieved in the treated feet. Unfortunately, exigencies of evacuation did not permit continued personal direction of treatment and it was learned
 
FIGURE 83.- Management of early inflammatory stage of trenchfoot by application of powder and pressure bandages. A. Trenchfoot observed in clearing station in early inflammatory stage. The feet were warm and dry, but edema had begun to develop. B. Pressure bandage applied to left foot and leg.


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FIGURE 84.- Application of powder and pressure bandage in early inflammatory stage of trenchfoot.

that the bandages which had been applied were removed as soon as the patients reached the evacuation hospital. The immediate results, however, suggested that this simple method is worthy of a further trial, which it does not seem to have received during World War II.
       
    While there was general agreement, from the beginning of the Mediterranean experience with cold injury, that the direct application of heat to the affected feet was absolutely contraindicated, there was originally some difference of opinion about how rapidly the feet should be allowed to become warm. In the fall of 1944, there were two distinct schools of thought in the Mediterranean theater.
       
    The observers who believed that thawing should be so gradual that the feet never actually became hyperemic were in the minority, and their concept was never generally applied. Their reasoning was as follows: Edema occurs because abnormal metabolic products are liberated after cold injury in very large quantities. The liberation of these substances is thought to proceed at a maximal rate when the temperature is about 59 F. (15 C.). It is therefore desirable that this level be passed as rapidly as possible during the process of thawing, though, as a practical matter, this is possible only on tissue cultures. Any kind of cold applied to the surface of an extremity produces, at best, a gradient of temperature if there is any circulation at all in the part. The temperature in the depth of the part may be 98.6 F. (37C.) when the surface temperature is 59F. (15 C.). In the light of these facts, even granting that edema and inflammatory products are injurious to tissues, it still seemed illogical to many observers to keep a limb without circulation, or with minimal circulation, when the duration of ischemia was believed to be an etiologic factor in trenchfoot (p.266).


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    Other observers regarded it as more reasonable to permit a limb to warm itself as long as the warming was accomplished by the return of the circulation to the part, which then would not become excessively warm in proportion to the efficiency of its blood supply. Simeone's experience inclined him to the opinion that, if the circulation did not return spontaneously within 6 hours, efforts should be made to induce vasodilatation, either reflexly or by the use of a vasodilator.
       
    Reflex vasodilatation could be induced by warming the body with blankets or hot water bottles, leaving the feet exposed. In many hospitals, the beds in trenchfoot wards were made up so that blankets and sheets could be rolled back, leaving the distal third of the lower extremities continuously exposed to room air. In addition, the position of the beds was often reversed, in order to keep the feet as far as possible from the stoves in the wards. These practices were in accord with the desires of the patients. Most of them complained of hot feet and wanted no covering at all over them. It was exceptional, in fact, to find a man who did not say that he was more comfrotable when his feet were exposed to cool air.

  Whisky was the most generally useful vasodilating agent, but, whatever the agent used, the best results were accomplished if, in the presence of maximal circulation, the tissues were cooled to a point at which vasoconstriction did not occur. It was then certain that the circulation was ample to dispose of products of metabolism and that tissue repair could begin and proceed.6

Inflammatory Stage
 
    As a rule, patients were kept at complete bed rest during the inflammatory stage. Those with mild injuries were occasionally permitted mess and latrine privileges shortly after hospitalization, but this was exceptional.
       
    During this stage, as during the previous ischemic stage, the chief objectives of treatment were to prevent trauma and infection and to avoid local heating of the affected part. To achieve the first objectives, strict surgical cleanliness was maintained. The feet were washed daily with warm, soapy water, at 70F. (21.1C.), then dried gently and carefully. The toes were kept separated by bits of cotton. Blisters were left undisturbed unless they were sufficiently tense to be painful. Then they were evacuated through a small bore needle. If blisters were already ruptured when the patient was admitted, dead tissue was removed and the area cleansed, after which the foot was wrapped loosely in a sterile towel. The practice of dusting sulfanilamide powder over the lesion was discontinued in the spring of 1944. Feet with gangrenous areas were kept loosely wrapped in sterile towels. Ointments
_____________
6 In an experimental study conducted during the course of the trenchfoot experience, two groups of animals which had been exposed to cold injury by immersion in cold water under identical conditions were treated, respectively, by rapid thawing and by slow thawing. Some animals in the group treated by rapid thawing developed gangrene, but only in the toes, while some in the group treated by slow thawing suffered total loss of tissue up to the level at which the extremities had been immersed. In terms of tissue salvage, the advantage appeared to lie with treatment by rapid thawing. In this group, however, massive fibrosis and induration ultimately occurred.


