MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II
Trenchfoot, ground type.
MEDICAL DEPARTMENT, UNITED STATES ARMY

COLD INJURY, GROUND TYPE

Prepared under the direction of

Major General S. B. Hays

The Surgeon General United States Army

Editor in Chief Colonel John Boyd Coates, Jk., MC

Associate Editor

Elizabeth M. McFetridge, M. A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON D. C., 1958
COLD INJURY, GROUND TYPE, IN WORLD WAR 11

The Historical Unit, United States Army Medical Service

Colonel John Boyd Coates, Jr., MC, Director

Colonel O. F. Goriup, MSC, Executive Officer Lieutenant Colonel C. A. Pendlyshok, Chief, Special Projects Branch

Donald O. Wagner, Ph. D., Chief, Historians Branch

Willa B. Dial, Chief, Editorial Branch

Wilbour C. Lown, Chief, Promotion Branch

Josephine R. Kyle, Chief, Research and Archives Branch

Hazel G. Hine, Chief, Administrative Branch

U. S. GOVERNMENT PRINTING OFFICE; 1958

For sale by the Superintendent of Documents, U. S. Government Printing Office

Washington 25, D. C. Price $6.25 (Buckram)
COLD INJURY, GROUND TYPE

by

Colonel Tom F. Whayne, MC, USA {Ret.)

Professor of Preventive Medicine, School of Medicine,

University oj Pennsylvania, Philadelphia, Pa.

and

Michael E. DeBakey, M. D.

Professor of Surgery and Chairman of the Department,

Baylor University College of Medicine, Houston, Tex.

Formerly Colonel, MC, AUS
MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department

of the United States Army in World War II are prepared by The Historical

Unit, United States Army Medical Service, and published under the direction

of The Surgeon General, United States Army. These volumes are divided into

two series: (1) The administrative or operational series; and (2) the professional, or clinical and technical, series. This is one of the volumes published in

the latter series.

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

Hospitalization and Evacuation, Zone of Interior

CLINICAL SERIES

Preventive Medicine in World War 11

Environmental Hygiene

Personal Health Measures and Immunization

Surgery in World War II:

General Surgery, vol. II

Hand Surgery

Ophthalmology and Otolaryngology

Orthopedic Surgery in the European Theater of Operations

Orthopedic Surgery in the Mediterranean Theater of Operations

The Physiologic Effects of Wounds

Vascular Surgery

Miscellaneous:

United States Army Dental Service in World War II
Foreword

It is lamentable but nonetheless incontrovertible fact that most of the

serious losses which occurred from cold injury among United States Army

troops in World WarII should not have occurred. It would be less than candid

not to acknowledge this painful truth.

These losses occurred, as is repeatedly pointed out in this volume on cold

injury, because the lessons of the past were not learned. The British experience in World War was not recollected by the United States Army in World

ar II. The experience of the Aleutians, where the losses from cold injury

were numerically small but proportionately large, was not transferred to the

Mediterranean theater, in which the losses were both numerically and proportionately significant. The lessons of the Mediterranean theater were not

transferred to the European theater, in which the preliminary figure of approximately 46,000 cases reported as cause of admission in the fall and winter of

1944-45 accounted for about percent of all admissions to medical treatment.

The more complete figures now available, which include cases of cold injuries

associated with wounds and other conditions, bring the total number of cold

injuries for the European theater to approximately 71,000, most of which

occurred in the 1944-45 winter. The total number of cold injury cases in all

theaters for the entire war period was 91,000.

The bitter experiences of the Aleutians campaign and the Mediterranean

and European theaters were finally appreciated, and there seems little doubt,

had invasion of Japan been necessary, that casualties from cold injury would

have been reduced to the irreducible minimum because the planning had been

so careful and so farsighted. In both the Mediterranean and the European

theaters, it is true, efficient plans of prevention and control of cold trauma

were eventually set up. They produced excellent results in the Mediterranean

theater in the second winter of fighting, but they were set up in the European theater almost too late to prove their efficiency. The individual ingenuity

of theAmerican soldier was factor in preventing worse disaster than actually

occurred.

There are no absolute excuses for the epidemics of cold injury which

occurred on the Continent of Europe during World War II. There are,

however, number of explanations for them. The first, as just pointed out,

was failure to learn the lessons of the past. For that matter, the European

theater failed to profit from its own early experience. It was not realized that

the high-altitude cold injuries which had originally beset the Eighth Air Force

in Europe in 1942 and 1943 were of the same general etiology as the ground

type of cold injury which was to occur later and that they were susceptible

to the same general principles of prevention and control.
VIII FOREWORD

Cold, wet, or cold and wet in combination are, of course, the basic causes

of cold injury, but this statement does not tell the whole story. Predisposing

factors are also of great importance. In World II, these factors included

(1) the intensity of combat; (2) the inadequacy of clothing and footgear; (3)

the pressure of events which required that new troops be taught so much in

such limited period of time that they were not taught the essential facts

of cold injury; and (4), as General Bradley himself has acknowledged, the taking

of calculated risk, for which price had to be paid, when, in the summer and

early fall of 1944, it was decided that gasoline and ammunition should take

precedence in transportation over supplies of winter clothing.

No single person and no single branch of service can be blamed for what

happened. The prevention of cold injury is primarily function of command

from the highest to the lowest echelon. It requires the assumption of responsibility by all personnel, including the Medical Corps, which, though

its role is purely advisory, must nonetheless assume the responsibility for

making its advice forceful as well as correct.

Cold injury is condition for which no satisfactory treatment existed in

World War or World War II and for which no fully satisfactory method of

treatment has yet been found. Its prevention is therefore doubly imperative.

Although, in the circumstances of warfare, the necessities of combat take

precedence of every other consideration, it is still perfectly possible to prevent

most cases.

The historical chapters of this volume set forth the important details

of what happened concerning cold injury in all recorded wars of history as well

as in World War and World War II. Its possible causes and predisposing

factors are set forth from every angle in the very complete chapter on epidemiology, in which the presentation is based on the concept that the same epidemiologic principles can be applied to trauma due to cold as are applied to infectious diseases and that the same general principles of control are operative.

The clinical chapters clearly indicate the inadequacy of our basic knowledge

of cold injury and the unsatisfactory results of present methods of treatment;

they also point up the necessity for continued studies in these fields. The

urgent necessity for preventing repetition of past experiences is apparent in

the chapter on costs.

think it no exaggeration to say that this is the most comprehensive volume

on the ground type of cold injury that has ever been published. think it

equally fair to say that, if it is carefully studied and if the lessons of the experience of the United States Army in World War II are properly read, marked,

learned, and inwardly digested, there should be no similar experience in any

future war.

S. B. Hays,

Major General,

The Surgeon General.
Preface

Cold injury as it affects large numbers of men is primarily form of war- time trauma. The history of all military campaigns conducted in winter, both in temperate and in cold climates, reveals crippling losses from this cause.

Between wars, the staggering cost of cold trauma in time of war is almost entirely forgotten.

The British losses in World War and the costly experiences of United States forces in Europe in World War II (as well as, more recently, in Korea) make it imperative that the knowledge so painfully gained shall not again be

forgotten. It is imperative that all of this knowledge be preserved. It is particularly imperative that the principles of prevention of cold injury become part of peacetime military training and planning.

This volume has three purposes:

1. To record the history of cold injury, ground type, in World War II.

2. To summarize what has been learned of the nature of this form of

trauma, including its pathologic physiology, its epidemiology, its military cost, and its management, including the rehabilitation of casualties from this cause.

3. To formulate, from the materials of the past history of cold injury,

the principles of sound program for its prevention and control in future military operations in cold regions and in temperate regions during cold weather.

It is hoped that by concentration on the broad scope of the problem and

on its multiple phases, including its epidemiology, research may be stimulated

which will result in more positive and more effective methods and practices

for preventing, controlling, and treating this important variety of environmental injury. This history of cold injury in World War II began as two independent

projects. One volume was intended as part of the surgical series and the

other as part of the preventive medicine series of the history of the Medical

Department of the United States Army in World War II. It soon became apparent that the interests of comprehensive, concise, and useful history

would best be served by joint effort. Happily, the data already assembled

independently could be readily amalgamated, and the combination suggested

fruitful avenues for further study of the historical files and the medical materials

of World War II.

Statistics used in the tables and text of this volume were personally collected by the authors or their collaborators or were based on preliminary summary unit reports. The Medical Statistics Division, Office of the Surgeon

General, has reviewed and, where possible, has verified all statistical data and

furnished more complete data based on sample tabulations of individual medical

records.
PREFACE

For statistical purposes, trenchfoot and frostbite are not always separated

in Army reports. Clinically, they are often indistinguishable. Practically,

it would have been better if no attempt had been made to differentiate them.

Generally speaking, whatever is said about one in the following pages may be

regarded as equally applicable to the other unless specific exception is made.

Similarly, whatever is said about cold injuries of the feet may be regarded as

equally applicable to cold injuries of the hands, which, as practical consideration, are affected in only very small proportion of the injuries of this type.

Tom F. Whayne,

Colonel, MC, USA {Ret.).

Michael E. DeBakey, M. D.
Acknowledgments

The preparation of comprehensive volume such as this requires the labor,

cooperation, and assistance of many persons other than the authors. We are

happy to acknowledge our debt to them.

The epidemiologic studies on cold trauma in the European Theater of

Operations during World War II were made by Col. John E. Gordon, MC,

formerly Chief, Preventive Medicine Division, Office of the Chief Surgeon, European Theater of Operations, and now Professor of Preventive Medicine and

Epidemiology, School of Public Health, Harvard University. Colonel Gordon

also gave indispensable advice and assistance in the final epidemiologic evaluations.

The chapter on cold injury in the Mediterranean Theater of Operations is

based almost entirely on the special reports made during the war by Col.

Fiorindo A. Simeone, MC, now Professor of Surgery, Western Reserve University School of Medicine. The discussions of therapy in the Mediterranean

theater are derived from the same reports.

Similarly, the clinical discussions of trenchfoot in the Zone of Interior, including therapy, were derived from special reports prepared by Lt. Col. Harris

B. Shumacker, MC, formerly Chief of Surgery, Mayo General Hospital, now

Professor of Surgery, Indiana University Medical Center.

Much of the information concerning the activities of the Medical Department in the Pacific theaters of operations was provided by Col. I. Ridgeway

Trimble, MC, formerly Consultant in Surgery, Southwest Pacific Area, now

Professor of Surgery, Johns Hopkins University School of Medicine.

Dr. Simeone, Dr. Shumacker, and Dr. Trimble have contributed materially

to this volume and have also checked and rechecked the chapters dealing with

their wartime fields of activity. Their assistance and cooperation are gratefully

acknowledged.

Mrs. Josephine P. Kyle and her staff in the Historical Unit, United States

Army Medical Service, provided material from the historical file and checked

and corroborated data obtained from other sources.

Miss Zelma E. Mcllvain, Historian, the Historical Unit, United States

Army Medical Service, collected and abstracted most of the material for the

chapter on cold injury in the European Theater of Operations. She also collected and abstracted some of the material used in the chapters on cold injury

in the Aleutian Islands, the Mediterranean Theater of Operations, and the

Pacific theaters.

Mr. E. L. Hamilton and his staff, Medical Statistics Division, Office of the

Surgeon General, furnished valuable statistical data, checked and revised tables

and graphs, and advised on methods of statistical analysis and presentation.

43840-n—58
ACKNOWLEDGMENTS

Mr. McDonald Smith, under the direction of Mr. Herman Van Cott,

Chief, Medical Illustration Service, Armed Forces Institute of Pathology, prepared the very excellent layouts for the illustrations in this volume and supervised the artwork and the preparation of the illustrations for printing.

We are also appreciative of the help and cooperation we have had from

Col. John Boyd Coates, Jr., MC, USA, Director of the Historical Unit, United

States Army Medical Service. He has read the entire volume critically several

times and, from his personal experience with cold injury in the European

theater, has corrected errors and supplied many details of interest and value

which had not come to our attention. His contribution to this volume has

gone considerably beyond the ordinary editorial function.

Finally, grateful and lasting appreciation is expressed to Miss Elizabeth

M. McFetridge, who, as associate editor of this volume, not only put together,

with uncommon skill, the manuscripts, notes, and thoughts of the authors but

also at times served as adviser, arbiter, and peacemaker, and always as

treasured and trusted friend.

Tom F. Whayne,

Colonel MC, USA {Ret.).

Michael E. DeBakey, M. D.
Contents Page

FOREWORD vn

PREFACE IX

ACKNOWLEDGMENTS XI

Chapter

General Considerations of Battle Trauma

The Epidemiology of Trauma

II General Considerations of Cold Injury

Types of Cold Injury

The Spectrum of Cold Injury 20

III Historical Note 29 The Napoleonic Wars 30 The Crimean War 34 The War of the Rebellion 37 Other Wars of the 19th Century 38 The Russo-Japanese War 38 The Tibet Expedition of 1903-4 39 The Balkan Wars 41 World War 42

The Spanish Civil War 52

Etiologic Considerations 53 Cold Injury of the Hand 56

IV Actions Taken in Zone of Interior 57 May 1942-October 1943 57 October 1943-March 1945 59

Training Program 68 Hospitalization of Trenchfoot Casualties 78

Investigations 79

Conclusion 80

The Aleutians 83 The Attu Campaign 84 The Occupation of Kiska 96

Summary 99

VI Mediterranean (Formerly North African) Theater of Operations 101

Incidence 101

Tactical Situation 107

Climatic Factors 109

Clothing and Footgear 111

Indoctrination and Training 118

Summary 125
XIV CONTEXTS

Chapter Page

VII European Theater of Operations 127

High-Altitude Cold Injury in the Eighth Air Force.. 130

Tactical and Environmental Considerations ..

136

Incidence 138

Clothing and Footwear ..

.. 143

Development of Trenchfoot-Control Program 160

Other Considerations of Prevention and Control__ 173

Epidemiologic Survey and Control 176

Conferences 178

Clinical Investigations ...... 185

Reporting and Nomenclature 186

Award of the Purple Heart 189

Public and Congressional Reactions to the Trenchfoot Situation in

Europe 196

Experiences of Other Armies 198

Statement by the General Board 208

The Calculated Risk 209

VIII The Pacific 211

Part I. Cold Injury in the Tropics

Clinical Aspects 213

Part II. The Wet-Cold Problem

Office of the Surgeon General 217

Medical Planning in the Pacific ..220

Action by Commanders in Pacific 224

The Quartermaster Corps 226

Practical Considerations of the Wet-Cold Indoctrination Program 229

Indoctrination of Other Services 233

Summary 234

IX Pathogenesis and Pathologic Process 235

Pathogenesis 235

Pathologic Process 241

Clinical Picture and Diagnosis 259

General Considerations 259

The Aleutians .. 260

The Mediterranean (Formerly North African) Theater. 263

The European Theater 280

Overseas Complications and Sequelae. 284

Observations in the Zone of Interior. 291

Diagnosis Overseas .. 302

XI Therapy and Disposition Overseas 307

Evacuation and Triage 307

The Aleutians 310

Mediterranean Theater of Operations- 315

European Theater 324

Results of Therapy—Disposition 327
CONTENTS

Chapter Page

XII Therapy and Disposition in Zone of Interior 333 Previous (Overseas) Treatment 333 Therapy (Medical Phase) 334 Therapy (Surgical Phase'' 339 Reconditioning 353 Disposition 357 Predictive Tests 361

XIII The Epidemiology of Cold Injury 363 General Considerations 363

Analysis of Selected Divisions by Correlation Studies__ 366

Epidemiologic Analyses of Agent, Host, and Environmental Factors. 376

Summary 452

XIV The Cold Injury Record of the 84th Infantry Division 455 8-28 November 1944 456 29 November-20 December 1944 459

21 December 1944-2 January 1945... 461 3-16 January 1945 463 16-31 January 1945 466

February-5 March 1945 466

Analysis of the Total Experience 468

XV The Prevention and Control of Cold Injury 471 General Considerations 471

Preventive Principles and Practices 473

Research on Cold Trauma 478

Comprehensive Program for the Prevention and Control of Cold

Trauma 479

Alternative Plans 487

Proposed Board for the Control of Trauma 488

XVI The Military Cost of Cold Injury 491

The Facts of Cold Injury in Theaters of Operations 491

An Evaluation of the Costs of Cold Injury 497

Advance Planning 507

APPENDIXES

War Department Technical Bulletin (TB MED 81) 509

Army Ground Forces Training Directive 517

Medical Circular No. 521

Letter on Trenchfoot, Headquarters, NATOUSA 523

Circular 108 525

Memorandum on Trenchfoot, Headquarters, Third U. S. Army 529

Trenchfoot-Control Officers, ETOUSA 531

Wet-Cold Indoctrination Program, AFPAC 533

Training Memorandum No. 1_ 535

Letter on Trenchfoot, Headquarters, NATOUSA 539

Circular No. 55 541

INDEX 543
XVI CONTENTS

Illustrations Figure Page

Photomicrograph of small artery of finger amputated for high-altitude

frostbite 14

Capillary bed in normal and frostbitten fingers 15

Blanching of fingers in high-altitude frostbite 15

Wet type of moderately severe high-altitude frostbite 16

Wet type of severe high-altitude frostbite 17

Wet type of moderately severe high-altitude frostbite 18

Wet type of severe high-altitude frostbite 19

Wet type of severe high-altitude frostbite 19

Photomicrograph of skin in high-altitude frostbite 20

10 Persistent hypesthesia in high-altitude frostbite 22

11 Dry type of mild high-altitude frostbite 22

12 Dry type of severe high-altitude frostbite- 23

13 Dry type of severe high-altitude frostbite 24

14 Dry type of severe high-altitude frostbite 25

15 Dry type of severe high-altitude frostbite 26

16 Mixed wet and dry types of severe high-altitude frostbite 27

17 Dry gangrene of toes of both feet due to freezing 37

18 Properly equipped and clothed soldier 84

19 Mired tractor and trailer, Massare Bay, Attu 86

20 Landing beach in Holtz Bay area, Attu 87

21 Field hospital on Attu 89

22 Combat boots worn on Kiska 92

23 Shoepacs worn during occupation of Kiska 93

24 Cold-weather uniform 112

25 Liri-Garigliano Valley, Italy, February 1945 113

26 Service shoes worn by trenchfoot casualty in Italy _. 114

27 United States Army field combat boot 115

28 Instructional material on prevention of trenchfoot. 123

29 Instructional material on prevention of trenchfoot 124

30 Instructional material on prevention of trenchfoot 125

31 Muddy roads in France, November 1944 136

32 Snow-covered terrain, Battle of Bulge 137

33 Winter footgear used by German troops in France 205

34 Tropical environment favorable to skin diseases 212

35 Phagocytosis of fat in late trenchfoot 245

36 Oil cyst in late trenchfoot 245

37 Connective tissue replacement in late trenchfoot 246

38 Changes in subcutaneous fat lobules in late trenchfoot 246

39 Thrombosis of posterior tibial vein in early trenchfoot 247

40 Thrombosis of artery in late trenchfoot 247

41 Mural angiitis in early trenchfoot 248

42 Changes in posterior tibial artery in early trenchfoot 248

43 Change in plantar artery in late trenchfoot 249

44 Changes in artery in trenchfoot 250

45 Obliteration of arterial lumen in late trenchfoot 251
CONTEXTS XVII

Figure Page

46 Recanalization of artery in trenchfoot 251

47 Recanalization of artery in late trenchfoot 252 48 Atrophy of muscle in late trenchfoot 252 49 Changes in posterior tibial nerve in early trenchfoot 253 50 Demeylinization of nerve in late trenchfoot 253 51 Changes in nerve in late trenchfoot 254 52 Phagocytosis in nerve in late trenchfoot 254 53 Degeneration of nerve in late trenchfoot 255 54 Sclerosis of nerves in late trenchfoot 256 55 Necrosis of bone in late trenchfoot 257 56 Subsiding inflammatory state of trenchfoot 265 57 Trenchfoot third day after exposure 267 58 Trench hands 268

59 Inflammatory stage of trenchfoot 270

60 Postinflammatory stage of trenchfoot 272 61 Late inflammatory stage of severe trenchfoot 273

62 Postinflammatory stage of trenchfoot 274

63 Early postinflammatory stage of severe trenchfoot 274

64 Subsiding inflammatory stage of trenchfoot 275

65 Subsiding inflammatory stage of trenchfoot 276

66 Late postinflammatory stage of trenchfoot 277

67 Postinflammatory stage of trenchfoot 277

68 Late postinflammatory stage of trenchfoot 278

69 Second- and third-degree cold injury 282

70 Serial changes in trenchfoot 283

71 Severe flexion contractures of toes after trenchfoot 285

72 Late postinflammatory stage of trenchfoot 286

73 Late postinflammatory stage of trenchfoot 286

74 Late postinflammatory stage of trenchfoot 287

75 Early postinflammatory stage of trenchfoot 287

76 Late postinflammatory stage of trenchfoot 288

77 Typical hyperkeratosis in late trenchfoot 295

78 Persistent swelling in late trenchfoot 296

79 Atrophy of muscles in late trenchfoot 297

80 Atrophy of muscles and peripheral neuritis in late trenchfoot 298

81 Superficial gangrene in late trenchfoot 299

82 Deep bilateral gangrene in late trenchfoot 301

83 Management of early trenchfoot in clearing station 316

84 Management of early trenchfoot in clearing station 317

85 Effect of sympathectomy in severe trenchfoot 323

86 Inflammatory stage of trenchfoot after hospitalization 323

87 Heelwalking in late trenchfoot 336

88 Correction of heelwalking 336

89 Management of extensive bilateral gangrene in late trenchfoot 339

90 Management of extensive bilateral gangrene in late trenchfoot 340

91 Management of extensive bilateral gangrene in late trenchfoot 340

92 Management of bilateral gangrene in late trenchfoot 341

93 Management of bilateral gangrene in late trenchfoot 342

94 Amputation for gangrene in late trenchfoot 344
CONTENTS

Page Figure

95 Amputation for gangrene in late trenchfoot... 445

96 Amputation for contractures of toes in late trenchfoot

97 Management of bilateral gangrene in late trenchfoot.

98 Management of bilateral gangrene in late trenchfoot 446

99 Skin grafting in late trenchfoot

100 Tube transfer grafts after amputation for gangrene in late trenchfoot._

101 Tube transfer grafts after amputation for gangrene in late trenchfoot 350

102 Tube transfer grafts after amputation for gangrene in late trenchfoot 351

103 Technique of tube transfer graft in late trenchfoot 351

104 Technique of plaster immobilization after tube transfer grafts

105 Unsatisfactory stump after loss of toes in trenchfoot 353

Tables

Number

Morbidity and mortality data. United States Army, in four major wars,

1861-1945

Cold injury on Attu

Trenchfoot and battle casualties, Fifth U. S. Army, Italy, 1943-44..

Trenchfoot and battle casualties, Fifth U. S. Army, Italy, 1944-45 104

Trenchfoot and battle casualties, British 10 Corps, Italy, 1943-44. 105

Comparative incidence rates for trenchfoot and battle casualties, ifth S.

Army, 1944-45 -- 4^*7

High-altitude frostbite, Eighth Air Force, 1942-45 ------

132

Tissue damage in trenchfoot in relation to duration of exposure 292

Residual manifestations of trenchfoot ______

293

10 Classification and disposition of trenchfoot cases 404

11 Scores of 21 infantry divisions, Fluropean theater, by cold injury modifying

factor, November 1944 397

12 Scores of 21 infantry divisions, European theater, by cold injury modifying

factor, December 1944 379

13 Cases of trenchfoot in 21 infantry divisions, European theater, NovemberDecember 1944 373

14 Comparative incidence rates for trenchfoot cases and battle casualties,

Italy, October 1944-March 1945

15 Age of 1,018patients with trenchfoot 379

16 Combat exposure of 1,018 patients with trenchfoot 492

17 Cold injury, 83d Infantry Division, European theater, November 1944-

January 1945 394

18 Cold injury, 8th Infantry Division, European theater, November 1944-

February 1945 3^®

19 Results of opinion survey on trenchfoot prevention.. --- 401

20 Cold injury, 95th Infantry Division, Fhiropean theater, November-December 1944 403

21 Mean temperature, precipitation, and cold injury cases, First U. S. Army,

European theater, November 1944-February 1945 --- 499

22 Mean temperature, precipitation, and cold injury cases, Third U. S. Army,

European theater, November 1944-February 1945 410

23 Cold injury admissions and rates for the First, Third, Seventh, Ninth, and

Fifteenth U. S. Armies, European theater, November 1944-April 1945_ 411
C( )NTENTS XIX

Number Page

24 Cold injury, 30th Infantry Division, European theater, November 1944-

February 1945 413

25 Cold injury, 9th Infantry Division, European theater, November 1944-

March 1945 415

26 Cold injury, 104th Infantry Division, European theater, November 1944-

January 1945 419

27 Cold injury. 29th Infantry Division, European theater, November-December 1944 422

28 Cold injury, 78th Infantry Division, European theater, December 1944-

January 1945 423

29 Cold injury cases in armored divisions, European theater, October 1944-

March 1945 424

30 Arm or service of 1,018patients with trenchfoot 425

31 Cold injury, 2d Infantry Division. European theater, November 1944-

February 1945 427

32 Daily incidence of trenchfoot and frostbite, 2d Infantry Division, European

theater, January-February 1945 428

33 Cold injury. 5th Infantry Division, European theater, 11-24 November

1944 429

34 Cold injury, 90th Infantry Division, European theater, November-December 1944 436

35 Cold injury, 102d Infantry Division, European theater, November 1944-

February 1945 438

36 Cold injury, 87th Infantry Division, European theater, 11-22 December

1944 441

37 Cold injury, 346th Regiment, 87th Infantry Division, European theater,

11-22 December 1944 442

38 Cold injury, 99th Infantry Division, European theater, November 1944-

March 1945 444

39 Cold injury, 45th Infantry Division, European theater, NovemberDecember 1944 446

40 Cold injury, 35th Infantry Division, European theater, 8-30 November

1944 449

41 Mean temperature, precipitation, and cold injury cases, 84th Infantry

Division, European theater, November 1944-January 1945 461

42 Admissions for cold injury, all theaters, 1942-45 493

43 Incidence of cold injury, all theaters, 1942-45 494

44 Incidence of cold injury, all theaters, 1942 495

45 Incidence of cold injury, all theaters, 1943 496

46 Incidence of cold injury, all theaters, 1944 497

47 Incidence of cold injury, all theaters, 1945 498

48 Cold injury, Ground Forces, European theater, 1944-45 500

49 Cold injury, major commands, European theater, 1944-45 501

50 Trenchfoot, immersion foot, and frostbite patients remaining in hospitals

and prevalence rates, United States forces, Mediterranean theater,

1943-45 503

51 Trenchfoot, immersion foot, and frostbite patients remaining in hospitals

and prevalence rates, United States forces, European theater, 1943-45_ 505

52 Ratio of cold injuries to battle casualties by United States force or army,

Attu and Mediterranean and European theaters 506
CONTENTS XX

Charts Page Number

Cold tolerance of normal and frostbitten hands 21

Gradient (schematic) of cold injury 28

Incidence of trenchfoot in relation to various environmental factors, Fifth

U. S. Army, Italy, 1943-44 102

Incidence of trenchfoot in relation to various environmental factors, Fifth

U. S. Army, Italy, 1944-45 104

Evacuation, cold injury casualties, European theater 309

Trenchfoot incidence rates, Italy, October 1944-March 1945 374

Comparison of ratios of trenchfoot to battle casualties, Italy, October

1944-March 1945 375

Cold injury, 83d Infantry Division, European theater, November 1944-

January 1945 '103

Cold injury, 8th Infantry Division, European theater, November 1944-

February 1945 395

10 Cold injury, 95th Infantry Division, European theater, November—

December 1944 402

11 Cold injury cases, mean temperature, and precipitation, First U. S. Army,

European theater, November-December 1944 405

12 Cold injury cases, mean temperature, and precipitation, First U. S. Army,

European theater, January-February 1945 406

13 Cold injury cases, mean temperature, and precipitation, Third U. S. Army,

European theater, November-December 1944 407

14 Cold injury cases, mean temperature, and precipitation, Third L. S. Army,

European theater, January-February 1945 408

15 Total cold injury incidence rates for the First, Third, Seventh, Ninth, and

Fifteenth U. S. Armies, European theater, November 1944-April 1945.. 412

16 Cold injury, 30th Infantry Division, European theater, November 1944-

February 1945 412

17 Trenchfoot and frostbite, 9th Infantry Division, European theater,

November 1944-March 1945 414

18 Cold injury, 104th Infantry Division, European theater, November 1944-

January 1945 419

19 Cold injury, 26th Infantry Division, European theater, NovemberDecember 1944 421

20 Cold injury, 29th Infantry Division, European theater, NovemberDecember 1944 422

21 Cold injury, 78th Infantry Division, European theater, December 1944-

January 1945 423

22 Cold injury, 2d Infantry Division, European theater, November 1944-

February 1945 426

23 Cold injury, 5th Infantry Division, European theater, 11-24 November

1944.: 429

24 Cold injury, 90th Infantry Division, Pluropean theater, NovemberDecember 1944 435

25 Cold injury, 102d Infantry Division, European theater, November 1944-

February 1945 437

26 Cold injury, 87th Infantry Division, European theater, 11-22 December

1944 440

27 Cold injury, 346th Regiment, 87th Infantry Division, European theater,

11-22 December 1944 441
CONTENTS

Number Page

28 Cold injury, 99th Infantry Division, European theater, November 1944- March 1945 443 29 Cold injury, 45th Infantry Division, European theater, November- December 1944 445

30 Cold injury, 35th Infantry Division, European theater, 8-30 November 1944 448 31 Cold injury in relation to environmental factors, 3d Infantry Division, European theater, January-February 1945 450 32 Mean temperature, precipitation, and cold injury cases, 84th Infantry

Division, European theater, November 1944-January 1945 460

CHAPTER

General Considerations of Battle Trauma

The inevitable consequence of war is physical injury to large numbers of

men. The injury may be caused directly by the weapons and engines of combat

(battle injuries) or may arise from the environment in which soldiers must

operate (nonbattle injuries, disease). Thermal injuries, because they are the

result of environmental heat or cold, are classified as nonbattle injuries, though

they are usually incurred in theline and in some respects might more reasonably

be classified as combat injuries. The sum total of all these injuries, no matter

what form they may assume, is designated as war trauma.

Military strategy and tactics have been greatly influenced by injury and

disease in many recorded campaigns. Medicomilitary history is the continuing

record of the effect of trauma and of the planning and research instituted to

improve methods of (1) treatment and repair of the injuries which result from

it, and (2) rehabilitation of battle casualties.

Disease formerly exacted much heavier toll in war than did combat

injuries. It is only in quite modern times, in fact, that battle deaths have

exceeded deaths from disease. This reversal was first observed in the Danish

War of 1864 in the German forces. similar excess of battle deaths over

disease deaths prevailed for German troops in the Franco-Prussian War of

1870-71, in the campaign in South-West Africa in 1904-7, and in World War I.

Records for the Russo-Japanese War show ratio of deaths from disease to

battle deaths of less than for both Russian and Japanese troops.

Improvement in this respect was considerably longer in coming in the

United States Army (table 1). The ratio of deaths from disease to battle

deaths (killed in action or died of wounds) in the Union Army in the Civil War

(1861-65) was 1.81:1. In the Spanish-American War, the ratio for the year

1898 was 12.65:1 if deaths from typhoid in the United States are included.

The ratio for the whole United States Army for period coinciding almost

exactly with the duration of the war (1 May 1898 to 31 August 1898) was

5.25:1. For the calendar year 1898, the ratio in the overseas area was 2.82:1.

In World War I, the tide finally turned; the ratio of deaths from disease

to battle deaths (killed in action plus died of wounds) became 0.34:1 in the

American Expeditionary Forces in Europe and 1.02:1 for the whole Army.

In World War IT, the ratio for United States forces in the European Theater

of Operations was 0.01:1; for the total United States Army, if killed in action

are included, the ratio is 0.07:1.

Gordon, J. E.: TheStrategic and Tactical Influence ofDisease in World War II. Am. J. M. Sc. 215: 311-326, March

1948.
COLD INJURY, GROUND TYPE

able 1.—Morbidity and mortality data for the United States Army in four major wars,

1861-1945

[Death rate and admission rate expressed as number per annum per 1,000 average strength]

Data on deaths are fairly well restricted to periods ofactual hostilities, but the admission rates, case fatality rates,

and noneffective rates shown in almost all instances are for somewhat longer periods, including the periods ofhostilities.

This is due to the basis on which the data were compiled in that only data for calendar or fiscalyears could be obtained.

Includes killed in action,

Data are not available.

The Army-wide death rate for disease in World War 11 was reduced to

less than one-twentieth of its World War level. Case fatality rates for

disease were reduced to about one-fifteenth of this level. Morbidity rates for

disease were generally reduced by about third, although the experience in

special theaters, particularly the tropical theaters at the beginning of the war,

was not uniformly favorable. The average daily rate for noneffectiveness per

1,000 average strength from all causes in the total Army was 58 in World War

(April 1917-December 1919) and 44 for World War II (1942-45). Comparable rates for noneffectiveness for all disease in the whole Army were 42 for

World War and 30 for World War II per 1,000 average strength.

The case fatality rate for battle casualties in World War 11 was approximately half of the rate for World War (exclusive of gas casualties), the

decrease reflecting the better medical care provided in World War II. The

case fatality rate for nonbattle injuries, on the other hand, increased by about

one-half in World War II as compared to World War 1. In terms of total

Army strength, the death rate from battle causes decreased by about onehalf between World War and World War II, but the non-battle-injury death

rate in World War II was almost double the rate for World War I.

As these data demonstrate, disease has become progressively less costly

in war, while battle trauma and nonbattle injuries have become relatively

more costly.

THE EPIDEMIOLOGY OF TRAUMA

In the past, great deal of effort has been expended in collecting the

records of battle casualties and in classifying, analyzing, and interpreting

them. Serious endeavors have been made to assess the influence on casualty

Wars

Deaths from— Ratio of deaths

from

disease

todeaths

from

Battle

injuries

and wounds

Death

rate

from

disease

Admission rate from

disease

Case fatalityrate from Daily non effec- tivenessper 1,000

from

Disease

Battle

injuries

and

wounds

Disease

Battle

injuries

and

wounds

Nonbattle

injuries Disease

Nonbattle

injuries

Number Number Percent Percent Percent

Civil War (North) 199. 720 110,238 1.81:1 62.0 2,339. 2.6 13.3 (?)

Spanish-American War- 1,939 369 5.25:1 25.6 2,005.8 1.6 6.1 1.6 17.5

World War 51,447 50,510 1.02:1 16.5 851. 1.7 6.1 1.9 41.6 4.5

World War II 15, 779 2)9,560 .07:1 .6 587.5 4.5 30.3 6.4
GENERAL CONSIDERATIONS, BATTLE TRAUMA

rates of such factors as equipment, training, nutrition, fatigue, seasoning,

leadership, psychologic preparation for war, and motivation in general. The

emphasis, however, has been almost entirely on battle casualties and the important communicable diseases. Up to the present time, the role of total

mass injury has received little attention. Almost no attempt has been made

to study noncombat injuries and to assess their importance in terms of the

mass problem or to determine whether military trauma can be approached

epidemiologically. On the contrary, it has been the general practice to look

upon nonbattle injuries and accidents as losses that are inevitable and that

must be accepted when many men operate many machines under stress.

Even less attention has been paid to the trauma that comes about directly

as the result of environment. Thermal injuries, as already noted, are included

in the latter category.

The advances which have been made in medical science have provided

better understanding of the causation of communicable disease, and better

knowledge of the behavior of disease has therefore also become predictable,

at least to some degree. It was this predictability, together with the development of the tools, procedures, and methods for the control of disease, that

brought about the reversal, already commented upon, in the relative positions

of disease and injury in the two World Wars. Historically, however, the

change from the conviction that loss from disease is an inevitable part of

military operations to the concept of concerted programs of prevention for

its control or eradication has been slow to evolve. Military history provides

dramatic episodes in this evolution. Against the conquest of typhoid fever

in World War I, for instance, must be set the disastrous effect of the dysenteries on the British forces on the Gallipoli Peninsula in 1915-16. Furthermore, the evolution of the new concept has been incomplete as well as slow, as is demonstrated by the casualties suffered from malaria by the Allied forces

in the Pacific in World War II.

As disease has become increasingly less costly in war, both battle casualties and nonbattle casualties have become relatively more costly, and the

question has naturally arisen: What can be done to make trauma less of

liability? There seems no real reason why mass injury should be less amenable to epidemiologic evaluation and interpretation than mass disease. Much

progress has been made in the experimental and clinical study of trauma.

Treatment by surgical measures has made great strides, and knowledge of the

clinical management of the individual traumatized soldier is now far advanced.

The study and understanding of injuries likely to be sustained in given types

of operations have become scientific enough to make preliminary estimates

accurate within reasonable limits.

