War Surgery and Medicine
CHAPTER 20 — Foot Disabilities
THE problems associated with the efficiency of the soldier's feet in the army are of the utmost importance.
During the First World War the infantry were essentially foot soldiers and had to march carrying their equipment whenever a change of location was made. In spite of this, there does not seem to have been an undue amount of disability produced by the feet. During the war there was a marked development of orthopaedic surgery as a specialty, and between the wars this specialisation continued. Attention was concentrated on orthopaedic conditions. The different abnormalities of the foot were studied and many operative procedures developed to rectify them. As was to be expected, the enthusiasm often led to over-elaboration of treatment for comparatively minor disabilities. There was also a tendency, especially amongst the less experienced surgeons, to overstress the anatomical as against the functional conditions of the foot.
In the code of instructions for medical boards in New Zealand at the beginning of the war it was directed that the grading of persons suffering from deformities of feet and toes should be determined by the degree of disablement occasioned and not by the nature of the deformity.
Conditions causing disability were noted as club foot, hammer toes, hallux valgus and rigidus, and flat feet. Severe cases of club foot were classed as totally unfit for service. Hammer toe was considered only to be a disability if painful corns or bursae were present, and the same applied to hallux valgus, though a man with severe hallux rigidus was considered to be only fit for base service in New Zealand. As regards flat feet, rigidity was held to be of special importance.
In 1942 the Regional Deputies were asked their opinions regarding the desirability of making changes in the code of instructions. There had been criticism from the army of the physical standard of many of the recruits graded I who had subsequently had to be down-graded or discharged either in New Zealand or overseas. Auckland was the only centre in which an orthopaedic board was available, and elsewhere the difficulty in getting an orthopaedic page 392 opinion without delay meant that the borderline case was generally rejected. As a result of the opinions received, the National Medical Committee altered the code of instructions.
It pointed out that it was important to investigate any degree of disablement experienced by the man in civilian life and his type of occupation. Consideration had to be given to the possibility of aggravation of the disability by the conditions of military service.
Callosities on the soles of the feet, if not curable, rendered a man unfit for overseas service, as did club foot in the majority of cases. Cases of flat feet were to be graded according to the degree of disablement or anatomical deformity. Cases of hallux rigidus were to be graded as unfit for overseas service. Men with hallux valgus could, in the absence of symptoms, be graded I. No operation was to be recommended for this condition, and no case previously operated on was to be graded I. Hammer toes, on the other hand, could be operated on to improve the grading. No case of pes cavus was to be made Grade I, and severe cases were not to be accepted except for base duties in New Zealand.
This advice was sound in that the grading was to be determined by the degree of disablement occasioned and not by the nature of the deformity. Stress was laid, however, on the anatomy of the foot, and any abnormality of anatomy was held suspect. The boarding was carried out all over New Zealand by very many practitioners, many without army experience, and most without any special orthopaedic or other experience of foot conditions. The functional standard of the feet was difficult to evaluate in a short examination. Without a functional test, it was natural that the anatomical aspect of the problem would be particularly considered.
When the test of training took place many soldiers were found to suffer from undue strain and fatigue, and this generally was first shown with regard to the feet. The problem was particularly well studied at Papakura Camp, where a remedial training group was formed and graduated training carried out. This proved successful, and as a result a special remedial training camp was set up at Rotorua at the end of 1940 and functioned for three years with varying success. Foot cases formed the largest single group referred for treatment. Special foot exercises were arranged and physical therapy training given by highly trained instructors. The great importance of the psychological aspect was realised, and it was found that the antagonistic type gained little benefit.
A lot of valuable work was done by chiropodists, the feet generally being in a very bad state when the men first came into camp. A routine inspection of all feet at the beginning of the camp revealed about an 80% incidence of ringworm of the toes and a large percentage of corns and callosities.
The shape of the Maori foot caused difficulty in the wearing of boots. It was noticed that most Maoris have flat feet and are very wide across the heads of the metatarsals with a definite tendency to bunion formation of the big toe as well as a similar condition of the little toe, with the result that corns readily formed at these sites.
In my opinion with this Maori Battalion anyway it would be worth spending much more time over the issue of boots by allowing the men to try on their boots first, and getting a pair which was comfortable at the start. They were, of course, allowed to change them, but many men seemed to think they could make their feet fit the boots just as easily as make the boots fit the feet.
