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Chapter XII



Therapy and Disposition in Zone of Interior

    Casualties from cold injury who did not complete their recovery overseas were evacuated to the Zone of Interior, where they were treated at the special vascular centers established at Ashford General Hospital, White Sulphur Springs, W. Va., DeWitt General Hospital, Auburn, Calif., and Mayo General Hospital, Galesburg, Ill., at the United States Army General Hospital at Camp Carson, Colo., or in other convalescent centers. Camp Carson, which had been an Army Service Forces Convalescent Hospital, was designated as a general and convalescent hospital, chiefly for the treatment of frostbite and trenchfoot, in February 1945.
    Triage at the ports of debarkation was carried out on two general principles:
    1. All casualties who had suffered any loss of tissue or who presented gangrene of the toes or other parts of the foot and all patients who had severe complaints or who were unable to walk were sent to vascular centers.
    2. All other patients were sent to convalescent centers, preferably in a mild climate.
    During the 18-month period ending in October 1945, 2,027 soldiers who had suffered from cold injury were treated in the three vascular centers. During the 4-month period of its operation as a special trenchfoot center, 4,892 soldiers with cold injuries were admitted to the general hospital at Camp Carson.
    An analysis of the clinical records of 1,275 of the 2,027 patients with cold injury treated at the three vascular centers forms the background for the general statements made and the conclusions reached in the following pages. Actual figures and percentages are chiefly derived from 656 cases studied intensively at the Mayo General Hospital Vascular Center.
    From a study of the records of patients with trenchfoot observed at vascular centers in the Zone of Interior, it was not possible to determine with any degree of accuracy the precise methods of management which had been employed in hospitals overseas. Many of the men had apparently been transported to the rear in well-heated ambulances, but thereafter a heated environment was usually avoided. Eleven patients at Mayo General Hospital furnished a striking exception; all had been treated by the application of moderate heat
1 The reports and analyses upon which most of the material in this chapter is based were prepared by Lt. Col. Harris B. Shumacker, Jr., MC, formerly Chief of Surgery, Mayo General Hospital.


to the feet. In another instance, in which bilateral gangrene subsequently developed, the feet had been exposed to a hot stove.
    For the most part, treatment of patients without gangrene had consisted of continuous exposure of the feet, with or without elevation, at room temperature. Electric fans and icepacks were sometimes used. In all but mild cases, complete bed rest was maintained for 2 to 3 months. In a few instances, alternate hot and cold soaks were used, and Buerger's exercises were also used in some cases. Penicillin and the sulfonamides were occasionally administered to combat secondary infection.
    Forty-seven patients without gangrene, who were treated at Mayo General Hospital, had had paravertebral lumbar sympathetic blocks overseas. The feet had always become warm, dry, and pink immediately afterward, but in every instance the response was transient. Two other patients had been treated by sympathectomy. In neither instance was there any relief of the aching sensation of which the patients complained, but it was thought that healing had been accelerated in a foot that showed an area of apparent deep gangrene.
    The initial therapy overseas in patients who were admitted with apparent deep gangrene to the vascular centers in the United States had been directed toward combating secondary infection by the use of penicillin and the sulfonamides. Sedatives and narcotics had been employed as necessary. Conservative therapy had been the rule. Early amputation of the toes or of part of the foot had been carried out in only 1 of 37 patients with deep gangrene received at Mayo General Hospital, and only 17 of the 1,275 patients treated at all three centers had had any kind of surgery overseas.
    The patients were told from the day of admission that their complete recovery depended upon their own efforts. It was emphasized that exercise and ambulation would expedite recovery, and they were told that they would be given every chance to improve on conservative management before surgical measures were considered.
    Massage and lubrication.- Treatment at the vascular centers began with cleansing the feet of accumulated dirt and dead and desquamating skin. This was best accomplished by soaking the feet and by the liberal use of soap. Desquamation was further expedited by rubbing the feet with lanolin ointment containing 4 percent salicylic acid. The patient carried out this massage himself, at regular, scheduled intervals, after demonstration by, and under the supervision of, the physical therapist. In addition to the practical considerations of removing dead epidermis, which was usually thick and unsightly, and stimulating the circulation by massage, this procedure kept the patient occupied and aided his morale by permitting him to share in his own treatment.
    When desquamation was complete, lanolin ointment was replaced by a preparation of mineral oil and a dilute solution of alcohol, which was rubbed


into the skin of the feet at least twice daily, for 30 minutes each time. The patient worked on his own feet or on the feet of the man in the bed next to him, as was most convenient. Much emphasis was placed on active manipulation of the toes, to counteract stiffness, contractures, and the atrophy of disuse.
    Exercise and ambulation.- Patients with residua of trenchfoot had usually been at complete bed rest, without even latrine privileges, on an average of 9 weeks (the range being from 1 to 20 weeks) when they arrived at the vascular centers in the Zone of Interior. The first objective of therapy was therefore to make them ambulatory. In many instances, it required considerable persuasion by the ward officers to overcome the inhibitions which had developed during the long periods of complete bed rest. Even when there was no real reason why they should not become ambulatory at once, the men often objected to getting out of bed. In other instances, the resumption of walking was really difficult and uncomfortable because of pain, swelling, and tenderness in the sole of the foot.
    When the toes were notably stiff, contracted, and atrophied, the daily routine of massage by the patient was supplemented by active and passive manipulations by the physical therapist. This treatment, supplemented by what the patient did for himself, freed up adhesions about tendon sheaths and joint capsules and loosened up fibrotic toes. The opinion was that the routine employment of these simple measures saved many toes which otherwise might have required amputation.
    Group exercises were conducted for all the patients by trained ward personnel. They consisted of active foot and ankle exercises designed to prevent contracture of the Achilles' tendon and the gastrocnemius-soleus muscle group, as well as to prevent talipes equinus and pes cavus.
    When the patients began to walk, they were fitted with low quarter shoes, which were more satisfactory than garrison shoes because of their light weight. Also, since less of the foot was covered, there was better provision for evaporation of perspiration. If hyperhidrosis was a prominent symptom, the shoes were perforated in numerous sites.
    Almost a third of the patients without gangrene treated at the Mayo General Hospital Vascular Center complained of tenderness over the distal portion of the foot on the plantar surface, and, to protect this area, shifted the weight of the body to the heel (fig.87) or to the lateral edge of the foot. To correct the resulting unnatural gait and the subsequent undesirable alterations in the dynamics of the foot and the spine, either a thick piece of leather or a second rubber heel was attached to the under surface of the shoe, in front of the regular heel (fig.88). The patient thus walked on two heels and experienced almost no pressure on the sensitive portion of the foot. As ambulation was continued, the anterior heel, which received most of the wear, gradually wore down until, eventually, pressure was applied to the entire sole of the shoe. By this time, the sensitivity originally complained of had usually disappeared or had so greatly diminished that the additional heel could be entirely


FIGURE 87.- Typical heelwalker, who shifts pressure to heel to remove weight from sensitive sole of foot in later stages of trench foot.