If, however, trauma is to be viewed as an entity, these advances are not

enough. Trauma must be studied through the whole range of cause and effect

and in terms of time, place, and person. It must be analyzed from the standpoint of the primary role of agent, host, and environment. All of the factors,

in short, which arise from, or which influence, these various circumstances and
COLT) INJURY, GROUND TYPE

which produce the final effect of trauma, or which prevent its occurrence,

must be evaluated and considered.

Such an epidemiologic concept of trauma is not entirely new. iiogo\,

toward the close of the last century, declared that war is the epidemiology ol

trauma. This is an extremely perceptive observation, though somewhat

oversimplified, since military trauma, as already pointed out, is not single

entity. An investigation of the epidemiology of trauma as group composed ol

special types of injuries would be as nonproductive as study ol the epidemiology of the exanthematous diseases as group. In the same manner that the

epidemiology of measles, scarlet fever, and smallpox, lor instance, must be

studied disease by disease, so must the general field of military trauma be

broken down into its component parts. Thus, the epidemiology of accidents

might be subdivided into industrial, vehicular, and other special types. The

epidemiology of thermal injuries would be subdivided into those caused by heat

and those caused by cold. Only by such an approach to single components that

are relatively clear-cut entities and are amenable to study can the broad

principles applicable to trauma as whole be ascertained.

Although this approach has never yet been properly or fully utilized, one

component of nonbattle trauma—cold injuries of the ground type assumed

such tactical and strategic importance during World War 11 that it was necessarily studied on mass basis. This was not necessity which had been

anticipated. The history of most past wars, including World AA ar I, shows that

during cold weather military activities were always either considerably lessened

or came to practically complete halt. It seems reasonable to assume, furthermore, that environmental factors will exert the same influence during the

winter on each of the two opposing military forces. In AA orld AA ar II, however,

the decision, in the autumn of 1944, to go forward with an intensrv wintei

campaign in the European theater, in an effort to hasten the end of the war,

reversed the usual circumstances, and the reversal introduced an unusual

opportunity to study the mass effects of injuries caused by cold during largescale military operations.

Before World War I, trauma caused by cold had never been subjected to

thorough scrutiny as military problem. That conflict, with its static trench

warfare, saw trenchfoot develop into significant medical and surgical problem

among British and French troops, as well as among German troops. he

studies on cold injury which were undertaken then, as soon as the problem

became apparent, were directed toward defining the clinical nature of this type

of trauma, establishing the pathologic process, and determining effective forms

of therapy. Prevention was emphasized in practice, but chiefly as it could be

applied to the individual soldier, to rotation of units, and to supplies. It is true

that all of these considerations are fundamental, but their applicability under

Pirogov, N. I.: Das Kriegs-Sanitats-Wescn und die Privat-Hiilfe auf dem Kriegsschaupialze in Bulgarien und ini

Riickcnder OperirendenArmee 1877-1878. Aus dem Russischen von Dr. WilhelmRoth und Dr. Anton Schmidt. Leipzig: Verlag von F. C. W.Vogel, 1882, p. 299.
GENERAL CONSIDERATIONS, BATTLE TRAUMA

the static trench warfare of World War could not have been expected to meet

the exigencies of the active mobile warfare characteristic of World War II.

The over-all problem of mass injury caused by cold was not approached

epidemiologically in World War I. In fact, trenchfoot was not even conceived

of as subject to epidemiologic principles and laws. At that time, epidemiology

was chiefly construed to mean the detailed study of outbreaks of infectious

diseases. Its scope did not include chronic disease or injury nor did it encompass the study of disease or injury as whole. Its application to chronic

noninfectious disease, however, was not long in coming after the war ended.

Emerson's discussion of heart disease as public health problem was first published in 1921. His similar discussion of mental health was published in 1922.

Since that time, the development of the broad concept of epidemiology in

the field of noncommunicable diseases, injuries, and accidents has been chiefly

the work of Gordon.

This same observer, with his associates in ETOUSA (European Theater of

Operations, United States Army), showed in World War II that mass injury is

quite as susceptible to epidemiologic analysis as is mass communicable disease.

similar epidemiologic analysis of cold injury, ground type, was not made

for the Army as whole in World War II. Its feasibility", however, is clearly

evident in the field surveys and investigations carried out iu the European

theater (p. 176) and by analyses of the data collected in the Office of the Chief

Surgeon of that theater and iu the Office of the Surgeon, MATOUSA (Mediterranean Theater of Operations, United States Army). These records, supplemented by records of individual units and divisions, all proved, as will be shown

in detail in the course of this presentation, that, as crippling malady, cold

trauma behaves in accordance with the same biologic laws and principles that

govern diseases of large populations.

The most significant and most distressing fact about cold injuries in World

War II is that the experiences in one theater were not transmitted to the other

theaters. The experiences in the Aleutians in 1943 were lost on the Mediterranean theater. The European theater did not profit from the lessons learned

in the Mediterranean theater, though the experience in Italy clearly demonstrated that trenchfoot is condition which is almost entirely preventable if

an epidemiologic analysis of its causation is made and if there is aggressive

command support. The cold injury experience in that theater occurred in

the winter of 1943-44. The prevention and control program established the

following winter was extremely effective. The losses from cold injury were

materially less than those sustained the previous winter. Yet it was not until

the late months of 1944, after an even more devastating cold injury experience,

that similarly effective program was instituted in the European theater.

Emerson, Haven; Selected Papers. Battle Creek: W. K. Kellogg Foundation, 1949.

(1) Gordon, J. E., and Augustine, D. L.: Tropical Environmentand Communicable Disease. Am. J. M. Sc. 216:

343-357, September 1948. (2) Gordon, J. E.: The Epidemiology of Accidents. Am. J. Pub. Health 39: 504-515, April 1949.

(3) Gordon, J. E.: Epidemiology—Old and New. J. Michigan M. Soc. 49; 194-199, February 1950. (4) Robert, H. L.,

and Gordon, J. E.: Home Accidents in Massachusetts. Study in the Epidemiologyof Trauma. New England J. Med.

241: 435-441, 22Sept. 1949.
COLD INJURY, GROUND TYPE

In the planning of the assault on Japan, the exorbitant military cost ol

losses from cold injury in Italy and in western Europe was lully recognized by

the War Department and the Commander in Chief, AFPAC (United States

Army Forces in the Pacific). The result was well-coordinated wet-cold

indoctrination program which made use of the principles and practices tested

in those theaters and which, if its implementation had proved necessary, would

undoubtedly have reduced to negligible proportions losses from this cause in

the Pacific.
CHAPTER II

General Considerations of Cold Injury

TYPES OF COLD INJURE

In addition to total freezing of the deep tissues, cold injuries include

chilblains, trenchfoot, frostbite, and immersion foot. All of these injuries,

irrespective of environmental and other modifying circumstances, are related

by the common factor of cold. They are differentiated and can be classified

chiefly according to the degree of cold which has given rise to the injury, the

duration of exposure, and the environmental factors, chiefly wet, which intensify

the effect of low temperatures.

The temperature level at which cold injury will occur is not absolute.

The level is dependent upon the various factors which have just been listed.

It is modified by such other factors as fatigue, malnutrition, and, perhaps,

individual variations in resistance. The upper limit of temperature at which

cold injury may occur has also not been established. During World War II,

men shipwrecked in the Gulf Stream, in which the temperature was 60°-70° F.

(15.6°-21.1° C.), presented immersion foot, with sensory changes and gangrene,

after days. Webster, Woolhouse, and Johnston, who reported some of

these cases, were unwilling to accept cold as causative agent, but their interpretation seems open to question in view of Lewis’ demonstration (p. 235) that

the skin begins to lose heat at 61° F. (16.1° C.) and that immersion in water

hastens the loss. variety of cold injury was observed in United Stales troops

after the landing atLeyte in the Philippine Islands (p. 211), and another variety,

so-called shelterleg (p. 9), was reported in persons who had spent the nights in

damp, but not necessarily very cold, London subways during the bombings

early in the winter.

Cold is the agent which causes tissue damage. This is true whether it is

the mild, continuous type of cold which causes chilblains; the severe, dry cold

which causes frostbite; or the combination of cold and wet which causes trenchfoot and immersion foot. Different degrees of cold may give rise to what

appear to be significant pathologic differences, and the resulting clinical

manifestations may also vary in severity, but basically the pathologic process

(1) White, J. C.: Vascular and Neurologic Lesions in Survivors of Shipwreck. I. Immersion Foot Syndrome

Following Exposure to Cold. New England J. Med. 228:211-222, 18 Feb. 1943. (2) White, J. C., and Scoville, W. B.:

Trench Foot and Immersion Foot. New England J. Med. 232:415-422, 12 Apr. 1954. (3) Webster, D. R., Woolhouse,

F. M., and Johnston, J. L.: Immersion Foot. J. Bone Joint Surg. 24:785-794, October 1942.

See footnote (3).

Ariev, T. V.: Fundamental Outlines of Present Day Knowledge of Frostbite. Medgiz: Moscow, 1943. This is

one of series of 16papers originally published inRussian from 1939 to 1944and translated into Englishand published by

Earl R. Hope, in Ottawa, Canada, in 1950 under the title “Frostbite.”
COLD INJURY, GROUND TYPE

is essentially the same in all cold injuries. This observation, while it holds

particularly for frostbite, trenchfoot, and immersion foot, which constitute

the ground-type injuries of military importance, does not exclude the occurrence of immersion foot in tropical waters when the period of exposure is

sufficiently long.

The interrelationships of the various cold injuries can best be understood

by defining them as entities and noting the etiologic factors which, in conjunction with cold, are responsible for their production.

Chilblains

Chilblain has been described as trenchfoot of the hand, though it may also

occur on the lower extremity. The lesions are most frequently located on the

dorsal surface of the phalanges, between, rather than over, the joints. Although

any portion of the dorsal surface may be affected, the thumbs are relatively

exempt. Any portion of the lower extremity may also be affected, though the

anterior tibia! surface of the leg, especially in women, is probably the most

common location.

Chilblains may disappear within few days or may assume chronic

form and last for weeks and months. In the chronic form, the condition is

also known as erythrocyanosis, Bazin’s disease, lupus, pernio, and dermatitis

hiemalis.

The disease is provoked by cold above freezing which is experienced

intermittently over long periods of time. It is observed chiefly in climates

characterized by moderate cold and high degree of humidity. The subjects

are usually young persons, whose hands are likely to be colder than normal,

and sometimes deeply colored, all the year round. The majority give history

of daily exposure in cold, moist atmosphere. As result, the injury of the

preceding day has not been compensated for before there is the insult of added

exposure on the succeeding day, and one lesion thus tends to develop over

another.

Skin which has previously been damaged in any way is peculiarly susceptible to chilblains. Lewis has also demonstrated that the condition is prone

to appear in persons whose skin is hypersusceptible to the stimulation of cold.

If the histamine test is carried out under standard conditions, with the skin

at its ordinary temperature, the reaction is abnormal. His explanation is

that the predisposing cause of chilblains is chronically defective circulation:

“It is to the high vascular tone of the limb vessels, to the readiness with which

the temperature of fingers or other parts falls to that of its surroundings, and

to the long delay in the release of this spastic condition of the vessels after

Ungley, C. C., and Blackwood, W.: Peripheral Vasoncuropathy After Chilling. “Immersion Foot and Immersion

Hand.” Lancet 2: 447-451, 17 Oct. 1942.

Cl) Lewis, T.: Observations on Some Normal and Injurious Effects of Cold Upon the Skin and UnderlyingTissues.

II. Chilblainsand Allied Conditions. Brit. M..1. 2: 837-839,13 Dee. 1941. (2) Schaefer, C. L., and Sanders, C. E.: Pernio

(Chilblains). ,1. Missouri M. A. 38:159-160, May 1941. See footnote (1).
GENERAL CONSIDERATIONS, COLD INJURY

general vasodilatation sets in, that the chilblain subject seems to owe his

predisposition to these lesions.”

The typical chilblain first appears as red, swollen, tender lesion, which

is usually warm or hot to the touch and which is characterized by obvious

vasodilatation and subcutaneous edema. The only symptom at this time is

itching. When the lesion becomes chronic, the original state of vasodilatation is no longer apparent, but the swelling may increase and the tissues may become

tenser. The color becomes deep purple or reddish purple. Blister formation

and ulceration may develop. In the chronic form, itching is replaced by tenderness and actual pain. Regardless of whether the condition is acute or

chronic, indolence and slow healing are prominent and are to be explained by

the defective circulation which underlies its development.

Shelterleg

Shelterleg is the term applied to the swollen lower extremities which physi- cians began to see in numbers soon after the initiation of the blitz of London in 1940. Knight, who first described the condition, referred to it as trenchfoot

in civilians. Although all ages and both sexes were affected, shelterleg was

most frequently observed in elderly, obese women. Contrary to expectations,

however, neither varicose veins nor cardiac lesions were present in affected

subjects any more frequently than they would be found in an average population

of the same age.

Inquiry of these patients practically always revealed that they had been

spending their nights in sitting position, sometimes at home, more often in

the subways. The platforms were crowded, no bunks had then been installed,

and people brought their own chairs, usually of the deck type, and slept upright in them. The subways were cold and damp, but the chief etiologic factor

seemed to be dependency of the parts, plus pressure on the popliteal space

from the crossbars of the chairs. In an occasional instance in which the

condition was unilateral, it was found that the patient had spent the night

with one leg crossed over the other. In other words, the responsible causes

cold, dampness, dependency, and interference with the circulation—were

precisely the causes which were later responsible for the cold injuries observed

in ground troops in Italy and western Europe. The lack of specific predisposing causes in most of the affected persons suggests that the capillary walls,

even when the extremities are entirely sound, are incapable of maintaining

their tone for an indefinite period against the influence of gravity without

intervals of recumbency or of active movement.

When the nocturnal habits were changed, rapid relief occurred in all

uncomplicated cases of shelterleg except for small group of patients whose

(1) Knight, B. W.: “Trench Foot” in Civilians (correspondence). Brit. M. J. 2:610-611, Nov. 1940. (2) Shelter

Legs (editorial). Lancet 2:722, Dec. 1940. (3) The Shelter Problem (reports of societies). Brit. M. J. 2:801-802,

Dec. 1940.

See footnote (1).

See footnote (2).
COLD INJURY, GROUND TYPE 10

deaths could be traced directly to these habits. Soon after Knight had described the condition, Simpson 10 called attention to significant increase

in the occurrence of fatal pulmonary emboli in London; there were fatal

cases in September and October 1939 and 24 for the same period in 1940.

Twenty-one of these twenty-four fatalities had occurred in persons who were in

the shelters or, more usually, who were just leaving them after night, or

succession of nights, spent in them. The subjects were usually elderly, 18 of the

24 being over 60 years of age. Most of the patients were somewhat obese, and

several had varicosities of the veins of the legs. In every instance, however, the

precipitating circumstance seemed to be the long period spent in deck chair

or some similar chair, the front edge of which compressed the popliteal space

and caused obstruction, with subsequent stasis, edema, and thrombosis, presumably in that order. Deaths from this cause, Simpson noted, were already

decreasing at the time of his report, as the provision of bunks was increasing,

and he put the figures on record merely to emphasize the need for haste in

providing the necessary equipment in the shelters. He also called attention

to the mechanical factor, which is not ordinarily so clear cut, in the development of thrombosis and to the fact that the thrombi originated in the tibial

veins and not in the large pelvic veins.

Shelterleg was no part of the war picture in the nited States, since the

circumstances which gave rise to the condition in England were ne\ ei duplicated in this country. Dependency for long periods, however, without change

of position, is responsible for the so-called traveler’s legs sometimes observed

in civilian practice after long trips in trains, automobiles, or airplanes. As

rule, the discomfort and edema are promptly relieved when movement is

resumed, though it may be matter of days before the edema disappears

completely.

Immersion Foot

Immersion foot 11 is form of tissue trauma which iollows piolonged

immersion of the feet in water not sufficiently cold to cause frostbite. It

has been observed, as already mentioned, after exposure in subtropical waters.

Ungley 12 described it as “peripheral vasoneuropathy after chilling.” Clinically

and pathologically, it is indistinguishable from trenchfoot, which would be

expected, since it originates from essentially the same causes.

Immersion foot typically appears in shipwrecked persons who have been

exposed to cold and wet for long periods of time. It is usually associated with

10 Simpson K.; Shelter Deaths From Pulmonary Embolism. Lancet 2: 744, 14 Dec. 1940.

(i) see footnote 4, p. 8. (2) Brownrigg, Q. M.: Frostbite in Shipwrecked Mariners. Am. J. Surg. 59:232-247,

February 1943. (3) Ungley, C. C.: Immersion Foot and Immersion Hand (Peripheral Vasoneuropathy After Chilling).

Bull War Med. 4:61-65, October 1943. (4) Ungley, C. C.: Treatment of Immersion Foot by Dry Cooling. Lancet 1:681-

682 29 May 1913. (5) Immersion Foot. Bull. U. S. Army M. Dept. No. 70, pp. 26-33, November 1943. (6) hite, J. C„

and Warren, S.: Causes of Pain in Feet After Prolonged Immersion in Cold Water. War Med. 5:6-13, January 1944.

(7) Blackwood, W.: Studies in the Pathology of Human “Immersion Foot.” Brit. J. Surg. 31:329-350, April 1944. (8)

Goldstone, B., and Corbett, H.: Aetiology of “Immersion Foot.” Brit. M. Bull. 2:148-149, 1944. (9) Fausel, E. G., and

Hemphill, J. A.: Study of the Late Symptoms of Cases of Immersion Foot. Surg., Oynec. Obst. 81:500-503, ovember

1945. (10) Wayburn, E.: Immersion Hypothermia. Arch. Int. Med, 79:77-91, Jaunary 1947.

is See footnote 11 (3).
GENERAL CONSIDERATIONS, COLD INJURY 11

dependency and immobility of the lower extremities and with constriction of

the limbs by clothing and shoes. Other factors which play more or less important roles are (1) body cooling, as the result of wind; (2) total immersion; (3) repeated immersion; and (4) inadequate clothing, seasickness, and starva- tion. In the reported cases, younger and older persons seemed to suffer more

severely from immersion foot than persons between 17 and 40 years of age. It was also the experience of shipwrecked survivors during World War II that those who lost heart and gave up hope suffered more severely, and sometimes died more quickly, than their companions who were of better spirit. The

incidence and severity of immersion foot, however, are more directly influenced by the duration of exposure and the temperature of the water than by any of

the other factors listed, though Ungley 13 expressed the opinion that the only specific effect of immersion is to keep the parts cold.

Three stages of immersion foot are recognized:

1. prehyperemic stage, lasting from few hours to few days. In this stage, the extremities are cold, numb, swollen, and discolored, and peripheral

arteries may be transiently or persistently pulseless. If pulsations continue absent, gangrene will ensue.

2. hyperemic stage, lasting from to 10 weeks. In this stage, the symptoms and signs include tingling or pain, motor disturbances, temperature differentials of the skin, increased swelling, blister formation, ulceration, and sometimes gangrene.

3. posthyperemic stage, lasting for weeks or months. In this stage, symptoms and signs are absent if the environment is reasonably warm, but

there is often sensitivity to cold suggestive of the similar sensitivity observed in Raynaud’s disease.

The immediate symptoms of immersion foot are numbness, moderate pain, tingling or itching, sometimes cramps in the calves of the legs, and

sensation, on walking, as if the feet were being pressed into cotton wool. Edema, which is the most prominent physical finding, may appear within few hours or after several days. The skin, which is initiallyreddened, becomes successively pale, mottled, and finally blue or black.

Trenchfoot

Trenchfoot is thermal injury sustained as the result of exposure to cold

short of freezing in damp or wet environment. Arbitrarily, it is said to occur

in the temperature range between 32° and 50° F. (0° and 10° C.). Actually, as already noted (p. 7), the maximum temperature has not been established. Recognized predisposing causes include immobility and dependency of the

limbs, insufficient clothing, and constriction of the parts by shoes, socks, and other garments. Trenchfoot commonly occurs under combat conditions, when immobility is forced by enemy action and when circumstances make adequate foot care difficult or entirely impractical. The prevalence is

13 See footnote 11 (4), p. 10.
12 COLD INJURY, GROUND TYPE

influenced by the weather, the type of combat action, the type of terrain, the

supply of food and clothing, and individual and organizational training policies

and procedures for the care of the feet.

Trenchfoot is characterized pathologically by circulatory, neurologic, and

sudomotor changes, which are manifested by signs of local tissue damage and

sterile inflammation. As some observers have pointed out, this type of cold

injury is almost identical with gradual frostbite, which might be expected,

since the primary etiologic factors are the same except for differences in the

degree of cold. 14

The term “trenchfoot” came into use in World War for the obvious

reason that the injury was prevalent when static trench warfare was the rule.

Although this type of warfare was the exception during World WarII, this type

of cold injury was unfortunately very frequent at certain periods in certain

theaters of operations, and the term was retained (p. 187), partly for lack of

better one and partly because the implications of the nomenclature were so

generally understood.

Frostbite

Frostbite is tissue injury 15 which evolves actual freezing of the skin

and subcutaneous tissues. It results from (1) prolonged exposure to freezing

and subfreezing temperatures, as distinguished from trenchfoot, which is

diagnosed (arbitrarily) when the temperature is above freezing, or (2) brief

exposure to extremely low temperatures. The lattertype of injury was observed

in World War IT chiefly in fliers, in the form of high-altitude frostbite.

Exposed portions of the body, such as the fingers, ears, nose, chin, cheeks,

forehead, and feet, are most frequently frostbitten. Frostbite of the penis,

from exposure during urination, is not infrequent in cold climates. Both the

incidence and the severity of the condition depend upon the degree of cold, the

duration of exposure, and the wind velocity. Contributory factors include

circulatory stagnation caused by inactivity, constriction of the parts, general

vasoconstriction, trauma, and nutritional deficiencies.

Frostbite may appear suddenly, as the result of direct exposure of unprotected parts during extremely cold or windy weather or as the result of contact

of unprotected skin with cold metal during such weather. It may also develop

gradually, and even insidiously, as the result of prolonged exposure of even

protected parts. local burning or stinging sensation or twinge of pain

followed by numbness usually supplies ample warning of what is occurring.

The skin assumes grayish or whitish, waxy appearance. Sometimes all the

Greene, R.; Frostbite and Kindred Ills. Lancet 2:689-693, December 1941. 15 (1) See footnotes 3, p. 7, and 14. (2) Lewis, T.; Observations on Some Normal and Injurious Effects of Cold

Upon the Skin and Underlying Tissues. III. Frost-Bite. Brit. M. J. 2:869-871, 20 Dec. 1941. (3) Frostbite. Bull.

U. S. Army M. Dept. No. 71, pp. 24-27, December 1943. (4) Stucke. K.: Kalteschaden and Erfrierungen im Pelde [Cold

Injuriesand Frostbite on Active Service], Bruns’ Beitr. z. klin. Chir. 174:1-10, November 1942. Abstract Bull. War Med.

4:507, May 1944. (5) Richards, R. L.: Injury From Exposure to Low Temperature: Clinical Features, Prevention,

Treatment. Brit. M. Bull. 2:141-142,1944.
Plate 1.—Various types and stages of high-altitude frostbite.

GENERAL CONSIDERATIONS, COLD INJURY 13

involved tissues are extremely hard and fixed. In other instances, the affected

part is indicated by the presence of small, superficial, plaquelike lesion. The first pathologic response to frostbite is an acute inflammatory reaction, quite similar to that observed in burns. Thawing is invariably followed by

state of reactive hyperemia, the intensity of which depends upon (1) the degree

and duration of the exposure and (2) the rate at which the temperature of the

part is raised. As in burns, the triple response characteristically present in the

affected area, which is explained by the release of histaminelike substances from

injured tissue cells, consists of (1) local reddening, (2) the appearance of blister

or of blister and wheal, and (3) flare.

The eventual tissue damage depends upon the degree and extent of the

actual freezing which has occurred and to an equal or even greater degree upon

the transudation of fluid, and sometimes of blood cells, into the tissue spaces

during the period of reactive hyperemia. The transudation is the direct result

of increased permeability of the damaged capillary endothelium, which leads

to swelling of the tissues, edema, and gross blister formation. In severe cases,

secondary thrombosis of arterioles and capillaries may produce regional anoxia

and cyanosis, which may go on to gangrene. Whatever the pathologic manifestation, the basis of the process is the prolonged peripheral vasoconstriction

induced by cold.

High-Altitude Frostbite

High-altitude frostbite (plate 1) is type of cold injury sustained by aviators and other flying personnel when they are flying in altitudes in which extreme degrees of cold (—40° to —52° C.) are encountered and in which wind

velocities may be in excess of 200 miles per hour. Among the contributing

causes are freezing of the oxygen mask, insufficient clothing, inefficiency of

electrically heated clothing, and inadequate supervision and discipline of flying

personnel, which result in unnecessary exposure of the hands by removal of the

gloves (p. 131) and other failures to prevent exposure. This type offrostbite is

most often observed on the hands, but it may occur on any exposed part of the

body and after only few seconds of exposure.

High-altitude frostbite was first described by Col. Loyal Davis, MC, Senior

Consultant in Neurosurgery, Office of the Chief Surgeon, ETOUSA, and his

associates, 16 in 1943. Since then, there has been rather general acceptance of

their thesis that this type of frostbite is essentially the same as other types of

cold injury but that it differs from the ground type in clinical severity and in

the rapidity with which pathologic changes occur. Cold, just as in the ground

type, is the primary agent which produces the pathologic changes, but the extreme low temperatures introduce two secondary mechanisms; namely, (1)

generalized anoxemia and (2) local anoxemia of the affected parts. The local

anoxemia is caused by the reduction of the local blood flow as result of acute

>6 Davis, L., Scarff, J. E., Rogers, N., and Dickinson, M.: High Altitude Frostbite. Preliminary Report. Surg

Oynec. Obst. 77: 561-575, December 1943.

438404'—58
14 COLD INJURY. GROUND TYPE

vascular spasm. The basic morphologic change, according to these observers, is damage by cold to the endothelium of the terminal capillary loops. In mild

injuries, the change is limited to pathologic permeability of the capillary walls. In more serious injuries,thrombus formation occurs at the arteriolar-capillary

junction. In the few pathologic specimens available for study, both arteries

and arterioles showed remarkable thickening of the intirna (fig. 1), the vessels

resembling those seen in endarteritis obliterans. The veins were not involved.

Figure 1.—Photomicrograph of cross

section of small artery cm. proximal to

line of demarcation of gangrene in finger

amputated because of severe high-altitude

frostbite, dry type. Note marked thickening of intima and absence of central

thrombus and of evidences of recanalization. The endothelium is intact.

AFIP MAMAS 221

In the mild type of high-altitude frostbite, the fingers, after brief period

of exposure, become painfully cold, numb, stiff, waxy white, hard, brittle, and

completely insensitive to touch. They cannot be flexed or extended voluntarily,

and often they cannot be moved passively. Surface temperatures of the

affected fingers may be 7.2° to 10.8° F. (4° to 6° C.) lower than those of the

corresponding fingers on the unaffected hand. Even early in the injury,

capillary microscopy shows no blood at all in the terminal capillaries on the

dorsum of the fingers about the nail beds (fig. 2). This phenomenon, according

to Davis and his associates, can be explained in two ways. It may be the

result of an initial intense vasomotor spasm of the terminal portions of the

arterioles, or, in some instances, it may be the result of secondary thrombus

at the point at which the arteriole, with its muscular wall, joins the thin-walled

capillary.

Recovery from even mild high-altitude frostbite may be quite slow (fig. 3).

Several hours are likely to elapse before the tips of the fingers begin to soften.

If, however, the extremities and body can be brought back to normal body

temperature there will be no blister formation, gangrene, or evident residuals, though the fingers may ache and throb for several hours and paresthesia may

persist for days or weeks.

If the exposure to cold has been prolonged, tissue damage is severe and

often permanent, and clinical manifestations are also severe. Two types of

lesions, wet type and dry type, have been observed.
GENERAL CONSIDERATIONS, COLD INJURY 15

Normal Abnormal AFIP 56-3917

Figure 2.— Drawing of microscopic appearance of capillary bed at base of nail in

normal finger and in frostbitten finger. Note hairpin appearance of parallel capillary loops

in normal fingerand their absence in affected finger. The thrombosed stumps of the arterioles

are characteristic of the frostbitten finger.

Figure 3.—Persistent blanching of fingers due to vasoconstriction hours after

exposure to high-altitude temperature of

-40° C. (-40° F.).

The wet lesion (figs. 4, 5, 6, 7, 8, 9) takes the form of multiple small cutaneous blisters, which appear almost at the same time upon manyareas of the

skin of the affected part. They increase rapidly in size and eventually coalesce

to form one or more huge blisters, which may involve the entire dorsum of

finger or even the whole hand. Though these blisters sometimes resemble the

simple vesicles of second-degree burns, more often the pathologically excessive

fluid is held fast within the tissues composing the superficial layers of the skin.
16 COLD INJURY, GROUND TYPE

AFIP 56-3925

Figure 4.—Wet type of moderately severe high-altitude frostbite. A. Typical blister

formation. The index finger shows single vesicle which has completely collapsed after

incision. The middle finger shows blister which has failed to collapse after liberal incision,

because of the excess fluid held within the tissues. Neither blister is hemorrhagic. B. Fingers

shown in view month later. Blisters have dried, and desquamation has occurred. Note

loss of nail and absence of normal skin markings, as well as the delicate, tight, shiny, new

epithelium. These fingers remained sensitive to cold for many months.

On aspiration, small amount of fluid is obtained, if any at all, but fluid which is sometimes clear and sometimes contains red blood cells will ooze slowly for

several hours from the puncture hole. Hemorrhage most often takes place beneath the nails, which are likely to be lost. Superficial layers of skin are

eventually dissected away from the deeper layers by extravasated fluid and

are cast off, frequently in the form of complete cast of the part (fig. 8). Most of the germinal layer comes away with the cast (fig. 9), and epithelial regeneration is therefore possible only from the remnants of germinal epithelium left in the ducts of the sweat glands. The newly regenerated skin varies in color from dusky pink to dusky blue. It is thin, smooth, shiny, and tightly drawn. Cold tolerance is greatly reduced (chart 1), and anesthesia or hypesthesia to pain and touch, with loss of sweating, may continue for months (fig. 10).

The dry type of high-altitude frostbite (figs. 11, 12, 13, 14, 15, 16), which usually follows more severe exposure to cold, at first resembles the wet type. Thawing is slow process, however, and instead of blister formation the affected parts become extremely tense, the skin has the appearance of dull ground glass and becomes progressively drier, and the deeper tissues assume

progressively darker shade of dusky gray. All the tissues eventually shrivel

and mummify, the changes being most marked at the distal portions of the extremities. After or weeks, line of demarcation is clearly evident, and

spontaneous natural amputation will take place unless surgical intervention

terminates the process.
GENERAL CONSIDERATIONS, COLD INJURY 17

AFIP 56-3924

Figure 5.—Wet type of severe high-altitude frostbite. A. Severe blister formation

24 hours after injury. B. Hands shown in view months later, showing regeneration of

lost nails. The skin in the blistered areas is beginning to recover its normal surface markings.

Sensory disturbances and loss of sweating persisted for many months.
18 COLD INJURY, GROUND TYPE

AFIP 56-3926

Figure 6.—Wet type of moderately severe high-altitude frostbite. A. Hemorrhagic

blisters. Note discoloration of nails. B. Hand shown in view 10 days later. The blisters

have dried up, and the skin has an ecchymotic appearance. Desquamation occurred later.
GENERAL CONSIDERATIONS, COLD INJURY 10

AFIP MAMAS 221

Figure /. Wet type of severe high-altitude frostbite, with hemorrhagic blister formation, 24 hours after injury.

AF1P MAMAS 221

igure 8.—\V et type of severe high-altitude

frostbite. Cast desquamation of tips of fingers followed severe blistering.
20 COLD INJURY, GROUND TYPP

AFIP MAMAS 221

Figure 9.—Photomicrograph of section of skin from blister

in wet type of moderately severe high-altitude frostbite. Note

separation of epidermis from dermis and, in particular, loss of

basal germinal layer with epidermis.

THE SPECTRUM OF COLD INJURY

Injuries caused by cold may be roughly grouped according to their primary

causes. In frostbite and freezing of the tissues, cold is the sole agent. In

immersion foot, cold and wet both play roles, with wetness occupying the

predominant role. In trenchfoot, cold and wet play approximately equal

parts.

It is possible to postulate range or spectrum of cold injury, beginning

with mild chilblains and ending with severe frostbite at low temperatures and

death from freezing of the deep tissues. While the place of the various injuries in the spectrum is determined by the degree of cold, the effect of cold may be

greatly intensified by contributing factors, such as wet in trenchfoot and immersion foot, and anoxemia in high-altitude frostbite.

Precise data gathered by long observation and study have made possible the quantitative evaluation of disease. range from inapparent disease

on the one hand through fulminating disease on the other can be easily demonstrated in relation to deaths. Data collected in World War II and from other

sources do not support similar gradient of cold trauma, though the explana- tion may well be the shortcomings of the available data rather than any defect in the principle itself. The variety of contributing factors also helps to explain

why it is difficult to formulate gradient of cold trauma. Epidemiologically, the establishment of such gradient would be highly desirable. Future experience must supply the data required and overcome other difficulties. Meantime, it is possible to postulate the probable behavior of cold trauma (chart 2).

Many factors come into play in cold-trauma gradient. Each component

constitutes gradient to itself, and each is influenced by multiple properties of

the agent, the host, and the environment. The development and interpretation
GENERAL CONSIDERATIONS, COLD INJURY 21

Chart 1.—Graph showing cold tolerance of normal right hand and frostbitten left hand

The curves shown represent the mean of the skin temperatures taken from the four

fingers by electrothermocouples. Note that the temperature of the normal right hand

could not be reduced below 5° C. (41° F.) after 50 minutes in the cold chamber. At that

point, the hand began to warm spontaneously, and in 25 minutes the skin temperature rose

4° C. (7.2° F.). After its removal from the cold chamber (after 75 minutes), the hand

quickly reached temperature 8° higher than in the beginning. In contrast, after 10 min- utes in the cold chamber, the skin temperature of the frostbitten left hand fell almost to

zero, and the hand became so painful that it had to be removed from the chamber. The

skin temperature of this hand did not then return to the original level.

of the gradient of cold injury are influenced by the degree of cold, the degree of

wetness, individual susceptibility, the duration of exposure, the use of protective

measures and equipment, and other modifying factors.

If the relationships illustrated in the gradient which has been postulated (chart 2) are correct, the total area of cold trauma is divided, though not equally,

into four principal components. Severity or degree of injury varies in each

component; it is least for chilblains and greatest for freezing of deep tissues,

thus forming an ascending gradient of severity from left to right. Trenchfoot
22 COLD INJURY, GROUND TYPI

Figure 10.—Persistent hypesthesia in

high-altitude frostbite, sustained at temperature of —40° C. 40° F.). Solid lines

represent limits of hypesthesia and dotted

lines limits of hypalgesia hours after exposure. There was complete loss of pain

and touch over the distal phalanges of the

index and little fingers.

AFIP 56-3922

Figure 11.—Dry type of mild high-altitude frostbite. A. Early stage. Blistering

has not occurred but note ground-glass appearance of skin of fingertips. The deeper underlying tissues were under great tension and were quite painful. Gangrene of the affected

parts followed. B. Hand shown in view months later, showing loss of nails and tissue

of fingertips.

and immersion foot occupy the largest area and chilblains the smallest in terms

of defect or more severe injury. This is the precise proportionate relationship

of these cold injuries in terms of their military importance. Few, if any,

deaths are caused by chilblains, and the disability they cause is not great.

Though deep freezing of the tissues is accompanied by high case fatality rate

and by some disability in the survivors, its importance, in terms of numbers of

cases, is far less than that of trenchfoot and immersion foot, as shown by the
GENERAL CONSIDERATIONS, COLD IXJI'RY 23

Figure 12.—Dry type of severe high-altitude

frostbite. A. Early stage (1 hour after injury).

B. Hand shown in view days later. Note

almost total absence of blistering. C. Hand

shown in view weeks later, showing far-advanced dry gangrene.

AFIP 56-3923

comparable areas in the schema. Trenchfoot and immersion foot are responsible for few deaths but for much temporary and permanent disability. Frostbite, while it carries higher case fatality rate than either trenchfoot or immersion foot, is proportionately less important in terms of temporary and

permanent disability or defect and over-all military cost.

It should be emphasized that these assumptions hold only for military

operations conducted in winter in temperate climate, such as that of western

Europe. They would be greatly altered for operations conducted in the intense

and sustained cold of the Arctic.
24 COLD INJURY, GROUND TYPE

AFIP 56-3919

Figure 13.—Dry type of severe high-altitude frostbite. A. Photograph 10 hours

after injury. The hand has been dressed with sulfanilamide powder. B. Hand shown

in view weeks later, showing spontaneous amputation of tissues as result of dry

gangrene.