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were avoided unless the skin was excessively dry and wrinkled. Then cottonseed oil or lanolin was applied, but only once daily and always lightly.
       
    The most desirable temperature to which the feet were exposed was thought to be between 600 and 65 F. (15.6 to 18.3C.). If it proved impossible to maintain this temperature in the ward, or if this environmental temperature was not low enough to keep the feet cool, icecaps were applied. Sterile pledgets of cotton were placed between the toes, and the feet were wrapped in sterile cotton batting and covered with sterile towels before the icecaps were applied. Care was taken not to cool the feet too much and to keep them dry. Equal care was taken to keep the ice bags dry. Wet cold was thought to be actually injurious.

    If ice was not available, transient relief was sometimes secured by spraying rubbing alcohol on the feet several times daily. The fan and spray method described by Webster, Woolhouse, and Johnston I proved simple and effective. In some hospitals, it was thought that some benefits were accomplished by soaks in cool water and whirlpool baths at 70 F. (21.1 C.) for 20 to 30 minutes daily. Not all patients could tolerate such methods, nor was it thought that they expedited recovery. They were used merely because some patients with hot, swollen, painful feet were temporarily relieved by them and were able to sleep without sedatives and analgesics after one or more of these methods had been employed.

    Relief of pain was accomplished by medication only when no other measures were effective. Whatever drug was used was discontinued as promptly as possible. A number of other methods were employed to relieve pain, with variable results or none at all. Polyvitamin therapy, thiamine chloride alone or in combination with other measures, nicotinic acid, pilocarpine, and carbamylcholine chloride gave no better results than were accomplished in cases in which only general measures, which were also employed when these agents were administered, were used exclusively.
       
    Edwards, Shapiro, and Ruffin 8 tested the use of daily intravenous injections of physiologic salt solution, in amounts of 150 to 300 cc. and had variable results. Nineteen patients who had previously had no relief from aspirin or codeine were promptly relieved of pain by the injections but two others, who were bedridden with painful, swollen feet, had no relief at all. No reduction of edema was observed in some cases, but in others it was thought that the swelling disappeared more promptly than usual. Intravenous injections of hypertonic salt solution relieved pains and aches present when the patients were at rest, but relief was transient; the difficulties recurred when the patients became ambulatory. Combined injections of physiologic salt solution and 50-percent glucose in 50-cc, doses were ineffective.
       
    In five cases of severe bilateral cold injury treated at the 23d General Hospital, a snug plaster cast was applied to one foot while the other was left
____________
7 Webster, D. R., Woolhouse, F. M., and Johnston, J. L.: Immersion Foot. J. Bone & Joint Surg. 24:785-794, October 1942.
8 Edwards, J. C., Shapiro, M. S., and Ruffin, J. B.: Trenchfoot: Report of 351 Cases. Bull. U. S. Army M. Dept. No. 83, December 1944.


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exposed, according to the usual practice. Every patient was convinced that the foot in the cast was less painful than the other, and 4 of the 5 requested that the cast be reapplied when it was removed. Objectively, it was not possible to detect any differences between the treated and control feet. During this period, almost any change in the environment of the foot or in the method of management was likely to produce transient relief, and too much influence therefore could not be attributed to any special therapeutic measure.
       
    The patients were usually most comfortable with the feet level. In a few instances, relief was obtained by elevating them 10 to 12 inches above heart level, but most of the men found this position uncomfortable. If there was considerable edema, the feet were kept elevated most of the time. This position was not practiced in patients with signs of circulatory inefficiency.
       
    As soon as acute pain was relieved, passive vascular exercises were begun. The routine was simple. The feet were elevated at an angle of 45 on a board or a chair, at first for 3 minutes and later for 5 minutes. Then, after the patient had lain with the legs horizontal for 5 minutes, he sat on the edge of the bed, with his feet dangling, at first for 2 minutes and later for 3 minutes. These exercises, which were carried out 3 or 4 times daily, were supplemented by calisthenics in bed, which were conducted each morning by the ward master.


    Areas of gangrene were kept under close observation, but in the absence of infection amputation could be safely delayed for 10 to 12 weeks; by this time, the necessity for the operation and the extent of resection required had become absolutely clear cut.
 