Dr D. Macdonald Wilson, who was a Regional Deputy and later medical officer in charge of treatment at the Pensions Department, and who had had active war service, made the following observations based on his experience of seeing men at recruitment and, later, the same men after being referred for boarding at Trentham Camp:
The enthusiast in the Drill Hall with some degree of flat feet had perhaps after a month in camp lost his enthusiasm and tended to trade on his flat feet. This was the psychological element.
Men with definite flat feet who had been shepherds around the hills without trouble were often disabled in camp. The heavy boots and marching with kit on a route march seemed too much for them. More attention to footwear and more gentle approach to ‘foot-slogging’ on a hard road would have enabled them to stand up to it. With gradual training and remedial training in the ordinary camp, and not in the equivalent of a special ‘hospital’ for foot trouble as the Rotorua Training Camp, such men might have made good.
Experience showed that attempts to improve feet by operation were useless to make men Grade I and, with hospitals full and waiting lists of other cases, we did not want these men to undergo surgery at the Army's expense and time if they were only to be discharged later. (Also there had been some unfortunate happenings.)
Therefore we forbade operations for hallux valgus and bunion, feeling the majority would not stand up to training. Minor operations for hammer toes and corns, if the recruit wished it, he could arrange himself and return for re-examination. As ‘remedial treatment’ had ceased, it was no use taking the man into camp on the understanding he would voluntarily have an operation, as likely as not he would later decline it.
Probably if some of these cases of minor foot disabilities had proceeded overseas their psychology would have changed. Nearer the seat of hostilities, amongst other men with similar disabilities who did not allow them to become disablements and where Army authority was more easily page 394 maintained, I think many of them would have carried on. But if they had not, would the Army overseas have complained of poor boarding in New Zealand?
Men graded to a lower category for foot conditions were utilised in the camps in New Zealand and in the Territorials and Home Guard. In the latter, ability to march for five miles was the standard laid down.
The Foot Problem in 2 NZEF
Although movement of troops was generally carried out by motor transport there were occasions where marching was necessary. The GOC 2 NZEF considered that training for long marching was essential, and this was part of the routine of army training overseas. Two long marches were especially noted, the one in England by troops of the Second Echelon and the other in Egypt prior to the embarkation of the Division for Italy. As a result of these marches many men suffered from foot strain which had prolonged aftereffects, necessitating down-grading in several instances. This drew the attention of the Medical Corps to the necessity of graduated training, and the necessity for RMOs to ensure that any men subjected to the strain of long marches were physically fit beforehand and to provide for transport of those falling out during the march. The campaign in Crete made a lasting impression on senior combatant officers with regard to the necessity for only having grade A men in the Division. The long march across the island proved too strenuous for some of the men, especially those more accustomed to mechanical transport. The employment of graded men on the understanding that normally they would not have to march long distances was discountenanced, though conditions similar to those in Crete never arose again during the war. This led to an unnecessary restriction in manpower available for the Division, and would, in the future, quite negative any value of the Pulheems system of evaluation as far as the locomotor system was concerned.
Different Types of Feet
Flat Foot with Free Mobility: This was associated with undue pronation and with some eversion at the ankles, and there was a tendency to a weakening of the transverse arch with widening at the metatarsal heads and a condition of hallux valgus. It was essentially a position of rest or inactivity. With strong musculature the position of activity could be readily attained and the foot function normally. With weak muscles and liability to fatigue, the foot could be the focus of discomfort.
Flat Foot with Rigidity due to the arthritic changes in the tarsal joints and general lack of flexibility in the foot. The position page 395 occupied was similar to the above, but the position of activity could not be resumed. If the condition had become stabilised and painless, satisfactory functional activity was possible. If not stabilised there might be definite disability.
Dropped Anterior Arch: This was really only a part of the relaxation of the foot, but often reconstitution of the arch was impossible and callosities formed under the tread and the foot would not stand the normal strain. Remedial exercises to strengthen the musculature were of special value.
Pes Cavus: The high-arched rigid foot with hammer-shaped toes and some restriction in ankle movement denoted a foot which could not stand undue strain, and in the severer forms was not accepted in the army for any branch necessitating marching. No treatment was of any use in the army.