The specific causative agent in cold injury is cold, 17 but evaluation of the

World War II experience makes it clear that wet, because it speeds loss of body

heat, is closely related. The influence of wetness, however, is entirely synergistic. It cannot of itself cause cold injury. Factors related to the soldier

himself and to his environment also play part in the total causation of cold

injury. Recognized human factors include the status of individual training,

the individual nutritional status, fatigue, previous experience with cold injury,

and inherent constitutional and psychosocial qualities, in addition to the

mechanical factors of posture and dependency. Elements of the physical

environment which enter the picture are the weather (that is, temperature,

precipitation, and wind), the altitude, the terrain, and thawing. Socioeconomic

influences include clothing supply and equipment, foot discipline, command

leadership and attitude, training and experience as applied to the unit, and

rotation of personnel.

17 See footnote 3, p. 7,
GENERAL CONSIDERATIONS, COLD INJURE •25

AFIP 56-3921

Figure 14.—Dry type of severe high-altitude frostbite. A. Early stages of mummification and dry gangrene 10 days after injury. B. Hands shown in view month

later, after guillotine amputation of gangrenous parts.
COLD INJURY, GROUND TYPE 26

AFIP 56-3920

Figure 15.—Dry type of severe high-altitude frostbite. A. Photograph 10 days after injury. Note developing dry gangrene in little

finger of left hand and absence of blistering. The thumb and index

fingers of the right hand show the late stage of hemorrhagic blistering;

the skin has turned hard and black, and to the uninitiated the changes

could easily be mistaken for gangrene. B. Hands shown in view

months later.
GENERAL CONSIDERATIONS, COLD INJURY 27

AFIP

MAMAS 221

Figure 16—Mixed wet

and

dry

types

of

severe high-altitude

frostbite.

A.

Huge

vesicular

blister

72

hours

after

injury.

B.

Hand

shown

in

view

10

days

later,

showing

developing

dry

gangrene in

deeper

tissues

of

fingertips.

C.

Hand

shown

in

view

months

later.
28 COLD INJURY, GROUND TYPE

Chart 2.—Gradient of cold injury (schematic)

Deaths Defect Disability (temporary)

PROPORTION OF COLD-INJURY INCIDENCE BY DIAGNOSIS

All of these factors enter into the total causation of cold injury. Effective

prevention and control, however, can be established only by evaluating the

weight of each factor by studying each of them in individual units. The control

of mass injury or disease depends upon methods and measures directed at

causes. Analyses of cause and effect provide the only means for developing

concerted plan for meeting the problem in any future war.

The simple, sound epidemiologic methods used in the field in World War II

to identify the several components in the total causation of cold injury demonstrate that only few of these components are amenable to practical control and

preventive practices. Thus, the type of combat action, terrain, and weather

are universal causes which influence the incidence of cold trauma wherever it

occurs but which are not amenable to control. On the other hand, as field

studies during World War II clearly demonstrated, the level of the clothing

supply, individual and unit discipline, rotation policies and practices, and the

training and experience of troops, all of which exert variable influence upon

the incidence of cold injury, are all subject to control within the limits of the

tactical situation. Further study and research should be directed to the

intangible causative factors, which are not susceptible to precise measurement,

to determine whether the base of practical control of cold injury can be

broadened.

Note.—For statistical purposes, trenchfoot and frostbite are not always separated in Army reports. Clinically, as

already indicated, they are oftenIndistinguishable. Practically, itwould have beenbetterif no attempt had been madeto

differentiate them (p. 303). Generally speaking, whatever is said about one in the following pages may be regarded as

equally applicable to theother unlessspecific exception is made. Similarly, whateveris said about cold injuries of the feet

may be regarded as equally applicable to cold injuries of the hands, which, as practical consideration, are affected in

only very small proportion of the injuriesof this type.
29

CHAPTER III

Historical Note

With the single, and notable, exception of Larrey’s observations during the

Napoleonic Wars, injuries of warfare caused by cold and exposure were not

recorded in any great detail until fairly modern times, more particularly until

World War I. Numerous brief references, however, indicate that this type of

injury was responsible for an important loss of manpower in early military

history. Thus, there are references to frostbite in the writings of Hippocrates,

Aristotle, and Galen. The armies of Alexander of Macedon experienced

casualties from this cause. According to Grattan, Xenophon, in the Anabasis, mentions cold injury as significant problem in the Greek armies operating in western Armenia late in the fourth and early in the third centuries B, C.

In more modern times, Thatcher described serious losses from cold injury.

In 1777, 2,900 of an army of 10,000 men were unfit for duty because of sickness

and lack of clothing. By February of the following year, the number of

casualties had been increased by nearly thousand men who, according to

General Washington, “had been left to perish by winter cold and nakedness.”

In January 1780, some 20 percent of 2,500 men sent from Elizabethtown to

attack the British on Staten Island also suffered cold injuries. Thatcher writes:

“The party passed over on the ice but the enemy having received intelligence of their design returned into their strongworks The snow was

three or four feet deep, the weather extremely cold, and American troops continued on the island for twenty-four hours without cover. About 500 were

slightly frozen.”

Benjamin Rush, who was physician general to the military hospitals of

the United States during the Revolutionary War, contributed, perhaps unwittingly, some useful advice in the prevention of cold injury. In small

pamphlet of directions for preserving the health of soldiers, he wrote: “The

Larrey, D. J.: Memoirs of Military Surgery and Campaigns of the French Armies, on the Rhine, in Corsica, Catalonia, Egypt, and Syria; at Boulogne, Ulm, and Austerlitz; in Saxony, Prussia, Poland, Spain, and Austria. Translated

by Richard Willmott Hall, with notes by the translator. First American edition from the secondParis edition. Baltimore: Joseph Cushing, 1814, 2: 153-164; 205-224; passim.

Ariev, T. V.- Fundamental Outlines of Present Day Knowledge of Frostbite. Medgiz: Moscow, 1943. This is

one of series of 16 papers originally published in Russia from 1939 to 1944 and translated into English and published by

Earl R. Hope, in Ottawa, Canada, in 1950 under the title “Frostbite.”

Grattan, H. W.: Trench Foot. In History of the Great War Based on Official Documents. Medical Services.

Surgery of the War. London: His Majesty’s Stationery Office, 1922, 1:169-177.

Thatcher, James: Military Journal of the American Revolution. Hartford: Hurlburt Williams and Co., 1862,

pp. 127, 188.

Rush, Benjamin; Directions for Preserving the Health of Soldiers, Addressed to the Officers of the Army of the

United States. Published by orderof the Board of War, 1777. Pennsylvania Packet, No. 284.
30 COLD INJURY, GROUND TYPE

commanding officer should take the utmost care never to suffer soldier to

sleep, or even to sit down in his tent with wet clothes, nor to lie down in wet

blanket or upon damp straw. The utmost vigilance will be necessary to guard

against this fruitful source of diseases among soldiers.”

THE NAPOLEONIC WARS

The role of cold as such in the production of injuries to the body tissues

was vividly, and for the most part correctly, described by Baron Larrey,

surgeon to the French armies in the Napoleonic Wars. His classic description

of the part played by frostbite and “congelation” in the defeat of these armies

in Poland in 1812 is an accurate and affecting resume of the tactical and clinical

effects of injuries caused by cold. It is of sufficient importance, in fact, to be

related in considerable detail.

Baron Larrey began Ids military medical career in the French Navy,

serving in waters in which immersion foot might well have been observed.

At the end of years, chiefly because of his susceptibility to seasickness, he

transferred to the army, in which he became division surgeon. In this new

position, he quickly perceived that the previously accepted practice of waiting

to care for the wounded and dispose of the dead until the battle had moved

on was resulting in great, and for the most part unnecessary, loss of life and

limb. To remedy the situation, he devised field medical organization in

which light ambulances, together with field stations, brought medical care to

the wounded immediately behind the lines. He eventually developed this

service to such point that it was often possible to have all the wounded off

the field and cared for by military surgeons within 24 hours after battle had

ended. The development of this effective divisional medical service gained

such recognition for Larrey that he was withdrawn from his division and

charged with the responsibility of developing similar system for the whole

army. Shortly afterward, he was ordered to join the army commanded by

Napoleon, with whom he served for many years, eventually becoming chief

surgeon of the Grande Armee which was to invade Russia.

The principles and practices of military medicine laid down by Larrey are

essentially those used in modern military field medicine. He was, in addition

to being an administrative genius, skillful and accomplished surgeon, and it

is not surprising, therefore, that his description of frostbite and of the changes

underlying its clinical manifestations comes very close to the present concept

of the causation and pathogenicity of injuries of warfare caused by cold.

Causes of cold injury.—Physicians who had previously written on this type

of “mortification,” Larrey pointed out, believed cold to bo the exciting cause

of the gangrene. Attention to the time at which the gangrene occurred, however, as well as to its progress and the phenomena which accompanied it, would

make it clear that cold was only the predisposing cause. Between the 5th and
HISTORICAL NOTE 31

9th of February 1807, before the battle at Eylau, in Prussia, not single soldier

in the French Army complained of frostbite, although the temperature ranged

from —10° to —15° R. (Reaumur thermometer) or from 9.5° to —1.8° F. and during this period they had spent all of their days and most of their nights

in the snow and in most severe frost. Even the Imperial Guard, which had

been on duty for more than 24 hours, in the snow, without much exercise, did

not suffer frostbitten feet.

During the night of and 10 Februrary, the temperature suddenly rose

to 3°-5° R. (38.8°-43.2° F.). On 10 February, copious fall of sleet occurred,

and the following day thaw set in and continued for some time. Almost

immediately, number of soldiers of both the guard and the line began to complain of their feet. Their first symptoms were “acute pains in the feet, torpour,

heaviness, and disagreeable pricking in the extremities, which were slightly

swelled and of dark red.” In some instances, the base of the toes and the

upper surface of the foot were slightly reddened. Sometimes, the toes were

without any sensation, heat, or motion and were black and “in manner dried.”

Without exception, the affected soldiers assured Larrey that they had felt

uo pain or other untoward sensations during the severe cold in bivouac on 5-9

February and that it was not until 10 February, when the temperature rose

by 18° to 20° R. (40.5°-45° F.), that they began to experience “congelation.”

The first symptoms were not severe. Painful, pricking sensations were succeeded by numbness, stiffness, immobility, and sense of heaviness as well as

of cold. Those men—fortunately the greater number—who followed the advice of Larrey and his colleagues, to rub the affected parts immediately with

snow and later with camphorated brandy, did not suffer from gangrene if it

was not already present when treatment was begun. Those able to go into

town, like those who approached the fire of the bivouac to warm themselves,

were severely affected. Gangrene appeared almost abruptly and progressed

rapidly in men who approached the fire. While it was generally limited to the

toes and seldom rose above the ankle, in some instances it extended over half

of the foot.

This type of “sphacelus of the foot,” Larrey emphasized, should not be

confused with gangrene of the skin. He had observed casualties in whom,

while the skin of the foot was deprived of life to greater or lesser degree,

the vessels, deep-seated nerves, tendons, ligaments, and bones were not affected.

The patient experienced pain when the subjacent parts were touched, but the

foot retained its internal heat and could be moved. Gangrene of this type,

Larrey continued, “*

is superficial, and cannot be considered as similar

to the sphacelus of the foot that deprives it of motion, of sensibility, and of all

the phenomena of life. The patient cannot feel that he has foot and it appears

like foreign body suspended to his leg.”

Then followed the important warning that the nature of the disorder

must be carefully ascertained before amputation was resorted to and that

general remedies should always precede surgery.
32 COLD INJURY, GROUND TYPE

Larrey’s explanation of the progress and development of this gangrene,

or, as he preferred to call it, of “the modus operandi of the causes which produce it,” follows, in his own words:

Cold acts on the living parts by blunting the sensibility of those organs which are subjected to its immediate impression: the natural heat is absorbed, and discharge and repercussion of calorick takes place; the pores are closed: the fibres and the capillary vessels

fall into state of contraction; the fluids are condensed, and flow more slowly. At first,

the action of the cold is painful: the skin wrinkles and loses its natural colour. Yet, the

animal heat and the vital powers resist this sedative and contracting power that opposes

the return of the fluids: the capillary system is obstructed more easily when its extreme

ramifications are weakened. The skin becomes red, its sensibility is blunted, and if the

effects of the cold continue, it gradually becomes extinguished and torpour soon takes place.

The parts may remain for longer or shorter period in this state of asphyxia without losing

their life; and if the cold be removed by degrees, or if the person affected by it pass gradually

into more elevated temperature, the equilibrium may be easily reestablished with the

functions of the organs, and the disposition that the parts have to fall into gangrene is removed: but if on the contrary, persons who are thus affected by cold pass suddenly from

temperature at the freezing point to one more elevated, an obstruction of the parts affected

must of necessity be produced; and if it be considerable, the vessels lose their elasticity altogether, become paralyzed, and sometimes burst, or are torn asunder: and hence follow

blisters and cracks, or fissures of the part. The course of the fluids in the vessels is interrupted; there is redundance of carbon, the parts turn black, and gangrene is abundant.

Infection is propagated to all those parts which have been seized on, or affected by the cold.

Thus the gangrene advances until it meets with resistance from the vital powers. Now the

systaltick motion of the vessels, the irritability of the cellular substance of the membranes

and of the skin, which had resisted the action of the cold, resist the principles of the gangrene,

and far from absorbing them, the extremities of the capillary vessels which convey blood,

and the lymphaticks being irritated by these heterogeneous qualities, become obstructed

and inflamed: the gangrene is circumscribed, and line of separation formed between the

dead and the living parts. If the mortification be superficial, the sloughs are generally

thrown off between the ninth and thirteenth days: they leave wound or ulcer which soon

heals. If the whole of limb be deprived of life, nature of herself is not sufficient to remove

the dead parts, because she has too many obstacles to surmount; at least she can seldom

overcome them. The resistance almost always surpasses her power, and the patient sinks

in consequence of the absorption that takes place when the sloughs are detached, and suppuration has opened the mouths of the absorbents. This absorption affects organick life;

slow fever ensues, with colliquative diarrhoea: the gaseous exhalations from the gangerened

parts disorder the organs of respiration, and concur with the matter that has been absorbed,

in producing general debility of the functions, and death. After some time, gangrene

may pass immediately to the neighbouring parts; but this can never happen before the

ninth or tenth day, when the sloughs fall off: the vessels and the cellular tissue are then

prepared to absorb, but that does not always take place, and then the disease may remain

stationary; it becomes defined, and the dead parts separate from those which retain their

vital power and action, and the general functions are not disturbed. The dead parts fall

off, the sores which are the consequence, soon heal up, and the patient recovers.

Larrey concluded his description of these phenomena with the assertion

that he was quite positive that they never appeared until the temperature was

suddenly raised “from very low to very high degree above zero.” He was

convinced that “partial or general death” cannot take place merely from the

severity of the weather in persons subjected to the influence of cold for long
HISTORICAL NOTE 33

period, “even until they are seized with asphyxia, unless second sedative or

narcotick cause act internally in concert with it.”

Numerous instances were cited to support this theory. Thus, travelers

who crossed the Alps and the Pyrenees during intense frosts did not suffer harm as long as the level of cold remained the same. Larrey had had this

experience himself. The Polonese chose “the time of the most regular cold” to undertake long and difficult journeys from Siberia but avoided travel when the temperature was variable because, they told Larrey, they feared “the effects of congelation.” In May 1788, while Larrey and his companions were

in North America, they found at Belle Isle, near Newfoundland, number of

persons who had been shipwrecked and who had passed several days lying under the snow during period of intense cold. The victims suffered no accidents during this period; but when the temperature changed, on the day of

their rescue, two died suddenly and the feet of several others “fell into gangrene.”

At the end of the winter of 1795, when Larrey was with the Army of the

Eastern Pyrenees, numerous soldiers suffered from frostbite when an extreme

degree of cold was succeeded by an elevated temperature. The suffering was

most extreme in men whose feet had already been frostbitten at the siege of

Roses. During the preceding 15 to 20 days of “rigorous cold” and up until

the time the thaw commenced, Larrey had observed no frozen limbs in any of

the ambulances over which he presided. Within 24 hours after the change of

weather, some of the more advanced sentinels were found dead at their posts.

Larrey also related instances of gangrene caused by “congelation” in

other parts of Europe. During the conquest of Holland, for instance, as he

was informed by M. Paroisse, first surgeon to the King ofSpain, great number of soldiers had their feet frostbitten. The men had long been exposed to snow

and ice, but gangrene did not appear until the thaw commenced.

Still another experience concerned the army which left Madrid on 22

December 1808 to cut off the retreat of the English Army on the road to Corunna. The next days were spent crossing the Guadarrama Mountains.

It had been snowing for several days, and, at the foot of the mountains, the wind blew directly from the north and the temperature was 9° below zero R. (11.75° F.). As the men ascended the mountains, the cold, already piercing, became still more intense, and thick whirlwinds of hoarfrost and snow made

halt imperative. During the overnight halt, the temperature rose several

degrees. When fires were kindled, Larrey continued:

they were more injurious than useful *. For all who subjected their hands

or feet to the warmth of the fire, were suddenly affected with gangrene from congelation, to greater or less extent. But this gangrene appeared in no case among those who avoided

the fire. One of the soldiers of our ambulance, having had his right hand affected with the

cold as he climbed the mountain, suddenly approached the fire of bivouac, and chafed his

hand near it. It instantly swelled in surprising manner, like dough when put into hot

oven. When he rejoined his ambulance some hours after, his hand was entirely sphacelated,

and was obliged to amputate it at the wrist. This fact supports the opinion on which

advanced relative to gangrene from congelation.
34 COLD INJURY, GROUND TYPE

Cold, Larrey concluded in the light of these various experiences, is only

the predisposing cause of gangrene, which can be averted by taking care to

remain away from heat and to avoid subjecting parts “benumbed by the cold

to its sudden action.” The exciting cause is heat “*

suddenly applied to

the parts which have been rendered torpid by cold *. Let this principle

be once established and it will be easy to prevent the effects of congelation.”

Data on injuries caused by cold among Russian troops in the campaign of

1812 are scanty. They probably suffered severely, though not as severely as

the French, because, according to Ariev, they were already acclimated to the

severe weather and they had some knowledge of the elementary rules for combating frostbite. These factors, he thought, exerted protective influence,

although Russian soldiers, like French soldiers, were hungry, tired, and poorly

clothed and thus were subject to the very conditions which might predispose

to cold injury.

Therapy.—Except for the warning against the sudden application of heat

to the affected part, which is still sound advice, Larrey’s methods of treating

cold injuries are merely of historic interest. First aid consisted of friction

with snow or ablutions with water in which ice had been dissolved. If snow

or ice could not be procured, cold red wine or vinegar and camphorated brandy

were substituted or the parts were immersed in well water. Full details were

given for the management of gangrenous limbs, but amputation, it was

emphasized, was always last resort.

THE CRIMEAN WAR

Many of Larrey’s observations were made on soldiers who operated under

conditions of extreme cold and who were facing, and later experienced, disastrous defeat. In the course of the defeat and the retreat which followed,

large part of the army was lost as consequence of cold and intercurrent

disease. The military cold injuries next recorded, in the Crimean War of

1854-56/ arose on very different basis, in that the cold in which they were

sustained was not extreme and the military circumstances were different.

During the first winter of the war, fighting in the Crimea took the form

of dogged trench warfare, with relatively little change in the position of either

side. The campaign was fought by inexperienced soldiers, who were handicapped by lack of supplies, clothing, and food. Diarrhea and dysentery were

prevalent and were attended with high mortality, and 1,924 cases of frostbite were reported. Mr. Dumbreck, of the First Regiment, did not find this

surprising. “I consider,” he observed, ‘That many of the cases of denominated

gelatio, were in reality gangrene from debility, many of the men having been

See footnote 2, p. 29.

Medical and Surgical History of the British Army During War Against Russia in Years 1854-56. London: His

Majesty’s Stationery Office, 1858, vol. 2.
HISTORICAL NOTE 35

attacked when the thermometer was between 40° and 50° Fahrenheit.” Dr. Longmore shared his views. The frostbite which occurred during 1854 and 1855, he stated, “could not be attributed to the severity of the climate, but was chiefly owing to the exceedingly depressed vital power which charac- terized the general condition of the soldier at that period.”

It seems reasonable to accept the opinion of these observers that the frostbite which occurred in the British Army during the first winter of the Crimean War was not primarily caused by cold. Through October, the weather was rather mild. In January, itis true, snow fell and there was much “frost,” but low temperatures, in themselves, did not seem to produce cold injuries. Many, on the contrary, seemed to occur as direct consequence of

exposure to wet, especially when the winds blew from the northeast. Periods of thawing seemed particularly likely to produce cold injuries, which were

notably frequent when frost by night alternated with thaw by day. Men in the trenches, especially the most forward trenches, experienced protracted

exposure under the most unfavorable possible conditions. They often had to stand knee-deep in mud and water as well as in snow. Their movements were restricted because of the vigilance of the enemy. Often, to protect themselves, they had to seek shelter in the bottom of the trenches, where the bad conditions under which they ordinarily existed were likely to be worse.

They sometimes remained in such situations for 12 to 24 hours. In addition, their hands sometimes became gangrenous from handling “wet metallic substances.”

The authors of the official history of the Crimean War recorded other deficiencies. The soldiers’ boots were defective and quite unsuited for this

type of operation. Often, they had been fitted in too small sizes, and the men

were afraid to remove them for fear that they would not be able to replace them. Shelter and bedding were equally unsatisfactory. Tents were of

single-thickness canvas, with flaps that were difficult to close. The allotment of blankets was one to man. Straw, hay, reeds, boards, stretchers, and similar makeshifts had to be used for beds. Firewood to be used for the preparation of food was difficult to come by, and the partial inadequacy of

nutrition was evidenced by the high incidence of scurvy. The chronic fatigue of the men, as well as the high incidence of diarrhea and dysentery, has already been mentioned.

It has already been pointed out that during the winter of 1854-55, in

force of slightly less than 50,000 men, there were 1,924 cases of cold injury, of

which 457 (23.75 percent) were fatal. During the winter of 1855-56, there

were only 474 reported cases, of which only (1.3 percent) were fatal. Since weather conditions and precipitation were essentially the same in both years,

one must look elsewhere for the explanation of the improvement in the second winter of the war. The clue is found in the medical records of the British experience, which describe two distinct types of cold injury. The first, which
COLD INJURY, GROUND TYPE 86

was caused by cold in conjunction with debility, occurred during the first

winter of the war. The second, which was caused by cold alone, occurred

during the second winter. Furthermore, the high death rate recorded for the

first winter was not the result of cold injury alone; it was caused also by enteric

diseases and typhus fever, which often developed when the soldiers were

hospitalized for their cold injuries.

The authors of the history of the Crimean War supply numerous details

which explain the improvement in the second winter of fighting. During the

summer, the troops in the Crimea regained most of their physical vigor and

“ability to resist the affection.” They were no longer the “raw unformed

lads” who had made up large part of the fighting force the previous winter.

Instead, they were seasoned, hardened troops. While the type of combat

action in the winter of 1855—56 did not differ greatly from the action in the

preceding winter, men had to spend less time in the forward trenches. Finally,

living conditions were better, food supplies were much more adequate, and

the individual soldier had gained some understanding of how to protect himself

against the cold.

number of other perspicacious observations on cold injury are found in

the official history of the Crimean War. It was the authors’ opinion that even

higher rates of injury might have been experienced had the type of warfare

been mobile instead of static and had there not been opportunities of “receiving

reinforcements from the seaboard.” reconnaissance in force made in the

midst of severe storm from which the men returned very cold and greatly

exhausted is described in this history. The authors noted that, if Sir Cohn

Campbell and the officers of the regiment had permitted the men in this operation to rest and had not taken the precaution of keeping them constantly in

motion, many more cases of frostbite might have resulted. British military

surgeons were fully cognizant of the effect of alcohol in cold injury and remarked

on the high rates in drunken men.They were also aware of the underreporting

of cases, some of them mild cases and others more severe gangrenous cases

associated with infectious diseases, to which death was likely to be attributed.

Finally, the British surgeons noticed that there was disproportionately

larger incidence of cold injury in the Infantry then in the Cavalry and Ordnance. The relative strengths of these arms is not recorded, but the distribution of fatalities is significant—5 in the Cavalry, 27 in the Ordnance, and 431

in the Infantry.

During this same 2-year period (1854-56), according to Sonnenburg and

Tschmarke (cited by Ariev), the 309,000 French troops in the Crimea experienced 5,215 cases of frostbite, of which 1,178 (22.6 percent) were fatal. Holmer, Hulke, and Florcken (also cited by Ariev), reported that during consecutive nights in Sevastopol, 2,800 cases of frostbite occurred, of which 900 were

fatal.
HISTORICAL NOTE 37

THE WAR OF THE REBELLION

he official history of the ar of the Rebellion does not describe frost- bite as distinct entity of medicornilitary importance nor are any statistics supplied for the incidence. It is possible, however, to derive some information from notes on amputations for gangrene attributable to frostbite or freezing, as well as from individual case histories under this heading.

large number of the 15,273 “other accidents and injuries” not caused by combat were instances offrostbite. There were 1,075 fatalities in this group (7.03 percent). In 259 amputations of the leg, in which there were 78 known deaths and 180 known recoveries, 147 of the operations were done for fractures, 44 for frostbite, 17 for gangrene, and the remainder for various other accidents and diseases. Twenty-two of fifty-one amputations of the feet were required for frostbite. One amputation was performed for gangrene caused by wearing tight boots and another for hospital gangrene. In 122 amputations of the toes, there were known deaths and 109 known recoveries. The indications for operation are stated only in the following case:

49-year-old hospital steward suffered frostbite of both feet when his

tent blew down and his feet were exposed in intensely cold weather. Although he was immediately aware, on awakening, that the foreparts of both feet were

frozen, he received no treatment until he was hospitalized month later. Then, dry gangrene of the toes of both feet was present (fig. 17), with destruction of the soft parts. Although the patient was in good spirits and doing well, disarticulation of the toes was regarded as indicated. year later, he was

discharged from service for disability and was pensioned. Twelve years later,

Figure 17.—Dry gangrene of toes of both feet, resulting from freezing, and extending on

the left side to the metatarsal bones, with destruction of the soft parts.

Medical and Surgical History of the War of the Rebellion. Surgical History. Washington; Government Printing

Office, 1883, pt. HI, vol, II, pp. 670-679, passim.
COLD INJURY, GROUND TYPE 38

he appeared before an examining board, which certified to his condition as

follows:

He has had all the toes of the right foot amputated through the metatarso-phalangeal

articulation except the little toe, which is drawn into the cicatrix. The foot is defective in

circulation and there are chronic ulcers of the leg extending from the ankle to within four

and half inches below the knee, being very offensive and requiring constant care and attention. This condition no doubt is due to anaesthesia of the foot and leg. The cicatrices

extend around the leg and are constantly scaling. There is also varix above to slight extent. The toes of the left foot were amputated at the tarso-metatarsal articulation, the

stump showing good horny cicatrix; hyperaesthesia of foot or stump; atrophy of leg;

stump alleged to be painful during changes of weather.

OTHER WARS OF THE 19TH CENTURY

During the Franco-Prussian War of 1870, there were 1,450 cases of severe

frostbite among 92,067 Prussian troops. Pirogov (cited by Ariev) observed

2,632 cases among 16,000 patients in the “gare de perruche” hospital, while

in General Burback’s military hospitals there were 610 cases in total of 5,944

casualties.

During the Russo-Turkish War of 1877-78, 4,500 patients suffering from

frostbite passed through the evacuation points in Jassy and Bendiara. These

casualties represented 1.5 percent of the total Russian expeditionary force of

300,000 troops in Bulgaria and 5.1 percent of the 87,989 evacuated casualties.

THE RUSSO-JAPANESE WAR

The British medical observers attached to the Japanese Army during

the Russo-Japanese War made detailed report on the cold injuries sustained

during the battle of Hei-kou-tai from 25 through 29 January 1905. According

to MacPherson, 300 men from one division and 205 from another were hospitalized for frostbite. Toke 10 stated that 300 men were hospitalized for

frostbite and that 173 others, who were not hospitalized, also sustained cold

injuries. It was additionally reported that about half of the men hospitalized

for other causes during the period of this engagement were likewise suffering

“more or less” from frostbite. Total casualties numbered 7,742, which makes

the ratio of uncomplicated frostbite to battle wounds about 1:15. The toes

were affected in 67 percent of the cold injury cases and the fingers in 28 percent, but the injury was usually mild and amputation of either fingers or toes

was seldom required.

On 23 January, days before the engagement began, the weather suddenly

changed. The temperature fell to low point, the relative humidity inMacPherson, W. H.: TheRusso-Japanese War. Medical and SanitaryReports from Officers Attached to the Japanese Forces in the Field. London; His Majesty’s Stationery Office, 1908, pp. 242, 349.

10 Toke, R. T.: The Effects of Cold During the Battle of Hei-kou-tai, 25-29 January 1905. In the Russo-Japanese

War. Medical and Sanitary Reports from Officers Attached to the JapaneseForces in the Field. London: His Majesty’s

Stationery Office, 1908, p. 201.
HISTORICAL NOTE 39

creased, and the wind began to blow from the north. Snow fell on 26 January, the second day of the engagement. The high humidity persisted, and the weather continued bad during the remaining days of the battle. Most of the casualties occurred on 27 and 28 January, and most of them occurred at night. Idie temperatures for the whole period ranged from maximum of 17.8° F.

(—7.9° C.) on 26 January to minimum of 11° F. (—24° C.) on 29 January. The British observers listed as predisposing causes of the cold injuries wet

feet resulting from the penetration of melting snow through the stitching of the welts of the boots; constriction of the feet and interference with the circulation as the leather of the boots became hard and frozen; lack of food; the frequent night fighting, with resulting fatigue from lack of sleep; the inability of the men

to move from their fixed positions in the snow, so that they had no way of

stimulating the circulation in their feet; and their inability to light fires for warmth because of the close proximity of the enemy.

After the unfortunate experience at the battle of Hei-kou-tai, certain preventive measures were instituted and were practiced during the battle of Mukden. This battle was fought from through 10 March 1905, in tempera- tures varying from minimum of 0° F. (—17.8° C.) to maximum of 53° F.

(11.7° C.). The men were given extra socks and gloves, so that they could change them when those they were wearing became wet. Boots were well greased. When there were halts for any period of time, the boots were

removed and were replaced by Chinese felt or straw shoes. Finally, each man

carried in his pocket an issue of sugar, to eat when he lay in position; this was

measure in which Japanese medical men had great faith. During the whole

battle, only 70 patients were admitted to field hospitals for frostbite, and most

of these had other wounds. The excessive number of deaths in battle, how- ever, was attributed in part to deaths from cold as the wounded lay on the battlefield before they could be picked up.

In contradistinction to the reports of the British observers which have just been cited, Ariev stated that the incidence of frostbite among Japanese troops

was “staggering.” To support his statement, he cited Lynch’s report of

between 1,200 and 1,600 amputations in single month as the result of frost- bite. Russian Army medical statistics, according to Ariev, show 1,021 cases of

frostbite for the whole Russo-Japanese War; 410 of these were treated in hos- pital. Statistical tables from the same source record 1,469 cold injuries, of

which 856 were severe. It was Ariev’s opinion that the Russian incidence must have been higher than these figures indicate, since in the battle of Mukden alone there were well over thousand casualties from this cause.

THE TIBET EXPEDITION OF 1903-4

Davys, 11 in 1904, recorded, without mentioning the exact number of cases, an experience with frostbite sustained during the winter of 1903-4 and during

11 Davys, G. I.: Frost-bite In the Tibet Mission Force. Indian M. Gaz., 39: 245-247, July 1904.
COLD INJURY, GROUND TYPE 40

the following spring, both by men who served with the Tibet Mission Force in

the Chumbi Valley and by native inhabitants of the valley. The prime cause

of the injury, Davys noted, was combination of damp clothing and extreme

cold. Simple dry cold was seldom cause in itself, and the most serious lesions

were, as in Larrey’s experience, produced not by excessive cold but by carelessly applied heat.

Three degrees of cold injury were recognized: (1) Death of superficial

layers of skin; (2) death of the whole thickness of the skin and sometimes of

superficial fascia; and (3) death of deeper tissues, such as muscles and tendons.

Examination of the patients during the first two (ischemic) stages revealed the

affected parts to be cold, white, and painless. The third stage was characterized either by simple dry gangrene, or by moist gangrene, with which emphysema of the tissues was often associated.

Methods of treatment included putting the feet in cold water placed “near

but not on fire”; massage (“friction”) to produce slow warming; and, in

few cases, wrapping the affected part very thickly in wool and bandages and

placing it in box of warm sand. All methods of warming, Davys warned,

must be applied “very slowly.” To prevent gangrene of the deeper tissues, he

recommended that superficial dead skin be removed as early as possible; by

this means, it was often possible to save fingers and toes which were apparently

quite dead.

Connor, 12 while working in the Depot Hospital of the 8th Gurkha Rifles at

Shillong, treated some of the more severely injured men from the Tibet Mission Force for weeks and in some instances for months after the original injury.

Like Davys, he emphasized the importance of extremely conservative surgery

because he too found that dead, blackened skin was often only superficial and

that the underlying tissues were viable. Connor also commented on the aftertreatment of amputation stumps and recorded such sequelae as loss of tactile

sensibility and “persistent stiffness of the adjacent joints.’’

In this connection, there might be quoted an unscientific but nonetheless

significant observation on presumable cold injury in the British Army in

India—“in the middle of the Tangi Pass it was”—at the turn of the century.

Says Mulvaney, one of Kipling’s famed “Soldiers Three”:

Our docthor, who knew our business as well as his own, he sez to me “How often

have tould you that marchin’ man is no stronger than his feet—his feet—his feet,’' he sez.

“Now to the hospital you go,” he sez, “for three weeks, an expense to your Quane, an

nuisance to your counthry. Next time,” sez he, “perhaps you’ll put some av the whiskey

you pour down your throat and some av the tallow you put into your hair, into your sock,

sez he. Faith, he was just man!

12 Connor, F. P.: Notes on Some Cases of Frost-bite. Indian M. Qaz., 39: 365-366, October 1904.
HISTORICAL NOTE 41

THE BALKAN WARS

According to Page, 15 large numbers of Turkish troops suffered from cold

injury in the First Balkan War in the latter part of 1912, particularly near Tchatalja. Precise figures are not available, but it is known that the death rate was high, especially in men with the moist, spreading type of gangrene and in those who also had enteric disease or whose injuries were complicated by tetanus. The gangrene was symmetrical and practically always involved the feet; the fingers alone were seldom affected. The lesions varied from mere discoloration and blister formation of one or two toes to death en masse of the leg to the knee.

he temperature of the area in which the injuries were sustained was usually about 41° F. (5° C.). Page’s opinion was that the trauma produced vasomotor disturbance; but he advanced no explanation which would cover all cases, other than exposure to weather for long periods, frequently in wet

trenches, combined with generally insufficient rations. About half of the men had enteritis. Their footgear varied. Some, hut by no means all, had been wearing boots and puttees of the European type, and Page granted that in some instances they were tight enough to predispose to gangrene. He was unwilling however, to accept, at least in universal application, Depage’s theory that the pathologic process could be explained by compression from the puttees, which underwent shrinkage as they dried, though Dreyer, who reported on 41 cases observed in the German Hospital in Constantinople, was ofDepage’s opinion. valid argument against this theory was that many of the Turkish soldiers who suffered frostbite wore the usual loose native footwear. The theory that gangrene was caused by the eating of infected rye bread could also be dismissed. The affected troops had had very little of this bread, for one thing, and, for another, there was complete absence of this type of gangrene in the local population before the war, although the suspected r} bread had been prominent article of diet in the area.

Page was familiar with the history of gangrene following frostbite among British troops in the Crimean ar and regarded it as comparable to the gan- grene observed in the Balkan war. Apparently, however, he did not consider the two conditions to be the same processes, nor did he seem to realize that, in both, cold and wet were the primary causative factors. This is curious, since both he and Dreyer agreed that in this type of gangrene, just as in frostbite, the arterial circulation of the affected men had been so impaired by starvation and fatigue that temperature above freezing was able to produce stasis in the peripheral vessels. Page noted, but did not comment on, the fact that fre- quently soldiers dated the development of gangrene to the time of their arrival in the hospital for treatment for some other injury or disease. Often, the gangrenous process was clearly of much longer duration, and it seems not

13 Page, C. M.; Gangrenein War. Brit. M. J. 2: 386-388, 30 Aug. 1914.
COLD INJURY, GROUND TYPE 42

unreasonable to postulate an aggravation of the vascular disturbance when

warmer environment was reached.

Ariev cites number of other observations on the high incidence offrostbite

in the Balkan wars of 1912-14: Meyer and Kohlschutter reported on 150

cases, all terminating in gangrene, and Wietiug recorded 300 cases. Kosogledova, who reported 400 cases, stated that at one time no less than 2,000 casualties from frostbite were in Sofia and that whole trainloads of other men with

this type of injury were en route to base hospitals.

WORLD WAR

The British Experience

Cold injury is recorded in considerable detail in the official British history

of World War 14 as well as in the large periodical literature of the war years. 15

It should be noted again that up to this time, except for the classic description

of cold injury by Larrey (p. 30) during the Napoleonic Wars and the briefer

but equally careful observations of British medical officers during the Crimean

War (p. 36), there had been no critical appreciation of the military significance

of this type of injury.