FIGURE 88.- Correction of heelwalking by application of second heel anteriorly, to remove pressure from sole of foot. A. Plantar view. B. Lateral view. Note present stance of patient, with sole of shoe off ground.
dispensed with. In the occasional case in which the patient complained of sensitivity to pressure in the heel, the front of the shoe was built up with leather beyond the level of the heel, which was thus protected from trauma.
    By these and other simple devices, patients who were fearful of leaving their beds were persuaded to become ambulatory, and a vicious circle was broken which, if it had been permitted to continue unchecked, would have led eventually to invalidism.
    Lumbar sympathetic block.- A number of patients in the vascular centers were treated by paravertebral lumbar sympathetic block, partly to establish

that their complaints of cyanosis, coldness, and hyperhidrosis were caused by excessive sympathetic activity, and partly to assess the therapeutic effects of this measure. In some instances, the only effect of the procedure was to bring about, for a short time, good coloration, warmth, and dryness of the foot. In other instances, there was transient alleviation of the sensitivity of the sole of the foot, which has just been described. Sympathectomy was later performed in several cases in both these groups. Hyperhidrosis and vasoconstriction both disappeared, but the results in respect to relief of pain on weight bearing were only indifferent.
    Typhoid vaccine therapy.- Some of the first patients with trenchfoot received at Mayo General Hospital were treated intravenously with typhoid vaccine, always after preliminary testing. The initial small dosage was gradually increased to the point at which a single injection was followed by a rise in body temperature to approximately 102? F. (38.9? C.). The course of treatment consisted of 10 to 15 intravenous injections at 2-day intervals.
    All of the first patients given this treatment had been chosen at random and with no selection. When the results in these cases were analyzed, it was found that the only significant change in the clinical picture after treatment was that some patients showed a considerable reduction in edema. Thereafter, the use of this method was limited to patients whose chief complaint was edema. In 6 of the 16 cases in which typhoid vaccine was used on this special indication, there were no evident results. The other 10 patients showed rapid improvement after the first or second injection; thereafter, their improvement, while it continued, was considerably less striking. At the end of the course, however, all 10 patients, who had previously spent most of their time in bed and whose edema had not been improved by 3 weeks of complete bed rest, were fully ambulatory. This method of treatment therefore seems to hold out some promise and seems worthy of further trial in late cases of trenchfoot in which swelling is prominent. Whether or not it will be effective in any given case can be determined after the first 2 or 3 injections.
    Control of hyperhidrosis. - Hyperhidrosis was a common and sometimes incapacitating complaint, which was relieved only moderately, if at all, by the use of low-cut, ventilated shoes, daily foot baths, frequent changes of socks, and foot powders. Frei's method of applying formalin by means of electrophoresis was tested in 121 patients with this complaint, on the ground that formalin baths are often used by dermatologists in the management of hyperhidrosis and that the therapeutic effect might be accentuated by forcing the formalin into the skin by means of a galvanic current.
    This method was never employed until the patients had been tested for sensitivity. The precaution proved essential, as well over a quarter of the men for whom the treatment was considered were found sensitive to formalin. Treatment consisted of placing the large negative electrode of an ordinary galvanic-current machine in close contact with the abdomen while the positive electrode was immersed in a bakelite container filled with 1-percent formalin solution in sufficient quantity to reach above the ankles. A course of treat-


ment consisted of six daily applications of 10 to 12 milliamperes of current for 20-minute periods.
    Results were variable. In 29 of the 121 cases in which the method was used, treatment could not be continued beyond the second or third application because of mild dermatitis or the development of fissures between the toes. Thirty-seven of seventy-four patients who had one course of treatment showed almost immediate cessation of sweating, twenty-one had a fair response, and the others had no benefit at all. At the end of a 4-week followup period, the therapeutic effect was still excellent in 7 patients and good in 32, but it was only fair in 16 and was poor in 19. Eighteen patients were given two courses of treatment, at an average interval of 39 days. In this group, the results were good in 6 cases, fair in 8, and poor in 4. At the end of a 2-month period of observation, hyperhidrosis had returned in most cases, regardless of the original results, but it was less severe, and it was concluded that this mode of treatment has a definite, if transient, beneficial effect in the late stages of trenchfoot. Patients with hyperhidrosis treated by sympathectomy had, of course, complete and lasting relief (p.342).

    Other measures.- A certain number of other therapeutic methods were tested at the vascular centers, not because there was any real expectation that they would prove effective but to give the patients the benefit of all possible techniques and to rule out, in the future management of trenchfoot, those techniques which were entirely useless. As expected, the results were for the most part unsatisfactory, and the data (all from Mayo General Hospital) are presented merely for the record.
    Four patients with prominent signs of excessive sympathetic activity were treated by electrophoresis with a 0.2-percent aqueous solution of Mecholyl Chloride (acetyl-beta-methylcholine chloride). Six daily applications were made, by the technique described for the similar application of formalin. The local vasodilating properties of Mecholyl furnished the rationale for this procedure, the objective of which was to counteract vasospasm. The feet were always transiently warmer after each treatment, but there was always a prompt reversion to the original cold, blue state, and, at the end of the period of observation, there was no permanent improvement in vasomotor tone in any instance.
    Eleven patients with complaints referable to the peripheral nervous system were given daily intravenous injections of thiamin chloride (100 mg.) for an average of 14 days. No untoward effects were noted, but there was also no alteration of symptoms. The patients continued to complain of paresthesias, aching, burning, and sensitivity in the soles of the feet. It was concluded that this form of therapy was of no value in the relief of neurologic complaints in the later stages of trenchfoot.
    Eight patients were treated in Sanders beds and by Buerger's exercises. There was no reduction in the severity of their complaints, and cyanosis, coldness, and hyperhidrosis remained unaffected.