Postinflammatory Stage  

    The number of therapeutic procedures advised for the management of the postinflammatory stage of trenchfoot was, as always, an index of the lack of effectiveness of any of them. As in the inflammatory stage, any new method of treatment, however irrational it might be, was likely to produce transient relief.
       
    During this stage, management was chiefly symptomatic, the principal objective being to prevent disabling atrophy of the feet. After men had been confined to bed for 5 to 6 weeks or longer, atrophy of the intrinsic muscles of the foot was often evident, and the ligamentous supports of the arches were weakened. Exercise was the best remedy, though it was extremely difficult to make the patients employ it when movement of the feet caused pain and discomfort. Arch supports, while theoretically advisable, were seldom tolerated in the cases in which they were tested. Plaster casts gave unsatisfactory results. Physiotherapy, which was contraindicated during the inflammatory stage, was frequently useful in the postinflammatory stage, but the results were uneven and were usually less good than those the patient accomplished by his own efforts.
       
    The first exercises consisted of gentle passive motion, followed by active motion in the toes and ankles. Walking was begun as soon as possible and was gradually increased until hikes and marches could be attempted. At one re-


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conditioning and training unit, an attempt was made to toughen the thin, delicate skin of the feet by having the men exercise barefoot on a beach, but the results were not notable.
       
    Most patients recovering from trenchfoot had aches and pains in the muscles and metatarsophalangeal joints for several weeks after objective signs of damage had disappeared. When ordinary walking had ceased to be uncomfortable, minor aches were common after hikes, but if they were ignored and regular exercise was continued, they usually disappeared.
       
    The morale of men with trenchfoot who required prolonged hospitalization was a serious problem. Opinion was divided concerning the wisdom of segregating groups of patients in the postinflammatory stage. They could be handled more easily, and group exercises could be conducted more efficiently, when they were kept together. On the other hand, symptoms seemed almost contagious, and a new complaint by one patient often meant its prompt appearance in many other men in the same ward. The best solution of the problem was the segregation of patients whose progress was satisfactory and the dispersion of those who presented problems requiring individual attention or who, for one reason or another, made en masse treatment difficult.
       
    The time of bed patients could be occupied by systematic planning, involving reading, writing letters, occupational therapy, supervised exercises, and games and other entertainment. Ambulatory patients required equally careful supervision, but it was less of a problem because outdoor games and exercises were possible.
       
    The establishment of a reconditioning and rehabilitation section in a hospital which treated patients with trenchfoot was always helpful because it took the men out of the ward atmosphere. After medical treatment had been concluded, this atmosphere was highly undesirable. In one hospital in which such a section was established, the men were required to attend formation each morning and retreat each evening. Also, according to their ability, they worked as ward attendants; helped in the post office, Red Cross, and message center; and acted as clerks, telephone operators, and mechanics. In addition, they participated in planned exercises and games and attended lectures on orientation, combat problems, and current events.
 
Sympathetic Block and Sympathectomy
 
    The value of sympathetic block and sympathectomy was a debatable matter in the Mediterranean theater. There was rather general agreement that very early block, shortly after vasoconstriction had occurred and before ischemia had been present for a considerable length of time, might be useful, but its employment at this time was an obvious impossibility under battle conditions. When the operation was performed later, the results were widely variable. Some observers explained the generally unsatisfactory results by the fact that sympathetic block is a delicate procedure and that many of those who were employing it were not trained in its technique. It is doubtful that


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this explanation covers the situation. Dubious or poor results were achieved by many surgeons who had had a large experience in this field.
       
    Simeone reported the results in several series of cases in which sympathetic block was employed:
       
    Early in the winter of 1943-44, this method was used, with the idea of relieving the subjective complaint of pain, on 11 patients seen within 14 days after injury and on 40 others seen in the postinflammatory stage. Immediate effects were good, but no results were permanent.
       
    In another group of 65 patients, seen within 14 days of the injury, it was thought that the blocks performed increased the chances of favorable results when skin grafting was necessary, and possibly shortened the convalescence after the acute or hyperemic stage had passed. There was, however, no significant difference in total hospitalization time for patients treated by this method and those who were treated only by general measures.
       
    Paravertebral block with Novocain relieved the pain of 5 of 17 patients in still another series, but the results were questionable, since comparable relief was experienced in 50 percent of the control group when the needle was merely introduced and no Novocain at all was injected.
       