That the British had not fully profited by their experience in the Crimean

War is indicated by the high incidence of cold injuries in their expeditionary

forces in the first winter of World War I. At this time, in spite of Larrey’s

emphasis upon this combination of causes, the role of wet in conjunction with

moderate temperatures was not clearly understood, as is evident from the

nomenclature employed for cold injuries early in World ar I. All through

the first months of the war, these injuries were reported as frostbite, water

bite, footbite, cold bite, puttee bite, trench bite, N.Y.D. feet, chilled (or cold)

feet, effects of exposure, or merely as “feet cases.” It was not until after the

first winter of fighting that the term “trenchfoot” began to come into general

use. Although trench warfare was the exception in orld War II, the term

was retained in it, partly for lack of better one and partly because its implications were so generally understood.

In spite of their lack of experience with cold injury, British Army surgeons

and nonmedical military officers alike promptly realized the enormous military

significance and the potential loss of manpower from trenchfoot, as well as the

14 (i) General History of the Medical Services. Hygiene of the War. London: His Majesty’s Stationery Office,

vol. 2,1931. (2) See footnote 3, p. 29. Except as otherwise indicated, all dataconcerning the British experience in World

War are derived from Grattan’s chapter on trenchfoot in History of the Great War Basedon Official Documents.

is (1) Lawson, C. B.: Frost-Bite. Brit. J. Surg. 2: 703-705, April 1915. (2) Frost, H. M.: Trench-Foot. Boston

M. S. J. 176: 301-304, Mar. 1917. (3) Trench Foot by Military Observer. Mil. Surgeon 41: 598-609, November

1917. (4) Hughes, B.: The Causes and Prevention of Trench Foot. Brit. M..T. 1: 712-714, 20 May 1916. (5) Delepine,

S.: The Prevention of Frost-Bites. Lancet 1: 271-272. Feb. 1915. (6) Johns, F. A.: Note on the After-Treatment of

So-Called “Frostbite.” Brit. J. Surg. 4; 336-337, October 1916. (7) Levick, G. M.: Electrical Treatment of Muscles in

“Trench Feet.” Brit. M. J. 1: 370-371, 30 Mar. 1918. (8) Moynihan, B.: Frostbite (correspondence). Lancet 1: 401,

20 Feb. 1915.
HISTORICAL NOTE 43

strictly financial consideration that these casualties, quite as much as battle casualties, would he entitled to pensions. Three points were generally em- phasized in the firstreports: (1) The number of men permanently lost to combat tioni this type ot injury; (2) the amount of time lost from service by the men eventually able to return (in mild cases, to weeks and in more severe cases, to weeks or sometimes much more); and (3) the possibility of recurrence in men sent back to the same environment in which their original injuries had been sustained.

The high incidence of cold injury and the long duration of the hospital stay, which often reached several months, both proved the intractable nature of injuries caused by cold and their impact upon military campaigns. Incidence. old injury began insidiously among British troops in France and Belgium in the first months ot lighting in \\ orld \\ ar I. The incidence of

frostbite, as it was then termed, rose from case in August 1914, in September, and 11 in October, to 1,555 in November and 4,823 in December. InDecember, the term trenchfoot first appeared in the medical reports, though only eight cases were so listed. All of the cases reported as frostbite from August through December, iiu lush e, ere cases in which cold injury was the only injury or disease present. Over the same period, frostbite was reported in association with rheumatism (306 cases), myalgia (69 cases), bronchitis (22 cases), and gunshot wounds (170 cases).

he highest incidence of cold injury was among infantrymen. Officers had somewhat lower rate of occurrence than enlisted men. Indian troops as well as Europeans were affected. According to official records, 16 the total cases of frostbite and trenchfoot foi the whole war, in all theaters of operations and all bases, including the United Kingdom, numbered 115,361. During 1915, when frostbite and trench- foot were differentiated in the returns (as they were not thereafter), there were 30,691 hospital admissions for frostbite and 29,172 for trenchfoot. Total cold injuries treated in hospitals in France and Flanders, practically all of them in the first years of the war, amounted to 97,414 cases. Only 443 cases were shown on hospital records during 1916-18.

Reports of individual observers 17 during the first months of the war are as significant as are the mass statistics. Thus Lawson recorded that, over 6-week period, 1,131 men with frostbite were admitted to single hospital in Rouen. Gangrene was present in 24 of 180 cases which he treated personally. Frost mentioned 120 cases in convoy of 160 casualties received at the Meerut Stationary Hospital in Boulogne. military observer wrote in the Military Surgeon for November 1917 that 400 men in single British battalion, many of whom later required amputation, had been disabled from cold injury in 48 hours.

16 See footnote 14 (1), p. 42. 17 See footnote 15 (1), (2), and (3), p. 42.
44 COLD INJURY, GROUND TYPE

Weekly divisional records for the First British Army from 12 December

1914 to 28 February 1915 are indicative of what happened as trenchfoot

gradually came under control. For the first week of this period, 579 cases were

recorded, and 530 cases were recorded for the third week. By the eighth week,

the number had fallen to 70 cases, and only 63 were recorded for the last week.

The total for the 10-week period was 3,013 cases. While the incidence of

trenchfoot was thus decreasing in the First Army coincidently with the institution of “strong disciplinary measures,” cold injury continued to occur in large

numbers in the Second British Army, which was then fighting in the Ypres

salient.

Frostbite case rates per 1,000 strength in France and Flanders were 33.93

for 1914 and 27.50 for 1915.18 Trenchfoot case rates for the same years were,

respectively, 33.97 and 38.43. Thereafter, the case rates for cold injury fell

progressively to 12.82 in 1916, 11.34 in 1917, and 3.82 in 1918. Death rates

per 1,000 in Europe ranged from maximum of 0.06 in 1914 to zero in 1917

and 1918.

The statistics for cold injury in the British forces in the Middle East are

far less reliable than those for the Western Front. Many of the available

sources for the winter of 1915 in Gallipoli are diaries, which merely state that

“many” or “several” cases were observed. In the Dardanelles, 19 for the period

April 1915 to January 1916 inclusive, there were 14,584 admissions for cold

injury, of which 6,602 were for frostbite and the remainder for trenchfoot. For

the 10-month period, the frostbite case rate was 56.39 per 1,000 average strength

and the trenchfoot case rate 68.18.

In Macedonia, from October through December 1915, there were 1,014

cases of frostbite and 1,125 cases of trenchfoot. The frostbite rate for this ear

was 16.65 cases per 1,000 average strength, against rate of 18.48 cases per

1,000 average strength for trenchfoot. In subsequent years, the trenchfoot

rates fell to less than cases per 1,000 average strength. Weekly admissions to

medical units were recorded only for the period from 25 March 1916 through

June 1918. During this time, there was total of 43,838 admissions for cold

injury, in 38,298 of which 187.36 percent) evacuation to the base was necessary.

Death rates for the campaign in Macedonia are not available. In the

Dardanelles in 1915, the death rate for frostbite was 0.58 per 1,000 and for

trenchfoot 0.67. These rates are approximately 10 times as high as the highest

rates reported from Europe. It is interesting to speculate on the possible role

of intercurrent diseases, especially dysentery, in the production of the higher

rates in the Middle East.

Diagnosis.—When trenchfoot once began to be carried in mind as possibility in British troops, its diagnosis seldom presented any difficulty. The circumstances of the injury, the characteristic symptoms of swelling, pain, and

disturbances of sensation, and the physical findings, including color changes

and edema, seldom left any doubt about the nature of the lesion. The occur18 See footnote 14 (1), p. 42. 19 See footnote 14 (1), p. 42.
HISTORICAL NOTE 45

rence of nocturnal pain was extremely significant. More than one observer

suggested that if it was suspected that the man might be malingering, tour of

the wards at night would often provide the answer; if the patient was awake,

sitting up in bed, and even crying with pain, there was no question about the

genuineness of his diurnal complaints.

Prevention.-—The methods of prevention employed by the British in World

War 20 were, in their fundamentals, the same as those they employed so successfully in World War II (p. 202). Because only few medical officers had had

previous experience with injuries caused by cold, these measures as well as

the whole program of control had to be organized hastily, though they wore

ultimately developed methodically. They consisted, in essence, of (1) the

maintenance of the men in as fit condition as possible; (2) the exercise of as

wide hygienic control over the troops as was compatible with the conditions of

trench warfare; (3) measures to protect the feet and legs from wet and cold and

to keep the men as warm, as dry, and as clean as was possible under the circumstances; and (4) measures to improve the condition of the trenches. Provision of hot food for men in the trenches was always an important feature of the

program.

Eventually, as the program developed, great emphasis was placed upon

the supervision of troops by unit commanders. The records of all units were

scrutinized daily and weekly to detect any rise in the incidence of trenchfoot;

increases called for an explanation and sometimes for an investigation. Supervision of this kind was found to be indispensable and was strictly enforced

when once it was realized (1) that even mild trenchfoot, without blister formation or gangrene,removed the soldier from service for weeks or months, and (2)

that men who had sustained one attack of cold injury were much more susceptible to another attack. The solution of the problem was therefore twofold;

(1) For the individual soldier to make fine art of the toilet of the feet, and (2)

for his leaders to see that he did so.

In December 1916, the Director General of Medical Services for the

Western Front issued instructions that thereafter all patients with trenchfoot

should receive tetanus antitoxin, whether or not the skin was broken. The

same instructions had been issued the previous winter by the Director of

Medical Services in Macedonia.

Therapy.—No really successful method of treatment of trenchfoot was ever

developed by British medical officers in World War I. Furthermore, many of

the methods used were empirical, particularly at the beginning of the outbreak

in 1914 because most medical officers were entirely unfamilar with the condition.

Lawson 21 relates what was probably typical experience. When the first 63

casualties from trenchfoot were suddenly received in British hospital in

France on 23 November 1914, no one had any idea what to do for them. The

following day, Lawson himself happened to remember that he had once read in

Rose and Carless’ Textbook of Surgeiy that Indians, lumbermen, and pros20 See footnote 14 (1), p. 42. 21 See footnote 15 (1) p. 42.

438404'—58
46 COLD INJURY, GROUND TYPE

pectors in northwest Canada treated cold injury by the liberal use of oil of

turpentine. This method was at once applied to these military casualties;

when the blebs broke and the pure oil proved too irritating, it was diluted with

lanolin. Lawson reported excellent results, stating that when toxemia developed it was almost invariably found that the oil had not been assiduously

applied. Nothing else seems to have been written about this special method,

and many other equally empirical methods are mentioned only in single reports.

Among the numerous agents used at one time and another for local applications, with or without massage, were alcohol in various strengths; mercuric

chloride (0.2 percent) in alcohol; chloral hydrate and camphor; carbolic acid

(1:40) and camphorated oil; camphorated oil alone; tincture of iodine; picric

acid; oil of wintergreen; evaporating solutions such as lead and opium; and

dusting powders containing starch, zinc, boric acid, and salicylic acid. Elaborate methods of massage, radiant heat, and various kinds of electric stimulation

were used in the later stages of trenchfoot. 22

In February 1915, Moynihan 23 called attention to the pain inflicted in

trenchfoot by the application of various ointments and liniments. Apart from

the degree of pain which they caused, he said, there was no appreciable difference between one form of treatment and another. It was Ins opinion that the

pain, which was always the outstanding complaint and which was sometimes

so severe as to require morphine for relief, was not caused so much by actual

damage to the tissues as by the general practice of wrapping the feet in bandages

and wool; the discomfort, in fact, was almost exactly proportionate to the

degree of warmth achieved. When the bandages and other wrappings were

removed, men who had previously suffered nights of torture had relief within

few hours. Since progress toward recovery was practically always at the

same rate, regardless of the method of treatment, it was Moynihan’s feeling

thatrelief of pain during healing should be the chief consideration. It therefore

became the practice in the Rouen hospitals after this time (February 1915) to

elevate the affected feet few inches on hard pillow and to cover them only

with thin layer of gauze and sheet.

Eventually, plan of treatment along much these general lines became

standard practice for British casualties with trenchfoot. 24 The injured foot

was carefully and thoroughly washed with soap and water, an antiseptic lotion

was applied, and the skin was painted with 1-percent solution of picric acid.

In mild cases, additional treatment consisted only of bed rest, with the feet

slightly elevated. If the feet were red and hot, they were left exposed, with

all dressings omitted. If they were cold and numb, they were wrapped in

cotton wool, which was removed at intervals so that they could be rubbed.

If blistering extensive, the bullae were punctured, and the feet were coated

with ambrine or some other preparation of paraffin wax. Salicylates were

used in large dosages for the control of pain. In the later stages of mild trench22 See footnote 15 (6) and (7), p. 42. 23 See footnote 15 (8), p. 42. 24 See footnote 14, p, 42.
HISTORICAL NOTE 47

foot, the application of high-frequency current together with massage was

thought to be beneficial.

Immediate amputation was never considered justified, even when gangrene

was evident, since even the early experience showed that in the majority

of cases the part could be saved. In the moist type of gangrene, fairly prompt

amputation was sometimes required, but, in the dry type, it was the practice

to wait for line of demarcation. Amputation through the leg was seldom

necessary, since the Syme operation was usually practiced, even in severe cases.

The United States Army Experience

Since the United States Army in World War had little experience with

trench warfare in cold weather, it had correspondingly limited experience

with trenchfoot. Most of the fighting in the trenches occurred at time

of year when exposure to combined cold and wet was not great. Noneffectiveness from this cause was therefore never important in the American

Expeditionary Forces.

The majority of cases of trenchfoot occurred during the Meuse-Argonne

operation, in October and November 1918, when fighting continued day after

day for several weeks until the soldiers were exhausted as well as chilled and wet.

It was difficult to bring relief troops forward; and the men, in addition to

being without shelter and heat, suffered for lack of dry clothing and proper

shoes.

With this exception, the majority of cases of trenchfoot observed in

American troops in overseas hospitals arose from conditions not connected

with trench warfare and would probably, in the absence of the previous British

experience, have been diagnosed as chilblains or frostbite. Most of the lesions

diagnosed as trenchfoot actually were instances of frostbite with minor grades

of inflammation and with some ulceration and abrasion of the waterlogged skin.

The deep sloughing and gangrene characteristic of much of the trenchfoot

experienced by British troops in the first winter of the war were seldom observed

in American troops.

Incidence.-—The official history of the Medical Department of the United

States Army in World War 26 lists total of 2,061 admissions for trenchfoot,

including 27 among officers. Sixty-seven admissions, one an officer, occurred in

training camps and other installations in the United States and Alaska. Most

of the remaining admissions occurred in Europe.

The peak number of cases, as already mentioned, occurred in the fall of

1918, during the Meuse-Argonne offensive. The hospital-admission rate per

1,000 troops per annum was 0.50 for the whole Army and 1.17 for the troops in

Europe, wdiere the rate for officers was 0.35, and for enlisted personnel 1.21.

2j Weed,Frank W.: Trench-Foot. In the Medical Department of the United States Armyin the World War. Washington: GovernmentPrinting Office, 1925, voh XI, pt. 1, pp. 290-293. Except as otherwiseindicated, all data concerning

the United States Army experience in World War are derived from this source.

26 Medical Department of the United States Armyin the World War. Statistics. Medical and Casualty Statistics.

Washington; Government Printing Office, 1925, vol. XV, pt. 2, passim.
48 COLD INJURY, GROUND TYPE

The loss from trenchfoot for all classes of personnel in the United States Army amounted to 97,219 days, an average of 47 days per case. In Europe,

the total loss was 92,249 days, an average of 47 days per case. The average loss

of time for officers was 29 days; for white enlisted men, 49 days; and for colored

enlisted men, 68 days. On the Western Front, the average loss per admission

for enlisted men of all races was 48 days.

Prevention.—The United States Army in World War I, partly because of

the comparatively favorable circumstances under which it fought and partly

because it had the advantage of the previous British experience, did not have

to learn by its own experience that trenchfoot can be prevented. In General

Orders No. 11, General Headquarters, American Expeditionary Forces, issued

on 17 January 1918, the causes were outlined, the prophylactic measures to be

employed by American troops were fully described, and organization commanders were charged with responsibility for their implementation.

The predisposing and exciting causes of trenchfoot were grouped in General

Orders No. 11 under two headings: Hygienic causes and causes of circulatory

interference. Under hygienic causes were listed the existence of systemic

disease insufficient food, particularly the lack of hot food insufficient sleep and

comfort and too infrequent changes of shoes and socks, which permitted the

accumulation of bacteria-laden secretions and the consequent maceration of the

skin of the feet. The causes of interference with the circulation were listed as

the wearing of tight shoes, socks, leggings, puttees, and breeches; long-continued standing or sitting without exercise and with the feet and legs in strained

positions; and prolonged exposure of the feet to the effects of cold and wet.

Commanding officers of all units were held personally responsible for seeing

that the following routine was carried out under the personal supervision of

commissioned officers:

1. Provision of clean, dry, well-fitting woolen socks, with further provision

for replacements and laundry, sufficient to insure each man at least one change

daily. The socks were to be pinned to the breeches with safety pins. Garters

were prohibited.

2. Provision of not less than one change of shoes or boots for each man.

The shoes were to be in serviceable condition, well fitted, thoroughly greased,

and large enough for woolen socks to be worn with them.

3. Provision “at all times” of suitable rooms for drying footgear and other

clothing.

4. Prohibition of the wearing of rubber boots for longer than few hours

at time. Neither puttees nor leggings were to be worn under them. The

disadvantages of this form of footgear were to be explained to the troops, who

were to be shown also how to care for the boots after they were removed.

5. Provision, whenever possible, of dry environment, even though it

amounted only to trench drainage and the use of duckboards.

6. Vigorous rubbing of the feet with animal fat at least once daily.

7. Active foot exercises, supplemented from time to time by removal of

shoes and socks so that the feet could be dried and massaged.
HISTORICAL NOTE 49

8. Regular inspections of the feet by the officers, to detect corns, ingrown

nails, blisters, and inflammations. Men with such lesions were to be referred

at once to medical officer.

9. Inspections by company commanders before troops moved into forward

areas, to be certain that all the provisions just listed had been complied with.

At this time, the men were also to be warned against winding their puttees too

tightly, since it had been found that shrinkage of percent occurred when

dry puttees, which had been applied according to regulations, became wet.

10. Suitable arrangements for provision of hot food and drinks so that all

men in forward areas had at least two hot meals daily.

The orders issued on 17 January 1918 also contained information about

how to secure the various instructions and equipment necessary for carrying

these orders into effect. Plans for improvising and constructing field cookers,

kitchens, clothes driers, and other special equipment were to be furnished upon

application to headquarters. Foot powders, oils, greases, and ointments were

to be furnished by the Medical Department. Supplies for the lubrication of

shoes and boots were to be secured from the quartermaster. Responsible officers were directed to prepare the necessary requisitions for these various

items without delay.

For the most part, these policies remained unchanged throughout the war.

The only important alteration was that whale oil and grease in general came to

be looked upon with disfavor, since the coating which lubricants formed held

back secretions and encouraged maceration of the skin. It therefore

became the practice to use these agents only when gum boots were not

available or when they had to be worn for unusually long periods of time.

Ashford 27 provided significant account of the real value of these measures.

In September 1917, shortly before he assumed the duties of commandant of

corps training school for American medical officers, he made visit of few

hours to the French Sanitary School, and, just before he left, was briefed on

trenchfoot by Col. Victor Raymond, of the Service de Saute of the French

Army, who also provided him with the brochure he had written on the subject.

This, wrote Ashford, “was the first notion had had of the disease.” The

remainder of the story seems worth quoting in detail:

training school for line officers was established in the damp October chill *. Our

division had arrived in July at their training area, and as most of us had been serving in

tropical or subtropical countries we had little idea of the climate of the Haute-Marne. The

army was just organizing, and we had little transportation and comparatively little wood

for fires. barrack cantonment for the line school sprang up overnight in beautiful

meadow, which in forty-eight hours became sea of mud. The temperature ran between

zero and 10° C. There had been no time to construct drying rooms. It rained for forty

days and forty nights with persistence, and men and officers were so intent upon learning,

that they forgot mud, water, and cold and trudged about all day with wet feet without

sufficient means for drying their shoes at night. The result was that every one in few

days had all their foot-wear muddy and soaked through, and were obliged to put on wet

shoes in the morning. battalion on duty at this camp, half mile from the town, were

27 Ashford, B. K.: Trench Foot: Its Treatment. War Med. 2: 717-724, December 1918.
50 COLD INJURY, GROUND TYPE

engaged in construction and were constantly wet through. From the very first, the commanding officer had been going to great lengths to secure fuel and to prevent the effects of

exposure; but before anyone had time to do anything, the camp surgeon, on the first day

was given medical supervision over this camp, called my attention to prevalent affection

of the feet of the men working there, as well as of the student officers. These men had not

been in the trenches, but the surgeon stated that the clinical picture resembled what he had

seen described somewhere as “trenchfoot”, and called me to go over the situation. By that

time the battalion was seriously crippled by large number of men who were actually unable

to walk with any degree of comfort. went over this organization, man by man and found

that good tw enty-five percent had w'hat they called "chilblains.” One or two men had

gone to the hospital with beginning necrosis, and those in quarters at the camp, as well as

many still trying to do duty, were in the first or second stage of the affection.

That same day Colonel Raymond’s brochure as abstracted, particularly that part

relating to prophylaxis and treatment; efforts were redoubled, and this time with success,

to provide more fuel; and the condition was reported to the Chief Surgeon with the diagnosis

of trenchfoot, one of the first, if not the very first, made in our Army. Telegraphic authority

as requested, and promptly obtained, for good supply of whale oil, camphor, borate of

soda, and green soap, secured in open market, and wdthin three or four days the outbreak

had declined as suddenly as it had appeared.

have detailed the conditions under wdiich the affection appeared, because the sudden

and severe onset as evidently precipitated by those conditions, and troops who have to live

under them here do not have to be in trenches to reap the results of exposure to moderate

cold, wnth constantly wet and muddy footwear. The disease made its appearance under

the very conditions considered by Raymond as favoring its development. It was short

lesson, but striking one, at propitious time for the American Army, and thanks to the

energetic action of the Chief Surgeon of the American E. F. in acquainting the entire Army

with its prevention and cure, it has never shown its head since as an important source of

invaliding of soldiers.

In the meantime, we had personally followed the cases and had carried into effect the

prophylaxis. In all, about 300 cases of some 1,000 strength were treated, all of which were

promptly and completely cured without loss of tissue. In fact, not over three men had

beginning necrosis, 15 percent blisters, and the rest merely the edematous, or first stage.

The most notable result was seen in the rapid return to normal of all treated by the camphor

and sodium borate fomentations. In forty-eight hours they ere usually free from symptoms

and ready for duty.

Ashford then quoted the first circular on the subject issued by the Army

School, which contained essentially the same recommendations as those in

General Orders No. 11, though in few instances they were even more specific:

(1) The daily examination of the feet in each squad by squad leaders *. (2) The

daily massage of the feet with camphorated oil *. This was to be done in the presence of

the squad leader *. (5) Furnishing of well-fitting shoes, presence of officers during

issue of same *.

When, about this time, nearby division received orders to go into the

trenches for the first time, the men were enjoined to carry out the provisions

of the circular just cited and were also given special instructions for prophylaxis in the trenches. Again the instructions were somewhat more specific than

those contained in General Orders No. 11. Among other things, the men were

warned to exercise their feet and toes from time to time, “and always as often

as possible if numbness should be perceived.” They were also warned against warming affected feet before the fire.
HISTORICAL NOTE 51

These measures, Ashford stated, saved the division from “the fate of the

training school,” in addition to cutting short the outbreak in the school itself. Practically no cases were reported in the division, “although much worse

predisposing conditions prevailed.”

Therapy.—The treatment of trenchfoot in the American Expeditionary

Forces was based chiefly on methods proposed by Raymond and Parisot of

the French Army Medical Service. 28 The essentials were set forth in Memorandum Xo. 4, Army Sanitary School, American Expeditionary Forces, in the

fall of 1917. The type of treatment depended upon the stage of the injury

at which the patient was seen.

1. During the edematous stage, the feet were first bathed with green

soap and water. Hot fomentations of camphor (1 part), sodium borate (15

parts), and boiled water (1,000 parts) were then applied. Finally, gauze

compresses were applied, well above the upper limits of the edema, and were

covered with some impermeable material such as oiled silk or oiled paper.

Ashford reported that this treatment provided such prompt relief from pain

that men previously unable to rest often fell asleep at once. He also recommended potassium iodide, which he said had almost specific action in relieving

the pain of trenchfoot.

2. In the second, or blister stage, treatment began with the excision of

all blisters larger than one-half inch in diameter, after which their gelatinous

bases were gently wiped with pledgets of sterile cotton. The application of

compresses of camphor (30 parts) and ether (1,000 parts) was followed by the

use of fomentations, as in the edematous stage. After edema had disappeared,

treatment with camphorated ether was continued.

3. Sloughs, which occasionally formed in spite of these measures, were

loosened by the application of compresses of camphor and ether and fomentations of alkaline camphor until access to the affected tissues beneath was

possible. An acceptable variation was the use of the paraffin footbath, in

which the affected feet, wrapped in cotton batting, were immersed for 30 to

60 minutes in small footbath filled with paraffin heated to 140° F. (60° C.)

or higher. When the feet were removed from the bath and exposed to the

air, the paraffin taken up by the cotton batting hardened and the patient had

what amounted to pair of paraffin sabots. Treatments were given daily.

Surgery was conservative and limited to hard sloughs. These were incised

down to the grumous layer, after which compresses were applied. “Blood

letting” was avoided, and the cautery was not used.

Ashford warned that feeding soldiers with trenchfoot was an essential

part of treatment, since they were apt to be weak, malnourished, and exhausted.

He also warned that trenchfoot predisposes to tetanus and that failure to

administer tetanus antitoxin to all patients who had passed beyond the first

stage and to repeat the injection every days until the lesion looked healthy,

would certainly result in some preventable deaths.

28 See footnote 23, p. 47.
52 COL] INJURY, GROUND TYRE

Other Experiences in World War

According to Tuffier (cited by Ariev), the 79,465 cases of trenchfoot in

the French Army in World War accounted for 3.02 percent of all battle

casualties. There were 170 fatalities from trenchfoot. According to Mignon

(also cited by Ariev), the average number of cases of trenchfoot per year was

more than 30,000. Records, however, support this statement only for 1916,

when there were 31,051 cases; 17,026 cases were recorded in 1915, and 15,870

in 1917. The French offensive at Verdun, which began on 15 December 1916,

is known to have produced more than 3,600 cases; 1,869 cases occurred in

single division, the 38th, which had 1,971 battle casualties. French Senegalese

troops fighting on the Aisne sustained 1,225 cold injuries between 15 and 17

April 1917.

The Italian Army, according to Bonomo (cited by Ariev), had almost

38,000 cases of frostbite during 1915-18. The Belgian Army seems to have

had few casualties from this cause.

Statistical records of frostbite and other cold injuries are not available

for the German Army in World War I, but the scope of the problem may be

gathered from the fact that special hospitals were set up for the treatment

of these injuries and that staff positions were set up in other hospitals for

surgeons who specialized in their treatment. According to Scliade (cited by

Ariev), there were 12,848 casualties caused by cold injuries in total of 500,000

sick and wounded in 1914 and 1915.

THE SPANISH CIVIL WAR

Trenchfoot does not seem to have been reported in any of the numerous

hostilities which occurred between the close of World War in 1918 and the

outbreak of World War II in 1939. Duelling, d’Harcourt, Folch, and Bonfill, 29

who made an extensive study of cold injuries during the Spanish Civil War,

stated that they had seen nothing precisely comparable to the type of trenchfoot observed in World War I, although they had observed numerous cases

which resembled it at some special time in their evolution. The troops who

were chiefly affected were operating on the Sierra Palomera, then covered with

snow, and were exposed for several days at time. About 500 men were

treated weekly for cold injuries of the lower extremities in total exposed force

of about 120,000, which gives weekly rate of approximately 4.16 per 1,000

average strength and an annual rate of 216.32 per 1,000 average strength.

This is very high in comparison to United States Army rates in World War IT.

During the period covered by their observations, Duelling and his associates also observed 10 cases of simultaneous freezing of the upper and lower

extremities and cases, all fatal, of total freezing.

29 Ducuing, J., d’Harcourt, •!., Folch, A., and Bonfill, ,T.: Les Troubles trophlques des ExtrOnites Produits par le

Froid. Sec. en Pathologic de Guerre. J. de Chlr. 55; 385-102, May 1940.
HISTORICAL NOTE 53

ETIOLOGIC CONSIDERATIONS

Although the theories of etiology advanced to explain cold injuries in the

wars prior to 1914 have already been mentioned, it might be well to summarize

them briefly. Larrey (p. 30) stated unequivocally that cold per se was merely

the predisposing, not the exciting, cause; that the condition was not caused by

freezing temperature but occurred during succeeding period of mild weather

or in the course of thaw; and that heat, suddenly applied, woidd promptly

bring on gangrene from “congelation.” Davys (p. 39), in recording the experiences of the Tibet Mission Force in 1904, also emphasized that the most

serious results of cold injuries could be explained by carelessly applied heat,

not by excessive cold. Page (p. 41), who compared the Balkan experience

with that of the Crimean War, believed that gangrene which followed cold

injury was on vasomotor basis and could be explained by the effect of cold

on an arterial circulation already impaired by starvation and fatigue. He

pointed out that under these circumstances temperatures above freezing could

cause tissue damage. He noted, but did not enlarge upon, the fact that in

many instances the first complaints related to the extremities came after the

men had been hospitalized. Their pain was very marked during the “period

of reaction.” Page granted the possible influence of tight boots and puttees

in some cases but was unwilling to accept constriction as universal explanation. Numerous early observers called attention to the possible indirect effects

of hunger, exhaustion, and concurrent wounds and illness.

The realization that cold injuries could not be explained entirely by cold

came early in World War I. In the first months of that war, British troops

were obliged to march miles along wet and muddy roads in order to reach the

entrance to communications trenches. When they arrived, cold, soaked to the

skin, and already fatigued, they had to expend an immense amount of additional

energy marching along the wet and muddy trenches to reach the forward

trenches. Once they reached their station they were never really warm, dry,

and comfortable until they were relieved; and that, in the early winter of 1914,

might be matter of weeks. Meantime, they remained almost immobile, in

cold and mud, frequently in the rain, but not in freezing temperatures. The

special correspondent in northern France 30 wrote in the British Medical Journal

for 26 December 1914:

The temperature so far has never been really low; in fact, there has never been more

than few degrees of frost for limited number of hours, mainly at night. In all probability

the actual temperature of the air at any given moment is only one of several factors in the

production of the condition *. Apart from actual frost, the factors in question appear

to be the soaking of the men’s boots and socks either in freezing water or mixture of mud

and slushy snow, the absence of any local output of muscle heat owing to the fact that the

men are standing still, and some tightness of their boots owing to the men putting on two or

three pairs of socks which are thick even when dry and thicker still when wet. [Cottell 31 had

previously made similar observation about the wearing of extra socks.] With their legs

Frostbite (TheWar). From special correspondentin northern France. Brit. M. J. 2: 1116, 26 Dee. 1914.

31 Cottell, A. B.: Frost-bite. Brit. M. J. 2: 992, Dec. 1914.

438404'—58
54 COLD INJURY, GROUND TYPE

thus chilled in advance, and the whole local circulation already reduced to very low ebb,

it is comprehensible that here and there in superficial areas it should be arrested for time

altogether. The usual history of these cases is that man who has just got into his dugout after standing for an hour or more with his rifle on the deck, has seen his way to good

rest and consequently has taken off his boots. On doing this he has noticed nothing the

matter with his feet but subsequently has found that they have become so swollen that, apart

from any question of pain, to get his boots on again is quite impossible.

In December 1915, Sir William Osier 32 called attention to another important cause of trenchfoot. The venous stasis which is the anatomic background,

he wrote, is not simply the effect of cold, wet, or both. The feet may be aglow

after 10-mile tramp in snowshoes with the thermometer 20° below zero; and

men actively at work on big lumber rafts in Canada have cold, wet feet for

weeks at time and yet suffer no injuries. It was not cold or wet, Osier concluded, and not puttees or boots which were doing the damage but the comparative inertia of the muscles of the leg. To keep the trenches dry and to use

special kinds of socks might be useful, but the disabling effects of “cold bite”

were inevitable in feet attached to legs whose muscles did not have play enough

to maintain circulation hampered by gravity and by cold and ’wet.

The principal causes of trenchfoot were thus clearly set forth many years

before World War IT as combination of conditions and not single condition.

These causes included cold, wet, constriction, and immobilization. Cold injury coidd occur with the temperature above freezing and with frost present

for limited periods only if at all. Lack of proper (principally warm) food and

the influence of fatigue were other contributing causes. Tullidge, 33 who had

been first an Austrian medical officer and then military surgeon with the

French Red Cross, advised recruiting physicians to remember that men with

circulatory disorders and sluggish circulation were most susceptible to frostbite.

If they were enlisted, he suggested that they be kept out of situations in which

these injuries coidd be sustained.

few other observers also called attention to possible individual predisposition to cold injury, or, more correctly, to possible individual variation in

susceptibility, as evidenced by striking differences in the development of trenchfoot under the same environmental conditions. It was noted that, as general

rule, symptoms appeared within or days after exposure and that disability

became marked within the next day or two. In some instances, however,

men would be completely incapacitated within 24 hours after their first tour

of duty in the trenches had begun, while others under precisely the same circumstances might not present symptoms for or days and might not be

completely incapacitated for another or days.

few other theories of the causation of trenchfoot were advanced in

World War in addition to the reasonable and generally accepted explanations

just set forth. Fearnsides and Culpin, 34 although they agreed with the generally

32 Osier, W.: Cold-bite+Muscle-inertia=Trench-foot. Lancet 2: 308, 18 Dec. 1915.

33 Tullidge, E. K.: Frozen Limbsand Their Treatment in the Present War. M. Rec. 90: 11-14, July 1916. 34 Fearnsides, E. O., and Culpin, M.: Frost-bite. Brit. M. J. 1: 84, Jan. 1915.
HISTORICAL NOTE 55

accepted theories, considered that apprehension and fear of new disease were

other possible causes.

Longridge’s 35 elaborate theory of leakage of electricity from the foot to

the earth, because the electrical resistance of the skin is enormously diminished

when it is wet, was based on the researches of one A. E. Baines, who, shortly

before the war, had published book on clectropathology. Longridge was so

impressed by the concept that he “ventured to predict” that in the future the

name of Baines would appear with those ofLister, Simpson, and Koch as among

the benefactors of the human race. Recommendations for prevention based

on the electrical theory of trenchfoot began with the wise, if unattainable,

order not to get wet. Other advice included soaking the shoes, socks, and

puttees in oil and applying dialectric oil (commercially available) directly to the feet. If trenchfoot had developed, the limb, from foot to knees, was to be

wrapped in gamgee tissue soaked in dialectric oil. “I have seen enough of this

treatment,” concluded Longridge, “to justify the assertion that no serious case

of trenchfoot necessitating amputation need take place.” It would scarcely

be necessary to refer to this curious item in serious account of trenchfoot

except that it was printed in the Lancet in January 1917, when the whole

problem of cold injury was well under control in the British Army.

The French were in general agreement with the British that the important etiologie factors in trenchfoot were cold, wet, and lack of movement. Almost

the only dissenters were Raymond and Parisot, 36 who argued that “gelure des

pieds” is infectious. They reported in 1916 that they had isolated from the

lesions fungus identified as Scopulariopsis komingu oudemans, which was

found in mud and straw and which came into contact with the feet by way of

the mud of the trenches. Under the influence of more or less continuous immersion in cold water, this fungus became pathogenic and readily invaded the

body through the macerated epidermis, frequently at the matrices of the nails.

Although Raymond and Parisot claimed to have reproduced the lesions of

trenchfoot by experimental animal inoculation of pure cultures of the fungus,

their work was not generally accepted nor was it ever confirmed.

British theories of the etiology of trenchfoot were generally accepted by

medical officers of the United States Army in World War I. The only deviation

was theory advanced by Sweet, Norris, and Wilmer, 37 who conducted comparative blood pressure studies on the upper and lower extremities, on the

assumption that trenchfoot was analogous to Raynaud’s disease and on the

further assumption that Raynaud’s disease can be explained by vasomotor

spasm. While they found pressures in the leg considerably increased over

pressures in the arm in casualties with trenchfoot, they were unable to determine

whether the increase was the result of an excess of vasoconstrictor substance or

35 Longridge, C. X.: Note on the Cause and Prevention of Trench-Foot. Lancet 1; 62-03,13 Jan. 1917. 36 Raymond, V. V.,and Parisot, J.: Etiologie Prophylaxie et Therapeutique de 1’Affection Dite “Gelure des Pleds.”

Presse mH. 24: 199, May 1916. 37 Sweet, J. E., Norris, G. W„ and Wilmer, H. B.: The Etiology and Treatmentof Trench-Foot. J. A. M. A. 70:

465-458, 16 Feb. 1918.
56 COLD INJURY, GROUND TYRE

of loss of vasodilator substance in the blood. Like Ashford (p. 49), they found

that notable relief ofpain could usually be secured (in 29 of their own 31 cases)

by the administration of potassium iodide, which they employed as “blood

pressure reducing substance.” Had they been able to obtain thyroid extract,

they would have preferred to use it on the ground that the clinical picture in

trenchfoot is the reverse of that in thyroid disease.