FIGURE 89.- Extensive gangrene of both feet in late stage of trenchfoot. A. Appearance of feet before operation. B. Appearance of feet after bilateral lumbar sympathectomy and amputation through line of demarcation. Healing was satisfactory, and the patient was discharged with useful feet


    Sympathectomy.- Since vasoconstriction is a fundamental factor in the pathogenesis of trenchfoot, as well as one of the most constant sequelae, it was natural that sympathectomy should be regarded as a rational procedure in the last stages, whether or not other procedures were necessary. Sixty-six lumbar sympathectomies were performed on forty-nine patients at the Mayo General Hospital, by excision of the second and third lumbar sympathetic ganglia, together with the intervening chain. The operations were performed through an anterior extraperitoneal approach, under spinal analgesia. There were no complications in any case. The distribution of cases according to indications was as follows:
    1. Deep gangrene.- There were 38 operations performed on 30 patients. Exposure had occurred in these cases on an average of 2 months earlier. From 1 to 5 toes were affected (figs. 89, 90, and 91). Evidences of vasoconstriction were conspicuous. The feet sweated profusely and were frequently cold and cyanotic. Secondary infection was present in 29 of the 30 cases. Local heat was originally present, as the result of the inflammatory reaction, in all of these cases, but cooling of the feet was observed as the infection cleared. Occasionally, the feet were warm, and sweating was almost completely absent.

.   Satisfactory and reasonably prompt healing occurred in all 30 cases (figs.89, 90, and 91), though at times, when the metatarsal bones were exposed,  tube transfer grafts were necessary before healing was complete (figs. 90 and 91)

Since no control series was run, it cannot be said positively that the rate of healing was expedited by svmpathectomy, but there is some evidence, as


FIGURE 90.- Extensive gangrene of both feet in late stage of trenchfoot. A. Appearpearance of feet before operation. B. Appearance of feet after bilateral lumbar sympathectomy, amputation, and tube transfer graft to left foot.

FIGURE 91.- Extensive gangrene of both feet in late stage of trenchfoot. A. Appearance of feet after sympathectomy and amputation. Dorsal view. B. Plantar view. C and D. Dorsal and plantar views showing appearance of feet after bilateral application of tube transfer grafts and removal of part of head of right first metatarsal.


FIGURE 92.- Gangrene of both feet in late stage of trenchfoot. A. Appearance of feet before operation. B. Appearance of feet after unilateral sympathectomy, amputation of gangrenous area of left great toe, application of split-thickness skin graft, which failed to take, and lateral amputation of distal phalanx of toe and revision of stump
case 1 indicates, that the increase in circulation following the operation had a beneficial effect on lesions associated with significant vasospasm.
    Case 1.- This patient was first seen after the first four toes on one foot had been amputated. The stumps were granulating and infected. After the infection had been treated for 4 months, small, deep grafts were applied, with poor results; the grafts did not take and little or no epithelization followed. Syrnpathectomy was then performed because the foot was cold, wet, and cyanotic. Complete healing occurred within a few days. The stump was subsequently revised because the skin over the distal end was thin and delicate.
    The contrast of rapid epithelization of raw areas following sympathectomy and the slow healing in cases in which it had not been performed was particularly evident when vasospasm was present. After operation, the feet were warm and had a healthy color, and sweating was no longer a problem. If the skin was excessively dry, lanolin was applied daily.
    When small split-thickness grafts were attempted after sympathectomy, it was riot always possible to secure takes (figs.92 and 93), but tube grafts were transferred as readily as to normal limbs.

.In 17 patients on whom unilateral sympathectomy had been performed, the skin temperature of the toes or stumps averaged 78.4? F. (25.8? C.) in the untreated limb and 91.8? F. (33.2? C.) in the sympathectomized limb. Oscillometry at the ankle averaged 2.6 on the untreated side and 4.6 on the sympathectomized side. After sympathectomy, dorsalis pedis and posterior tibial pulsations were generally present and full, and there was nothing to suggest any extensive obliterative change in the arteries of the feet, although there

FIGURE 93.- Gangrene of both feet in late stage of trenchfoot. A. Appearance of feet after excision of gangrenous parts and bilateral sympathectomy. A split-thickness skin graft applied to the left great toe failed to heal, because of infection. B. Appearance of feet after revision of stumps of both great toes, because of osteomyelitis, and amputation of right fifth toe for same reason.  

may have been thromboses of the digital artery or of small branches in the stump immediately adjacent to the line of demarcation.
    2. Cold sensitivity.- There were 13 operations on 9 patients. Four patients in this group suffered from sweating to such a degree that their socks were almost constantly wet. In two cases, maceration of the skin had occurred, followed by secondary infection. These 4 patients, as well as the other 5, whose chief symptom was cold sensitivity, all complained of pain on exposure, with a distressing sense of numbness. In every case, the feet became warm and dry and the coloration normal after sympathectomy. The abnormal response to cold, and the associated discomfort, were diminished or reduced in degree, and the infection present in two patients with hyperhidrosis promptly cleared up.
    3. Pain on weight bearing.- There were 15 operations on 10 patients. All the patients in this group had fairly well-marked vasospasm, which was completely relieved by the operation. Two patients who complained of pain in the heels had complete relief of pain, as did three of the eight who complained of pain in the metatarsal region. Two other patients with metatarsal pain secured moderate relief, but there was no improvement in the remaining cases.
    In the light of these results, it was concluded that sympathectomy (1) is useful in minimizing tissue loss and in accelerating healing in patients with gangrene associated with vasospasm; (2) is of value when hyperhidrosis is a prominent symptom, particularly when maceration of the skin, local infection, and cold sensitivity are associated; and (3) is of questionable value in the


relief of pain on weight bearing and in mild vasoconstriction in the absence of severe associated manifestations. <>       

    General measures.- Of all measures instituted to control infection, before gangrenous areas were excised, the most useful was the application of warm sterile compresses saturated with physiologic salt solution. It was frequently necessary to use in addition some ointment, such as zinc oxide, to protect the intact skin against maceration, the tendency toward which seemed greater than in normal limbs. Perhaps the explanation was the very recent epithelization of large areas of skin following extensive desquamation. Another possible explanation was the extensive hyperhidrosis from which so many patients suffered.