    Simeone reported only slight relief from the performance of unilateral sympathectomy on 13 patients who had disabling pain; the operation was done at periods varying from the late inflammatory to the late postinflammatory stage. On the other hand, edema disappeared more rapidly than usual in some of these cases, and, in at least one instance of gangrene of the toes, more tissue was salvaged than had originally been thought possible (fig.85).
       
    Simeone also reported another series of 23 sympathectomies performed in 17 patients who were suffering from such late sequelae of cold injury as vasospasm, hyperhidrosis, bromidrosis, and maceration of the skin. In the only case in which there was no improvement at all, it was found that the operation had been incomplete. Edwards and his associates found unilateral sympathectomy of value in patients with hyperhidrosis; the treated foot improved remarkably in comparison with the untreated foot. Telford's s results in rye British soldiers were generally good.
       
    The total experience with interruption of the sympathetic-nerve supply in the management of cold injury in the Mediterranean Theater of Operations was uneven and, on the whole, disappointing. As has been pointed out, it was thought that the operation might be of value in cases of obvious circulatory insufficiency (fig. 86), if it could be carried out soon after injury. This would usually be impractical. The procedure seemed of some value late in the course of the injury, for the relief of chronic vasospasm, hyperhidrosis, and the complications of these conditions. It did not seem, however, to have any effect upon subjective complaints of persistent pain in any stage of the condition, nor did it seem to modify the clinical course in any material way.
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9 Telford, E. D.: Sympatheetomy in Treatment of the Cryopathies. Brit. M. J. 2:360, 18 Sept. 1943.


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FIGURE 85.- Effect of sympathectomy in severe trenchfoot. A. Appearance of feet after 3 months of hospitalization and 2 months after right lumbar ganglionectomy. The circulation in the right foot improved considerably after the operation, and more tissue was salvaged than had originally been thought possible. B. Plantar aspect of feet shown in view A.

FIGURE 86.- Inflammatory stage of trenchfoot after 14 days of hospitalization. In this case, the skin cleared distal to the serpentine line at the base of the right great toe after alcohol block of the lumbar sympathetic trunk.


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Amputation  

    Amputation was always delayed as long as possible, being employed early only for advancing and intractable infection. In such cases, particular care had to be taken to distinguish between an infectious inflammation and the nonbacterial reaction characteristic of the inflammatory stage of trenchfoot.
       
    The practice of delaying amputation as long as possible proved well worthwhile. Circulatory channels were frequently reestablished, and unexpectedly large amounts of tissue were saved. In some of these cases, it was thought that lumbar sympathetic block had increased the salvage. It was repeatedly observed that gangrene, which had seemed deep, was only superficial and that healthy epithelization was present beneath the eschar when it separated spontaneously (p.296).
 
EUROPEAN THEATER
 
    In the European Theater of Operations, methods of treatment of cold injury were essentially the same as those finally standardized in the Mediterranean theater. When the European experience occurred, the official policy of management, based on the Mediterranean experience, had already been published in TB MED 81, though its circulation in the theater was later than it should have been to achieve the greatest possible usefulness (p.164).

    General measures.- As the first step, the patient was required to get off his feet. He was transported by litter, and, after his wet clothing had been changed for warm, dry garments, he was kept recumbent. The feet were covered loosely and were protected from further trauma and from infection. No active treatment was undertaken until the evacuation hospital was reached.
       
    Here, the patient was placed at complete bed rest, with the feet on a level with the heart. Care was taken to protect pressure points and to guard against infection. Massage was not practiced, and the feet were handled as little as possible after they had been cleansed when the patient was admitted. The body was kept well covered, but the feet were left exposed, preferably at room temperature of 65 to 70 F. (18.3 to 21.1 C.). Heat was not applied in any form. Artificial cooling was sometimes accomplished by electric fans. If the feet were covered, the covering was elevated by a wooden cradle. The maintenance of minimal tissue metabolism was the objective during the hyperemic stage.

    Measures to prevent infection were limited to the use of a careful aseptic technique when the feet had to be handled. The sulfonamides and penicillin were used only when established infection was present. Surgical measures were conservative. Blisters were left intact, and ulcers were treated by simple aseptic methods.
       
    A nutritious diet, high in proteins and vitamins, was provided. The occasional use of vitamin and nicotinic acid therapy was no more successful in European theater hospitals than it had been in the Mediterranean theater.


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    At the 114th General Hospital, in England, it was noted that 5 patients with streptococcic sore throat, who had had fever of 1020 F. (38.9 0 C.) for 24 hours or more, showed much more rapid improvement than 26 other patients who were admitted at the same time and who had apparently the same degree of cold injury. The possible significance of this observation is not clear.
       