COLD INJURY OF THE HAND

In the great majority of cases of cold injury in World War I, only the feet

were affected. Cold injuries of the hand, when they did occur, were seldom of

consequence. Walther, however, reported an interesting exception in the experience of Pereand Boye, 38 who observed, in 120 cases of “frostbite of the foot,”

30 instances offrostbite of the hand (main de tranchees). The explanation was

particular series of circumstances. Because of the violence of the bombardment, the men had to remain crouched in the same position for several hours,

without moving at all. Snow fell on their hands as they grasped their rifles, and they could not wipe it off. Many of them were then obliged to move on all

fours for considerable distance, over ground covered with snow and mud.

When they had been relieved, they complained of pricking of the fingers and of

difficulty in holding their rifles; some could not hold them at all. They also

complained of edema of rapid development, which was apparently transient

since it was not present when they reached the ambulance. Almost all of the

lesions were bilateral and symmetrical. There were eight instances of gangrene,

which in advanced cases extended almost to the metacarpophalangeal articulations.

38 Cere et Boye (reported by Charles Walther): Main de Tranches. Bull, et Mem. Soc. de Chir. de Paris 43: 1483-

1485, July 1917.
57

CHAPTER 1\

Actions Taken in Zone of Interior

MAY 1942-OCTOBER 1943

The first formal mention of cold injury in the Office of the Surgeon General

after the United States entered World War II was contained in note dated

12 May 1942 and addressed by Col. (later Brig. Gen.) James S. Simmons, MC,

Chief, Preventive Medicine Division, to Dr. Lewis H. Weed, Chairman, Division

of Medical Sciences, National Research Council. In this note, three points

were made: (1) United States troops were already operating in Arctic regions,

(2) the chances were that their operations in these areas would be expanded, and

(3) it was therefore necessary to institute studies on health and sanitation in

cold environment. Frostbite was specifically mentioned in this letter, but

trenchfoot was not. In view of the circumstances listed, the National Research Council was requested to set up committee to study these problems.

Copies of available field manuals were forwarded with the letter, together with

bibliography on cold injury and letter and comments from the noted Arctic

explorer, Vilhjalmur Stefansson. The activities of the committee set up by the

National Research Council in response to this request are reported later in this

chapter.

The next recognition of the ground type of cold injury as medicomilitary

problem was early in 1943, in the Surgical Division, Office of the Surgeon

General. The essential pathologic process in this type of injury is vascular,

and the interest of this division in it stemmed from the fact that several of the

surgical consultants had had wide experience with vascular diseases in civilian

practice. At this particular time, unfortunatley, no similar interest was manifested by any of the other divisions which later concerned themselves with the

matter, and the opportunity was therefore lost to plan and provide for coordinated program of prevention before cases of cold injury developed.

During the first months of 1943, reports on cases of cold injury in the Air

Force in England and on immersion foot in shipwrecked Navy and other personnel began to come into the Office of the Surgeon General. These reports were

followed by the reports of large number of cases of exposure to cold during the

Attn campaign in May and June 1943 (p. 84). This experience was the subject

of extensive correspondence between the Surgical Division, Office of the Surgeon

General, and the Surgeon, Alaska Defense Command. Correspondence was

DuringWorld War II, it wasfrequently customary torefer to patientswith cold injuryas casualties. Current Army

regulations (AR 600-400, 23 Aug. 1954) direct that injuries or illnesses due to the elements, exhaustion, or self-inflicted

wound or injuries will not be consideredcasualties.
58 COLD INJURY, GROUND TYPE

also conducted with the Office of the Base Surgeon, Greenland, and with surgeons

in various hospitals which had received patients from the Attn campaign. The

implications of the Attn experience, in terms of future military operations in

other theaters, caused great concern in the Office of the Surgeon General among

the medical officers who had already begun to interest themselves in cold injury.

Survey of official publications.—Among the first activities in this Office

was review of the whole subject of cold injury as it had been reported in the

medical and other literature in previous wars (p. 29). This review concerned

both the clinical aspects of these injuries and the military responsibility for

their prevention. Methods of treatment were also reviewed in an endeavor

to bring together whatever authoritative knowledge was then available. At

the same time, two other reviews were undertaken. One had to do with the

Army equipment available for use in conditions of combat in wet and cold.

The other was review of current official publications, such as training manuals,

in which it might be expected that preventive and therapeutic measures would

be emphasized.

When these reviews had been completed, memorandum was addressed by

Lt. Col. (later Col.) B. Noland Carter, MC, Chief, Surgery Branch, Surgical

Division, to Brig. Gen. Charles C. Hillman, Chief, Professional Service, Office

of the Surgeon General. In this memorandum, dated 23 August 1943, it was

pointed out that measures currently recommended for the control of cold injury

were completely inadequate. It was also emphasized that (1) current military

publications dealing with operations under conditions of extreme cold contained

number of contradictions; (2) many of the measures advocated for the treatment of cold injuries were not in accord with current authoritative concepts of

rational therapy; and (3) no reference at all was made to immersion foot,

trenchfoot, or shelterleg in any of the technical manuals then current except

in FM 21-11, First Aid for Soldiers. In view of these findings, it was recommended that the deficiencies listed be brought to the attention of appropriate

agencies in the Surgeon General’s Office so that data published concerning cold

injuries might be corrected and brought up to date.

On the receipt of this memorandum, General Hillman requested the Training Division, Office of the Surgeon General, to confer with the Surgical Division

on these various matters. The report of this conference, which was held on

27 August 1943, contained recommendations for the changes necessary to

bring the publications dealing with the prophylactic and therapeutic aspects of

cold injury into accord with current principles and practices. Changes made

in the manuals as the war progressed are discussed elsewhere in this chapter

(p. 68).

Conferences on exposure to cold.—A conference on exposure to cold,

organized by the Division of Medical Sciences, acting for the Committee on

Medical Research, Office of Scientific Research and Development, was held on

28 July 1943. It was attended by representatives of the United States Army,

the United States Navy, the United States Public Health Service; representatives of the Royal Navy, the Royal Air Force, the Royal Canadian Navy, and
ZONE OF INTERIOR 59

the National Research Council of Canada; and number of physicians and

surgeons with civilian experience in the management of vascular diseases. The

conference was under the chairmanship of Dr. E. M. Landis, Professor of

Physiology, Harvard University Medical School.

At this meeting, three points were especially emphasized: (1) Standard

clothing and equipment, particularly footgear, had not been entirely efficient

in combat under cold conditions to date; (2) more important, both clothing and

equipment had been more satisfactory than the manner in which they had been

employed, for the reason that troops had been only poorly trained or not

trained at all in the personal precautions necessaiy under Arctic conditions;

and (3) War Department publications, if they mentioned cold injury at all.

were universally inadequate and were frequently contradictory.

The conference recommended that military personnel should be trained in

the prevention of cold injury. Preventive measures and basic first-aid measures

were outlined. Representatives from the Offices of the Surgeons General of

the Army and the Navy were appointed to prepare articles on immersion foot,

frostbite, and trenchfoot and to draw up instructions for the prevention and

treatment of these injuries so that as much information as possible might be

disseminated concerning them.

At second conference on cold injury held on October 1943, the material

which had been prepared as recommended by the first conference was reviewed

in detail, approved by the whole conference, and recommended to the Surgeons

General of the Army and the Navy for publication as the official policy on

trenchfoot, immersion foot, and frostbite. The articles were published in the

Bulletin of the United States Army Medical Department and in Health

OCTOBER 1943-MARCH 1945

In further attempt to emphasize the significance of cold injury and the

extreme hazards inherent in military operations in conditions of cold and wet,

another memorandum on the subject of frostbite, trenchfoot, and immersion

foot was addressed to General Hillman by Colonel Carter, on 16 October 1943,

as follows:

1. The Attu experience was outlined, and reports from the Northwest

Service Command and the Base Surgeon, Greenland, were cited and commented

on.

(1) Immersion Foot. Bull. U. S. Army M. Dept. No. 70, pp. 26-33, November 1943. (2) Frostbite. Bull. U. S,

Army M. Dept. No. 71, pp. 24-27, December 1943.

MonthlyProgress Report, Army Service Forces, War Department, 31 Dee. 1943, Section 7: Health.

Health was monthly publication, entirely informative in nature, prepared in the Office of the Surgeon General,

chiefly for the benefit of Medical Department personnel. It dealt with certain matters ofhealth, including their statistical

aspects. It was not command publication, and its circulation was necessarily limited. It was not likely to have been

widely received or read at lower echelons where the control of trenchfoot had to beinitiated and implemented.

In addition to the publications mentioned in this section, articles prepared in the Office of the Surgeon General on

the subject of trenchfoot appeared in the Bulletin of the United States Army Medical Department for March, June, and

December 1944 and for February, April, May, June, September, and October 1945.
60 COLD INJURY, GROUND TYPE

2. The experience in England with cold injury of the high-altitude type

in fliers was reviewed.

3. It was pointed out that, while cold injury was still not serious problem

in United States Army troops from the standpoint of either frequency or

morbidity, the solution, as the experience in the Aleutians and in the Army Air

Force in England had shown, lay in prevention of this form of trauma. The

immediate requirements were the adoption of proper equipment for use in cold

weather, training in its efficient use, and the education of military personnel in

methods of protecting themselves against the hazards of exposure to cold.

4. The steps being taken to bring official publications into accord with

modern principles and practices concerning cold injury were also reviewed.

The Office of the Surgeon General could not, of course, do more than

advise concerning either equipment or training. These matters were the

responsibility of the Army General Staff, especially the Assistant Chief of

Staff, G-3 (operations and training). Clothing was the special responsibility

of The Quartermaster General. The situation was admittedly difficult. The

Army was expanding rapidly. New types of supplies required timefor development, procurement, and distribution. The training load was at peak, as to

both the subjects to be taught and the number of men to be trained. Because

of lack of time and space on the program, the introduction of additional required training subjects was not readily achieved. It is not surprising, therefore, that many frustrations were experienced by the medical officers who had

quickly grasped the military, as well as the medical, significance of cold injury

and the urgent necessity for the training of personnel and for the provision of

appropriate protective equipment if costly losses were to be avoided in winter

operations.

Impact of Experience in Mediterranean Theater

Less than month after the memorandum of 16 October 1943 had been

prepared, trenchfoot began to be reported from Italy where itrapidly assumed

serious proportions (p. 101). The tremendous military significance of this type

of injury immediately became apparent, even to those who had not previously

considered it of much importance. It was obvious, however, in reports from

Italy concerning United States casualties, that the importance of preventive

measures was not well understood in that theater, and the lack of appreciation

of their importance was further evident, although the comparisons were not

always as valid as they seemed, in the contrasting experiences reported by

British troops fighting in the same area and under much the same circumstances

as United States troops.

As result of the Italian experience, the whole problem of cold injury was

repeatedly surveyed in Health. The first of this series of articles, published in

December 1943, discussed trenchfoot, immersion foot, and frostbite, with

particular reference to the incidence of this type of injury in previous wars,
ZONE OF INTERIOR 61

the incidence in the Aleutians campaign, and the current situation on the

Italian front. The article emphasized that the prophylaxis of cold injury is

command responsibility. The results obtained by the British by the use of

preventive measures were summarized.

The medical aspects of the Italian campaign were analyzed in the February

1944 issue of Health from the standpoint of comparative battle casualties,

neuropsychiatric casualties, and hospitalization for disease. The article closed

with the statement that, while the surgical care of battle casualties had been

exceptionally good, “the total rates for disease were high and jaundice, trenchfoot, malaria, and venereal disease were outstanding medical hazards over

which it proved difficult to exercise sufficient control.”

In the March 1944 issue of Health, the experience of the 1943-44 winter in

Italy was analyzed in considerable detail. The discussion covered etiologic

factors of cold injury with particular reference to the influence of terrain, the

tactical situation, and climatic conditions; the disappointing results accomplished by the first corrective measures; the serious losses in combat strength

because of the long periods of hospitalization usually necessary in trenchfoot;

and the frequently poor end results. The United States Army experience was

contrasted with the British experience; among British troops, the incidence of

trenchfoot was very low, presumably because preventive measures were well

established and strictly enforced. The inadequacies of the clothing which had

been supplied United States troops for winter use were noted, and preventive

measures were reviewed, with emphasis on command responsibilities.

The June 1944 issue of Health carried another analysis of the trenchfoot situation to date. It was pointed out in it that although the number of casualties

in the Attu campaign was small, the incidence of cold injury was actually high.

The small number of cases could be attributed more to the short period of time

covered by the fighting and the small number of troops involved than to any

other factor. In addition, certain of the troops engaged were accustomed to

cold, wet weather, knew how to take care of themselves in it, and therefore

did not develop this form of cold injury.

The article went on to say that, while medical officers were aware of the

problem presented by trenchfoot, instruction concerning this type of injury had

formed no part of the training for troops going overseas. Their ignorance of the

risk helped to explain why they had become patients from cold trauma. The

possibilities of prophylactic measures were again related to the British experiences in World War and on the Italian front the previous winter. The several

thousands cases which had occurred from United States Army troops in Italy

were chiefly in frontline troops whose replacement was military necessity.

The average time lost from duty per man was in the neighborhood of from

to weeks.

program of control was outlined, in which it was stressed that trenchfoot,

like venereal disease and malaria, can be prevented “only by the intelligent

behavior of the individual soldier under conditions of exposure.” The article
02 COLD INJURY, GROUND TYPE

closed with the prophetic warning that “A winter campaign in northwestern

Europe could create trenchfoot problem of major importance if the lesson

of Italy were not heeded.”

Analysis of Reports From Overseas

Meantime, reports and special studies prepared in the Mediterranean

theater were evaluated and analyzed in the Office of the Surgeon General with

particular reference to methods of therapy and problems of prevention and

control.

memorandum, prepared by Brig. Gen. Fred W. Rankin, Chief Consultant

in Surgery, and addressed to The Surgeon General on 17 March 1944, reviewed

the experiences in Italy, as well as in the Aleutians, and summarized the activities concerning cold injury which had been undertaken to date in the Office of

the Surgeon General. Preventive measures and management were outlined in

the light of these experiences. Special emphasis was placed on the fact that it

was not only preventive measures, but the rigidity with which they were enforced, that determined their effectiveness. In the final analysis, it was pointed

out, their implementation “is measure of discipline and is the responsibility of

unit commanders.”

The Essential Technical Medical Data report from the North African

Theater of Operations for February 1944 had included the statement from the

Office of the Surgeon, Fifth U. S. Army, that “No solution has been found for

the trenchfoot problem.” The Surgery Division, Office of the Surgeon General,

recommended on 24 May 1944 that the reply to the theater should point out that

the experience of previous wars and the British experience in Italy in the winter

of 1943-44 had demonstrated that solution to the problem did exist and that

it lay in the bold, vigorous, and diligent application of well-established prophylactic measures. It is unfortunate, and perhaps indicative of the general lack of

appreciation of cold injury in military operations, that this plain-spoken comment had been considerably watered down by the time it reached the theater

in July.

The March Essential Technical Medical Data report from the North

African theater, which was extensive and comprehensive, revealed that program of control was by this time well understood in the theater. Responsible

theater personnel had concluded, in the light of the low incidence among

British troops, that all troops should wear heavy wool socks; that their shoes

should be well fitted over these socks; that dry socks should be taken to frontline troops withrations; that laundry facilities for washing socks should be available in divisional areas; that squad leaders should be directly responsible for

enforcing proper care of the feet by the individual soldier; and that commanders

should arrange for rotation of frontline troops. Requisitions for new winter

equipment were placed by the theater in July 1944.

Letter, Brig. Gen. R. W. Bliss, Chief, Operations Service, Office of the Surgeon General, to Commanding General,

North African Theater of Operations, 16 June 1944, subject: ETMD.
ZONE OF INTERIOR 63

In memorandum addressed to The Surgeon General on 19 June 1944, by

General Rankin, the whole experience in Italy during the winter of 1943-44 was

reviewed. It was pointed out that inadequate instruction of personnel, failure

to provide suitable equipment, especially shoes and socks, and failure to apply

preventive measures consistently had been responsible for the heavy losses from

cold injury in the Italian campaign. Since prevention was the responsibility of

command, it was recommended that vigorous program be instituted at once to

include (1) dissemination of information to troops, with instruction in proper

methods of prevention of cold injury, (2) provision of proper equipment and

footgear, (3) dissemination of information to Medical Department personnel on

first aid and definitive treatment, and (4) emphasis on command responsibility

for prevention.

In the annual report of the Surgical Consultants Division, Office of the

Surgeon General, for the fiscal year ending on 30 June 1944, trenchfoot was

described as “perhaps the most unsatisfactory experience of the war.” Much

the same feeling had been expressed in General Rankin’s memorandum to The

Surgeon General dated 19 June 1944.

War Department Publications

On 29 May 1944, with the purpose of augmenting existing regulations governing care of the feet, as well as to prevent and control any further outbreaks

of trenchfoot such as had occurred on Attu and in the Mediterranean theater,

Lt. Gen. Brehon B. Somervell, Commanding General, Army Service Forces,

directed The Surgeon General to prepare without delay circular on the subject of trenchfoot, to include causes, symptoms, prevention, first aid, and

treatment. It was desired that this publication be ready by 10 June, but,

because of the number of divisions, offices, and special personnel whose assistance and concurrence were required, the date was extended.

War Department Circular No. 312, section TV, was issued 22 July 1944

as the official policy of the War Department in respect to trenchfoot. It read

as follows:

IV. TRENCH FOOT.—1. Trench foot is the name given to condition which result

from

a. Prolonged standing in water, wet snow, or mud under cold to freezing temperatures.

b. The continuous wearing of wet socks, shoes or boots. Trench foot is promoted by

wearing shoes, socks, boots, leggings, or combination of these which are too tight, and

when the individual who is forced to stay in muddy trenches, fox holes, or shell holes for

extended periods neglects exercising his feet and legs.

2. Signs and symptoms of trench foot usually develop as follows;

a. Numbness of the feet or toes. The feet feel like heavy blocks of wood and walking

becomes difficult.

b. Burning or stinging pain in the feet or toes.

c. Aching of the ankles and bottoms of the feet.

d. Swelling of the feet, and the skin becomes pale and cold.

e. Development of blisters and blebs.

f. Finally, gangrene may occur.
64 COLD INJURY, GROUND TYRE

3. Trench foot can be prevented by instructing the individual soldier in the proper

care of the feet, by providing suitable footgear where conditions promoting trench foot are

present, and by insuring that proper measures are carried out through use of disciplinary

action, if necessary.

4. When conditions promoting trench foot exist, and in order to minimize the occurrence of trench foot, unit commanders will be held responsible that the following instructions

are carried out:

a. Troops will be given the following specific instructions in the care of their feet:

(1) The feet must be kept dry. Damp soles (also, insoles, if worn) will be replaced by

dry ones as soon as possible.

(2) An extra pair of heavy woolen socks (also, insoles, if worn) will be carried at all

times to permit changing to dry ones once daily.

(3) Shoes will be removed at least once daily and the feet cleaned and dried. Foot

powder will be dusted over the feet and into the socks and shoes.

(4) When shoes or leggings feel tight they must be loosened immediately. Tight

footgear interferes with the circulation.

(5) If required to stand for long periods, the feet and legs will be exercised frequently.

Conditions might require that this be only in the form of wiggling the toes within the shoes

and bending the ankle. Positional exercises of the legs such as knee-bending when standing and elevating legs above level of body when sitting or lying down should be accomplished.

(6) Avoid standing in water, wet snow, or mud. Whenever feasible, the water in

trenches, fox holes and shell holes should be bailed out, and rocks, pieces of wood, or tree

branches used to stand on.

(7) When necessary to sleep while in sitting position, prop feet as high as possible to

help blood circulation. Put on dry socks. Place wet or damp socks in trouser pockets or

beneath the shirt to dry. Do not sleep wearing wet socks.

b. Before troops enter combat in cold, damp areas, unit commanders will insure that

the troops have cleaned and dried their feet and dusted them with foot powder before

putting on dry, heavy woolen socks and waterproof or water-resistant boots or shoes.

c. Arrangements will be made to furnish troops with clean, dry pair of heavy woolen

socks (also, insoles, if worn) once daily. This may be accomplished by bringing them up

with the daily ration.

d. Proper waterproof or water-resistant footgear will be issued to the troops when

fighting in cold, water-soaked terrain. Care will be taken that the footgear fits properly.

The footgear should be loose enough to permit wearing heavy woolen socks without constricting circulation.

e. Foot inspections will be held frequently and the necessary corrective measures

instituted.

Therapy was not covered in this circular, partly because treatment was

regarded as technical medical procedure and partly because itwas to be covered

in technical medical bulletin on trenchfoot then in preparation. Suggestions

that instructions be given to massage the feet, unless trenchfoot had already

set in, and to use lanolin, were disapproved by The Surgeon General, on the

ground that (1) the soldier could not himself determine whether or not he had

already contracted trenchfoot; (2) he might do considerable damage to the

tissues by massage;and (3) the use of oils and greases on the feet as of questionable value and could be harmful. The suggestion, made by the Quartermaster General, that the shoepac be recommended as the best footgear to prevent

trenchfoot, as also disapproved, on the ground that the improper use of shoepacs could result in serious damage to the feet.
ZONE OF INTERIOR 65

Revision of War Department Circular No. 312.—-Shortly after War Department Circular No. 312 had been published, the Quartermaster General requested that it be revised in order to clarify the reference to heavy woolen

socks, since too strict an interpretation of the instructions to use them might

result in sudden depletion of the supply. All commanding generals at ports

of embarkation had been notified August 1944 that this circular was designed

for the prevention of trenchfoot and was not to be construed as justification

for an increase in the authorized allowances of socks. Theaters served by the

various ports were to be informed of this ruling.

The Surgeon General did not concur in the changes requested by the

Quartermaster General, and conference to discuss the matter was held

18 September 1944. Representatives of the Quartermaster General explained

why they opposed the circular as it had been issued: If theater commanders

should make requisitions for heavy woolen socks, to comply with its terms, the

demand could not be met, since at that time these socks amounted to only 10

percent of the total sock procurement. Wool was available for additional

supplies of socks, but machinery to make them was not and it could not be

constructed in less than or months. It was agreed that before any action

was taken in this matter, the Quartermaster General should inquire from the

commanders in all theaters how many heavy woolen socks would be needed

to comply with the terms of the circular. When it was learned from the

European theater that the circular would have no effect upon the initial issue

of this type of sock (although it was requested that the maintenance factor

for cushion-sole socks be increased from 11 to 25 percent), War Department

Circular No. 312 was thereupon modified as follows, at the request of the

Quartermaster General:

V. TRENCH FOOT. 1. Reference is made to section IV, Circular 312, \VD 1944.

2. The provisions of paragraph 4, section IV, Circular 312, will not be considered as

authorization for an increase in allowances of heavy wool socks, authorized in T/E 21,

Clothing and Individual Equipment, June 1944, as socks, wool, cushion sole; socks, wool,

heavy; or socks, wool, ski. When increased allowances are requii’ed to comply with the

provisions of Circular 312, requests will be submitted through channels.

War Department Technical Bulletin 81.—The publication of War Department Circular No. 312 on 22 July 1944 was followed by the publication of

War Department Technical Bulletin (TB MED) 81, August 1944. This

bulletin (appendix A, pp. 509-515), which covered all phases of cold injury,

with special emphasis on prophylactic measures, was largely based upon the experience, both in the clinical aspects of the condition and in its prevention,

gained in the recent Italian campaign. Minor changes in therapy were suggested in an amended version published October 1944 (appendix A, p. 515).

(1) Memorandum, Director, Distribution Division, Army Service Forces, for Director, Military Training Division,

23 Aug. 1944, subject; Trench Foot. (2) Memorandum, Headquarters, Army Service Forces, for Quartermaster General,

23 Aug, 1944, subject: Heavy Woolen Socks.

Telegram toall commandinggenerals at ports ofembarkationfrom Lt. Gen. Brehon B. Somervell, dated Aug. 1944.

War Department Circular No. 459, Dec. 1944.
66 COLD INJURY, GROUND TYPE

The Assistant Secretary of War, Mr. John J. McCloy, wrote to The Surgeon General on 16 August 1944 to point out that in polls taken of the Army

overseas and published in What the Soldier Thinks, 85 percent of those questioned felt that they had received too little training in how to avoid having

trenchfoot and how to take care of it. The only other item in which the percentage was similarly high had to do with the handling of land mines. The

Secretary felt that these figures were significant, though he was uninformed as

to what The Surgeon General was doing in “training in the avoidance and

treatment of trenchfoot.”

The Surgeon General replied on 17 August that the soldier was indeed

receiving too little instruction in the care of his feet but that prevention of

trenchfoot was really command function, to be carried out with medical

advice. He sent the Secretary copy of War Department Circular No. 312

and also described TB MED 81, then in production, which covered all phases

of trenchfoot. copy of this publication was sent to the Secretary 31 August

1944, just after it had been published and received from The Adjutant General.

Review and Evaluation of European Theater Problem

Either the lesson of the Italian campaign was not heeded in the European

Theater of Operations, or appreciation of its significance came too late. The

official publications of the War Department on the subject (War Department

Circular No. 312 and TB MED 81) were not received in the European theater

until after sporadic cases of trenchfoot had already occurred and only shortly

before an outbreak of cold injury, of much greater gravity than the outbreak in Italy the previous winter, began in France and Germany.

During November 1944, approximately 11,000 cases of trenchfoot were

reported in the European theater, more than 6,000 in the Third U. S. Army

alone. The November rates for this theater, which were already in excess of

those in January and February 1944 in the Fifth U. S. Army in Italy, were

analyzed in the November 1944 issue of Health The elements of satisfactory

control program, as outlined in War Department Circular No. 312 published

in July 1944 and in TB MED 81 published the following month, were reviewed with special emphasis on the provision of suitable equipment, the

avoidance of unnecessary risks, and the enforcement of adequate care of the

feet. It was pointed out again that the solution of the problem lay in the

assumption of the responsibility by commanders.

As described in detail elsewhere (p. 146), shortages of winter clothing and

other winterizing equipment were at this time compounding the difficulties in

the European theater. An iirgent cable from Headquarters, Communications

Zone, European Theater of Operations, to the War Department December

1944, described the trenchfoot outbreak in detail and urged that the Department make all possible efforts to expedite supplies of shoepacs, socks, and

winter clothing.

This cable gave rise to series of meetings, all held December.
ZONE OF INTERIOR 67

The first of these meetings was held in the office of Brig. Gen. (later Maj. Gen.) Raymond W. Bliss, Chief, Operations Service, Office of the Surgeon

General, to discuss in detail the situation in the European theater.

At the conclusion of this meeting, General Bliss and General Rankin met

with Maj. Gen. Norman T. Kirk, The Surgeon General. General Rankin read

prepared summary of the efforts which had been made in the Surgical Consultants Division, Office of the Surgeon General, to set up an adequate program

for the control of cold injury. He concluded with the statement: “The most

important factor in assuring the success of this program is enforcement of these

elements [prevention and foot discipline] and this lies within the province of

command rather than medical authority.”

At the conclusion of the second meeting, meeting was arranged between

General Kirk, General Somervell, and Gen. George C. Marshall, Chief of Staff,

to provide The Surgeon General with an opportunity to state the seriousness of

the cold injury situation in the European theater and to emphasize the need

for renewed command efforts to bring preventive measures into full implementation at all levels. Special emphasis was to be placed upon indoctrination

of the smaller units. The recommended preventive measures also included (1)

provision of suitable and properly fitted footgear and heavy woolen socks, (2)

daily foot inspections and daily changes of socks, and (3) frequent rotation of

troops who were serving under conditions predisposing to cold injury. 10 These

measures are discussed in detail in the chapter dealing with cold injury in the

European Theater of Operations (pp. 167 and 173).

In the December 1944 issue of Health the current situation in the European

theater was analyzed on the basis of the weekly rates and analyses cabled from

it. It was noted that the incidence of cold injury was considerably higher in

that theater in certain units than it had ever been during the Italian campaign,

and the close parallel between tactical activity and cold injury was pointed out.

The situation in the European theater was again reviewed in the January

1945 issue of Health, and the increasing incidence was commented on. Control

measures were being pushed vigorously, it was stated, but the tactical situation

and the weather hampered their full implementation. The British experience

was analyzed, and it was noted that the British attributed their comparative

freedom from trenchfoot to the superiorfit of the shoes provided for their troops

and to their better foot discipline.

In the March 1945 issue of Health, the entire European experience was

reviewed and it was pointed out that about 30 percent of the 45,000 predominantly frontline troops who had contracted cold injury in that theater

would require evacuation to the Zone of Interior. Although estimates indicated that 55 percent of the wounded could be returned to frontline duty, it

was doubted that this proportion of trenchfoot patients could be returned to

combat. The British experience in the European theater was again reviewed.

Memorandum, Brig. Gen. F. W. Rankin, Chief Consultant in Surgery, Surgical Consultants Division, for The

Surgeon General, Dec. 1944, subject: Trench Foot. i° Memorandum, The Surgeon General for the Chief of Staff, Dec. 1944, subject: Trench Foot.
68 COLD INJURY, GROUND TYPE

Among other subjects discussed in this article were the advantages of control

teams, the necessity for the allotment of additional time in the training schedule

for instructions in the prevention of trenchfoot, the shortages of shoepacs in the European theater, the relationship between tactical activity and exposure

to cold, and the necessity for advanced planning whenever there was remote

likelihood of combat under winter conditions.

TRAINING PROGRAM

Manuals

As has already been pointed out (p. 58), the various military publications

current when the United States entered World War II were neither complete

nor satisfactory from the standpoint of the discussion of cold injury, and they

were often contradictory as well. For the record, they will be briefly mentioned,

together with the revisions which they underwent in the course of the war.

Operations in Snow and Extreme Cold.—This manual (FM 31-15) was

published on 18 September 1941 to supplement training circular of the same

title which did not contain full information on the subject. Changes were

published on 16 April and on 29 September 1942. Frostbite was briefly

discussed in this manual, and it was pointed out that wounded men need special

protection against cold injury. Trenchfoot was not mentioned.

First Aid for Soldiers.—This manual (FM 21-11), which was published on

April 1943, contained extended discussions of frostbite and freezing, including

diagnosis, first aid, treatment, and prevention. Trenchfoot, shelterleg, and

immersion foot were briefly discussed. All three conditions, it was stated,

resembled mild frostbite but could occur at higher temperatures. The causes

were listed as standing or sitting still for long periods in wet trenches or shelters

and letting the feet hang for long periods in water after shipwreck. Tight

leggings and cramped positions of the legs were listed as contributing causes.

The best methods of prevention, it was stated, were keeping the feet dry and

exercising the extremities to increase the flow of blood in them. First-aid

measures were the same as those recommended for frostbite. No changes

were made in these sections when the manual was revised on 20 May 1943.

On 14 September 1944, The Surgeon General requested the Commandant,

Medical Field Service School, Carlisle Barracks, Pa., to proceed at once with

complete revision of the text of First Aid for Soldiers, to bring it into accord

with most recent doctrine. 11 In The Surgeon General’s request for approval

of the revision which went to the Director, Military Training, Army Service

Forces, on 16 September 1944, trenchfoot was mentioned as one of the subjects

requiring more extended attention. The same necessity was mentioned when

The Surgeon General submitted the outline of the proposed revision to the

11 An article on the subjects of frostbite, immersion foot, and trenchfoot had been published from this school (Wright,

I. S.. and Allen. E. V.: Frostbite, Immersion Foot, and Allied Conditions. Bull. U. S. Army M. Dept. No. 65, pp. 136-

150, January 1943). This was comprehensive article, dealing with all phases of these injuries, including prevention.
ZONE OF INTERIOR 69

Commanding General, Army Service Forces, on 31 October 1944. On 29

January 1945, the Surgeon General’s Office concurred in the plan to reprint the

unrevised manual at this time, on the ground that it would be another months

before the revision then in progress could be accomplished.

Actually, the revised manual did not appear until August 1946. In this

revision, trenchfoot was described in detail in the light of the World War II

experience, and special emphasis was put upon preventive measures including

the care of the feet. It was recommended that the feet be kept clean and dry,

that they be exercised and massaged, that constriction be avoided, and that

the socks be changed at least once daily. Frostbite was also discussed in detail from the standpoint of prevention.

Field Sanitation.—This manual (FM 8-40), prepared under the direction

of The Surgeon General and published by the War Department on 15 August

1940, did not mention either trenchfoot or frostbite in the original issue or in

the three changes published in 1942.

Military Sanitation and First Aid. —This manual (FM 21-10), published on

31 July 1940, contained full clinical discussion of frostbite but did not mention

trenchfoot either in the original edition or in the seven changes made between

the date of issue and 17 February 1944. Trenchfoot was also not mentioned

in any of the correspondence, begun in October 1943, concerning revision of

the text.

The revision was not completed until July 1945. Chapter 13, which deals

with personal hygiene, contains an extensive discussion of trenchfoot, as well

as of immersion foot and frostbite, with emphasis on the care of the feet, the

proper use of clothing and footgear, and similar matters. The following

paragraph is cited as an illustration that the lessons of the experiences in

Italy and Europe had by this time been well learned:

Remember that no single type of footgear or combination of shoes alone will keep

the feet dry and warm under the varying conditions met in combat areas. Proper footgear

is at best only help in keeping the feet warm and dry. The prevention of trench foot

depends on the care given the feet by constant attention to all the rules outlined above.

In May 1944, while the revision of this manual was in progress, General

Bliss recommended that pamphlet proposed by the Military Training Division, Army Service Forces, should not be published because the material,

in substance, was included in this proposed revision and would also appear in

Personal Health, War Department pamphlet then in preparation. It was

expected that this revision would also eliminate the need for FM 8-40, Field

Sanitation. The request received by radiogram from Headquarters, European

Theater of Operations, on 10 January 1945, for 200,000 copies of FM 21-10,

Military Sanitation and First Aid, included request for information concerning the revision which, as noted above, appeared too late to be of value in

World War II.

Soldier’s Handbook.—This manual (FM 21-100) was first published on 23

July 1941. The need for it had been realized much earlier, but funds could not

be secured for publication. The distribution was Army-wide. The care*of
TO COLD INJURY, GROUND TYPE

clothing and the cleansing of boots and shoes were described, but the only

mention of cold injury concerned the management of individuals exposed to

freezing. Trenchfoot was not mentioned in the changes made in May and

December 1942. revision of this manual was planned in the summer of

1943, and several suggestions were made to the effect that the text should be

more interesting, more easily comprehended, and more readable. The revision

was not carried out, the manual being rescinded on 10 August 1944, because

tlie material in it was either obsolete or was duplicated in other field manuals.

Permission was given in War Department Circular No. 375, dated 15 September

1944, to use the handbook, with whatever corrections were necessary, until the

pamphlet intended to replace it (War Department Pamphlet 21-13, Arm}’

Life) should become available. Army Life was published on 10 August 1944.

Principles of Cold Weather Clothing and Equipment.—This manual

(TM 10-275) was prepared by the Office of the Quartermaster General on 26

October 1944. It had been in preparation for almost year, large part of

the delay being for editorial reasons. Changes were initiated almost as soon

as the manual appeared and were issued on February 1945; they had to do

with preferred types of footgear, including sock combinations. Excellent

advice was given in this publication about the care of the feet, the importance

of exercising them, and other preventive measures. Although the military

experience had been that dubbing was not useful in the prevention of trenchfoot, instructions for its use were given in the changes in the manual issued in

February 1945.

Medical Department Soldier’s Handbook.—This manual (TM 8-220)

replaced the earlier handbook prepared by Maj. Arnold 1). Tuttle, MC, and

published in 1927.12 Frostbite, freezing, and chilblains were briefly discussed

in the earlier text, but trenchfoot was not mentioned.

The Medical Department Soldier’s Handbook, which was issued on

March 1941, contained clinical descriptions of the effects of prolonged exposure

to extreme cold, descriptions of frostbite and chilblains, and instructions for

the management of these lesions. Trenchfoot was not mentioned. Directions

were given for the proper fitting of shoes and socks and for the care of the feet.

In the third set of changes, issued in February 1944, the section on frostbite

was considerably expanded and became substantially the same as the similar

section in FM 21-11, First Aid for Soldiers. Also included was section on

immersion foot dealing with contributing factors, clinical considerations,

preventive measures, and emergency management. Trenchfoot was not

mentioned in any of these changes.

Guides to Therapy for Medical Officers.—This manual (TM 8-210), which

was published 20 March 1942, contained an extended discussion of frostbite,

covering prophylaxis, etiology, and treatment, but did not mention trenchfoot.

Athlete’s foot was also discussed. Details of foot hygiene were outlined,

12 Tuttle, Arnold D.; Handbook for the Medical Soldier of the Regular Army, National Guard, Organized Reserves,

and Enlisted Reserve Corps of the Army of the United States and Others Interested in National Medicomilitary Pre- paredness. New York: William Wood and Co., 1927.
ZONE OF INTERIOR 71

including the care of the feet after long marches. The importance of wearing

properly fitted shoes and socks was emphasized. Light wool socks were recommended, and it was specifically stated that the shoes should be laced snugly.