Hammer Toes: These were often a part of pes cavus but, in minor forms, were of little importance, except for the discomfort from corns which formed on the prominent joints. A simple operative procedure brought about relief in the mild cases.
Hallux Valgus: In the milder forms this was of no importance except as an indication of a weaker foot. When there was a pronounced exostosis of the head of the first metatarsal with a bunion over it treatment to remove both bunion and exostosis was useful. In the severer forms where this simple operation was unavailing no treatment was of use and the men were down-graded. (Lieutenant-Colonel J. K. Elliott reported in 1949 that the removal of the exostoses had in many cases resulted in increased lateral deviation due to the weakening of the capsular ligament.)
Hallux Rigidus: This was a genuine disability because of the inability to spring off the big toe. Treatment was of no use in the army and grading down was necessary.
Overlapping Little Toes: This was a congenital deformity often giving rise to symptoms. The removal of the toe was done if there was real disability. A plastic operation with dorsal division of the capsule of the metatarso-phalangeal joint was preferable to amputation and protected the fourth toe.
Exostosis of the fifth metatarsal, generally associated with a broad foot with spreading transverse arch. If a wide-fitting boot was available, no treatment was necessary. The exostosis was removed, with relief in some cases.
Ingrowing Toenails: This was a very frequent condition, being associated with infection, especially in feet prone to sweating. Simple attention cleared up the milder infection, but in the severer forms the removal of the side of the nail with the nail bed was required. A form of operation popular amongst some orthopaedic page 396 surgeons of removal of the terminal part of the last phalanx of the big toe with all the nail bed was unnecessarily drastic, and constituted a permanent pensionable disability in many cases. (Like other radical measures it is not suitable for army conditions, though indications for its use may arise in civil surgery in cases of engrained and long-standing infection.)
A similar outlook on operative procedures in the army was shown by an Australian Army Instruction.
Operative Treatment Carried Out in 2 NZEF
From the outset, operations were not encouraged unless they were simple in nature and likely to bring about a rapid and definite improvement in the condition, thus rendering the man of more value in the army. It was felt that any major procedure would entail a long convalescence, and almost certain down-grading, so in cases demanding such measures, down-grading without operation was the more practical procedure.
Hammer Toes: Simple arthrodesis of the prominent knuckle was the type of operation performed.
Hallux Valgus: The removal of a prominent exostosis with the overlying bunion was all that was done in the large majority of the cases. The more radical procedures were discouraged.
Hallux Rigidus: Again, operation was discouraged and down-grading adopted as necessary, the majority of the cases carrying out base duties satisfactorily.
Overlapping Toes: These were removed at the metatarso-phalangeal joint as required.
Ingrowing Toenail, as already stated, simple removal of the affected part of the nail and nail bed.
A review of cases either operated on or regraded in the 2 NZEF was made in December 1941. There had been very few cases dealt with, and it was evident that hallux valgus was not a common disability in the army. Radical operations had proved unnecessary and unsatisfactory. The lesser operations of removal of the exostosis had proved at least temporarily successful.
Remedial Treatment in 2 NZEF
A considerable number of men were down-graded in the 2 NZEF for foot disabilities, most of them for flat feet. The disability was present generally in debilitated individuals prone to fatigue, and was often just part of a general lack of vitality and also part of a psychoneurosis. The man robust physically and mentally could carry on with a very flat foot without complaint, but the weakling not only felt the results of fatigue more often but used the mild page 397 disability as a refuge. Efforts were made by special remedial training units to make the men Grade I, but because of the psychological condition of so many it was difficult to improve their condition.
A report written by the DMS 2 NZEF in August 1941 gives a clear idea of the difficulties experienced at that time:
The problem of men who become unfit through flat feet and other foot disabilities is becoming an acute one. A number of men are sent to the bone and joint specialists at the general hospitals and are ordered foot exercises, graduated training, and various matters of attention to boots and socks. In very few cases are the results successful.
It is felt, therefore, that some arrangement must be made to get these men together under supervision so that all these necessary measures may be carried out and decision made as to whether men are fit to resume training for the field, or must be re-graded. The most suitable arrangement would seem to be to form a special group at the Base Reception Depot under the control of a junior officer or senior NCO.