    Vasodilator agents.- Vasodilator drugs were tested in some hospitals, with equivocal results. Whisky was occasionally used but was not generally recommended. It was mentioned at the Paris conference on trenchfoot in January 1945 (p.179) that the Stars and Stripes had described trenchfoot as the way to get "this nice treatment." The rather enthusiastic early reports from one general hospital on the use of a special negative-pressure respirator were not substantiated when further trials with this method were made.


    Sympathetic block and sympathectomy.- The consensus in the European theater was that sympathetic block and sympathectomy did not promote recovery in cold injury. At the Paris conference just mentioned, several observers stated that, while relief of pain was sometimes accomplished and earlier movement of the feet was thus made possible, these results were too infrequent to justify the routine use of this method. Another observer stated that the results were always transient and that some of them were shared by the man in the next bed. An occasional officer thought that sympathetic block or sympathectomy was justified when edema was intractable. In the late stages of cold injury, relief of chronic vasospasm and hyperhidrosis was sometimes secured by these methods.

    Amputation.- Superficial gangrene was not uncommon in the European theater, but the necessity for surgical intervention and amputation seldom arose. The only indication regarded as valid for early amputation was intractable advancing infection. Gangrene frequently proved to be only superficial. When the eschar separated, healthy epithelization was present, and rapid regeneration of the tissues was likely to follow. If it did not, skin grafting was performed later.

    Orthopedic appliances.- In late stages of cold injury orthopedic appliances or specially fitted or constructed shoes were sometimes used to make walking more comfortable. At the 216th General Hospital, walking was expedited in 8 or 9 cases by injecting the posterior tibial nerve with Novocain and Pontocaine Hydrochloride. Weight bearing was then possible for some hours without pain. This method does not seem to have had any other trial. Physiotherapy was of value in the correction of deformities arising from fibrosis, muscular atrophy, and chronic edema.
       
    Rehabilitation.- On the whole, the best results were accomplished when active muscular exercise was instituted promptly and carried out energetically. This policy was strongly emphasized at the Paris conference on trenchfoot. One particularly aggressive surgeon, it was reported there, supplied his patients with marbles, which they had to transfer from one box to another with their toes. One group of men who were treated by this method were walking 9 and 10 miles within a month after their injuries. It was stressed that medical


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officers with a "defeatist attitude," who let their patients merely lie on their backs, "with toes pointed heavenward," had very poor results, including deformities of the toes and feet caused by too prolonged bed rest.
       
    As a general rule, it was the policy to segregate patients with trenchfoot of the same average severity in the same ward. This made it possible to set up a sound program of muscular rehabilitation under the direction of a good noncommissioned officer, or an officer patient, who would see to it that the program was carried out energetically several times a day. As soon as possible, the men were fitted with shoes, in larger sizes than they had previously worn, and were required to be ambulatory.
       
    All patients who could be returned to duty were sent to the rehabilitation service for at least 2 weeks before reassignment to a replacement (reinforcement) depot. During this time, hikes of a minimum of 5 to 6 miles were used to gage their progress. This program was applicable, of course, only in patients with mild to moderate injuries, but even patients with severe injuries, when they became ambulatory, could undertake a modified program of this kind and were improved by it. At the 110th Station Hospital, for instance, it was instituted in 25 cases of trenchfoot of more than average severity, in some instances associated with superficial gangrene. At the end of 5 weeks, 12 of the 25 accomplished a route march of 5 miles. Eleven of the others were ambulatory, and all twenty-three had duties about the ward.
       
    All reconditioning and rehabilitation programs, even if they did not return men to full or limited duty, were successful in the sense that most patients became ambulatory reasonably early and that many were spared neuropsychiatric complications. In addition, hospital beds were conserved, as were the time and effort of medical personnel.
       
    Heparin therapy.- In December 1944, a joint effort was made by the Medical and Surgical Consultants Divisions, Office of the Surgeon General, to set up an investigation of the effect of heparin in the treatment of cold injury, as had been proposed by Lange and Boyd.10 The rationale of this method of therapy was explained as follows: The primary pathologic process in trenchfoot is tissue injury caused by cold and anoxia. At low temperatures, the tissues release a substance which initiates sterile inflammation. Small blood vessels are injured in this inflammatory process, and transudation of plasma occurs through their thin walls. Because of a combination of factors resulting from arteriolar constriction and diffuse inflammation, clotting of the blood tends to occur in these vessels and is apparently responsible for the most serious damage to the tissues, which in some instances may include gangrene. Whether the associated nerve injury is caused by exudation and anoxia is not yet known. The proposed therapy was the use of an anticoagulant, based on the assumption that thrombosis would thus be halted in its progression if not prevented entirely.
Heparin suspended in Pitkin menstruum was selected for the trial, in
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10 Lange, K., and Boyd, L. J.: The Functional Pathology of Experimental Frostbite and the Prevention of Subsequent Gangrene. Surg., Gynec. & Obst. 80: 346-350, April 1945.