This manual was rescinded in 1944, and the material which had previously

appeared in it was thereafter published in medical technical bulletins.

Arctic Manual.—This manual (TM 1-240), which was published on April

1942, superseded the two volumes of similar title published on November 1940.

It was specifically intended for the use of personnel in the North American

Arctic region who were not assigned to permanent posts. Frostbite was

described at some length in the 1940 publication, but neither frostbite nor

trenchfoot was mentioned in the 1942 edition. When this manual was revised

on 17 January 1944, an extensive discussion of all aspects of frostbite was

included, but, again, trenchfoot was not mentioned.

Personal Health.—This publication (WD Pamphlet 8-9) was initiated as

manual in the fall of 1943. When it was learned that publication in this

form would probably not be permitted, approval was requested for it as

pamphlet in the same format. When the material was sent to the Surgeon

General’s Office in August 1944 for review before publication, personnel in

that office requested that subtitle, An Eye to Your Future, be added, and

that an illustration be provided for the cover. 13 The pamphlet, it was stated,

contained much valuable material, and it was thought desirable to try to remove

it from the category of routine War Department training manuals. The

average soldier, the note pointed out, “considers that he has sufficient knowledge of personal health without further advice, and often casts aside any document on personal health without reading it” unless it can be made attractive

enough to stimulate his interest. In view of the urgent need for this pamphlet

in the field, it was requested that its publication be expedited. It is not clear

why work on this publication lapsed.

The Fitting of Shoes and Socks.—This manual (TM 10-228) was undertaken shortly before V-J Day but was not completed when the immediate

necessity for it ceased.

Comment,—In analyzing the various publications of the War Department

dealing with the health of the soldier and his training and equipment for cold

weather, one is impressed, as has already been pointed out, with the inadequacy

of the instructions for the prevention and management of cold injury, and

with the inaccuracy of much of the material that was published. Trenchfoot

was entirely ignored in the manuals current when the United States entered

the war. When revisions of these manuals were undertaken, trenchfoot continued, for the most part, to be ignored. Revisions were initiated late, and

many months usually passed before the concurrence of the various offices and

personnel concerned could be secured. Many disagreements concerned trivia.

Further delays ensued as the manuals were processed and issued. None of

them reached the Mediterranean or the European theater in time to be useful

13 Memorandum, The Surgeon General, for Office of The Adjutant General, 16 Aug. 1941, subject: WD Pamphlet

8-9 “Personal Health.”
72 COLD INJURY, GROUND TYRE

in the prevention and control of trenchfoot. Some of them, in fact, would

probably not have been ready in time for cold weather operations in the Pacific

had war in that theater continued into the fall and winter.

Posters

The difficulties just outlined, which attended the publication of field and

technical manuals, also attended the preparation of posters and films designed

to educate troops in the prevention of cold injuries. There would therefore be

no point to rehearsal of the details.

Multiple charts for company-size units were planned and prepared in the

Training Division, Surgeon General’s Office, on numerous subjects, including

trenchfoot. They took time to prepare. Coordination with many offices was

necessary. Additional time was required to make the changes required or

desired to correct facts, alter emphasis, or change the method of presentation.

For these reasons, when urgent requests were received from the European

theater in December 1944 for posters on cold injury for general distribution,

the requests could not be filled. On January 1945, General Bliss sent two

posters to the Chief Surgeon, European theater, with request that he order

the number desired. One of these posters was an offieial War Department

poster (GTA 8-16) in four colors, designed to drive home the necessity for

daily individual foot care. The other had been prepared by units of Army

Ground Forces, Fort Benning, Ga. Orders were placed on 19 January for

12,000 copies of each of these posters, half to come by air and half by fast

boat shipment.

In the European theater, as in the Zone of Interior, when official posters

were not available, many units prepared and displayed their own. Some were

excellent, others were not too expert, but most were useful as well as immediately effective.

There was, of course, an element of danger in the local preparation of

posters. An offieial observer from the Surgeon General’s Office noted that he

had recommended that one such poster which had come to his attention be

removed and destroyed at once, on the ground that trenchfoot was not subject

to be treated humorously. Similar advice was given at another camp, where

trenchfoot was presented as form of athlete’s foot and as preventable by the

methods used for the prevention of that infection. Since the cause of cold

injury was presented as germ, and not as impairment of the blood supply to

the feet, the soldier would naturally not understand that it could be prevented

by exercise, massage of the feet, warmth, and the unloosing of constricting shoes,

seeks, and leggings.

The official observer just quoted stated in his report on this tour of inspection that the major reason for the difficulty in explaining the concept of trenchfoot was the fact that line officers had not read, and would not read and familiarize themselves with, the various directives on the condition. If, as the

poster just described indicated, unit officers thought that cold injury was just
ZONE OF INTERIOR 73

severe case of athlete’s foot, soldiers under their command would have the

same ideas. The knowledge of trenchfoot, in short, was weak because of the

average line officer’s complete ignorance of the material contained in existing

directives. 14

Films

The film undertaken in the fall of 1942, under the title “Personal Health

in Operations in Snow and Extreme Cold,” was approved for release on 28

December 1943.

The Training Division, Office of the Surgeon General, requested authorization on 18 September 1944 for the production of film bulletin on the cause

and prevention of trenchfoot, to be based on the doctrine contained in War

Department Circular No. 312. Although the film was put into production

promptly, it was not finally approved until 17 February 1945 and was not

released until March as Film Bulletin 180, subject: Trench Foot.

This film, which had running time of 18 minutes, was intended to be

shown to all ground troops before they went on maneuvers or into combat,

the objective being to focus attention on proper care of the feet immediately

before such care would abruptly become of the greatest importance. Troops

were shown hiking through mud and snow and living in muddy foxholes.

Cold, numb, wet feet, it was shown, could lead to trenchfoot, with cold, numbness, and stiffness the first symptoms, followed by blister formation; these

relatively mild symptoms and signs, it was indicated, could lead to gangrene,

with amputation the possible end result. Preventive measures were illustrated, such as the use of rocks and branches of trees in the bottom of foxholes, to keep the feet from direct contact with mud and water; daily removal of the

shoes and daily changes of socks; vigorous massage of the feet, with the application of foot powder; sleeping with the legs elevated; and methods of drying

the wet socks by body heat. It was repeatedly emphasized in the course of the

presentation that only by adherence to these cardinal principles could the feet

be kept warm and dry, and trenchfoot with its ghastly consequences be prevented. The message was driven home by repeated flashbacks to pictures of

gangrenous feet which required amputation.

This vigorous presentation proved both useful and effective in the United

States, where the film was widely distributed, and in the training program

14 There were, of course, exceptions to this generalization. An occasional commander was wise before the event. An observer for the Army Ground Forces Board, NATOUSA, quoted the colonel of an infantryregiment as saying

“I wrote monograph at Benning in 1928-29 on the subject of the care of the feet. thought it was an important subject

then, though some other people did not. It is still one of the most important subjects for an Infantry officer to know.

Trenchfoot is one of the major causes of non-battle casualties, and non-battle casualty reduces your combat strength

just as much as does battle casualty *. The remainder of this regiment [he excluded the Japanese-American component, p. 380] has consistently had the lowest trench-foot rate among the infantry of the division. This, am sure, is

largely due to the emphasis we have placed on care of the feet. have personally conducted school on care of the feet

for the juniorofficers of the regiment. We require every man to go into combat with clean, dry pair of socksinside his

shirtand werequire platoonleaders to see that their men change wet socks for dry ones, and massage their feet, whenever

it isatall practicable. If Benning does not already have itin its officer-candidate course, it should include short course

on care of the feet. The instructor should be competent doughboy who has done lot of marching and knows how to

take care of feet in wet, cold weather. don’t think that anything that Benning can teach its students is of more im- portance.”
74 COLD INJURY, GROUND TYPE

in the Pacific (p. 231). Itwas issued too late to be employed when it was most

needed, in the Mediterranean and European Theaters of Operations. Repeated requests for films on the subject of trenchfoot were received from the

European theater but could not be filled.

Indoctrination of Troops

Pearl Harbor-July 1944. —Instruction in the risks of cold injury and in

methods of preventing it formed no part of the training of combat troops in

the early days of the United States participation in World War 11. It was

not, in fact, until trenchfoot had become major problem in combat operations in Italy in the winter of 1943-44 that serious attempt was made to

include indoctrination on cold injury as part of the combat training, and

the war was almost over before satisfactory courses were set up. This was,

of course, an error of the first magnitude, for which heavy price was paid

in loss of manpower and reduced combat efficiency.

On the other hand, it is only fair to point out certain facts in explanation,

though not in excuse, for this situation. The United States had been quite

as unprepared to enter World War II as it has been to enter World War I.

In the space of months after Pearl Harbor, an army of approximately 1.6

million men became an army of several million. New troops had to be taught

great many things, many of them of the utmost importance. There was

constant competition for space in the training program. Even after the importance of cold injury was fully realized, instruction in its prevention had to

compete for room with other subjects. Furthermore, the Medical Department, which realized the dangerous possibilities of this sort of injury relatively

early in the war, and which repeatedly called attention to them, could do no

more than advise, and advise only indirectly (p. 81), since the prevention of

trenchfoot is primarily command, not medical, function.

Cold injury in the training program was first conceived of as relating to

combat operations in the Arctic. This is clear from the material contained

in the manuals issued early in the war and already discussed (p. 68). The

same concept is evident in the training outline prepared in October 1943; it provided only for 12 hours of instruction for training in operations in extreme

cold, devoted to sanitation and to first aid.

War Department Circular No. 48, issued on February 1944, provided

that training schedules and courses of instruction be so planned as to insure

minimum standards ofproficiency in the care of the feet, including the prevention of trenchfoot. This circular was amplified on 17 March 1944, in training

directive which specified that unit schedules be revised to include such additional instruction as might be necessary to meet these requirements. Tests

were prescribed to determine achievement of the required proficiency.

July 1944 toV-J Day —Action in respect to training of troops became much

more vigorous in the summer of 1944, as the full realization of the cost of the

cold injury experience in Italy in 1943-44 became more general.
ZONE OF INTERIOR 75

Weekly Directive Xo. 31, Headquarters, Army Ground Forces, dated

August 1944, pointed out that the alarming number of cases of trenchfoot could be attributed to lack of proper training and command supervision.

Immediate and positive steps were to he taken by all commanders to eliminate this deficiency and to comply with current directives, which were listed.

command letter from Headquarters, Army Ground Forces, was forwarded on 26 August 1944 to all subordinate commands. This letter, which

was entitled “Trench Foot and Training in Foot Hygiene,” stated that reports

received at that headquarters had indicated unsatisfactory ratings in proficiency in the care of the feet and that investigation had showed that sample

test questions often did not include this point. Meantime, the rate of trenchfoot cases was alarming. The military importance of such losses was stressed.

Attention was called to the various publications available on cold injury, including TB MED 81, which would become available on 31 August. It was

directed that “positive and immediate action” be undertaken by all command

echelons “to insure adequate training, enforce proper hygiene, and fully indoctrinate all individuals.”

Letters to the same effect were sent from Headquarters, Army Ground

Forces, to the Commanding General, Second U. S. Army, on 24 October 1944

and to the Commanding General, Fourth U. S. Army, on 30 October 1944.

Instruction to date, it was pointed out, had failed to impress the individual

enlisted man with basic knowledge concerning cold injury. Additional effort

to improve the situation was required. When necessary, further instruction

and testing should be carried out on shipboard, en route to theaters of operations.

The information and instructions in this letter were relayed to all commands in the Second Army on 31 October 1944 and followed up the command

letter which had been sent from Headquarters, Second Army, on 29 July 1944.

In the latter letter, it had been pointed out that reports from overseas and tests

conducted by this headquarters had shown lack of knowledge and appreciation of the prevalence, seriousness, causes, and methods of prevention of

trenchfoot. The causes, symptoms, first-aid management, and methods of

prevention were briefly outlined, and attention was called to available publications on the subject. Division and separate unit commanders were directed to

impress the seriousness of this type of injury upon all officers and noncommissioned officers of their commands.

All units in the Replacement and School Command, Army Ground Forces,

received information and instructions concerning cold injury in letter from

Headquarters, Army Ground Forces, on November 1944. The special

periods at which this instruction was to be given were listed for the replacement training centers, infantry advanced-replacement training centers, and

special-service schools.

At about this time, each division surgeon in the Zone of Interior also received letter from Brig. Gen. Frederick A. Blesse, Surgeon, Army Ground

Forces, emphasizing that instruction in trenchfoot must be given accurately,
76 COLD INJURY, GROUND TYPE

must be clearly understood, and must be followed by application of the information, inspections, quizzes, and continuous correction of errors.

After the issuance of these letters, upon instructions of Lt. Gen. (later

Gen.) Ben Lear, Commanding General, Army Ground Forces, staff officers

from his headquarters, in their inspections of Ground Forces installations and

replacement training centers, always put particular emphasis upon proficiency

in the care of the feet and in knowledge of trenchfoot. General Lear’s stated

policy was that each company be given two foot inspections weekly, one by

commissioned officer and one by noncommissioned officer. Inspecting

officers from his headquarters were instructed to assure themselves that this

policy was being carried out. They also made spot checks of the condition of

the men’s feet and of their knowledge of trenchfoot. Special emphasis was

placed upon trenchfoot when surgeon was added to the staff of each replacement center in December 1944, and instruction on medical subjects was increased.

In December 1944, the Office of the Surgeon General prepared an outline

for 15-hour program in military sanitation and hygiene, for proposed

revision of the courses in these subjects in the Army Service Forces officers

candidate schools. Lesson No. 2, dealing with personal hygiene, laid special

emphasis on foot care and the prevention of athlete’s foot and trenchfoot.

An outline of the training program instituted in the European theater

after the November 1944 outbreak of trenchfoot contained full information

about the prevention of the condition, including both the proper use of clothing

and the proper care of the feet. This outline was distributed by Headquarters,

Army Ground Forces, as inclosure to letter dated 20 January 1945, on the

subject of prevention of trenchfoot and frostbite (appendix B). team of

three specially qualified officers, one from G-4 (logistics), Army Ground Forces,

and two from the Office of the Quartermaster General, was appointed to train

instructors at each port of embarkation. The mission of these instructors was

to insure that all military personnel passing through ports for overseas assignment received the indoctrination contained in this directive. No man was

supposed to leave the port of embarkation for combat area until his AG Form

20 or 66-1 bore the notation that he had received hours of training in the

prevention of cold injury and in the use of the winter combat uniform and other

equipment, just as he could not leave without record of the inoculations required in the area to which he was going.

When sufficient number of instructors had been trained to cover the

various ports of embarkation, similar training programs were set up at the large

camps and training centers throughout the country. Courses were also conducted at both embarkation points and training centers for supply personnel,

who were instructed how to requisition, fit, and issue the new clothing.

This program was continued until the end of the war. In all, more than

100,000 officers and men were trained by the original team and by the instructors who had been trained by this team. The need for the program was evident
ZONE OF INTERIOR 77

in single fact, that at no time did any team of instructors encounter units

which had already been 100-percent trained.

In the meantime, training was continuing in Army installations throughout

the country. request was made April 1945 by Brig. Gen. Stanhope BayneJones, Acting Chief, Preventive Medicine Division, Office of the Surgeon

General, to the Training Division to increase the time allotted to the teaching of sanitation in War Department Circular No. 48, 1944, from 20 hours to 22

hours, to permit increased emphasis upon certain subjects, including fungous

infections of the feet and trenchfoot.

Training Memorandum No. 1, Headquarters, Army Ground Forces, June

1945,reiterated the requirements specified in War Department Circular No. 48, 1944. Training Memorandum No. 5, issued from the same headquarters on 16

July 1945, directed that all personnel be given instruction in the capabilities,

limitations, use, care, and preservation of clothing and equipment and in the

principles of living in the cold. Instructional kits included wet-cold kit,

which contained complete wet-cold uniform assembly (p. 222), as well as training aids. All of this information, it was stressed, was intimately related to the

prevention of trenchfoot. Instruction was to consist of hours for enlisted

men and hours for officers. detailed question-and-answer guide was prepared by Headquarters, Army Ground Forces, and made available to Headquarters, Replacement and School Command, on 17 July 1945. This guide

presented the minimum knowledge considered essential for proficiency in basic

medical subjects, including trenchfoot.

Mobile Intelligence Training Units, whose function was to aid in the training of redeployed units in subjects of special importance in the Pacific, were set

up and supervised by specially qualified medical officer from Headquarters,

Army Ground Forces. These units were trained to put particular emphasis

upon the prevention and control of trenchfoot. It was contemplated that

team would be made available to each Army post at which Ground Forces

units were receiving redeployment training, but the ending of the war terminated the necessity. At the end of the fighting, teams had been trained and

were ready to function, 10 more were in training, and arrangements were under

way for the training of 13 others.

In memorandum, dated 27 July 1945, to the Chief ofStaff, Army Ground

Forces, General Blesse summarized the steps which had been taken for the

training of ground troops in the prevention of trenchfoot from February 1944

to 27 July 1945, as follows:

1. All War Department publications relative to the subject of cold injury

and foot care were listed, including War Department Circulars No. 48, 1944, and

No. 312, 1944; TB MED 81, 1944; publications in the Bulletin of the United

States Army Medical Department; and publication in Health.

2. Measures taken by Headquarters, Army Ground Forces, to implement

these publications and assure effective training were also listed. These measures

included the training directives described earlier in this chapter, training aids,

438404 —58
78 COLD INJURY, GROUND TYPE

posters, clinical photographs and models, letters to various divisions and other

commands, inspection trips, and proposed course of instruction in diseases

likely to be encountered in the Pacific theater.

This memorandum to the Chief of Staff, Army Ground Forces, was accompanied by the draft of letter which it was proposed should be sent by

Gen. Jacob L. Devers, Commanding General, Army Ground Forces, to each of

his major subordinate commanders. The letter reiterated the various points

of importance concerning trenchfoot and stressed command and individual

responsibility. Attached to it was an enclosure covering all of these points in

detail.

General Devers approved the proposed letter and directed General Blesse

to prepare summary embodying the latest information on trenchfoot, to cover

concepts and measures necessary for prevention. This was accomplished on

August 1945. The summary outlined the causes of trenchfoot, its clinical

aspects, individual measures of prevention (clothing, footgear, and care of the

feet), and control program. In the directions for formal training, provision

was made for trenchfoot control teams and control noncommissioned officers,

in line with the system which had proved so effective in the European theater

(p. 177). The facilities and training aids available for this program were listed.

Command responsibility for trenchfoot, discipline, clothing, and rotation of

troops was unequivocally stated.

The course of instruction mentioned in the correspondence with the Chief

of Staff, Army Ground Forces, was to deal with diseases prevalent in the

Pacific and was to be given to selected Medical Department officers. The

allotment for trenchfoot was hours. The plan was that student officers would

indoctrinate their own organizations after they had completed the course. It

was proposed that the course should begin on 13 August 1945 and that each

course would last for weeks. The plans were cancelled when the war ended on

14 August, and the text being prepared for use in the course in the Office of the

Surgeon General was not completed.

HOSPITALIZATION OF TRENCHFOOT CASUALTIES

In the fall of 1944, the vascular center at Letterman General Hospital, San

Francisco, Calif., Mayo General Hospital, Galesburg, 111., and Ashford General

Hospital, White Sulphur Springs, W. Va., were designated to receive trenchfoot

cases. In January 1945, Brooke General Hospital, San Antonio, Tex., and the

Army Service Forces hospitals at Camp Butner, N. C., and Camp Carson, Colo.,

were designated for the same purpose, with the expectation that one or two

additional hospitals might be designated later. During the peak load, in the

late winter and spring of 1945, trenchfoot patients were necessarily sent to other

hospitals, but no others were formally designated as trenchfoot centers. The

original plan was to handle all these patients on medical wards. Later it became

evident that surgical wards would also have to be provided.
ZONE OF INTERIOR 79

In planning for the management of trenchfoot cases received in the Zone of Interior, the Ashford experience was used as sample. 15 Of 135 patients under treatment for cold injury in January 1945, percent had gangrene and

would probably require surgery. Sixty-two percent had moderately severe

injuries which would require specialized treatment, probably including sympathectomy. The other 35 percent had mild injuries and could be managed in convalescent hospital.

On the assumption that possibly half of the 18,000 cases of cold injury

which had occurred in the European theater in December 1944 would require

evacuation, it was estimated that facilities must be provided for from 7,000 to

9,000 casualties from this cause in Zone of Interior hospitals during the first

months of 1945. It was further estimated that 5,850 of these injuries would be

severe or moderately severe. Since this would be an undesirable and impractical

load for the vascular centers designated for the care of trenchfoot, it was suggested that the best plan might be to send all returning trenchfoot patients to the

convalescent centers set up at Camp Butner and Camp Carson and to route

them from there as beds become available, to the vascular centers for such

specialized care as might be necessary.

Later, on 17 January 1945, it was proposed in memorandum to the Resources and Planning Division, Office of the Surgeon General, from the chief

consultants in surgery and medicine that the best plan of management for the

minimum of 2,000 trenchfoot patients to be expected each month for the next

months would be, after triage at ports of embarkation, (1) to send all patients

with gangrene and any loss of tissue, as well as those unable to walk or with

serious subjective complaints, to vascular centers, and (2) to send all others to

convalescent centers, preferably in mild climate. This plan was, in effect,

finally adopted.

INVESTIGATIONS

The Climatic Research Laboratory at Lawrence, Mass., had as one of its

purposes the study of the physiologic effects of clothing and the influence of

meteorologic conditions on health in cold climates. In January 1943, representatives of the Preventive Medicine Division, Office of the Surgeon General,

began to work with the Research Clothing Board appointed from the Office of

the Quartermaster General and already at work in this laboratory.

The Surgeon General, after visit to the laboratory in December 1944,

wrote to congratulate those in charge upon what was being accomplished. 16 He

could not, however, agree with the investigations being conducted on trenchfoot.

The place to study that condition, he emphasized, was in the field, where it could

be determined whether foot discipline was being correctly carried out and

whether the clothing recommended “is available to the doughboy in the trench

Memorandum,Lt. Col. R. H. Turner, Medical Consultants Division, for Brig. Gen. Hugh J. Morgan, 13 Jan. 1945,

subject: Hospitalization of Trench Foot Cases.

16 Letter, The Surgeon General, to Col. J. H. Talbott, Climatic Research Laboratory, Lawrence, Mass., Dee. 1944.
80 COLD INJURY, GROUND TYPE

or whether it is on the shelves in the depots or in the dumps far to the rear.”

Trenchfoot was then epidemic in the European theater, The Surgeon General

pointed out, in spite of the directives issued for its prevention.

Medical officers were eventually assigned to this laboratory, but the work

accomplished there was of little practical value in the control of trenchfoot and

came too late, anyway, to influence the situation in Europe.

In March 1945, plans were made for the investigation of certain phases

of trenchfoot at the trenchfoot center at Camp Butner, particularly the extent

and character of the lesion, the resulting disability, and the determination of

objective criteria upon which to base the decision as to fitness for duty. 17

The following techniques were thought to be most promising; Lange’s fluorescein procedures, both visual and instrumental; measurements of foot volume

by the water-displacement technique, both before and after the foot had been

subjected to heat, cold, and the stress of physical activity; changes in the

temperature and color of the skin of the extremities in response to posture and

environmental temperature as measured by the electric skin thermometer;

capillary microscopy, in spite of the known limitations of this technique;

foot-pattern studies by the technique of Silverman and Howell, to trace the

relation between nerve injury and abnormal sweating; plethysmography, with

special reference to the toes; and the histamine wheal.

Since it was obviousl}" impossible for the staff of single center to undertake all of these studies, it was decided that the investigations at Camp Butner

should be limited to the fluorescein technique in severe trenchfoot; foot volume

studies in milder trenchfoot; and studies in sweating, including plethysmographic studies, in an attempt to throw light upon the nerve and vascular

lesions of trenchfoot. The war ended before any of these special studies

were set up.

CONCLUSION

The annual report of the Surgical Consultants Division to The Surgeon

General for the fiscal year ending 30 June 1945 read, in part, as follows:

During the two winters when American forces were suffering heavy casualties from

trench foot much was written, said, and done about this condition. In fact, an uncritical

observer might readily conclude that despite all that was done high incidence of the condition resulted and that trench foot, after all, is not preventable. Any historian or student

of the subject who in the future may be reviewing the trench foot experiences of American

Armies during this war in order to maintain proper perspective must constantly ask himself

two questions;

(1) What was the situation at the time this publication was printed or this action taken?

(2) Was the information in this publication or this action felt by line officers and soldiers

in the field at time when it would be effective? Trench foot does not occur during summer months. It is condition which occurs as

result of prolonged uninterrupted exposure to cold and wetness. In order for troops to pro17 Memorandum, Medical Consultants Division for Brig. Gen. Hugh J. Morgan, 31 Mar. 1945, subject: Trench Foot

Studies.
ZONE OF INTERIOR 81

tect themselves, they must be thoroughly educated and informed on the subject before these

weather conditions are encountered. Training troops on subject of this type after they

are engaged in intensive combat is less effective than training them during period prior to

such action. The main concern of men engaged in combat is the preservation of their lives.

Attempts to teach men under such conditions measures for preventing trench foot, which

to them is seemingly unimportant at the moment, are not likely to meet with any great

degree of success.

For all practical purposes, this quotation summarizes the experience of

the United States Army with cold injury in World War II and points the way

to its prevention in any future war. No one realized the significance of this

type of injury early in the war. Many did not appreciate it until very late. The Surgical Consultants Division, in the Office of the Surgeon General, first

appreciated the danger and for some time was the only division of that office to study and report cold injury and to recommend the appropriate command

and staff action.

The prevention of trenchfoot, as has been repeatedly stated, is primarily

command, not medical, responsibility. Higher command and staff echelons

were in the beginning almost totally unaware of the medicomilitary dangers of cold injury. Until losses from it became serious, they did not fully accept

their responsibilities for it.

The Surgeon General had the responsibility for the health and medical

care of the Army, but he could normally convey his recommendations to the

highest echelons of the War Department only through what were, in effect,

command and logistic channels. By virtue of his position on the staff of the

Commanding General, Army Services Forces, he was responsible to, and reported to, that officer. As consequence, he had, as rule, little direct access

to the Chief of Staff or to the Secretary of War.

An additional difficulty arose from the fact that the activities of The

Surgeon General and, indeed of the entire Medical Department, were, of

necessity, closely allied with logistics. Frequently, and for obvious reasons, logistic personnel without medical knowledge failed to realize that medical

care, in its broadest definition, cannot be placed in the same status, or administered in the same fashion, as rations or ammunition.

In the opinion of many observers, the situation just described considerably

reduced The Surgeon General’s authority and diminished the effectiveness of such actions as he could take or recommend. This fact unquestionably played

part in the cold injury epidemics which occurred in World War II. Close

liaison did not exist between his office and that of the Chief of Staff. When

The Surgeon General made recommendations pertaining to the prevention of

cold injury, they normally reached the Chief of Staff or the Secretary of War

only through command channels, that is, through the Commanding General, Army Service Forces. Considerable evidence exists to show that until planning

for the final operations in the Pacific was begun The Surgeon General’s numerous

warnings did not reach higher authority and that none of them reached the

theaters of operations. It is quite conceivable that, if these plainly worded
82 COLD INJURY, GROUND TYPE

warnings, many of which antedated the official publications (WD Circular

No. 312 and TB MED 81), had fulfilled their purpose, the incidence of cold

injury might have been great deal lower than it was.

Many of the medical lessons of World War I, like many of the strictly

military lessons, had to be relearned in World War II because the experiences

of the First World War were ignored. That was true of cold injury. Eventually,

but only after grave losses had been suffered in the Aleutian Islands campaign

and in the Mediterranean and European theaters, measures of prevention

and control were instituted, and training in trenchfoot prevention became

part of the training program of Army Ground Forces. All concerned must

accept the responsibility for failure to institute them early enough to prevent

most of the thousands of casualties which occurred from this cause during World

War II. The influence of the Medical Department was exerted toward this

end earlier than that of any other branch of service and was also exerted more

continuously. The Surgeon General, however, was handicapped by the anomalous position which he occupied in respect to higher authority. Whether

greater effort should have been made to exert such influence as he possessed

is matter for debate. In retrospect, it seems that more vigorous effort

probably should have been made.
83

CHAPTER

The Aleutians

In February 1941, the Territory of Alaska, in which United States Army

garrison had been maintained for some 75 years, was designated as the Alaska

Defense Command. The first surgeon of the command was appointed the

following December.

The conditions under which troops originally served in this area in no way

resembled combat conditions. The weather, on occasion, was extremely cold,

but the barracks to which the men returned were warm and comfortable, and

their food was always excellent.

The clothing which was used by troops in Alaska was patterned after

that worn by the Eskimos and was made of furs, which could easily be provided

in sufficient amounts for limited number of soldiers. Both clothing and

equipment were slightly revised in 1928, but otherwise the issue remained

unchanged until 1940. In 1935, however, when the aggressive policies of Japan

began to indicate the possibility of war and when developments in airpower

made it clear that Alaska was highly vulnerable to air attack, clothing for cold

weather became subject for scientific research, and many new and improved

items were available by the time of the Aleutians campaign in 1943 (fig. 18).

Throughout the war, occasional cases of frostbite occurred among United

States troops stationed in Alaska, and some cases of immersion foot also occurred in this area in fliers forced down at sea. On the whole, however, cold

injury was of no great consequence because the troops were well fed, they had

superior equipment and used it correctly, and they were trained in techniques

of prevention of cold trauma, especially frostbite. On one occasion, 17 of 21

men engaged in practice maneuver over the Valdez Glacier were frostbitten,

and on another similar maneuver, near Nome, 126 men, 23.6 percent of the

total strength, were also frostbitten. In both instances the explanation was

not only highly unfavorable weather conditions but also neglect of the precautions essential under such conditions. Elsewhere in the command, the

number of cases was small because line officers and medical officers alike were

very much aware of the necessity for such measures.

The situation in the Aleutians was very different from that in Alaska.

Because of the location of these islands, far out in the Bering Sea, the dry cold

of the Alaska Peninsula is replaced by wet cold. Most of the task force which

invaded Attu had not been trained in the prevention of cold injuries. They

had to subsist on combat rations instead of hot, regular meals. Many items of

Unless otherwiseindicated, all materialin this chapter was secured fromMcNeil, Gordon H.: History of the Medical

Departmentin Alaska in World War II, pp. 401-477. [Official record.]
84 COLD INJURY, GROUND TYPE

U. S. Army photo

Figure 18.—Properly equipped and clothed soldier advancing in snow, in scout position

Aleutian Islands.

their clothing were unsatisfactory. The background of these difficulties and

deficiencies was, of course, that the men were engaged in combat and not in the

peacetime garrison duties in which the troops in Alaska had been engaged up

to the outbreak of the war and in which, for all practical purposes, they continued to be engaged throughout the rest of the war.

THE ATTU CAMPAIGN

Attu and Kiska, where the first cold injuries were sustained by United

States troops under combat conditions in World War II, were occupied by the

Japanese, without opposition, in 1942. Attu was retaken by Allied (chiefly

American) forces in May and June 1943, and Kiska was retaken, without

opposition, by forces of approximately the same components in August of the

same year.

The force which invaded Attu, consisting of about 15,300 men, required

22 days to take the island. It sustained total of 3,829 casualties from all

causes (table 2). Cold injuries, which numbered 1,200 up to June, exceeded

the number of casualties caused by wounds (1,148) and accounted for more

than 31 percent of all casualties from all causes. After June, only scattered

cases occurred. Seven patients with cold injuries were admitted to the shore

hospital on 12 May, 146 were admitted on 16 May, and 191 were admitted on

17 May.
THE ALEUTIANS 85

Table 2.—Battle casualties and admissions for disease and nonbatlle injury

Allied troops on Attu, 11 May through June 1943

Rate expressed as number per day per 1,000 average strength]

Figures In parentheses are subtotals.

The invasion began 11 May. The theater policy was to evacuate to the

Zone of Interior all patients who, it was thought, would require more than 21

days of hospital care, and by June, 241 casualties from cold injury had left

the island. By the same time, 691 had been returned to duty. Although

this fact might suggest that many of these cold injuries were of mild degree,

generalizations would not be warranted. Of 93 patients with trenchfoot

treated at the 183d Station Hospital, Fort Richardson, Alaska, for instance, 14

were discharged to duty as cured and the other 79 were discharged as improved,

but considerable number of these men were unable to continue their duties

and were subsequently returned to the hospital for further treatment. Recurrence, or perhaps recrudescence, of their original injuries also explained many

of the casualties from trenchfoot during the later Kiska operation (p. 99).

Furthermore, during the winter of 1943-44, men who had been discharged as

cured after the Attu experience began to appear with complaints of various

subjective symptoms as well as with such objective signs as redness, cyanosis,

and excessive perspiration.

Only of the 93 cold injuries treated at the 183d Station Hospital were

graded as third degree and only as fourth degree. Nonetheless, in these 93

cases alone, total of 5,827 days was lost from duty. The potential seriousness

of this condition from the standpoint of military manpower is evident from

these figures, which do not take into account the expenditure of medical care,

including hospital bed space, and the tax on military transportation caused

by these injuries.

Annual Report, 183d Station Hospital, 1943.

438404'—58

Cause Number Rate

Battle casualties:

Killed in action 549 1.

Wounded in action

Nonbattle admissions:

1, 148 3.

Disease 614 1.

Nonbattle injury. 1, 518 4.

Cold injury '(1, 200) >(3.6)

Other >(318) >(•9)

All causes 3, 829 11.
86 COLD INJURY, GROUND TYPE

Tactical Situation, Environment, and Weather

D-day on Attn was originally set for May, the plan being that the troops

should sail from Cold Bay on May. Because of bad weather, the invasion

had to be postponed to 11 May. The landing was unopposed, the enemy

having withdrawn from the beaches to occupy the high central ridges. From

these vantage points, they could descend to within the fog line, which was at

times within 500 feet of sea level, where they could see without being seen and

could effectively pin down attacking units in waterlogged foxholes in the

boggy tundra.

As result of the dense fogs, the landings began later than had been

planned, and the second wave of troops was not landed until almost hours

after the first. The operational plan, which was to take the island in 38

hours, thus proved completely unrealistic. Later, it was agreed that the task

force would have done well if, within this time and without meeting any opposition at all, the troops had merely walked over the ground which they were

scheduled to take.

Opposition from small-arms fire and mortars was encountered within 1,000 yards of the beach, and the initial main line of resistance from Massacre Bay

was about 2,000 yards. For days, there was practically no forward moveU. S. Army photo

Figure 19.—Tractor and trailer mired down near the beach, Massacre Bay, Attu

19 May 1943.

Orr, R. D.; Report on Attu Operations May 11-June 16,1943, dated 30 July 1943.
THE ALEUTIANS 87

ment of American positions. The ar' illery never left the beaches because the

guns could not be pulled over the tundra, and firing was at maximum ranges

throughout the battle (fig. 19). The Japanese launched desperation (banzai)

attack on 29 May against American infantry positions and so exhausted their

own fighting strength that by June all organized resistance was at an end.

Both terrain and weather served to make the conquest of Attu an extremely

difficult operation. Attu and Kiska are islands far out on the Aleutian chain,

in the Bering Sea, about due north of Midway. The terrain on both is rugged and mountainous. The elevations are not particularly high, but when bad

weather is added the conditions are comparable to those in altitudes twice as

high in milder climates. On Attu, where peaks and ridges rise to 3,000 feet

above sea level, the heavy winter snowfall remains on some of the higher

points throughout the summer. There is an almost complete absence of

natural shelter. The ground cover is boggy tundra, without trees (fig. 20).

The air on Attu is continuously cold, even on the occasional sunny days.

There are long months of wind, fog, rain, snow, sleet, and mud. man

walking along road on an ordinary day may suddenly, even when the sun is

shining, be struck by terrific gust of wind, which blows sand, snow, and rain

in his face, all at the same time. An observer from the Office of the QuarterU. S. Army photo

Figure 20.—Landing beach in Holtz Bay area, Attu, seen from top of ridge

separating Holtz Bay and Chichagof Bay. The steep, jagged crags, knifelike

ridges, and boggy tundra greatly impeded the movement of the troops and made

any extensive use of mechanized equipment entirely impractical.
88 COLD INJURY, GROUND TYPE

master General, who had spent February, March, and April on other Aleutian

Islands, commented on the weather of the region as follows:

one needs pretty strong imagination to get the full flavor of it (even if you have

previously heard of it). In one day have seen it cold and snappy in the early morning

with light snow on the ground, followed by warm, Springlike sunny weather, followed by

blizzard of very small hail-like snow, followed by sun, followed by rain, etc. The mud is

often more than knee deep, and generally is of very slushy type *. More often than

not biting wind whips the rain, snow and sand (where there is any) about all day and all

night.