A good surgical bootmaker is desirable, though a certain amount of alterations to boots is carried out by the splint-maker attached to 2 NZ General Hospital. A chiropodist attached at present to 1 Camp Hospital could be transferred and a medical officer could be detailed to check all cases twice a week.
This statement was supported by a report by the Consultant Surgeon 2 NZEF on the problem:
In cases appearing before medical boards for reclassification during the last few months, there has been an increased incidence of cases designated as flat feet, metatarsalgia, or other afflictions of the anterior arch, and a small number of cases of pes cavus. The following observations are made after carefully eliciting the history and symptoms of the cases, and after examination of them, by both general and orthopaedic surgeons:
In only a very small proportion of the cases has there been any real anatomical abnormality that can be readily ascertained on physical examination. In almost all the cases the symptoms complained of are not those pathognomonic of flat feet or metatarsalgia.
Treatment by raising the inner aspect of the sole and heel of the boot has not only been of no benefit in most cases but has aggravated the condition, the men being more comfortable in tennis shoes. In a definite proportion the boots have been found to be illfitting and they are always stiff and rigid. In many cases the first onset of the symptoms has followed very prolonged route marches. It is an almost constant statement that no route marching had been done in New Zealand and often little or none done in Egypt previously.
As a result of these observations it is clear that the symptoms complained of are not those due to flat feet but rather to muscular fatigue, especially and naturally shown as foot fatigue in men undergoing training by route marches or constantly on their feet. This is shown by the symptoms being aggravated rather than relieved by wedging of the boot, and by the relative comfort of sand shoes. These symptoms naturally arise in those soldiers who are unable temperamentally to put up with discomfort of any kind—the feebler type of soldier.
The problem is naturally difficult to solve, but, if looked upon as one of fatigue and lack of energy generally, perhaps something can be done page 398 to solve it by arranging a special platoon at the Base for men suffering from foot fatigue and other somewhat similar conditions, such as convalescence from knee and leg injuries. This platoon could be given special graduated training by physical instructors capable of dealing with the position sympathetically yet firmly. Special attention could be paid in the platoon to the fitting of boots, the wearing of satisfactory and clean socks as well as to any alterations in the boots advised by the medical officer. Chiropody could be made available from the camp hospital. An orthopaedic surgeon could carry out regular visits to the platoon to advise on problems connected with the training, and also to examine any special cases.
Finally I consider that observation of these cases shows that massage and physiotherapy is not only useless and a waste of time, but actually aggravates the condition by fixing the disability in the mind of the patient and giving him a sense of invalidism.
Special clinics were set up in Maadi Camp for a short time, but were not successful as was at first hoped.
For the remainder of the war there was no special incidence of foot trouble in the 2 NZEF and no fresh problems encountered. In Italy there were no long marches and no abnormal conditions such as heat and sand likely to aggravate foot disabilities. It was noticeable that there were no fatigue fractures seen. The foot disability had been evaluated in its relation to the army, and all that was necessary was a regular grading of personnel who were unable to stand the stress of front-line service.
The General Problem of the Function of the Foot
It is very difficult to get a proper perspective to evaluate the foot as to its functions in locomotion. It is unfortunate that the physiological outlook has for so long been neglected and that the anatomical shape of the foot has come, in the minds of perhaps the majority of medical men, to be considered of supreme importance. This has led to a classification of foot disabilities under anatomical groups and a false idea of a normal foot has evolved. The position of the foot, in what we may call the mid-position between rest and activity, is treated as the ideal foot, and a relatively high longitudinal arch is considered ideal. If the arch is still more prominent, as it is in pes cavus, the appearance of the foot seems preferable to the pronated flat-looking foot, which is the normal position of rest. If the foot is very mobile, then during rest it will appear very flat, and under the anatomical classification will be a flat foot and disability will be expected. The foot is looked upon as a mechanical means of support and the bones and ligaments are looked upon as the structures that take the strain, and it is natural to expect them to function better if the shape of the foot appears to be mechanically better able to sustain the body weight. This outlook has vitiated the whole management of foot conditions.page 399
It would be of great value if, for a while, the anatomy of the foot were forgotten and the medical student had instead to study the foot in action in athletics, in walking, in standing, and at rest. Perhaps the foot of the ballet dancer is as efficient as any other, yet at rest it is very flat and pronated. The bare foot of the native races also appears to be a flattish foot. If one is observant one will have noticed many of our fellows with just such flat feet who are able to do the most strenuous work. Even rigid flat feet are no bar to strenuous and prolonged work. What it is essential to realise is that the foot is normally a very mobile and pliable structure with constant changes in position. There is a position of activity with the foot adducted, the longitudinal arch raised, the foot extended, the toes flexed, and the muscles of the leg and foot acting strongly. Then there is the position of rest with no muscular action the foot pronated or abducted, and the longitudinal arch flattened. Then there is the mid-position adopted during standing, when the muscles are acting less strongly and the bony ligamentous structures have to take part of the strain.