    Most of the patients were treated either with sulfadiazine or penicillin or both. If streptomycin had been available, the results might have been better, since some of the organisms which were present are sensitive to this antibiotic. Chemotherapy and antibiotic therapy were possibly effective in preventing the spread of infection, but neither method had any evident effect on the local infection. Aqueous Mercurochrome solution proved more efficacious than dilute acetic acid in clearing up infection caused by Bacillus pyocyaneus.
    In a number of instances of apparently superficial dry gangrene, an active infection, which led to osteomyelitis, was present under the crust. Amputation was often necessary in these cases. In order to prevent such an outcome, the practice eventually developed of using compresses in all cases in which areas of superficial gangrene failed to separate promptly, in an effort to hasten separation and subsequent epithelization. The prompt removal of all well-demarcated, gangrenous tissue was found to be an important step in the management of these cases.
    Even when infection cleared grossly under treatment, it was often still. present deep in the tissues. The surgeon was therefore greatly handicapped in the use of split-thickness and other types of skin grafts.
    Amputation.- Gangrenous plaques and digits were, as a rule, amputated through the line of demarcation as soon as possible after the patients were received in the vascular centers. Sympathectomy was performed at the same time in selected cases. The prevalence of infection, as already noted, permitted closed amputations in very few cases.
    The extent of the amputation depended upon the degree of the gangrene. The policy of conservation of all tissue that could be salvaged was strictly adhered to.
    In some of the 37 patients with deep gangrene treated at Mayo General Hospital, only a single toe was affected. In other cases, the process was limited to the distal, or the distal and middle, phalanges. In still others, all the toes were completely gangrenous. In 13 cases the gangrene was so extensive that the heads of the metatarsals were left exposed after operation, and in 7 cases it was necessary to remove portions of the metatarsal bones. Protruding stumps of bone were often left in situ because infection made complete revision inadvisable at the time. Later, the stumps were further revised, and the pro-


FIGURE 94- Extensive gangrene in late stage trenchfoot, for which amputation through leg was eventually necessary. A. Dorsal View. B. Plantar view.

truding phalanges were rongeured off. Disarticulation was performed in several cases. The operation was technically simple, and it was thought that osteomyelitis of the proximal stump was less common after this procedure than after amputation through the phalanges.
    Amputation of a portion of the foot or leg was necessary in only two instances. One patient, who had gangrene of both feet (fig.94) was transferred to an amputation center for amputation of the leg. The other patient (fig.95), who had previously undergone amputation (partly tarsal-metatarsal and partly through the proximal portion of the metatarsals), had been left with a painful, unstable and entirely unsatisfactory stump. He was transferred to an amputation center for a Syme's operation.
     Contractures of the toes and stiffness of the joints and muscles were rather frequent in patients who had sustained loss of tissue from gangrene, as well as in other cases. Stiffness could usually be relieved by physiotherapy and exercise, but contractures did not always respond to these methods or to the use of metatarsal bars. The commonest deformity resulted from extensor contractures. Flexion contractures were less common. Both types were more likely- to occur in stumps than in intact toes. In a few instances, the contracture was so severe and disabling that amputation seemed wiser than continued attempts to remedy the situation by conservative methods (fig. 96).
    Skin grafts and plastic revision.- Skin grafting was unnecessary in most patients, even those with deep gangrene (figs. 89, 97, and 98), the majority of whom were discharged with useful feet after amputation. When the toes had been amputated through the phalanges, epithelization usually occurred promptly, and the new skin was usually strong enough to withstand the trauma of walking.

FIGURE 95.- Appearance of feet after amputation (partly tarsal-metatarsal and partly through proximal portion of metatarsals) for extensive gangrene in late stage of trenchfoot. The resulting stumps were painful, unstable, and highly unsatisfactory. This patient was eventually transferred to an amputation center for a Syme operation. A. Dorsal view. B. Plantar view.

FIGURE 96.- Contractures of toes in late trenchfoot, requiring amputation for relief. A. Contractures before operation. B. Appearance of feet after amputation and revision of stumps. The patient was left with comfortable feet.
     In a few cases in which thin skin was adherent to the bone, revision with primary closure was carried out. If the defect was large, and particularly if an entire toe or several toes had been lost, it was often desirable to employ a split-thickness graft as a temporary procedure even if a full-thickness graft later had to be used. In some cases, split-thickness grafts were satisfactory


FIGURE 97.- Deep gangrene of feet, extending to bone, in late stage of trenchfoot. A. Appearance of feet before sympathectomy. B. Appearance of feet after unilateral sympathectomy and excision of gangrenous parts. Healing was prompt and satisfactory, without additional surgery. In this case, an area of gangrene on the sole of the right foot also healed promptly.

FIGURE 98.- Deep gangrene of feet, extending to bone, in late stage of trenchfoot. A. Appearance of feet before unilateral sympathectomy. B. Appearance of feet after unilateral sympathectomy and excision of gangrenous parts. Healing was prompt and satisfactory, without additional surgery.


FIGURE 99.- Gangrene of feet in late stage of trenchfoot. Application of split-thickness skin grafts, followed by good healing, minimal loss of tissue, and good functional results. A. Appearance of left foot before operation. B. Appearance of foot shown in view A after unilateral sympathectomy and coverage of stumps of first, third, and fourth toes with split-thickness skin grafts. C. Appearance of feet before operation. D. Appearance of feet shown in view C after unilateral sympathectomy and coverage of ulcerated area over right metatarsal ends with split-thickness skin grafts

(fig. 99), but in general they were not (figs. 92 and 93) probably because of infection rather than because of poor circulation in the stump.
    Tube grafts (figs. 90, 91, 100, 101, and 102) had to be used in five cases, in all of which amputation left the metatarsal heads exposed. The skin of the sole was, fortunately, intact in these cases, so that the graft did not have to be placed on a weight-bearing surface.


FIGURE 99- Continued. E. Appearance of feet before operation. F. Appearance of feet shown in view E after unilateral sympathectomy and coverage of defect along dorsomesial aspect of toes of right foot with split-thickness skin grafts. G. Appearance of feet before operation. H. Appearance of feet shown in view G after bilateral sympathectomy and coverage of ulcers over stumps of both first toes with split-thickness skin grafts.
    When the first of these five patients was operated on, a double pedicle graft was elevated from the opposite leg, a split-thickness graft was placed beneath the pedicle graft, and the pedicle graft was then transferred to the defect in the foot. It was found at this stage of the procedure that sufficient atrophy had occurred to permit primary closure of the skin beneath the pedicle, which was then converted into a tube. Three weeks later, the tube was divided at the lower end and sutured to the defect of the foot, the limbs being held in place with plaster of paris. The same technique was employed in the four other cases in which transfer grafts were necessary.