During the campaign, the weather, for the Aleutian Islands, was reasonably

good. Light rain is known to have fallen on days between 22 and 27 May,

from to 12 hours at time, and light snow fell on 23 May, for 12 hours.

During the same period, the wind velocity ranged from 20 to 36 miles an hour

most of the time. On of the days between 22 and 27 May, there was fog

for hours at time. Reports submitted by vessel and weather station in

the vicinity show that, between 11 and 27 May, the temperature averaged

between 25° and 30° F. (—3.9° and —1.1° C.) in the valleys (1,000 feet) and

between 33° and 37° F. (0.5° and 2.8° C.) at sea level. On the highest ridges,

where there was considerable combat, the average temperature was 24° F.

(—4.4° C.) and the minimum 10° F. (—12.2° C.). The men were constantly

exposed to cold and dampness, often for several days at time without relief.

The foxholes were always filled with water, and the troops, of necessity, remained in them for hours at lime. There is evidence that many of the troops

found the cold, damp, wet weather harder to endure than the enemy fire.

Medical Care and Evacuation

Planning for Attn called for medical care to be provided through aidmen,

battalion aid stations, collecting platoons, clearing stations, field hospitals,

shore-party medical sections, and the Navy medical service aboard ship.

Revisions were inevitably made. The first principle of treatment of cold

injuries is that the casualties should not be permitted to walk, even if they

feel able to do so. Many of the injuries sustained on Attu were so severe

that the men were scarcely able to walk, but, because of the difficulties of evacuation, many of them had to walk; some of them crawled. The wheeled litters

which had been brought ashore were useless, and evacuation had to be by

hand carry, because of the precipitous slopes of the mountainous terrain in

which most of the fighting occurred. Aid which was but few miles away in

direct line was often hours away by litter carry. Casualties often had to be

taken down cliffs by ropes, pulleys, and improvised elevators.

The task force surgeon, utilizing elements of the 14th Field Hospital and

personnel from an antiaircraft artillery unit and shore-party medical section,

improvised and set up small convalescent-type hospital on the west side of

Letter, 1st Lt. Robert D. Orr, to the Quartermaster General, attention: Col. Georges F. Doriot, 17 Apr. 1943.

See footnote 2, p. 85.
THE ALEUTIANS 89

assacre Bay on 16 May (fig. 21). Patients who had sustained moderately

severe exposure were treated here after they had been evacuated from field

hospitals. Evacuation from the island was by boat and plane to Adak and

thence toFort Mears, Fort Greely, and Fort Richardson. Most of the severely

wounded casualties were evacuated by ship or were flown directly to the Zone

of Interior. The air evacuation planned from Attn to Fort Richardson did not

prove practical, but special flights were arranged from the 183dStation Hospital

to Barnes General Hospital, Vancouver, Wash.

U. S. Army photo

Figure 21. —Field hospital on Attn. It was set up and in operation the day after

the landing.

Clothing and Footgear

When the invasion of Attu was being planned and organized, cold-weather

specialists from the Special Forces Section, Office of the Quartermaster General,

were sent to the Alaska Defense Command for observation and for advisory

purposes. They recommended that special types of footgear and clothing be

selected for the invasion, but their advice was not accepted. The items used

were chosen without sufficient consideration of the special environmental

conditions certain to be encountered, as well as without due evaluation of the

newly developed cold-weather equipment. The sole responsibility for the high

incidence of casualties from cold injury cannot, of course, be placed upon

single erroneous decision, but later analyses indicated that failure to use the
90 COLD INJURY, GROUND TYPE

special Arctic equipment which was available was probably the explanation

of many cases.

Clothing.—There were numerous adverse comments on some of the clothing

supplied for the invasion, although, as just noted, the selection had been

deliberate command decision, and more efficient types had been available.

Specific comments were as follows:

The issue olive-drab woolen trousers did not provide the protection which

kersey-lined trousers would have provided. The issue trousers had been waterproofed, but, under the conditions of combat and terrain, the material was

not sufficiently durable to remain impervious to moisture for more than

few days.

The Arctic field jacket did not furnish the protection against wind and

rain which the lightweight reversible ski parka would have provided. In

addition, the field jacket had no hood.

Sweaters were not permitted, though experience in Alaska had shown

them to be real necessity in extreme cold.

The parka overcoat was not originally intended to be part of the equipment, but certain number had been picked up at the rendezvous point when

the task force first encountered the severity of the Aleutian weather. The

supply, however, was not sufficient. Furthermore, while this overcoat furnished

excellent protection for men who could remain relatively immobile, it was not

satisfactory for active combat.

The troops were not permitted to wear their rainsuits ashore, and therefore,

since their clothing was not water repellent, many of them were drenched

immediately. The rainsuits were in rucksacks, which usually did not reach the

men in the frontlines until several days after the initial landings.

Since rucksacks were entirely too bulky to be carried ashore by the troops,

the operational plan was that they would be brought forward by nightfall of

the first day of the invasion. The men would thus have sleeping bags, rainsuits,

and other equipment, to supplement the small amount which they had carried

ashore with them in the canvas field bags attached to their belts. The delays

in landing and the difficulties of terrain and weather made the implementation

of this plan completely impossible. Once supplies could be landed, ammunition

and food had to be brought forward before clothing. As matter of fact, few men in the frontlines ever received their rucksacks.

Whenever it was possible, sleeping bags were removed from the rucksacks

on the shore and were sent forward as conditions permitted. Few troops,

however, received them before the fourth or fifth day, and until that time the

men had no protection during sleep, when sleep was possible, except from the

shelter halves which they had carried ashore in their field bags. Had the sleeping bags been received earlier, it is highly probable that some cases of trenchfoot could have been prevented. One unit which obtained its bags on the second

and third days and could hold on to them throughout the campaign experienced

almost no cold injuries.

See footnote 3, p. 86.
THE ALEUTIANS 91

After tlie invasion, it was suggested that the Arctic sleeping bag which

had been used, and which was too bulky to be carried on the person, should be replaced by model small enough to be carried into combat, with the same

lining as the Arctic bag and with waterproof outer covering. During his

periods of rest, it was reasoned, the soldier equipped with this bag could rest

in it with his boots and socks off and could dry his socks inside the bag by

body heat. The Quartermaster General’s Office, replying to the criticism of

the sleeping bag used during the Attu campaign, stated that the bag had been

badly chosen. The model selected should have been either the inner lining of

the Arctic bag or the mountain sleeping bag, both of which could be used with

water-repellent case. It was also pointed out that tests had shown that

fully waterproof covering for sleeping bag was not practical, since condensation of moisture from the body within the bag would set up conditions favorable

in themselves for the development of trenchfoot.

Footgear.—The shoepac recommended by the observers from the Quarter- master General’s Office had number of admitted defects, including lack of

an arch support, but it was relatively waterproof, because of its rubber sole,

and it kept the feet warm. The blucher boot for which it was passed over

was model which reached to about inches below the knee (fig. 22). This

boot had number of disadvantages. It did not keep the feet warm. It was

not waterproof, even when dubbing was regularly applied to it. It did not

wear well; some soles were worn through in to weeks. Once it became wet,

it could not be thoroughly dried under conditions of combat. The leather

tended to contract, and the tight fit, combined with tight lacing, resulted in

embarrassment of the circulation to the feet. Most of the fittings were originally too snug, since no attention had been paid to the plan that the boot be

worn over two pairs of socks, one of them woolen. Finally, the steel support

in the heel was not carried high enough, so that the boot broke against the

Achilles’ tendon and severe traumatic tenosynovitis was sometimes added to

the disability caused by cold. possible explanation of this particular complaint was that many of the troops had been issued their boots on shipboard

and had no opportunity to break them in before they were landed on the

Attu shore.

The only troops equipped with shoepacs for the invasion of Attu were

men who had had long service in Alaska. This type of footgear was therefore

not universally tested in combat in the Aleutians (fig. 23).

Japanese clothing and footgear.—There is no evidence thatthe Japanese on

Attu sustained cold injuries to anything like the degree that the Americans

sustained them. The Japanese were favored by their occupation of higher

ground, it is tine, and were less often immobilized. On the other hand, they

were more suitably clothed, and they seem to have had better footgear. They

Memorandum, Maj. Gen. LeRoy Lutes, Director of Operations, Army Service Forces, for Quartermaster General,

Army Service Forces, attention; Storage and Distribution Division, Oct. 1943, subject: Reportof Operations on Attu.

Memorandum, Research and Development Branch, Military Planning Division, to Operations Branch, Military

Planning Division, 13 Oct. 1943, subject: Report of Operations on Attu.
92 COLD INJURY, GROUND TYPE

U. 8. Army photo

Figure 22.—Combat-type boots supplied to infantrymen on Kiska after occupation. Staff

sergeant supervises fitting, while private at right boxes ammunition.

wore hobnailed, fur-lined rubber boots, which extended to just below the knee.

rolled legging, applied outside the boot just below the top, kept most moisture

out of the boot, even if the wearer stepped into water above boot-top level.

Some American troops, in spite of the risk of being shot by their own comrades,

equipped themselves with Japanese caps, hoods, and boots as they became

available.

Training and Discipline

The task force which recaptured Attu consisted chiefly of units ol the

7th Infantry Division, plus battalion from the 4th Infantry Division, which

had had years of service previously in Alaska. The units which bore the

brunt of the fighting had been trained as motorized infantry division at Fort

Ord, Calif., and in the Mojave Desert, and then had undergone amphibious

training on the California coast. Nothing in their previous training and experience fitted these troops for the climate and terrain which they were to encounter on Attu.

Specifically, these troops had not been trained to care for their feet. They

did not understand that they must remove their boots at frequent, regular

intervals, change their socks, and dry their insoles. Some of them did not

remove their boots for days or even longer, after the landing. When they
THE ALEUTIANS 93

U. S. Army photo

Figure 23.—Shoepacs worn during occupation of Kiska. The soldier is

treating them according to the method used by experienced Alaskan sourdoughs

finally took them off, they could not replace them because their feet had

swelled. Many soldiers threw away their wet socks without making any

endeavor to dry them. Often, when the terrain made going hard, the men

discarded their cold-weather clothing. Many of them, when they received

their sleeping bags, made little or no effort to keep them dry.

Preventive measures are not easy to accomplish under the conditions in

which these soldiers worked and fought, and the total accomplishment of such

measures was obviously impossible. The underlying fault, however, was that

none of the troops had been taught that every effort must be made to accomplish them, in spite of adverse circumstances. There is no doubt that the

effort would have paid dividends in the prevention of trenchfoot.

Some of the troops trained at Fort Ord were brought from California by

surface water transport and could change their shoes and socks regularly up

until the time they entered combat. Others, who were brought up by submarine, could not change their footgear during the journey because of cramped

quarters and the constant alert status which had to be maintained. The

advance troops, wdio were landed in rubber boats, were instructed to discard all of their equipment as soon as they made contact with the enemy. Their

feet and legs became soaked as they landed, and, because additional boots and

socks were lacking as the result of this order, they remained wet, even wdien

Lesser, A.: Report on Immersion Foot Casualties from the Battle of Attu. Ann. Surg. 121: 257-271, March 1944.
94 COLD INJURY, GROUND TYPE

occasional opportunities would have permitted change of footgear. The men

spent most of their time in foxholes filled with icy water and cold slush, usually

in cramped, inactive positions, with little food, and without any real physical

rest or sleep during their whole stay on Attn. They had not been taught such

simple precautions as moving their feet in their shoes or exercising their legs,

and they therefore did not employ even the limited prophylactic activity which

is possible under almost any conditions.

The differences between training and lack of training were immediately

obvious. 10 provisional battalion, consisting of the 7th Reconnaissance

Troop and the 7th Scout Company, had particularly hazardous mission, for

which special clothing was requisitioned and supplied. These men were completely untrained for fighting in cold weather, and, by order of higher authorities, none of the special equipment just mentioned was issued except pistol

covers. At the end of days, 30 of these 350 men had been killed or wounded

in action and only 40 of the remaining 320 were still able to walk.

In contrast, one of the battalions which spearheaded the attack had battle

casualties as high as any unit engaged in the operation, but it had only eight

casualties who required evacuation because of trenchfoot. The men in this

battalion had been well taught. They had foot-care drills and were paired off

in what they themselves termed the “buddy” system, whereby foot-conscious

soldiers worked on each other’s feet. Attempts were made to supply lubricants

for their boots and ointment for their feet at least once daily, with the realization that the virtue of the application to the feet was in the massage and not

in the agent used with it. Whenever possible, provision was made to relieve

all the men, especially the outposts, for few hours each day. During this

interval of relief, the men removed and dried their shoes, changed their socks,

and rested in their relatively dry sleeping bags.

Generally speaking, the severity of cold injury was directly proportionate to the length of time during which the footgear was not changed. 11

Fifteen of twenty-five patients observed at McCaw General Hospital, Walla

Walla, Wash., who had been taken to Attn by surface water transport, went

from to days in combat on the island without change of footgear. All had

rather mild degrees of trenchfoot. The other 10 men, taken to Attu bj submarine, averaged an additional 10 days in combat without change of footgear,

and all had severe injuries with gangrene.

Another illustration of the value of training is seen in the experience of

detachment of 30 men of the Alaskan Scouts, the combat intelligence platoon

of G-2, Alaska Defense Command. 12 These men were trained for the climate

and terrain. They were properly acclimated. They knew what to expect and

how to take care of themselves. They fought through the entire Attu campaign

under the most unfavorable possible environmental conditions, and they were

still serving as reconnaissance patrol long after the last organized Japanese

10 See footnote 3, p. 86 11 See footnote 9, p. 93. 12 See footnote 3, p. 86.
THE ALEUTIANS 95

resistance had ended. Their casualties consisted of man killed in action,

wounded in action, and with slight cold injury.

Physical Status

Practically all of the men engaged in the Attn operation were young and in good general condition. They were free from such constitutional diseases

as arteriosclerosis, cardiorenal disease, and diabetes, which complicate the majority of cases of peripheral vascular disease observed in civilian practice.

They had not suffered from dysentery, malaria, and the other debilitating

diseases which complicated the management of so many battle and nonbattle

injuries in certain other theaters of operations.

Because these troops went directly into combat from noncombat status, they had not previously been subjected to prolonged dietary insufficiencies, though they had hot food only infrequently during the period of active fighting.

They did not, however, because of lack of training, make use of the concentrated rations with which they had been supplied. Because they had not been

taught the importance of eating their rations, whether they liked them or not,

and the necessity for eating them to keep up their resistance, they threw away

whatever they did not like. Among the provisions, for instance, was fortified

dried lemon juice, to provide vitamin C. It was not palatable, and most of

the men threw it away. As result, few instances of incipient scurvy were

observed before the campaign ended. There was apparently no relationship

between this minor vitamin deficiency and the cold injuries which occurred,

although it was speculated that such correlation might have developed if the

campaign had lasted much longer.

Individual Susceptibility

Wide variations in individual susceptibility to cold and wet were observed

among the men taking part in the Attu operation. If group of soldiers

spent the night in forward observation post, might return with no complaints, or with minimal complaints, while the third would have numb, mottled,

swollen feet. Among 224 patients observed at Letterman General Hospital,

San Francisco, Calif., the average duration of exposure was about 6.5 days. 13

One hundred and sixty-five (74 percent), with exposures varying from to 14

days, presented only desquamation of the skin. Thirty-three (15 percent),

with exposures varying from to 11 days, had lost toenails, tips of toes, and

thick layers of skin. Twenty-three (10 percent), with exposures varying from

to days, had lost one or more toes or portions of their feet. Three men

who required amputation of both feet had been exposed 4, 6, and days,

respectively.

13 Patterson, R. H.: Effect of Prolonged Wet and Cold on the Extremities. Bull. U. S. Army M. Dept. No. 75, pp. 62-70, April 1944.
96 COLD INJURY, GROUND TYPE

One patient at Letterman General Hospital, who had gangrene of both

feet up to the level of the metatarsophalangeal junction, was found to have

suffered previously in civilian life from frostbite of both feet.

Other Etiologic Factors

At least two other factors, in addition to those already discussed, played

part in the production of cold injuries on Attu;

1. Many of the men, in their natural desire to get warm as fast as possible,

wrapped up their cold feet and exposed them to heat. Most of them had not

been warned that this was the worst possible thing they could do.

2. The incidental trauma of walking over rough terrain on numb feet

added to the damage already done by wet, cold, and constriction. It was

recognized that walking was harmful, but it has already been pointed out that,

as matter of necessity, patients who could be ambulatory often had to be,

since litter carries over tundra and down steep, snow-covered ridges were slow

and exhausting work and personnel to move the injured were always in short

supply.

THE OCCUPATION OF KISKA

The operation on Kiska, which began 15 August 1943 and was concluded

31 August 1943, was being planned and organized while Attu was under assault.

The task force for this landing consisted of the 87th Mountain Infantry Regiment; the 184th Infantry Regiment, which had been trained at Fort Ord; the

17th Infantry Regiment (minus), which had been transferred from Attu; the

53d Infantry Regiment of the Alaska Defense Command; and the 13th

Canadian Infantry Brigade. The last three components joined the force at

Adak, just before the landing. The others had been assembled at Adak and

Amchitka in the central Aleutians, for several weeks of training.

After these troops were landed, it was found that the enemy had fled before

the invasion had occurred, though the fact of their evacuation was determined

only after slow, cautious search of the entire island. There were no true

battle casualties, but there were 28 deaths and 50 injuries from accidents and

from fire due to mistaken identity.

The terrain was difficult. The land everywhere was cut by fresh-water

lakes and streams. Hills and valleys were covered with tundra, which Royal

Canadian Army surgeon 14 graphically described:

Walking on this growth is like walking on gigantic spring mattress, into which one’s

feet sink for foot or more with each step that is taken *, During the warm weather

the surface thaws to form vast bog, or tundra-moor, which is probably unequaled anywhere

in those qualities of cohesion and adhesions which make mud the objectionable surface that

it is.

14 Lane, Q. A.: Medical Experience with the 13th Canadian Infantry Brigade at Kiska. J. Canad. M. Service 1.282-288, May 1944.
THE ALEUTIANS 97

.Although the terrain on Kiska, as this description suggests, resembled that

on Attn, the general situation was not as difficult, chiefly because of the timing of the invasion. The invasion of Attn occurred in May, when there was snow

on most of the hills and snow water running down all of them. During this

invasion, there were no dry surface areas until after Japanese installations could

be occupied. Level spaces were all marsh, and there was an incredible amount

of moisture in and under the tundra on sharp declivities. Theinvasion ofKiska

occurred in August, when there was no snow and when the runoff had largely

stopped, except for springs and water courses. Since there was no combat, these could be avoided. Once the troops got away from the landing beaches

and the adjacent swamps, they could be on fairly dry ground most of the time.

Also, the sun shone for an hour or two daily during most of the period of

occupation, and it was therefore possible to dry out in the sun.

Other circumstances were also much more favorable than on Attn. There

had been an excellent liaison between the 7th Infantry Division units on Attu

and the training authorities at Fort Ord, with the result that the troops who

went to Kiska from that area were trained and equipped in the light of the Attu

experience. Men physically and mentally unequipped for Army life had been

cleared from the unit before it was dispatched to Kiska. The troops who had

fought on Attu were acclimated and knew what to expect of weather and

terrain. All the men had been given careful instruction for protecting themselves in cold, wet weather, had been trained in foot care, and had been given

foot inspections before landing.

Clothing and footgear, although not entirely satisfactory, were great

improvement over what had been selected for the Attu landing. 15 The men went

ashore with Alaskan field jackets, parkas, rainsuits, kersey-lined trousers, and

toeques to protect the face. Their garments were all water repellent, though

in the opinion of some observers only fully waterproofed garments would have

been really adequate for the conditions encountered. Shoepacs were used universally. This was wise decision, though the model employed was not satisfactory in many respects. Most of the men were fitted with such large sizes

that their feet had little support. The shoepacs were also cut too low to furnish

any protection when troops had to wear them ashore on the beaches, or when

much activity in deep mud was required. The shoepacs were also less effective

than the low leather boots worn by the Canadian brigade. Nonetheless, they

were great improvement over the blucher boots worn in the Attu invasion. 16

In addition to the general indoctrination already described, troops who

participated in the Kiska operation were furnished with small handbook

15 Memorandum, Director of Operations, Army Service Forces, for The Quartermaster General, attention: Military

Planning Division, Col. G. F. Doriot, Oct. 1943, subject: Report of Observer on Klska Operation, Clothing and Equipment. 16 medical officer who participated in the occupation ofKiska wroteas followsabout footgear: “Mypersonal experience was that the best footwear for me was the regular Army boot over which wore standard overshoe (galosh). This

assured relative protection from wet terrain and permitted me to open the overshoe and allow the feet to dry as soon as

the opportunitypresented. Thus,even though my feet tend to perspire readily, was able to keep them dry most of the

time and to allow proper circulation at all times. Thiscombination was arrived at by trial and error, and proved much

more satisfactory than the shoepac,combat boot orknee-length rubberboots. Of course, the latter would have been necessary if had been standing in waterof any deplh.”
98 COLD INJURY, GROUND TYPE

entitled “Soldiers Manual (How To Get Along in the Field).” The foreword to

the troops was written by Maj. Gen. Charles H. Corlett, who commanded the

task force (ATF9). The suggestions had been collected by General Corlett’s

staff and had been compiled by Capt. (later Maj.) Roy L. Atteberry, Jr., who,

said the introduction, “*

has had much experience in our future hunting

grounds. He knows the score.”

The introduction pointed out that the soldier had two major jobs. The

first was to do the military job he had been taught to do. The second was to

spend the rest of his timekeeping himself and his equipment in the best possible

condition. It was to help in the second job, said the introduction, that this

pamphlet had been prepared.

The pamphlet contained sensible instructions for the care of the feet before

and during combat; instructions for the use and care of socks, including the

statement that pair of spare socks was the most valuable piece of extra clothing

soldier could possess; and description of, and instructions for the use of,

shoepacs. It was pointed out that, though the soldiers had probably never

worn them before, shoepacs had been selected as the best type of footgear for

mud and water; that they had been purposely fitted oversize to take care of

extra socks and insoles; and that they should be laced loosely. Instructions

were also given for moving the feet, toes, and legs, even in foxholes in combat.

Noncommissioned officers were reminded that one of their most important duties

was to see that their men took care of their feet.

Other sections of the pamphlet dealt with the proper use and care of clothing and other cold-weather equipment; with the importance of eating the rations

that had been provided, heating them when possible, and saving what was left;

with the importance of drinking tea, for which teabags could be used; and with

the means of keeping foxholes dry. Two cartoons showed what happened to

soldiers who left their equipment behind and suffered from the cold as result.

Incidence of Cold Injury 17

The approximately 28,450 troops who participated in the occupation of

Kiska suffered total of 130 cold injuries. In spite of the training given them before landing, some of these casualties admitted that they had failed to follow

instructions given them and did not remove their shoepacs and socks for several

days at time.

The footgear used seemed to influence the incidence. The Canadian brigade, whose footgear was thought to be better than that worn by American

troops, sustained only trenchfoot casualty in their strength of 5,326 men.

Their rate of per 10,000 for the 15-day period of the operation was far lower

than the comparable American rate of 55.6 per 10,000, according to the report

submitted by the surgeon of the task force at the conclusion of the operation.

17 Letter, Col. L. R. Moore, MC, Surgeon, Headquarters,Alaskan Department, to The Surgeon General, Dec. 1943,

subject: Medical Service, Occupation of Kiska, Alaska.
THE ALEUTIANS 99

It is doubtful that the somewhat better weather in which the Canadians landed

accounted for this considerable difference.

The use of lanolin for massage of the feet seemed of doubtful value. The

87th Mountain Infantry Regiment, which used it before disembarking, suffered

casualties from trenchfoot in strength of 5,517 men. The 184th Infantry

Regiment, with strength of 5,999 men, did not use it and had 15 casualties

from trenchfoot. This is not significant difference.

The high incidence of cold injury in the 17th Infantry Regiment, which

had 76 cases in strength of 3,906 men, was thought to be related to their

previous exposure on Attu. The environmental and other circumstances under

under which they operated were no worse than those of any of the other troops,

and it seemed logical to explain at least some of their injuries on the basis of

pathologic changes present as the result of the earlier experience. number of

men in this regiment were evacuated and were classified as casualties due to

cold because it was feared that their condition might be more serious than it

seemed superficially.

SUMMARY

On Attn, the tactical and environmental hazard, improperly chosen

equipment, and lack of individual and unit training in the proper use of equipment and in preventive measures against cold and exposure combined to set

pattern which was to be repeated, in varying degrees, during the remainder

of the war. Within the next few months, trenchfoot occurred during the

occupation of Kiska, but to lesser degree. Within months, there was

major epidemic of trenchfoot in Italy. Within the next 18 months, there was

an even more explosive outbreak in Europe, on the Western Front.

While the actual number of cases of cold injury was small in the Attu

operation, the incidence was high. Twelve hundred cold injuries occurred in

22 days, in force of 15,300 men, which is an incidence rate for the period of

about 80 per thousand. Expressed as an annual rate, this is 1,300 cases per

thousand. An almost equal number of wounded-in-action cases occurred.

The ratio of cold injuries to wounded-in-action cases was approximately 1:1, as compared with 1:5 in Italy in 1943-44 and about 1:4 in the European

theater in the winter of 1944-45.

On Kiska, the troops were exposed to cold injury only for the short time

required to establish that the enemy had withdrawn. Circumstances were

favorable. Because the enemy had fled, there was no combat activity. The

operation was started months later than the Attu invasion, so that the

weather was less severe. Equipment and footgear were better than what had

been provided on Attu. Many of the men had fought on Attu and had learned

by experience how to take care of themselves in cold, wet weather. The other

troops had been specifically trained to care for their feet.
100 COLD INJURY, GROUND TYPE

Yet, in spite of the brevity of their exposure and other favorable circumstances, the 28,450 troops who participated in the landing on Kiska sustained

130 cold injuries. What the incidence might have been if the enemy force,

estimated at 10,000 men, had not abandoned the island before the allied troops

arrived is matter of conjecture. It would probably not have been as high as

the incidence in the Attu operation, but it would undoubtedly have been

considerably higher than it was in an unopposed landing.

Note.—Because the clinical observations in trenchfoot were essentially

similar in all theaters, they are discussed elsewhere, under single heading

(p. 259). Treatment is also discussed under single heading (p. 307). In the

Attu campaign, treatment consisted of variety of methods, depending upon

the knowledge and preferences of the individual medical officer. There was

no background of experience in cold injury, and no directives concerning its

management had yet been issued.
101

CHAPTER VI

Mediterranean (Formerly North African)

Theater of Operations

Low temperatures and wet cold were no problem to United States Army

ground troops in combat in North Africa in the winter of 1942-43, and the

occasional cold injuries which occurred therefore attracted no particular

attention. Cold injury was also not problem in the fighting in Sicily in the

summer of 1943. It was not until comparatively cold weather, which often

was of the wet cold variety, was encountered in the Apennines in the fall of

1943 that United States troops of the Fifth U. S. Army were first subjected

to the environmental conditions which constitute the essential, though by no

means the entire, basis for the development of cold injuries in appreciable

numbers of cases.

When these circumstances arose, the Office of the Surgeon, NATOUSA

(North African Theater of Operations), was still without information concerning the cold injuries which United States troops had sustained in Attn in

the spring of 1943, although these experiences had been investigated immediately in the Office of the Surgeon General (p. 57). Col. Edward D. Churchill,

MC, Consultant in Surgery, Office of the Surgeon, NATOUSA, was, however,

sufficiently aware of the possibilities of trouble to write the Surgeon on 31

October 1943 that, with the approach of cold weather during the forthcoming

fighting in the Apennines, circulatory disturbances (trenchfoot) were to be

anticipated. Even before this date, informal consultations had been held

with number of medical officers with combat units concerning the possible

occurrence of cold injury and its dangerous potentialities.

INCIDENCE

1943-44.—It was only week after Colonel Churchill had alerted the

Surgeon to the possibility of cold injuries that the first patients with trenchfoot to be observed in Italy passed through clearing station south of Cassino.

By 12 November, cases are known to have occurred. Not all had been

recognized immediately as instances of cold injury. One or two of the first

casualties were thought to have suffered sprains and were treated with hot

applications.

Unless otherwise Indicated, all material in this chapter is based on the cumulativereport on trenchfoot in the Italian

campaign, by Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, 1945. Data collected during the

wartime experience have been modified to utilize the more accurate data available after the war ended.
102 COLD INJURY, GROUND TYPE

After trenchfoot once began to appear, the incidence increased rapidly,

and, over the 6-month period ending on 30 April 1944, there were more than

5,700 casualties from this cause in the Fifth U. S. Army (chart 3, table 3). The

alltime weekly high of 901 cases was recorded for the week ending on 18 February 1944. During the same 6-month period, casualties wounded in action

totaled 27,602. The losses from cold injury occurred in strength of infantry

divisions and armored division.

The mere statement of these figures does not, of course, tell the whole

story. It does not indicate that losses from cold injury were, case for case,

actually as serious as combat losses, because practically all cold injury occurred

in combat troops, who are the most difficult to replace in all wars and who were

always in extremely short supply during the Italian campaign. Losses from

cold injury during the winterof 1943-44 amounted to about percent of division

strength, and hospital admissions for this cause constituted percent of all

admissions for disease. The ratio of trenchfoot cases to battle casualties was

1: for the November 1943-April 1944 period. It varied from month to month

and was highest in January 1944. Since the impact of cold injury can best be

evaluated in comparison with casualties from combat operations, the figures

leave no doubt that therewas major loss in effective Fifth U. S. Army fighting

strength from trenchfoot during the winter of 1943-44.

Chart 3.—Monthly incidence of trenchfoot in relation to battle casualties; maximum, minimum,

and average temperatures; and rainfall, inFifth U. S. Armyin Italy, September 1943through

April 1944

Annual Report, Surgeon, Fifth U. S. Army, 1944.

Annual Report, Surgeon, Fifth U. S. Army, 1945.
MEDITERRANEAN THEATER 103

Table 3.—Hospital and quarters cases of trenchfoot and of battle injuries and wounds, and

average minimum temperature and average rainfall, by month, Fifth U. S. Army, November

1943 through April 1944

[Rate expressed as number per annum per 1,000 average strength]

1944-45.—The lessons of the 1943-44 experience in Italy were well learned, as will be pointed out shortly, and the incidence of cold injury during the

winter of 1944-45 was far lower than during the preceding winter. The 1,572 injuries which occurred during the 6-month period ending on 31 March 1945

(chart 4, table 4) accounted for an admission rate of 20 per 1,000 men per year,

which is sharp decline from the rate of 54 (table 3) during the preceding winter.

The annual rate for wounded in action also fell during the second winter of

fighting in Italy because the front was frequently static, but the decrease was

much less striking than the decrease in cold injuries.

As matter of convenience, recurrent trenchfoot, which was considerable

problem during the second winter in Italy, as well as during the latter part of

the first winter, is discussed elsewhere, under single heading (p. 381). Precise

figures are not available, but it is well established that definite proportion of

the cold injuries observed during the winter of 1944-45 represented recurrent

cases. The proportion decreased, however, as medical officers began to realize,

from hard experience, that return to full duty is possible in only limited number of cases of trauma from cold.

The British experience.—A point of major interest in the story of cold

injury in Italy is the comparative experiences of British and American troops.

During the winter of 1943-44, the British 10 Corps was an integral component

of the Fifth U. S. Army. It fought over the same terrain and for the same

objectives. It is therefore possible to make valid comparisons of British and

Month and year

Trenchfoot Battle injuries and wounds Ratio of trenchfoot

tobattle in- juries and wounds

Average

minimum

temperature (°F.)

Average

rainfall

(inches) Cases Rate Cases Rate

1943 November 371 24 3, 897 249 1:11 47 10.

December 1, 265 69 5, 020 274 1:4 44 6.

1944 January 1, 490 96 4, 496 289 1:3 36 1.

February 1, 805 108 8, 378 500 1:5 34 5.

March 779 35 3, 685 167 1:5 36 3.

April 42 2, 126 121 1:51 49 2.

Total 5, 752 54 27, 602 261 1:5

Data in this table, collected during the wartime experience, have been modified to utilize the more accurate data

available after thewar ended.

Admissions; excludes killed in action.

In Army forwardareas.
104 COLD INJURY, GROUND TYPE

Chart 4.—Monthly incidence of trenchfoot inrelation to battle casualties; maximum, minimum, and average temperatures; and rainfall, in Fifth U. S. Army in Italy, September 1944 through April 1945

(There were days of snow in December 1944 nd 18 days of snow in January 1945)

Parle 4.—Hospital and quarters cases of trenchfoot and of battle injuries and wounds, and

average minimum temperature and average rainfall, by month Fifth U. S. Army, October

1944 through March 1945

[Rate expressed as number per annum per 1,000 average strength]

Month and year

Trenchfoot Battle injuries and wounds Ratio of trenchfoot

tobattle injuries and

wounds

Average

minimum

temperature (°F.)i

Average

rainfall

(inches) Cases Rate. Cases Rate

1944 October 258 24 8, 404 783 1:33 51 6. November 274 25 2, 046 188 1:7 44 5. December 305 22 1, 274 90 1:4 33 3.

1945 January 309 26 561 48 1:2 25 4. February 324 25 1, 966 154 1:6 36 1.

March 102 1, 613 97 1:16 39 1.

Total. I, 572 20 15, 864 206 1:10

Data in the table, collectedduringthe wartimeexperience,have been modified to utilize the moreaccurate dataavail- able after the war ended.

Admissions; excludes killed in action.

In Armyforward areas.
ME I)ITERRAX EAX T11EATER 105

United States experiences. This is in contrast to the situation in the European

Theater of Operations, where many comparisons are unsound because the

troops of the two nations occupied entirely different positions and their tactical

activity and deployment were also different.

Incidence of cold injury among British troops in Italy during 1943-44 was

strikingly lower than among United States troops. Early in the fall of 1943,

trenchfoot was apparently of so little consequence in British troops that it was

not reported at all. Reports from the week ending on December 1943 through

the week ending on 19 February 1944 show total of only 102 cold injuries in

British troops, in contrast to 4,583 battle casualties, ratio of 1:45. During

the same period, there were 4,560 cold injuries and 17,894 battle casualties in

Fifth U. S. Army troops, ratio of 1:4.

Table 5. Cases of trenchfoot and battle casualties in British 10 Corps, for weeks ending

December 1943 through 19 February 1944

The explanation of these differences is not entirely clear. Among the

obvious reasons for the better British showing were the excellent boots with

which British troops were provided; the heavy wool socks which they used, in

contrast to the lighter socks provided for American troops; the daily sock exchange which was routine in the British Army; the British practice of keeping

troops in the line for shorter periods of time than the American practice; and

the very strict foot discipline enforced on British troops. An observer from

the Office of the Quartermaster General considered that the British custom of

Week ending— Trenchfoot Battle

casualties

Ratio of trenchfoot to battle

casualties

191,3

December 279 1:279

11 44 1G5 1:3.7

18 38 1:12.G

25 29 1:29

19U January 127 1:68.5

170 1:21.2

15 135 1:15

22 1, 782 1:891

29 707 1:707

February 714 1:714

12 198 1:66

19 27 239 1:8.8

Total 102 4, 583 1:45
10G COLD INJURY. GROUND TYPE

classifying cold injury, from the disciplinary point of view, as self-inflicted

wound had much to do with the lower British incidence.

Milder cases of trenchfoot among British troops were likely to be treated

in quarters and not to appear in formal statistics, whereas among United States

troops practically every casualty with trenchfoot was either hospitalized,

treated in quarters, or carded for the record, and included in the statistics.

Any reasonable allowance for these different practices, however, could explain

no more than minor part of the very considerable difference in the incidence

of cold injury in British and United States troops. The opinion was expressed

by one corps surgeon (VI Corps) that the discrepancy would have been less

notable if there had been taken into account the readiness of United States

Army unit surgeons to evacuate all soldiers with cold injury, regardless of its

degree.

These various explanations may or may not be valid. The important

fact remains that when the circumstances of combat were precisely the same,

as they were on the Anzio beachhead, the disparity between the American and

the British incidence of cold injury is very striking, as the Surgeon, VI Corps,

pointed out in report to the Surgeon, Fifth U. S. Army, on 13 April 1944, after

survey of that area:

During the months of February and March there was total of 1,951 cases of "trench foot” reported among the American troops, and 103 in the British forces. The American

forces on the beachhead are approximately twice the number of British troops. Thus

there was one case of this disability occurring in the British troops to ten cases among the

Americans. That is, the incidence of "trench foot” in the American forces was ten times

that of the British—climatic and tactical conditions were the same for both forces.

General Blesse had made essentially the same point in report to the

Commanding General, NATOUSA, on 16 March 1944: During the 10-day

period ending on 17 February, 550 American soldiers were hospitalized from

the southern sector and 501 from the Anzio beachhead. British troops on

the beachhead, fighting under the same conditions as United States troops,

had very few cases.