On muscular activity depends the functional efficiency of the foot. Pliability of the foot is essential to full function, and the real disabilities of the foot are associated with rigidity of the foot structures, especially when this is associated with any inflammatory condition. This is seen in the partially rigid foot due to inflammatory adhesions, which is often relieved by manipulation. The foot with bony rigidity, though awkward, generally gives rise to little trouble. Pes cavus in a marked degree is often a serious disability as regards marching.
When there is marked muscular weakness, often associated with general debility, and so often seen in adolescents, there will be undue strain put on the ligaments of the foot during activity, including standing, and this strain tends to exaggerate and sometimes fix the position of rest and later to bring about some generally slight anatomical changes such as hallux valgus. The causative factor has been the muscular weakness; the anatomical changes are secondary. On the other hand, with strongly developed muscles even a foot weak structurally will be able to act efficiently, always remembering that a freely mobile foot is not a weak foot.
A valuable demonstration of the essential difference between anatomical structure and physiological efficiency was given by an investigation carried out in the British Army to ascertain what number of men in a typical infantry brigade had anatomical deformities of the feet which were symptomless. A thorough examination of the feet of all the men was carried out and the following abnormalities observed: (i) abducted feet, (ii) pes cavus, (iii) deformity of the toes. Rigorous tests were then carried page 400 out, including 3-mile runs and 14- and 21-mile route marches. Some 24 per cent of the men had foot deformities, but the feet were supple and they were not foot conscious. There was relatively no more disability recorded in the men with deformities. These conclusions were reached: firstly, in an infantry brigade there were men with anatomical deformities of the feet who were performing normal duties; therefore anatomical deformity of the foot alone was not a sufficient indication for down-grading. Secondly, approximately the same proportion of men with normal and abnormal feet reported sick with foot complaints. This investigation suggested that the deformed foot was no more liable to give rise to disablement than the normal foot.
This was valuable support to the idea that anatomical abnormalities, when unassociated with rigidity, are of no importance as regards the efficiency of the soldier.
The two factors of prime importance in the fitness of the soldier are graduated training and psychological normality.
Graduated Training and Physical Fitness
During the war constant reference was made to the importance of adequate, and especially graduated, training of the soldier in marching. Complaints were made from the 2 NZEF that men were sent overseas without adequate military training and especially without having done any marching. In New Zealand a special remedial training camp was established at Rotorua, where graduated physical training was given to men with weak feet to render them fit for service. The type of man chosen was mainly the underdeveloped and undernourished man who had led a sedentary life and had not taken part in any physical sport. The medical authorities were alive to the importance of the physiological aspect of the problem.
In the 2 NZEF it was quickly realised that foot disability was largely a question of fatigue, and that graduated training would enable many men with abnormal feet to become fully efficient. Radical surgical procedures were discountenanced. Special remedial training groups were formed at the base camp where graduated training was carried out. The treatment by physiotherapy in the hospital was discouraged as likely to make the soldier foot-conscious.
The psychoneurotics undoubtedly formed the majority of those who complained of foot disability. This may have been due in some measure to the possibly lower physical standard of this type. The main reason, however, was that the foot was used as the means page 401 of escape, and the normal symptoms of fatigue were exaggerated into a disability which the individual gave in to. If there was some anatomical abnormality, then it was easier for the man to plead disability and more difficult for the medical officer to deny it.
It was realised very early in the war that the large majority of the men complaining of foot disability were the psychoneurotics and the poorer types in the force, and that as often as not there was no demonstrable abnormality in the feet. The flat foot was not an anatomical defect but could produce an abnormal personality. The undue stress laid on the anatomical factor naturally made the management of these cases at times very difficult. Colonel Spencer, OC 2 NZ General Hospital, stressed this aspect very strongly in a valuable report he submitted on the psychological aspect of hospital treatment early in the war.