FIGURE 100.- Deep gangrene of feet in late stage of trenchfoot. Utilization of tube transfer grafts with bilateral sympathectomy after amputation. The functional result was excellent. A. Appearance of left foot after bilateral sympathectomy and amputation of toes. B. Appearance of foot shown in view A after application of tube transfer graft.
    The operation was performed as follows: Two parallel incisions were made on the posteromedial aspect of the contralateral leg, the width and length of the pedicle depending upon the size of the area to be covered. The anterior incision was placed just posterior to the saphenous vein; care was taken to avoid injury to the saphenous nerve. The skin between the incisions, together with the underlying subcutaneous fat, was elevated. The pedicle was gently retracted and the skin margins were sufficiently reflected both anteriorly and posteriorly to permit closure without tension. Approximation of the skin edges with interrupted sutures of fine cotton converted the pedicle into a tube (fig.103). Between the second and third weeks after operation, the circulation in the tube was tested by the application of a rubber tourniquet about the distal end. In all five cases in which this method was used, good circulation was maintained during the period of tentative constriction.

    At the second operation, the tube was divided at the lower end and the resulting defect in the leg was closed by suture. The tube was then opened and sutured in place about the ulcerated area, the skin edges of which had been freshly mobilized. Proper position was maintained with a plaster cast applied to both lower extremities (fig.104) . The patients seldom complained of this position. Three weeks later, the cast was removed, the proximal end of the tube was divided, and the free end of the graft was sutured in place.
    In 3 of the 5 cases in which this technique was used, healing occurred without complications of any kind. In the fourth case, about 10 percent of the distal end of the graft was lost, but the small ulcer which resulted healed promptly. In the remaining case, a small draining sinus persisted in the suture line and did not respond to compresses, curetting, or excision of the margins with secondary closure. Exploration revealed a small sequestrum from the


FIGURE 101.- Deep gangrene of feet in late stage of trenchfoot. Utilization of tube transfer grafts with bilateral sympathectomy after amputation. The functional result was excellent. A. Appearance of feet before operation. B. Appearance of feet after bilateral sympathectomy and amputation. Note exposure of first and third left metatarsals and first through fourth right metatarsals. C. Appearance of feet on dorsal aspect after transfer of full-thickness skin to both feet by means of tube grafts. D. Plantar view.
head of a metatarsal bone. Its removal was followed by prompt healing, but the patient's hospital stay had meantime been considerably prolonged.
    When gangrene was limited to a portion of a toe and revision of the stump was necessary because of osteomyelitis or because the skin was thin and adherent, the sacrifice of a small amount of tissue did not affect the result. When, however, the heads of the metatarsal bones formed the stump, they were usually preserved. Good function was sometimes obtained by simple revision (fig.105), but in such cases, as a rule, a more comfortable and more useful foot was obtained when the metatarsal heads were left in situ and were covered by a skin graft.

Prostheses.- The majority of patients with deep gangrene following trenchfoot had useful feet when they were discharged, though in some instances


FIGURE 102.- Deep gangrene of feet in late stage of trenchfoot. Utilization of tube transfer graft with bilateral sympathectomy after amputation. The functional result was excellent. A. Appearance of feet before operation. B. Appearance of feet shown in view A after amputation of toes, bilateral sympathectomy, and application of tube transfer graft. The fourth and fifth toes were originally preserved in this case but were subsequently amputated because of stiffness and discomfort.  

FIGURE 103.- Technique of tube transfer graft. Pedicle has been converted into tube by approximation of skin edges with interrupted sutures of fine cotton.


FIGURE 104.- A and B. Technique of plaster immobilization after tube transfer graft.

FIGURE 105.- Appearance of right foot after loss of toes. Healing occurred after sympathectomy, but the stump was covered with thin, adherent skin and was not satisfactory. Revision was accomplished by sacrificing most of the heads of the first and second metatarsals. Though this patient was left with a satisfactory stump, a better result would probably have been obtained if a tube transfer graft had been used instead of a reamputation operation.

prostheses were necessary. When all the toes had been amputated, a sponge-rubber or cotton pad was used in the toe of the shoe to prevent the foot from sliding forward. In an occasional case in which the second and third toes had been amputated and the great toe left in situ, a pad of chamois-covered sponge rubber, inserted between the toes and kept in position with the sock, helped to prevent hallux valgus. Some patients with relaxed feet, who experienced discomfort on walking, found resilient arch supports helpful. In general, there was little complaint on either standing or walking except for slight to moderate discomfort in the metatarsal area. This type of discomfort, however, was complained of just as frequently by patients who had not developed gangrene and had not undergone amputation. Relief was frequently obtained by the use of a metatarsal bar or of a second heel in front of the regular heel of the shoe (p.335).

    Although reconditioning of men with trenchfoot was a most important and essential phase of their treatment in the Zone of Interior hospital, almost nothing was available on the subject in the literature, and it was necessary to set up what amounted to a new program. During the period since exposure and injury, most of the patients received in the United States had been at complete bed rest and they were reluctant to get up (p.324) . Men hospitalized in England had had Buerger's exercises as part of their regular treatment, but, as a rule, reconditioning had been on a voluntary basis since their arrival in the Zone of Interior, and most of them had not participated. rjh1eir morale was poor. They had no concept of the nature of their injuries, and their fear of complete future invalidism was combined with disbelief in the efficacy of any treatment. Many of them were in poor physical condition and were convinced that they could do nothing active. The reconditioning program, as it was set

up at the vascular centers, Camp Carson and elsewhere, had to overcome psychologic as well as physical difficulties.
    The following reconditioning program, which was carried out at Mayo General Hospital, differs only in details from the programs carried out elsewhere.