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preference to Dicumarol, because of the immediate effectiveness of the former and the lag of 48 to 72 hours before the anticoagulant effect of the latter becomes manifest. Heparin was also better adapted for military use for another reason. When it is used, sufficient control can be maintained by determination of the clotting time by the Lee-White method, which is a relatively simple test. When Dicumarol is used, the prothrombin time must be determined repeatedly by a decidedly more complicated method.
       
    Plans for controlled experimental testing of the technique were carefully worked out and a supply of heparin was sent to the European theater. By the time it arrived and could be distributed, the trenchfoot experience was practically over,11 and a controlled experiment therefore could not be continued.12

RESULTS OF THERAPY - DISPOSITION
 
    As has already been pointed out, the evacuation of casualties within and from a theater of operations is conditioned on the one hand by the continuous necessity of maintaining open beds in forward areas for the reception of battle casualties, and on the other hand by the advisability of keeping as near the frontline as possible all men who might be expected to return to the front within the permitted holding period in this area. Experience in World War II showed that this plan favored the return to duty of the maximum number of non-wounded men within the shortest possible time.
       
    Trenchfoot was managed according to this general plan (p.307), but the results, from the standpoint of returning men to duty, were far from satisfactory. Crisler stated at the Paris conference on trenchfoot in January 1945 (p.179) that about 25 percent of all casualties with suspected trenchfoot were sent to the medical gas-treatment battalion centers for trenchfoot. The figure sounds promising, but, when it is broken down into its components, it is found that only one-fifth of these men were ambulatory and able to return to frontline duty at the end of the permitted holding period. The other four-fifths had to be evacuated to general hospitals for definitive treatment. Furthermore, as other observers brought out at this conference, many of those sent back to frontline duty continued to complain of pain in their feet, exactly as many other men in the Zone of Interior had constantly complained of low-back pain.
       
    The disposition of patients with trenchfoot was always a major problem. The disability was of long duration. The results of therapy were discouraging.
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11 Toone, E. C., and William, J. P.: Trenchfoot: Prognosis and Disposition. Bull. U. S. Army M. Dept. 5: 198-210, February 1946.
12 Heparin seems to have given good results when it was used in Korea. Lt. Col. Kenneth D. Orr, MC, who observed approximately 1,500 cases of cold injury in December 1950, wrote as follows on 14 March 1956: "No agent or procedure was clearly demonstrated to prevent gangrene in 4th degree frostbite. However, in those cases treated with heparin in which treatment was begun less than 36 hours after rewarming, the eventual tissue loss was less than predicted when the patient was first seen. Fifty percent of cases of 4th degree frostbite extending proximal to the web of the toes who received only general supportive measures developed soft, wet, infected gangrene. This same result occurred among patients receiving vasodilators and sympathetic ganglion blocks. Those cases of severe 4th degree frostbite extending proximal to the web of the toes who received heparin all dried and mummified. These heparin-treated cases had asymptomatic, afebrile courses and were transportable after 14 days to the Zone of Interior for definitive surgery."


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    Only small numbers of men could be returned to full duty, from either forward or rear areas, and additional problems were introduced by the inability of even men returned to limited duty to hold up under any sort of strain.
       
    It was essential for medical officers accustomed to civilian practices to bear in mind that soldiers who were returned to duty, whether full or limited, had to be able to perform all the duties for which they were classified. No arrangements could be made for intermittent or partial performance of assigned tasks. Moreover, the return to duty of soldiers who promptly had to be evacuated again entailed a great waste of valuable time, effort, material, and transportation facilities. A strict disposition policy therefore proved, in the end, to be far wiser than a liberal policy, but, in both the Mediterranean and the European theaters, this had to be learned by experience.