Brigadier Ogilvie, Consultant Surgeon MEF, stressed the importance of sizing the man up as a whole, and of referring men without demonstrable signs of disability to the psychiatrist for his opinion. He emphasized that flat foot was merely an abnormality of posture and that in the absence of stiffness was not a sign of disability.
The Military Boot and Other Footwear
It has to be realised that for the large majority of recruits entering camp there is a violent change in footwear and in the work that the foot has to accomplish. The average civilian wears light shoes and light socks, and does little in the way of walking, and certainly not with heavy loads. It is not to be wondered at that he has difficulty in accommodating himself to the heavy rigid boots, the thick socks, the marching in formation with packs. The soldier's feet have to be broken in, and common sense should lead one to do this gradually.
In the provision of boots there is need for great care. The size of the boot required may be, and often is, different from the size of the light civilian shoe usually worn. There must be provision for a thick sock and maybe two pairs of socks, and provision also for some swelling of the feet after long marches.
In the British Army, officers are required to see that boots are fitted in accordance with instructions. Experience has shown that very few soldiers know how to select suitable boots. It must be remembered that the foot spreads out a quarter to a third of an inch in length and one-fifth to one-half of an inch in breadth under the weight of a full marching load. Boots should be fitted indoors in a long room in which men can walk up and down. They should be put on over regulation army socks. If there is any doubt, the larger size should be taken. The soldier should select the boot page 402 which gives him greatest comfort. This is a different method from that often seen, where a pair of boots of the size named by the soldier is simply given to him at the same time as he receives other articles of his kit, without any provision for trying the boots on.
There was at times criticism of the army boots and shoes issued to the New Zealand soldier, but in general they were satisfactory if they fitted. Difficulties, however, did arise:
There was an insufficient supply of broader boots. This was of considerable importance as the Maori foot is wider than the normal European foot, as his general physique is sturdier. This width is seen whether the foot is short or long. (This peculiarity of the Maori foot was recognised by Dr Thomson, surgeon to the 58th Regiment during the Maori Wars.) There is no special provision made for the Maori soldier in this respect, though frequent complaints were made and recommendations also made by medical officers associated with the Maori Battalion, and by the consultant surgeon. As a consequence of wearing the narrow boots, bunions and callosities developed both over the prominent heads of the first metatarsal and also over the fifth metatarsal. Removal of the prominent bone was often resorted to in consequence, and it seemed as if we were trimming the Maori's feet to fit the boots rather than providing boots to fit the feet. The strong recommendation is made that special lasts be provided to enable adequate provision of broader boots for Maoris and the relatively few Europeans with the same shape of foot.
When boots were repaired provision was not always made for the soldier to get back his own boots, and he was issued with some other soldier's second-hand boots. This was at one time the established custom in the MEF, and the records show that the same thing happened in New Zealand. Strong comments naturally were made by medical officers, with sometimes little effect on administration officers. It cannot be too strongly urged that the practice should be condemned and that fuller provision should be made for the repair of boots, so that every soldier can without difficulty get his own boots repaired.
Complaint was made that the wearing of rubber shoes on transports was detrimental to the feet and caused disability in subsequent training. Leather-soled sandals were recommended and were supplied later in the war.
The provision of special boots for soldiers with abnormalities of the feet was arranged for both in New Zealand and overseas. In New Zealand the main hospitals agreed to supply special boots page 403 and to adjust the boots as required. In several of the hospitals well-equipped departments with skilled personnel were available. Overseas, light boots were supplied by the army when required, and special boots were also made for selected cases on the order of the consultant surgeon. Adjustment to boots was carried out both at the hospitals and in the camps. A special department was developed at Helwan Hospital.
The ordinary adjustments to the boots such as the raising of the inside of the heel and its prolongation forward, and the raising of the inner part of the sole, were useless in the desert, where the boot sank into the sand. The adjustments simply increased the weight and clumsiness of the boot and aggravated the fatigue which generally underlay the real disability.
The need for constant attention to boots was stressed in the army, and many memoranda were issued to this effect. It was recommended that the boots be kept in good repair to prevent the feet getting wet, and that if the boots did get wet they should be dried slowly and then well oiled. The boots should also be softened regularly with vaseline, neatsfoot oil, or dubbin.