Initial Phase
    Bedridden patients.- A special type of program was necessary for men who could not become ambulatory as soon as they were admitted to the Zone of Interior hospital, either because of gangrenous lesions or because the soles of the feet were too sensitive to permit weight bearing. The routine, which was conducted under the supervision of the ward officer and ward master, consisted of corrective exercises in bed in the morning, with games, tournaments, and various tests for physical fitness in the afternoon.
    Ambulatory patients.- As soon as the patients were able to walk around the ward without too much difficulty and discomfort and were able to go to the mess hall for their meals, they were transferred to special barracks, set aside for trenchfoot patients, and were placed on an ambulatory reconditioning program. Although they were still regarded as hospital patients, they were at once given all the pass privileges of soldiers in the command, with the objective of encouraging walking.
    The program was graduated. For the first 4 weeks, the exercises, although they were carried out in the gymnasium, were of such a character that only a small portion of the time was spent on the feet. Volleyball, shot-putting contests, and various exercises designed to strengthen the muscles of the upper portion of the body were performed sitting down. At the end of 4 weeks, a number of exercises performed on the feet were added to the program. Then mild weight-bearing exercises and games were substituted for some of the exercises and games which had been performed sitting down. The amount of exercise performed on the feet was gradually increased until the desired level of activity was reached. This took from 1 to 3 months, depending upon the rate of progress of the individual patient. At this time, the patients also engaged in occupational therapy requiring the use of the muscles of the feet and legs, to counteract the stiffness and atrophy which were the residua of trenchfoot.
    Water calisthenics formed an important part of the program for ambulatory patients. It was thought that the buoyancy of the water in the pool would enhance the recovery of a sense of balance and permit more vigorous use of the muscles of the feet, with less pain. At first, the men merely sat on the edge of the pool and kicked their feet in the water. It was often necessary to overcome their reluctance to do even this, for fear that wetting the feet would make their condition worse. As a matter of fact, a few men with more severe degrees of trenchfoot did respond badly to this part of the program. Some complaints were intensified. Sometimes hot, prickly sensations were experienced. In some instances, a dermatitis appeared, perhaps because of


the effect of the chlorine in the water on the sensitive skin. Patients who had any untoward effects from immersion of the feet were excused from this part of the reconditioning program, but all patients who could tolerate immersion were encouraged to carry it out.
    After a few days of merely kicking the feet in the water, various types of water calisthenics were undertaken. Then the patients walked in the water, first on the toes, and later on the feet. Finally, water games were engaged in. Weight-bearing exercises that could not be tolerated in the gymnasium often proved feasible in the pool, in which, by regulating the depth of the water, it was possible to regulate the weight borne by the feet.
    With the few exceptions noted, all patients, no matter how severe their condition, could engage in the scheduled exercises in water up to the shoulder. Patients with milder injuries could perform them in water up to the waist. The depth of the water was gradually reduced for each individual, so that more and more weight could be borne on the feet, which could thus be conditioned, without much discomfort, to normal weight bearing and body balance.
    For the first week after exercises in the pool were begun, there were frequent complaints of soreness and stiffness in the muscles of the legs and thighs, probably because of the unaccustomed movements. If the exercises were persisted in, these gradually disappeared. Some patients ceased to suffer from hyperhidrosis, though others found it increased. Most of the men felt that the water had a relaxing effect on the muscles of the feet and permitted greater freedom of movement. Both patients and staff, in fact, agreed that water calisthenics constituted perhaps the most effective part of the reconditioning program.
    All of the patients, as soon as their condition permitted, were assigned, as already mentioned, to different departments in the command, such as the motor pool, electrical shop, post office, and communications center, as well as to the educational reconditioning program. Their own preference, as far as possible, served as the basis for the assignment. Other men furnished work details for different parts of the hospital. Although all of these assignments required walking and standing, sometimes for considerable periods of time, the men were usually interested in what they were doing, as well as in their own progress, and there were few fresh complaints.
Second Phase
    Outdoor activities were begun at the end of 8 weeks of the reconditioning program, with hiking and bicycle riding occupying most of the time allotted for them. Group walking at a leisurely pace was continued all during the program, the short distances at first attempted being gradually increased to 1 or 2 miles. A definite goal was set for each hike, but it was made clear that men who were in distress from pain or cold could drop out at any time without penalty. At first, most of the walking was done on asphalt roads. Later, as tolerance increased, irregularly surfaced roads were no longer bypassed.

A marching cadence was required only at Retreat, which was conducted three times a week.
    At first, there were numerous complaints, particularly when walking was begun over uneven ground. Burning and aching were chiefly complained of, not when the men were walking but afterward when they were at rest. Later, as the skin of the sole hardened, all complaints became fewer. Since there were general complaints of the discomfort produced by socks wet with perspiration, dry cotton socks were always put on before the hike and were changed as soon as it was over. Care was taken to keep the feet as dry as possible outdoors, since exposure to cold in wet socks always resulted in an exacerbation of symptoms.
    If the outdoor reconditioning program had to be carried out in winter, when the environmental temperature was low and the ground was often covered with snow, four-buckle arctic galoshes were provided, for wear over the ordinary low quarter shoes. However, so many of the patients complained of burning, swelling, and excessive sweating when galoshes were worn that their use was eventually made entirely voluntary.
    After bicycle riding was begun, the level of the seat was gradually raised, so that more and more strain was placed on the small muscles of the foot. The distance ridden was also gradually increased. At the end of the period of reconditioning, most of the patients could ride 3 to 4 miles without difficulty, though some continued to have pain in the small muscles of the foot. Since this symptom did not materially improve with graded increases in the distance ridden, men who experienced it were excused from this type of exercise.
Immediate Results
    The first and most obvious therapeutic effect of the reconditioning program at Mayo General Hospital was a rapid change in the mental outlook of the patients. For the previous weeks or months, they had led lives of bedridden invalidism, and they saw little beyond it. Then they suddenly found themselves part of a program of gradually increasing physical activity. They began to do things which they had thought they could never do again, and they saw others doing them. Their self-confidence returned as their general physical condition and capacity improved. Furthermore, continuing participation in competitive sports had a wholesome effect on their outlook toward future duties and responsibilities.
    The reconditioning program, which was begun on 24 November 1944, for 35 enlisted men, eventually included 550 enlisted men and 17 officers. It developed by trial and error. When it was started, it was not clear how much physical activity could be undertaken without ill effects. The patients in the first groups, realizing that the program was still experimental and that their reactions would govern the content of the program in the future, entered into it with great enthusiasm and supplied much helpful comment on the various phases. Future programs were modified in the light of these first reactions.

    As time passed and disposition in larger and larger numbers became necessary, the mental outlook of the patients became very different, particularly as the war drew to a close. Many of them were no longer interested, and the spirit of cooperation which had played so vital a part in the success of the early courses began to disappear. Emphasis was now shifted to disposition and compensation for injuries, and complete restoration of the feet to normal became a secondary objective.