Mediterranean Theater  

    The experience in the Mediterranean theater, which from the standpoint of disposition was much longer than the experience in the European theater, may be accepted as typical. In general, the criteria of return to full duty were as follows:
       
    1. There must be complete subsidence of swelling and erythema.

  2. Vasomotor stability must have been reestablished.         

    3. Paresthesia and pain must have disappeared entirely unless there was clear evidence that their presence could be explained on psychogenic grounds.
        
    4. There must be no evidence of mechanical strain or arthritic processes.
      
    5. The soldier must have demonstrated, in actual practice, his ability to hike, march, and otherwise stand up under the physical strain of military life.
       
    Criteria for evacuation to the Zone of Interior were as follows: (1) Extensive edema or blister formation; (2) hyperhidrosis or signs of generalized vasomotor instability in either upper or lower extremities; (3) persistence of symptoms after 3 months of adequate treatment; (4) disabling amputations; and (5) associated arthritis, fallen arches, bunions, exostosis, or similar abnormalities.

    Of the 50 patients with trenchfoot who formed the material for the first investigation of cold injury in the Mediterranean theater, 8 were returned to duty at the end of a month and 3 more at the end of 6 weeks. At the end of 6 weeks, however, 16 had already been evacuated to hospitals in the Communications Zone, and the remainder were still under treatment in the army area.  The duration of edema had proved the best index of the severity of the injury. None of the 11 patients returned to duty within the 6-week period had had edema for more than 9 days.
       
    Although it was not realized at the time, the experience with these 50 patients was to be typical of the whole experience in both the Mediterranean and the European theaters. The duration of treatment was to prove prolonged, and the number of men returned to duty was to be small. Furthermore-as these figures do not show-many of the men returned to duty as


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cured were to prove unable to carry out their duties satisfactorily. The following experience, reported by Toone and Williams from an evacuation hospital in Italy, shows very clearly that a liberal disposition policy did not pay.
       
    In all, 1,057 patients with cold injury were disposed of in this hospital between 24 December 1943 and 1 May 1945. During the first month of the survey, the holding period could not exceed 30 days, and 95 percent of the 318 patients with trenchfoot admitted during this time were transferred, as promptly as evacuation facilities permitted, to hospitals in North Africa. Only patients with very mild injuries were retained, because the need for hospital beds in the area was extremely acute.
       
    During the second month of the survey, the holding period was increased to 90 days, and only patients with severe trenchfoot (grades 3 and 4) had to be evacuated. This policy, however, did not prove practical; it resulted in a serious shortage of beds, since the rate of admission for cold injury far outstripped the rate of discharge. It was therefore necessary to transfer some patients to convalescent hospitals in the vicinity and others to other hospitals in the Peninsular Base Section. The establishment of a reconditioning section in each general hospital which received trenchfoot casualties finally solved this special problem.
       
    Between 1 January and 1 June 1944, 249 casualties with trenchfoot were disposed of. Of these, 125 (50.2 percent) were classified for full duty or provisional duty. Seventy-four were reclassified for limited duty and fifty as unfit for duty. At this time, it was thought that the greater number of the men classified for provisional duty could be returned to combat duty after another month of hard reconditioning. It was also thought that many of the men classified for limited assignment could eventually be reclassified for full duty. The 50 patients classified as unfit for any duty were returned to the Zone of Interior. All had had severe initial lesions or, even though their initial lesions had not been severe, had had persistent edema or incapacitating pain.
       
    Between 1 June and 15 October 1944, this evacuation hospital readmitted 99 patients with chronic, persistent, or recurrent trenchfoot, as well as 10 others who had attempted to sweat it out without hospitalization during their primary attacks of trenchfoot. Although only 2 of these 99 patients had originally been treated in this particular hospital, the medical staff was fully aware that their own errors of prognosis were undoubtedly being corrected in other hospitals. The staff also realized that, while they had originally considered their proportion of disposition to duty as too low, actually, because of inexperience with trenchfoot, the proportion had been too high and had proved wasteful rather than conservative. As a result, when these 109 patients were disposed of, only 1 was returned to full duty. Thirty-two were returned to limited duty, and seventy-six were sent to the Zone of Interior.
       
    An analysis of 60 of the 99 patients rehospitalized for trenchfoot made it clear that the new policy was the only sound and practical one. The combined time these 60 patients had been hospitalized and had spent in rehabilitation far


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exceeded the time in which they had been able to do any kind of duty after disposition. Furthermore, 46 of these men had spent from 4 to 6 weeks of the duty period in training, and their effective combat time had been at the most, 6 weeks; in some instances, it had not exceeded 2 weeks. The prolonged hospitalization time and the rehabilitation effort expended on them were thus almost entirely wasted. They had had to be withdrawn from combat during a very active campaign and be replaced by men who, for the most part, had not had the benefit of the intensive training which had been wasted on the trenchfoot casualties.
       