Socks: Soldiers were issued with four pairs of socks, and in addition most of them had some hand-knitted pairs. The need for cleanliness, with constant washing of the socks and care to prevent shrinking, was ever present. Thick socks capable of absorbing perspiration were provided.
Foot Cleanliness: Of all matters concerned with the feet this was the most important. The provision of facilities for washing the feet, especially after long marches, was essential. The provision of showers was important to any army. The use of foot powder after thorough drying of the skin was of great value. A useful foot powder was salicylic acid, 3 parts; boric acid, 10 parts; talc, 87 parts.
The Care of the Feet after Illness: The natural sequel to any debilitating disease or to any prolonged rest was an absence of fitness for physical exercise or strain. This was specially noted in regard to the lower limbs, and, in consequence, foot strain was frequently complained of when convalescents resumed their military training.
The necessity for graduated training with physical exercise for the lower limbs became obvious, and the British type of convalescent depot was mainly occupied with this training. The British physical training instructors were invaluable in the training of convalescents, and one of their depots well forward on the North-West European front was one of the most efficient medical units observed during the war.
Skin Diseases of the Feet
These were relatively common in the 2 NZEF and led to much of the real foot disability. The commonest disturbances were, in order of frequency: (1) hyperidrosis, (2) eczema, (3) pyogenic infection, (4) tinea. The prevention of the spread of tinea exercised the minds of medical officers in every theatre of war. The Americans had shallow troughs at the entrance to their shower or bath rooms filled with antiseptic solution. Provision was made for the frequent washing of the floors with antiseptics. The boots and socks of infected men were treated with formalin vapour in a closed container or otherwise sterilised. The infection was difficult to eradicate either in the individual or the group.
The problem of foot disability in the army is quite distinct from that in civil life. It has been found that, provided the foot is mobile, minor deformities of any kind are of no significance in function. The grosser deformities and the rigid feet are generally not suitable for full military service, except that fixed bony deformity does not seem to give rise to any marked disability. There are three danger points: on enlistment, at physical training, and on long route marches.
There is profound alteration of the foot habit of the individual when he enters camp. From a sedentary worker wearing light shoes and thin socks, he is transformed into a soldier with heavy boots, thick socks, and then subjected to strenuous physical exercises and long route marches. An ill-fitting boot can play havoc with his feet, and his muscles will need gradual training to enable him to carry out his military duties without foot strain.
The recruit may then come under the control of an over-zealous and exacting physical training instructor who may not realise that the feeble leg musculature cannot at once do all that is asked of it, and as a consequence acute foot strain may develop.
Finally, long route marches may overtax the relatively untrained man, who may feel in honour bound to keep up with his fellows and so subject his feet to severe strain from which he may take a long time to recover.
The provision of well-fitting boots is essential and must be given every attention by combatant officers. The repair of boots, and return to the man of his own boots, is also of great importance. The care of both boots and socks and cleanliness of the feet will guard against most troubles.
Difficulty arose because of the mistaken idea of foot physiology, page 405 and the overstress laid on anatomical variations, which were often mere temporary postural attitudes.
With regard to the treatment of foot deformities, it has been amply proved that no major surgical procedures are advisable under army conditions, and only minor procedures to alleviate a few of the lesser marked deformities are of any real value.
Skin diseases demand attention, and of all diseases hyperidrosis is the most common and most disabling. Eczema, pyogenic infections, especially with reference to ingrowing toenails, and tinea are also of importance. Tinea necessitated constant vigilance in preventing the spread of the infection at bath houses, but did not cause much disability.
The association of psychoneurosis with the disabilities of the foot was the most important, and the most difficult, aspect of the whole problem. It was found that the feebler type of soldier complained, often with perfectly shaped feet, whereas the keen, alert men would carry on under the most rigorous conditions with badly deformed feet.
The realisation that the foot is a highly mobile structure depending for its strength on muscular action is necessary to appreciate its function.
These disabilities were commonly associated with other conditions affecting the general health of the soldier, especially if he was in the older age group.
The total number of cases diagnosed as flat feet reviewed by the War Pensions Department up to March 1952 was 1009 with overseas service and 444 with service only in New Zealand, but the number of those actually receiving pensions was not available.