    When it was thought that a patient with trenchfoot had obtained the maximal possible benefit from the reconditioning program with respect to his general health and that his feet were sufficiently recovered to allow participation in a fairly normal program of daily activity, he was brought before the hospital disposition board. At the vascular centers, this board consisted of the chief or the assistant chief of the medical section, the chief of the medical vascular section, and the ward officer in closest contact with the patient during his period of hospitalization. The procedure consisted of the reading of a summary of the case history, the examination of the patient by members of the board, including a survey of his gait without shoes, and a discussion of the findings. All information obtained during a board proceeding was placed on a special sheet.
     The following considerations governed the disposition of patients: (1) The rate of progress in the hospital, (2) the duration of hospitalization, (3) the severity of persisting signs and symptoms, (4) the degree of hyperhidrosis, (5) the amount of atrophy in the small muscles of the feet, (6) the actual loss of tissue as a result of gangrene, (7) the tendency to blister formation and fissures, (8) the condition of the skin on the soles of the feet, (9) the type of persistent symptoms, such as neuritic pains, (10) the gait, (11) the distance that could be walked without difficulty, (12) other defects, and (13) the mental outlook.
Enlisted Men  

    Final disposition was made on 1,042 of the enlisted men with trenchfoot treated at the three vascular centers. They were (1) sent to duty, with a "3" or "4" (indicating disability of the lower extremities) in their profiles, or (2) sent to convalescent centers or other hospitals for additional treatment, or (3) given a Certificate of Disability Discharge. In about two-thirds of the cases, there was no difficulty at all in arriving at a decision. The patients clearly fell into one category or another. In the remaining third, there was a good deal of difficulty, and, in numerous instances, the decision was not unanimous. There seems little doubt that in many cases disposition might have been different if the matter had been brought up again or had been brought up before another board of medical officers.

    Of the 1,042 enlisted men on whom disposition was made at the vascular centers, 332 (31.9 percent) were returned to duty. All had shown fairly rapid progress. None of them had any other medical or surgical disability. All had normal gaits. All could stand on their toes. Most of them could walk without difficulty for at least a mile. Cyanosis was minimal, and none presented signs of excessive sweating, coldness, atrophy of the small muscles of the feet, or stiffness of the toes. Very few complained of neuritic pains, numbness of the toes, or tenderness of the soles of the feet on weight bearing and walking.
    Three hundred and ninety-four enlisted men (37.8 percent of the total number) were discharged from the hospital to civilian life. About a third of those discharged presented an associated condition which in itself might not have been disabling but which, when combined with moderate residua of trenchfoot, was sufficient to warrant discharge from the Army. These conditions included plantar warts, various orthopedic disabilities of the feet, partially disabling wounds of the lower extremities, and mild to moderate psycho-neurosis.
    Men given medical discharges because of trenchfoot residua usually presented findings indicative of excessive sympathetic activity, such as cold and cyanotic feet and hyperhidrosis, which was sometimes incapacitating and might require changes of socks two or three times daily. Increase of symptoms, particularly hyperhidrosis and swelling, was frequent during hot weather. Hypesthesia on the plantar surfaces of the toes and the adjacent portion of the foot was still present. Some men complained of a neuritic type of pain while they were at rest, as well as of numbness of one or more toes. Usually, the skin on the sole of the foot was delicate, perhaps because the patients, to avoid the pain caused by ambulation, walked very little. The gait was likely to be abnormal. They walked chiefly on the heel or the lateral edges of the foot or failed to push off properly with the toes.
    Most of the patients with a history of deep gangrene and subsequent loss of tissue were discharged to civilian life. Most of them had had severe attacks of trenchfoot, and at the time of discharge, in addition to having lost toes or portions of the feet, they had such sequelae as hyperhidrosis, extreme coldness and cyanosis of the feet, and neuritic symptoms and signs.
    As a general rule, the men returned to civilian life had little desire to remain in the Army. Attempts had been made, during the entire period of their hospitalization, to alter their point of view. Weekly group conferences, conducted by the psychiatrist, had given them opportunities to present their problems and discuss the reasons for their discontent, but these efforts had failed. They all felt that they had done their share of fighting. There was no actual proof, but there seems little doubt that the symptoms complained of by at least some of the men in this group were exaggerated. Some men frankly admitted that they were making the most of their complaints, but they justified themselves by saying that they felt that they could no longer be of use to the Army.


    The remaining 316 patients, 30.3 percent of the total number disposed of, were thought to need further reconditioning, and were sent to convalescent centers. Most of them had been transferred from hospitals in which reconditioning programs for trenchfoot had not been pursued vigorously. Their disposition on discharge from the convalescent centers is not known.
    Followup.- Eighty-six replies were received from a letter and questionnaire sent, 3 months after they had left the hospital, to the first one hundred and twenty-five enlisted men discharged to civilian life from the Mayo General Hospital Vascular Center. More than two-thirds had obtained work within a little over a month after discharge, and well over half of these held their original jobs. Six percent were enrolled in technical schools and colleges. About a quarter were not working; the questionnaire, unfortunately, failed to inquire specifically whether work had been sought and had not been secured.
    Most of the men who were working held jobs which required physical activity. Although they spent an average of 4 hours daily on their feet, most of them felt that they were able to do their work with as little difficulty as fellow workmen without a history of physical disability from cold injury.
    In spite of the generally good working record of these 86 men, two-thirds of them complained of burning sensations in the feet, tenderness of the soles, and hyperhidrosis. More than half said that their feet swelled. A few complained of blister formation and trichophy tosis. Less than half could walk a mile or more without difficulty. Twelve percent had noted moderate to marked improvement in the condition of their feet since they had returned to civilian life, but 41 percent reported no improvement at all.

    Disposition of officers with trenchfoot, as exemplified by the 17 observed at Mayo General Hospital, differed in a number of respects from the disposition of enlisted men. Only one of these officers was brought before a retirement board. He had had a severe attack of cold injury, and his feet were in bad condition when he was admitted. Although his progress was satisfactory, at the time of disposition he still had numerous residua, such as tenderness in the soles of the feet on walking, marked cyanosis, coldness, hyperhidrosis, and some swelling.
    The other 16 officers, all of whom had had moderately severe degrees of trenchfoot, showed rapid improvement after hospitalization in the United States. They took part in the reconditioning program with enthusiasm and showed the benefits of it very quickly. As compared with enlisted men with practically the same amount of exposure and practically the same objective findings, they had far fewer complaints. Their relatively higher morale undoubtedly accounted for their generally better response to treatment and reconditioning.