    Toone and Williams told in some detail the dismal story of 25 men who had been discharged from various hospitals to full duty. They had been unable to meet duty requirements either in training programs or actual combat. They had to fall out on hikes and marches. They caught rides as best they could on trucks, jeeps, or tanks. If they were fortunate, they finally found assignments as clerks or cooks at headquarters or with a rear echelon group. They were totally unfit for combat. Their disability was a hardship to themselves, it increased administrative difficulties, and it reduced the combat effectiveness of their organizations, which would have been better off if this group of men had never been assigned to them.
       
    The symptoms from which these men suffered all suggested that none of them had recovered completely from the damage resulting from their original exposure to cold, wet weather. All had a history of persistence of one or more of the symptoms of the posthyperemic phase of their original injuries. These symptoms had gradually increased in severity during their brief periods of duty and had been acutely exacerbated by excessive walking or by marching for even short distances. Most of the men also told stories of mild recurrences of the hyperemic phase of the cold injury after minor exposure. In fact, chronic trenchfoot with exacerbation seemed a more appropriate diagnosis in these cases than recurrent trenchfoot.
       
    As a result of this experience, the disposition policies of this particular evacuation hospital were radically altered. Of the 315 men with trenchfoot disposed of between 1 September 1944 and 1 May 1945, only 7 (2.2 percent) were classified for full duty, in sharp contrast to the 50 percent thus classified during the preceding winter. One hundred and twenty-nine (41.0 percent) were reclassified for limited duty, and one hundred seventy-nine (56.8 percent) were returned to the United States. A fairly large number of men with relatively mild trenchfoot were discharged from the hospital when the winter was at its height, and perhaps, had weather conditions been more favorable, 10 to 15 percent of them might have been given a trial at full duty. Even if this had been possible and the trial had been successful, the total number of men returned to full duty would still have been under 10 percent.
       
    It was the conclusion of the staff of this hospital, as it was eventually the conclusion of the staffs of most other hospitals which received trenchfoot casualties, that less than 10 percent of soldiers who suffer attacks of cold injury can be restored to duty as combat infantrymen. It was also their opinion


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that prolonged and futile attempts to rehabilitate the other 90 percent should be abandoned as wasteful and impractical. When the men in this group had only moderate injuries, the best plan was to train them for such combat duties as they could perform in tank companies, antiaircraft or field-artillery batteries, or motor-transport units. Men with the most severe injuries should be assigned at once to duties in the rear echelons of combat units or in the more protected environment of the base areas. The rationale of this policy of classification was that, from the standpoint of manpower necessities and losses, hospitalization and rehabilitation in excess of 2 months could accomplish nothing that could not be accomplished better by prompt assignment to a duty status which was likely to be maintained.
       
    The duration of hospitalization, which furnished an index of the severity of the cold injury, was a useful aid in disposition.13 About 140 patients with trenchfoot were still hospitalized when a study of dispositions was made in the spring of 1945, as part of the continuing theater investigation of this condition. Between 16 September 1944 and 6 April 1945, 1,617 men hospitalized for the ground type of cold injury had already appeared before hospital disposition boards, with the following results:

    Six hundred and seventy-one (41 percent of the total number) were discharged to full duty. The average period of hospitalization was known in 618 cases and averaged 26.1 days.
       
    Six hundred and seventy-three (42 percent of the total number) were discharged to limited duty. The average period of hospitalization was known in 504 cases and averaged 56.3 days.
       
    Two hundred and seventy-three (17 percent of the total number) were evacuated to the United States. The average period of hospitalization was known in 210 cases and averaged 63 days.
    
    The average period of hospitalization for the whole group in which these data were known was 43.4 days. Seventeen percent were lost from an active theater of operations after they had occupied hospital beds on an average of 2 months each, and only 42 percent, less than half, were returned to full duty. If allowance is made for the undoubted recurrences in the group returned to full duty, the picture is even more discouraging.
       
    Over the period in which these 1,607 patients were disposed of, 2 patients with cold injury of the hand appeared before disposition boards in the Mediterranean theater. One man was returned to full duty after 15 days of hospitalization and the other to limited duty after 31 days.
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13 See footnote 1, p. 307.