    All 16 officers were assigned to limited duty when they left Mayo General Hospital, with the understanding that they were to be reexamined in one of the vascular centers at the end of 6 months, to determine whether they could then be returned to full duty. At the end of 3 months, it was learned that several of them had already had to be rehospitalized because of aggravation of their symptoms.
    One officer could not do even office work because of burning and swelling of the feet. He had been assigned to a post in the South and attributed his difficulties to the high environmental temperature.
    Another officer had been able to work with only slight discomfort in California, but, 2 months after his transfer to a camp in Texas, where the environmental temperature was high, he began to suffer from aching sensations in the soles of the foot, followed by paresthesia in the toes. His work as an instructor, which necessitated his being on his feet a great deal, caused an increase of all his symptoms. When transferred to desk work, he continued to experience aching and pain in the arch of the foot, so severe as to require hospitalization at the station hospital to which he was assigned and eventual return to the Mayo General Hospital Vascular Center. At this time, he complained of a throbbing sensation in the soles of both feet after walking about three blocks. He walked on the edges of his feet, to reduce the amount of weight on the soles. This gait had not been present when he was originally a patient at the vascular center. Examination of the feet was entirely negative except for some cyanosis when they were dependent. This officer's story closely resembles the stories of at least four other officers who had to be rehospitalized at other institutions within 2 or 3 months after leaving Mayo General Hospital.
    In contrast to the preceding histories are the results in four officers with trenchfoot who were assigned to Mayo General Hospital and who could be closely watched. For the most part, these four performed their assigned duties with few complaints. They also indulged in sports, such as baseball and golf, without ill effects. There were almost no objective findings when their feet were examined periodically.
    The morale of the four officers assigned to the hospital was very high. They were doing work for which they were well suited and which was exactly what they wanted to do. The officers with recurrent symptoms, on the other hand, were all dissatisfied with their assignments and all felt that, because they were likely to be returned to the hospital within 6 months, no real effort had been made to assign them according to their ability. None of them was kept especially busy, and all had time to concentrate upon the state of their feet. Under the circumstances, they had excellent opportunities to exaggerate their complaints in their own minds.



    In the Zone of Interior, as well as overseas, the patient with residual complaints from cold injury, who had few objective signs or none at all, presented serious diagnostic problems. Burch and his associates,2 working under the Office of Scientific Research and Development, devised for this kind of patient what they called an activity index, predicated upon changes in the skin temperature before, during, and after occlusion of the vessels of the leg. In this test, the degree of inflammatory activity in a part injured by cold and moisture is determined by three observations: (1) The initial stabilization temperature of the affected part, (2) the fall in temperature after 15 minutes of occlusion, and (3) the rise in temperature during the hyperemic period after release of the occlusion.
    The investigation, which was carried out on 46 men who had suffered from trenchfoot, was carefully controlled, the controls including both normal subjects and psychoneurotic subjects without organic disease of any kind. All observations were made in a constant-temperature room, and all other environmental circumstances were also carefully controlled.
    Under the conditions of this study, Burch and his associates, while recognizing the necessity for further investigation and evaluation of this test, regarded the following observations as justified:
    1. If the temperature of a toe at the end of 15 minutes' stay in a constant-temperature room at 68? F. (20? C.) is above 84.2? F. (29? C.), the chances are almost 100 percent that the toe is not normal. If the temperature is above 80.6? F. (27 ? C.), the chances of abnormality are about 75 percent.
    2. If, at the end of the whole study (approximately an hour), the rate of refilling is less than 8.0 seconds, the chances are almost 100 percent that the part is not normal. At the end of 2 minutes', and of 15 minutes', stay in the observation room, the rate of refilling of the skin vessels which had been emptied by pressure was essentially the same for the control subjects and the subjects with previous cold injury.
    3. If the temperature of the big toe falls more than 9? F. (5 ? C.) during the period of occlusion and if there is a maximum rise of 9? F. (5? C) or more above the control value during the period of reactive hyperemia, the chances of abnormality are about 90 percent. If the fall is greater than 5.4? F. (3? C,) and the rise after the release of the circulation is greater than 5.4? F (3? C.), the chances of abnormality are about 75 percent. In fact, with a fall of 3.6? F. (2? C.) during occlusion and a rise on the same order during release, the chances of abnormality are more than 50 percent.
2 Burch, G. H.. Myers, H. L., Porter, R. R., and Schaffer, N.: Objective Studies of Some Physiologic Responses in Mild Chronic Trench Foot. Bull. Johns Hopkins Ilosp. 80: 1-70, January 1947.


    4. When all three of the phenomena just described are clearly abnormal, the chances that the part is diseased approach 100 percent, and the observations, naturally, are more conclusive than if only one of the reactions is suggestively abnormal. The availability of two separate objective phenomena and one quasi-objective phenomenon obviously makes for greater accuracy. The accuracy of the test can be further insured by making observations on both limbs simultaneously, one part serving as a control for the other.
    Burch and his associates, as already noted, recognized both the limits of this activity index and the need for further research on it. The index, nonetheless, is practical and should prove useful in the evaluation of the numerous late cases of cold injury which are characterized by subjective complaints and by a total, or almost total, absence of objective findings.3
3 The long-term story of trenchfoot, as has been intimated elsewhere, remains to be told. It may eventually be told by the Veterans' Administration. Redisch, in an article entitled "Chronic Trench Foot .- A Problem in the Care of World War II Veterans," which appeared in the Military Surgeon for December 1947, stated that the Veterans' Administration Regional Office in Newark, N. J., had seen 54 men with chronic trenchfoot in a single 12-day period in 1946. He expected that, by the end of 1947, from 50,000 to 100,000 veterans would have claimed disability from this type of injury. It is significant that sufferers from chronic cold injury were continuing to seek medical care from the Veterans' Administration late in 1946, almost 2 years after the last cold injuries had been sustained in combat.
    Information personally secured from the Veterans' Administration showed that, in 1948, 161 patients with cold injury (trenchfoot or immersion foot) were discharged from Veterans' Administration medical facilities; in 58 of these cases, cold injury was the principal diagnosis. Comparable information for 1949 showed 115 patients discharged, 50 of them with the principal diagnosis of cold injury. These figures give no indication of the number of patients with cold injury still under medical supervision, but they do emphasize the chronicity of this type of injury and the long-term medical cost.
    It is interesting and highly significant that, as late as 1949, some veterans who had sustained their cold injuries in World War I were still under the care of the Administration. Five such patients were discharged in 1946, and four more were observed in 1949.
    A followup study of men with previous cold injury has been under way as a research project in the Veterans' Adminstration since 1950. The information secured will make it possible to determine the permanent residua (or lack of residua) in men discharged to civilian life after their injuries.
    Another followup study of 100 cold injury patients, made 4 years after occurrence of the injury in Korea was published by Blair, Schatzi, and Orr in the Journal of the American Medical Association, 6 April 1957.