During the winter of 1944-45, recordkeeping practices in the British and

American elements of the Fifth U. S. Army were the same, and comparisons

of the cold inj ury rates are therefore valid (table 6). The average annual rate

for trenchfoot per 1,000 men was again higher in American than in British

troops (20.5 in contrast to 6.3). The average annual rate for battle casualties

per 1,000 men was, however, higher in United States troops than in British

troops, so that the ratio of cold injury rates to battle-casualty rates was really

about the same in both groups (1:10 in United States troops; 1:11 in British

troops).

Letter No. 57, Maj. Robert H. Bates, Quartermaster Observer with the Fifth U. S. Army, to General Doriot, Office

of the Quartermaster General, 25 Apr. 1945.

Annual Report, Surgeon, VI Corps, 1944, annex D.

Ibid.

Essential Technical Medical Data, Headquarters, NATOUSA, for February 1944. Appendix II, dated 16 Mar.

1944, subject: Health of Command for February 1944.
MEDITERRANEAN THEATER 107

Table 6.—Incidence rates for irenchfoot cases and battle casualties, United States and British

elements, Fifth U. S. Army, for weeks ending IS October 1944 through April 1945 [Rate expressed as numberper annum per 1,000 average strength]

TACTICAL SITUATION

Although the winter of 1943-44 was not punctuated by the intervals of

bitter combat which had occurred earlier, at the time of the Salerno landings,

and which were to occur later, with the fall of Rome and the breach of the

Gothic Line, combat was nonetheless sufficiently intensive for casualty rates

Fifth Army History, pts. 1I-IV, Oct. 1943-31 Mar. 1944.

u. s. Army British Army

Week ending— Trenchfoot

(rate) Battle casual- ties (rate)

Trenchfoot

(rate) Battle casual- ties (rate)

1944

October 13 45 913 255

20 874 307

27 505 300

November 52 296 22 80

10 32 166 97

17 24 176 10 35

24 159 78

December 19 112 20 89

19 78 10 89

15 110 157

22 22 80 14 41

29 35 70 13 33

1945

January 33 75 11 50

12 25 33 23 18

19 17 36 13 12

26 16 44 10

February 22 34

19 212 33

16 37 135 16

23 19 234

March 11 112

223

16 73

23 45 21

30 36 18

April 111 26

Average. 19. 190 6. 68.
108 COLD INJURY, GROUND TYPE

to be high and for the tactical situation to require the exposure of troops to

the risk of cold injury. Much of the fighting was in the mountains and was

especially difficult and demanding. After the fall of Naples and the crossing of the Volturno River in October 1943, monthly casualty rates were continuously high; the maximum number of cases (8,378) occurred in February

1944 (table 3).

November and December 1943 found United States troops operating in

wet cold over the mountainous terrain before the German winter line. In

January, following the breakthrough on the winter line, tlie Rapido River

was crossed, Cassino was approached, and new positions were established

before the Gustav Line. Operations of the Fifth U. S. Army during this

period can best be described as continuous assault, over unfavorable terrain,

upon prepared positions, with the enemy largely free to make such stands

as he chose while he conducted an orderly withdrawal up the peninsula. The

individual United States foot soldier, as result of this type of combat, was

often immobilized by enemy fire. The terrain was unfavorable, and dry

shelter was almost impossible to find. Moreover, supply was major problem.

Cargo trucks could go only short distance up the mountains after they had

left the main roads, and food and ammunition had to be brought up by mule

pack or, very often, by hand carry. As result, days might pass without

supplies of hot rations’ being brought up.

Landings on the Anzio beachhead were undertaken in January 1944 in

an effort to draw German strength away from the Gustav Line, which guarded

the approaches to Rome. Conditions on the beachhead were simply an exaggeration of the conditions which prevailed throughout the Fifth U. S. Army

area at this time. The VI Corps was contained within space roughly 15 miles

long and miles wide. Here it was raked by concentrated artillery fire and

air attacks throughout the remainder of the winter and until the breakthrough

in May, just before the fall of Rome. During this time, there were few quiet

intervals. Heavy attacks by armor and infantry were repeatedly delivered by the Germans, under cover of merciless artillery fire from well-placed ground

positions, and there were also heavy bombings from the air.

Under these circumstances, infantrymen were often obliged to spend days immobilized in water-filled foxholes, in icy weather, with no chance of relief.

Because the beachhead, as just pointed out, was held from the first under very

heavy opposition, Allied reverses were serious, and until almost month after the landings the issue was in doubt. Although it then became clear that the

position could be held, it was another months before it could be extended.

After March and until the Allied breakthrough in May, the opposing forces

maintained state of no more than active defense of theirrespective positions,

though conditions on the Anzio beachhead could never be described as truly

static.

The battle for Cassino was another ordeal in which the individual soldier

found himself obliged to take cover in isolated foxholes or other positions in
MEI)ITERRANEAN THEATER 109

which his movement and communications were severely restricted. Here, as elsewhere in Italy, the tactical situation influenced the degree to which

troops could be supplied with hot food, dry socks, shoes, clothing, and other

necessities. In general, it fostered the type of exposure and other circumstances which would be most conducive to trenchfoot.

Nowhere in Italy during the winter of 1943-44 was controlled, frequent

rotation of either units or individuals out of frontlines practiced by United

State troops. This was in contrast to the rotation of both units and individuals regularly practiced, for preventive purposes, by British commanders.

United States combat commanders in the Fifth U. S. Army explained the

policy of nonrotation by the scarcity of combat replacements and the seriousness of the tactical situation. Whatever the causes, the long periods of duty in heavy combat, without relief, which were exacted of United States soldiers

during the winter of 1943-44 favored the development of cold injury and

helped to explain its high incidence. As an extreme illustration, one division

spent 115 of its first 122 days in Italy in combat.

During the winter of 1944-45, the tactical situation was much less favorable to the development of cold injury. After the breach in the Gothic Line

in October 1944, the front was comparatively inactive until the end of January

1945, when large-scale offensive was undertaken by the Allied forces. Casualty rates during this period of inactivity were the lowest for any period of

comparable length during the entire Italian campaign. The inactivity from

the standpoint of combat was reflected in the decreased incidence of trenchfoot. Troops could be in relatively comfortable quarters. They had time to

take care of themselves. They were more easily supplied. They had better food. In short, all the circumstances were far less conducive to trenchfoot

than those which had prevailed in the winter of 1943-44. Tactical inactivity

was, of course, only one of Several factors which accounted for the decreased

incidence; improvement in clothing and footgear and the institution of preventive measures also played large part in it.

CLIMATIC FACTORS

The relationship between weather conditions and the incidence of cold

injury was promptly evident in the Mediterranean theater (tables and 4,

charts and 4). Cold injury was not reported before November 1943, as

might have been expected. Up to that time, the temperature on the front

had not fallen below 50° F. (10° C.) and there had been very little rain. In

November, temperatures began to fall below this level, and rainfall was heavy.

Climatic conditions were promptly reflected in the incidence of cold injury

(table 3, chart 3). The average minimum temperatures were 47° F, (8.3° C.)

in November, 44° F. (6.7° C.) in December, 36° F. (2.2° C.) in January, and

34° F. (1.1° C.) in February.
110 COLD INJURY, GROUND TYPE

An average of 10.2 inches of rain fell in the Fifth U. S. Army area in

November, and an average of 6.9 inches in December. Between 14 and 19

November, heavy rains flooded the Volturno River and swept away all the

bridges except the one at Capua. The environmental hazard was therefore

enhanced by the difficulty of getting supplies to the front. On the Anzio

beachhead, conditions were even worse. This area has high water table,

and, at the best of times, the ground is marshy and soggy. These naturally

unfavorable conditions were made worse by the heavy rainfall. Here, as on

other parts of the front, the weather was very cold and ice formation was

frequent.

The combination of cold and wet invited trenchfoot. As already pointed

out, the soldiers were forced to remain in water-filled foxholes or other ground

positions for days, and sometimes for weeks, at time. Even if they had been

trained to care for their feet—as they had not been—foot care would have

been extremely difficult under such circumstances. The removal and replacement of mud-caked shoes, boots, and leggings were not easy to accomplish and

were frequently not even attempted.

The correlations between the occurrence of trenchfoot and the prevalence

of cold, wet weather held all through the winter of 1948-44. The peak of the

trenchfoot incidence in February 1944 (table 3, chart 3) followed period of

cold, rainy weather. Combat activity was also heavy at this time, as shown

by the peak number of wounded in action, and troops were less able to take

proper care of themselves and to practice foot hygiene.

Most of the fighting in the winter of 1943-44 had been south of Cassino.

In the winter 1944-45, military operations were conducted in the northern

Apennines and on the Ligurian coast, and cold weather came month earlier

than it had come the previous winter. In September 1944, the average minimum temperature in the Fifth U. S. Army sector north of Florence was 62° F.

(16.7° C.), and the average rainfall was 2.7 inches. No cases of trenchfoot

were reported. In October, when the average minimum temperature was 51° F, (10.6° C.) and the rainfall averaged 6.5 inches, trenchfoot began to reappear

(table 4, chart 4), and cases were reported thereafter until the end of the winter,

though the number, as already stated, was considerably less than during the

preceding winter.

The course of events left no doubt of the influence of the combination of

cold and wet in the production of trenchfoot. The correlation was demonstrated not only by the total figures for the Fifth U. S. Army but also by its

daily and monthly incidence in individual combat divisions. In neither winter

of fighting, however, did trenchfoot appear until the temperature had fallen

to an average minimum of approximately 50° F. (10° C.) and until rainfall had become considerable.
MEl)ITERRANEAN THEATER 111

CLOTHING AND FOOTGEAR

In general, neither clothing nor footgear worn by American troops in

Italy during the winter of 1943-44 was entirely satisfactory. Many items

were in short supply until the winter was well advanced. Others, such as

woolen socks, were not forthcoming in adequate quantities until the weather

had become warmer and the environmental hazard of cold injury had been

greatly reduced. These deficiencies played an important part in the incidence

of trenchfoot in the winter of 1943-44, and the improved record in the following

winter can be attributed in considerable part to their correction.

Clothing

When the deficiencies of clothing originally supplied to troops in Italy

were realized, Maj. (later Lt. Col.) Robert H. Bates, QMC, an observer from

the Office of the Quartermaster General, was sent to the theater, by request,

to study the situation. His observations upon the clothing worn by the 3d

Infantry Division on the Anzio beachhead resulted in the replacement of the

unsatisfactory uniform worn the first winter by the M-1943 uniform, which

was devised on the layering principle (fig. 24) (p. 430). Major Bates’ observations also formed the basis of the requisitions placed for the winter of 1944-45

for both the Fifth and Seventh U. S. Armies. It is significant, in view of the

delays which attended the placing of orders for these articles in the European

theater (p. 143), that the requisitions for the Mediterranean theater for the

winter of 1944-45 were placed in April 1944. The supplies reached the theater

in September, and distribution was begun in October. 10

The new items issued in the fall of 1944 included field jacket with hood

and field trousers, which, when worn together, provided completely windproof and fairly water-repellent outer layer. Underneath this layer, the soldier

wore high-necked sweater and warm pile jacket, in addition to the wool shirt

and wool underwear worn the preceding winter. Cotton field trousers worn

over regulation wool trousers provided an additional layer of insulation and

warmth, as well as additional protection against cold winds. For men in

particularly exposed positions, the issue included warm overcoat parka, with

windproof exterior and thick pile lining, and special rain outfit consisting of

hooded parka and completely waterproofed trousers. The leather gloves

supplied had separate woolen linings, and fabric mittens had special wool inserts. Mufflers and down and feather sleeping bags were also issued.

See footnote 8, p. 107. )0 Annual Report, Surgeon, MTOUSA, 1944, vol. II, annex J,
112 COLD INJURY, GROUND TYPE

U. S. Army photos

Figure 24.—Cold-weather uniform. A. Utilization of layering principle (note

combat boots). B. Field jacket M-1943 (note buttoned collar). C. Same jacket as seen

in B, with adjustable tie cord.
MEDITERRANEAN THEATER 113

Footgear

Socks.—When trenchfoot first began to appear in Italy in November 1943,

United States troops were wearing the cotton socks or light wool socks which

they had worn during the summer and early fall. 11 These socks, while satisfactory for warm-weather operations, were totally inadequate for winter fighting in the valleys and on the mountains between the Volturno, Garigliano, and

Rapido Rivers (fig. 25). Furthermore, even these inadequate socks were in

short supply. Only 10 percent of the requests made for them could be filled

during October. At one time, it was possible to get together only 500 pairs

for the 45th Infantry Division, which had requested 16,000 pairs. An investigation of 50 soldiers with trenchfoot in November 1943 showed that only

possessed more than pair of socks. One man was wearing cotton socks,

forty-eight were wearing light wool socks, and the only man who was wearing

heavy wool socks had received them from his family. During periods of exposure, which had averaged days, 45 of the 50 men had been unable to change

their socks at all, and the other had changed them only once.

Dry shoes could not, of course, be supplied in combat. On the other

hand, if dry socks had been available and if the importance of substituting

them for wet socks, even in wet shoes, had been understood by the soldiers,

the dry socks would have provided period of insulation before they in turn

had become wet. Ski socks, which were used only with shoepacs or by mounAFIP CA-44-689XX

Figure 25.—Liri-Garigliano Valley in February 1945. Floods of the same extent played

role in the incidence of trenchfoot in the Fifth U. S. Army the previous winter.

11 See footnote 8, p. 107.
114 COLD INJURY, GROUND TYRE

tain troops, became available late in the winter of 1943-44, when the need

for them had almost ended, but they proved extremely useful in the following

winter, when the troops had been taught to wear shoepacs efficiently.

Socks issued to United States troops late in the winter of 1943-44 and

in the following winter were more satisfactory than the previous issue. At

most, however, they contained only 50 percent wool, and they were never as

efficient as the British-issue socks.

Socks were finally in sufficient supply in the theater for each man to

carry 2, or even 3, extra pairs upon his person. It is indicative of the general

lack of appreciation of the dangers of trenchfoot in an army in combat that as

late as April 1944 the provision of pair of socks daily with his ration for every

soldier was being described as luxury which could not be met from present

resources. 12 The facts were undoubtedly as stated, but the language was

unconsciously revealing.

The inner soles tested by an infantry division in January 1944 were

thought to be of some benefit, but the impression was that their use would not

significantly influence the incidence of cold injury.

Shoes and boots.—During the early winter of 1943-44, American soldiers

in Italy wore the regulation enlisted man’s service shoes (fig. 26), usually with

AFIP A-44-147

Figure 26.—Service shoes, wet and covered with mud, removed

from feet of soldier who contracted trenchfoot in fighting in Rapido

River Valley, February 1944.

12 Report, Brig. Gen. C. L. Adcock, GSC, Office of Assistant Chief of Staff, Q-4, NATOUSA, dated 20 Apr. 1944,

subject; Health of Command Report for February 1944.
MEDITERRAXEAX THEATER 115

AFIP 54-3045-f

Figure 27.—United States Army field combat boot.

leggings. Later, many wore combat boots (fig. 27) without leggings. From

the standpoint of prevention of cold injury, the boots had few advantages

over the service slices, and both were open to the same general objections.

Both were made on lasts which fitted the foot closely. Both were fitted too

small, partly from carelessness and partly because of the habit of wearing

tightly fitted shoes. Shoes fitted over cotton or lightweight wool socks were

too tight when they were worn over wool socks, particularly after the leather

had become wet and had shrunk. Both shoes and boots were usually laced

too tightly, and when leggings were worn with service shoes another cause for

circulatory insufficiency was provided, as well as another deterrent to removing

the shoes to care for the feet.

The 12-inch blucher boot sometimes used in the first winter in Italy was

more efficient than either the service shoe or the combat boot, both because

of its construction and because it could be worn with ski socks and inner soles.

When the leather became wet, however, whatever advantage the blucher boot

might have had originally was promptly lost.

The ski mountain boot, which was issued to mountain troops, had very

high box toe, which made constriction of the foot practically impossible. This

boot was designed to be worn with two pairs of heavy ski socks and with an

inner sole as well. It was the warmest leather boot known to be in use by any

army in World War II, but it was suitable only for mountain troops. It proved extremely satisfactory for mountain use under most dry cold conditions, but
COLD INJURY, GROUND TYPE 116

once the leather became wet some of the original advantages were lost, though

the heavy ski socks worn with it still provided some protection against cold

injury.

Dubbing was of no value in winter weather in Italy, and in the opinion

of some observers its use made conditions worse.

Galoshes and rubber boots.—In December 1943, galoshes became available, but the quantities were limited and “sufficient to equip no more than

handful of troops.” The need, which was estimated at 230,000 pairs, could

not be met because of the rubber shortage. Such supplies as became available

were issued to combat troops. 13

Stationary troops found galoshes useful. Combat troops found them

awkward, heavy, clumsy, noisy, and hot. They would not wear them on patrol

or during combat, and many infantrymen threw them away rather than be

burdened with them. Rubber boots were satisfactory for engineering units

and other special organizations working in water but were not suitable for

troops in combat and on the march.

The first 50 soldiers with trenchfoot who were studied in Italy did not

have galoshes or rubber boots. Shoepacs.—Four hundred pairs of shoepacs were issued on trial basis to

the 34th Infantry Division in January 1944, but they were not found satisfactory for number of reasons. The model supplied did not grip the ankle, as

did the service shoe. After prolonged activity in mild cold, the feet became

uncomfortably hot, perspiration was profuse, and the skin eventually became

macerated. Sizing was not satisfactory. There was an excess of large

sizes and shortage of small sizes, so that men with small feet continued to

have trenchfoot or developed blisters because the shoepacs they wore were

too large. No instructions had been given as to how shoepacs were to be worn

(with ski socks and insoles), and, when they were worn incorrectly, trenchfoot

continued to occur. The complaint was general that shoepacs did not support

the arch of the foot satisfactorily, although examination revealed no arch

troubles among the men who were wearing them. 14

In spite of the defects of the model provided and the objections raised to

them, there was general agreement that shoepacs were preferable to any other

type of footwear for use in short operations in cold weather in mud, water, and

snow When they were provided in proper sizes and widths, were properly

fitted, and were worn with the proper combination of socks and insoles, their

popularity increased. They eventually became standard footgear in Italy for

all United States troops who had to fight over terrain for which ski boots were

not appropriate. They also proved the only really satisfactory type of footgear

for climbing in rugged country with heavy loads; under these circumstances,

the soldier wearing shoepacs could keep his feet reasonably dry. This was

most important consideration in Italy, in many parts of which the mountain

terrain was so rugged that all supplies beyond muleheads had to be brought

13 See footnote 8, p. 107,

14 See footnote 4, p. 106.
MEDITERRANEAN T11RATE 117

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

more.

Properly fitted shoepacs, worn with socks and insoles as intended, seemed

to furnish real protection against cold injury, particularly when temperatures

fell to 20° to 30° F. (—6.7° to —1.1° C.). Of 282 patents with trenchfoot

observed in Fifth U. S. Army hospitals in November 1944, only 18 percent wore

shoepacs. Of 327 observed in December, only 11 percent wore them with the

correct socks. Another 27 percent of the December casualties wore shoepacs

but did not have correct socks. 15 During the entire winter of 1944-45, out

of every casualties from cold injury did not wear them.

There were also explanations for the apparent inefficiency of shoepacs in

some cases: (1) considerable number of the men who contracted cold injury

while wearing them suffered from recurrences of earlier injuries and (2) another

group failed to care for their feet after they had been in water over the tops of

their shoepacs.

Training,—A significant result of the study on clothing conducted in Italy by Major Bates was the setting up of training courses on the supply and use of

winter clothing and other equipment by the Quartermaster, Fifth U. S. Army.

These courses were instituted in November 1944 when it was found that trenchfoot was still occurring in spite of the provision of satisfactory clothing and

footgear, including shoepacs. The courses were conducted separately for line

officers, combat troops, and quartermaster and supply officers and sergeants.

Units which could not send representatives to the scheduled courses were

visited later for instructional purposes. The lessons which were learned were

transmitted through channels down to platoons, and by the end of the year

about 50,000 officers and enlisted men had been indoctrinated.

During these courses, all items of clothing and footgear were explained,

and their use was demonstrated. The layering principle in clothing and the

proper sizing of shoes, shoepacs, and socks were also demonstrated. Demonstrations were given in the use of the sleeping bag and shelter halves, in the

drying of wet socks and inner soles inside the sleeping bag or inside the shirt

if dry substitutes were not available, in the fitting of shoepacs, and in the combinations of socks and inner soles to be worn with the shoepac. Simple devices

were shown for keeping the feet from direct contact with wet ground, such as

the use under the feet of food containers, packboards, and branches of trees.

The importance of using these materials in foxholes at night was particularly

emphasized. It was constantly stressed that the removal of shoes and socks,

even for brief periods and even when dry socks were not available, was an

essential of foot care.

When formal instruction was concluded, plans were made for continuation

of instruction by the use of small mobile training teams. Particular attention

was given to the instruction of fresh replacements from the United States. 16

These soldiers had had no instruction at all in these matters in the Zone of

15 Essential Technical Medical Data, Headquarters, NATOUSA, for January 1945. See footnote4, 106.

438404'— 58 10
118 COLD INJURY, GROUND TYPE

Interior, and they had not yet learned from contact with other troops, or from

personal experience, how to protect themselves against exposure to cold and

wet. 17

An outgrowth of the courses for supply personnel was program to correct

the initial errors made in the fitting of shoepacs. These mistakes had arisen

when distribution had to be effected to organizations already in the line. Each

unit commander was directed to check his men and to make such exchanges

within the unit as might correct errors of sizing. Sizes not available within the

unit were drawn at the training center or were put on orderfor later issue. 18

INDOCTRINATION AND TRAINING

When the early trenchfoot experience in Italy was analyzed, it promptly

became evident that, while such basic factors as climatic conditions, intensity

of combat, and deficiencies in clothing and equipment were responsible for the

high incidence of cold injury, ignorance of the disastrous potentialities of this

type of trauma and of methods of preventing it played an even more important

role in its development. 19 In the winter of 1943-44, troops of the Fifth U. S.

Army and their commanding officers were almost equally ignorant of cold

injury and were almost totally unprepared to combat it.20

The annual report of the Medical Section, NATOUSA, for 1943 minced

no words in setting forth these facts. Present Army regulations and instructional material on the care of the feet, said this report, were inadequate. Troops

did not know how to carry out this important precaution. Commanding

officers were equally ignorant of foot care and had not been impressed with the

essential importance offoot discipline. Troops had not been trained in methods of drying shoes and socks under all conditions. They did not know how to

care for minor foot ailments. Instruction in these matters, the report went on,

should be part of all training and should be followed up by frequent foot inspections. The prevention of trenchfoot and of other foot ailments depends

primarily upon the care of the feet and only secondarily upon proper footgear

and socks. leaflet on foot care, it was noted, had been prepared in the theater and was being used for instructional purposes, and it was suggested

that the War Department should prepare and issue similar leaflet.

sample group of 142 men with cold injuries were interviewed between 26

January and 12 February 1944 as they passed through clearing station. 21

Not one of them had had any instruction in the prevention of this type of

trauma. Not one of them understood the risk he ran from resting in the cold

without removing and changing his wet socks and shoes. Not one of them

17 Report, Surgeon, 3d Infantry Division, to Surgeon, NATOUSA, 28 Mar. 1944. 18 See footnote 4, p. 106. 19 (1) See footnote 5, p. 106. (2) Annual Report, Surgeon, NATOUSA, 1943. 20 See footnotes4, p. 106, and 19 (2).

21 Essential Technical Medical Data, Headquarters,NATOUSA, for February 1944,and inelosure, dated Apr. 1944, subject: ETMD from Overseas Forces.
MEDITERRANEAN THEATER 119

knew how to use overshoes to the best advantage. The few who were wearing

heavy wool socks did not change them regularly; one man had changed his

socks only times in weeks. The only man who was wearing shoepacs had

never been told how to use them. He wore them with light socks, which

promptly became soaked with perspiration, and he slept in the cold without

changing to dry socks.

Later, in February 1944, an analysis of another group of 320 patients with

trenchfoot showed that 59 percent had never received any instruction in how

to prevent it. 22 The medical officer responsible for the special surveys on

trenchfoot, Maj. (later Col.) Fiorindo A. Simeone, MC, wrote the Surgeon,

Fifth U. S. Army, that under such circumstances “the incidence of trench foot

will be entirely at the mercy of the weather.” 23

Trenchfoot was particular menace in new, untrained troops. survey

of 129 cases in the 3d Infantry Division showed that 30 percent were in soldiers

who had been overseas month or less, although these new troops made lip only

percent of the division strength, and that the incidence in this group of cases

was times the average division incidence. 24 The officer who prepared the

basic report stated, “I have never seen new replacement in this theater who

had received instruction in the prevention of trenchfoot prior to joining the

division.”

secondary result of the ignorance of trenchfoot was that soldiers who

had sustained cold injuries often did not realize what had happened, or the

possible consequences of the injury, and did not report to the aid station

until the condition was far advanced.

Publications.—The first medical circular published on the subject of

trenchfoot in the Mediterranean theater (Medical Circular No. 6) was dated

24 November 1943 (appendix C, p. 521). Although it was chiefly devoted to

therapy, it emphasized that the best management of cold injury was prophylactic. It also noted that, of approximately 200 men with trenchfoot

hospitalized during the previous days, most had worn wet socks for from

to 14 days.

The material on trenchfoot which the Surgeon. NATOUSA, submitted

in memorandum to G-l (personnel and administration), NATOUSA, on

December 1943, was still under discussion on 11 December. G-l was unwilling to accept the material as circular, as was proposed, and suggested that

it appear as training memorandum. G-3 (operations and training),

NATOUSA, considered training memorandum an inappropriate vehicle and

suggested that the material appear as circular or memorandum. G-l then

suggested that the material appear as technical publication by the Surgeon,

adding, “The material is largely, if not entirely, already in field manuals, etc.”

22 See footnote 17, p. 118. 23 Letter, Maj. F. A. Simeone, MC, Headquarters, Fifth U. S. Army, to Surgeon, Fifth U. S. Army, 14 Feb. 1944

subject: Prevention of Trench Foot. 23 See footnote 17, p. 118.
120 COLD INJURY, GROUND TYPE

The Surgeon replied to the latter comment on 11 December as follows:

1. Very many cases of trench foot have occurred in troops of the 5th Army. With

continued wet weather, this condition can be expected to be prevalent in the 5th Army

as well as other commands. The material requested on the prevention of trench foot is

not properly covered in existing field manuals. To minimize the occurrence of trench

foot, troops must be informed of the cause of this condition and trained in the measures

necessary for its prevention. Technical publications by the surgeon can not be expected

to be used as means of individual troop training and inspections required.

2. Since the prevention of disease is command responsibility, and the medical department only recommends preventive measures, it is our opinion that this information should

be disseminated through command channels.

The communication ended with the renewed request that the material

be published in NATOUSA circular. communication from G-l to the

adjutant general of the theater on 15 December 1943 directed that it be published as soon as possible. Accordingly, on 21 December 1943, letter on

the subject of trenchfoot was sent from Headquarters, NATOUSA, to the

commanding generals, Fifth and Seventh U. S. Armies and the Peninsular

Base Section (appendix D, p. 523).

Meantime, the Fifth U. S. Army issued information on cold injury in

letter which was distributed to all units of this army on December 1943.

In this communication, it was pointed out that trenchfoot was likely to

become major cause of disability among United States troops unless unit

commanders and medical officers used all the means at their disposal to prevent it. Unit commands were directed to exercise all possible ingenuity and

vigilance to see that the following prophylactic measures were instituted and

applied: (1) Rigid enforcement of the rules of foot hygiene with frequent foot

inspections; (2) the use of foot powder on the feet and in the socks; (3) the

wearing of fresh socks into combat, with at least one extra pair to be carried

on the person; (4) loose fitting of shoes whenever possible and, when dry socks

were not available, the removal of the shoes and the wringing of water out

of the socks; (5) the use of overshoes in wet weather whenever combat conditions permitted; (6) muscular activity and simple exercises, designed to delay

the development of cold injury; and (7) the rotation of frontline troops whenever possible after 48 hours on duty, so that they could wash and dry their

feet and change into dry socks and shoes. This letter called the attention of

the commanding generals to the increasing incidence of trenchfoot and to the

importance of measures of prevention and first aid. Special emphasis was

placed upon simple foot exercises, practical under combat conditions, and frequent foot inspections were ordered for troops subjected to exposure, to make

certain that they were taking proper care of their feet.

Training Memorandum No. 9, NATOUSA, on the care of the feet was

issued on 24 December 1943 from General Eisenhower’s headquarters. It

repeated the facts about trenchfoot already published in other forms and provided that unit commanders must include in their training programs at least

hours of formal instruction covering the care of the feet. Frequent foot inspections were again ordered.
MEDITERRANEAN T11E ATER 121

The Surgeon, NATOUSA, in comment on this memorandum, addressed

to G-3 and dated 19 December 1943, raised the question of supplementing

it with leaflet on the care of the feet for individual distribution to all United

States Army officers. The material was duly prepared, and, on 13 January

1944, publication in the form of booklet was recommended. 25 In the recommendation from G-3 to the deputy theater commander, it was pointed out

that the Surgeon considered the subject one of increasing importance and had recommended publication for the additional reason that War Department

data were scattered, were difficult to piece together, and did not cover the

subject matter satisfactorily.

The theater quartermaster concurred in the publication of the booklet

with only minor changes. The Chief of Staff, NATOUSA, did not. He

wrote the Surgeon on 19 January 1944 that, in discussions with the deputy

theater commander, it had been concluded that “the problem was one which

could best be solved by utilizing the services of unit surgeons, at the same time

receiving the attention of unit commanders and their staffs.” He also remarked; “It would seem that the necessary knowledge of the subject must

exist in the Army, Divisions and other Commands, and that possibly better results would be attained by short communication to Army and base section

commanders, pointing out the need for personal attention in the matter.”

The Surgeon, NATOUSA, replied to this communication on February 1944

that he could not concur with these arguments. The problem was essentially

one of unit training and command responsibility, which could not be assumed

primarily by the unit surgeon. He also stated that instructional matter

presently in existence was incomplete and scattered. Finally, he said that

many of the more than 2,000 trenchfoot casualties which had occurred since

November of the previous year could have been prevented if troops had known

how to care for their feet and if unit commanders had insisted upon proper

preventive measures. The Surgeon doubted that short communication to

army and base surgeons would correct the situation and renewed his recommendation for publication of the proposed booklet.

This recommendation was accepted on 12 February 1944, and an issue of

14,000 copies was authorized on 25 February. Distribution was begun on 29

March 1944,26 too late, however, to have any influence on the incidence of

trenchfoot during the first winter of fighting in Italy.

Command responsibility.—As many of the facts just stated indicate, command responsibility for trenchfoot had not been realized early in the winter

of 1943-44, and preventive measures were late in being put into effect. This

error was not made during the following winter. The subject was kept alive, in fact, throughout the late spring and early summer.

radiogram to the War Department from Headquarters, MTOUSA, on

31 May 1944 pointed out that training in the care of the feet and in foot disci25 Memorandum (intraofflce), Headquarters, NATOUSA, comments 1-9 dated 13, 16, 18, and 19 Jan. 1944 and 9,

12, lo, 16, and 17 Feb. 1944, subject; Printing of Booklet on Care of Feet. 2« Memorandum, Maj. Qen. Daniel Noce, GSC, Office of Assistant Chief of Staff, G-3 to 0-4,12 June 1944, subject:

Trench Foot.
122 COLT) INJURY, GROUND TYPE

pline had not yet reached required standards. It was therefore recommended

that the handbook prepared in NATOUSA be used as basis for all unit training

programs, which should include at least hours of instruction in the care of

the feet; that unit commanders and noncommissioned officers be given special

training in foot care and be taught the fundamentals of foot inspection by unit

medical officers; that high incidence of cold injury be regarded as an indication

of faulty leadership; that all replacement depots conduct schools in the care of

the feet and certify that all men furnished to combat units had completed this

course; that dry socks be brought up with individual rations; that laundry

facilities for socks be provided for combat troops during wet, cold weather; and

that commanders arrange, during cold weather, for men in frontlines to be

released at frequent intervals, on the ground that without this precaution they

could expect to lose man with cold injury for every or battle casualties.

The Surgeon, NATOUSA, on June 1944, sent the theater commander

letter in which he made the following points:

1. Trenchfoot during the previous winter accounted for 5,670 hospital

admissions, or percent of all admissions for disease to Fifth U. S. Army

hospitals over this period. The ratio of trenchfoot to battle casualties was

1:3.8.

2. It was not likely that more than 60 percent of these men could return

to duty, and high rate of recurrence could be anticipated in those who did

return.

3. Trenchfoot is primarily training problem which involves the education

and discipline of the individual soldier. Indoctrination and training are made

more difficult by the fact that the infantry, which is the most susceptible group,

has high turnover and that the recruit must be taught to save himself from

becoming casualty from trenchfoot at the most tense moment of his life, when

he is about to engage in combat for the first time. Experience during the

previous winter had showed that replacements had not been properly trained

in the prevention of cold injuries.

4. British troops in the theater had had less trenchfoot than United

States troops, probably because of more efficient equipment, including better

fitting shoes, more effective sock exchange, and frequent rotation of troops

in the line.

Medical Circular No. 14, which was issued by the Surgeon, Fifth U. S.

Army, on September 1944, contained one section (II) in which the facts of

trenchfoot were reviewed in respect to etiology, clinical considerations, therapy,

and disposition.

Training Memorandum No. 2, Headquarters, NATOUSA, 29 September

1944, was based on War Department Circular No. 312. section IV, dated 22

July 1944 (p. 63). This memorandum directed that the instruction of troops in

preventive measures against cold injury should begin immediately upon the

receipt of the communication. It stated unequivocally that the enforcement of

precautions against trenchfoot was command responsibility and that commanders would be held responsible for unreasonably high incidences.
i\IE ITER T11E E1 123

This warning meant just what it said. As the winter progressed, commanding officers of various units were required to explain to higher authority

why the incidence of trenchfoot in their units had exceeded certain levels and

were informed that additional cases resulting from failure to carry out prescribed preventive measures would be considered to reflect lack of discipline

and training for which the unit commander would be held responsible.

In addition to the formal program of training in the prevention of cold

injury, all possible devices were employed to make the soldier foot conscious.

The effects of poor foot hygiene were illustrated by photographs of disabling

early and late lesions. These pictures were furnished to battalion surgeons, who

demonstrated them in classes held for enlisted men in their intervals out of the

line. Spot radio announcements were made. Posters were displayed in the

bathing facilities provided (figs. 28, 29, and 30). Small pamphlets of instructions listing “Cold Weather Don’ts” and “Cold Weather Do’s” were distributed among the men to carry on their persons. No opportunity was spared

to alert the soldier to the consequences of neglect of his feet and to school him

in the precautions by which he could protect himself against cold injury.

Specifically, the training of the individual soldier was directed toward the

following considerations:

1. Conserving body heat.

2. Keeping the feet warm and dry. This was to be accomplished by the

avoidance of any form of constriction, immobility, dependency, and cramped

Figure 28. —Drawings used to instruct troops how to keep their feet dry and care

for their shoes.
124 COLD INJURY, GROUND TYPI

Figure 29.—Drawings used to instruct troops in care of wet shoes and socks

position; by the promotion of circulation through exercises; and by periodic

removal of the shoes and socks, and massage of the feet.

3. Using equipment to the best possible advantage, with particular emphasis on the correct use of overshoes and shoepacs.
MEDITERRANEAX TilEATER 125

Figure 30. —Drawing used to instruct troops in causes of trenchfoot

4. Changing shoes and socks frequently, particularly when they had

become wet from rain, mud, or perspiration.

SUMMARY

The heavy losses from trenchfoot which occurred during the winter of

1943- in Italy were greatly reduced during the succeeding winter. It is quite

true that during the second winter the front was frequently static, troops were

not kept in the front lines for overlong periods, exposure to cold was therefore

briefer, and men were evacuated promptly when they first complained of their

feet. When, however, all due allowance is made for these considerations, there

is still no doubt that the preventive measures devised and put into practice were

fundamentally responsible for the improvement evident in the winter of

1944-

Between October 1944 and January 1945, inclusive, total trenchfoot casualties in infantry divisions amounted to only 1.3 percent of total infantry strength,

as compared with percent for the same period in the preceding winter.27 Over

this period, surveys had showed steady improvement, from month to month, in

the use of preventive measures by the troops, and it was to the use of these

measures, even more than to the provision of better clothing and footgear, that

the decrease in trenchfoot was attributed. The schooling had been expensive,

but the lessons of 1943-44, as the experience of the succeeding winter showed,

had been well learned in the Mediterranean theater.

27 Progress on the Trench Foot Problem. U. S. Army M. Dept. Bull. No. 88, May 1945, p. 3.

127

CHAPTER VII

European Theater of Operations

Statistics collected during World War II indicate that approximately

46,000 cases of cold injury occurred in ETOUSA (European Theater of Operations, United States Army) during the fall and winter of 1944-45. This was

about percent of all admissions to medical treatment. The more complete

statistics now available, which include not only cases of cold injury without

other injuries but cases which occurred in association with other injuries, bring

the number of casualties from this cause in the European theater to approximately 71,000 cases (p. 494).

Other armies which fought in Europe had no such incidence of cold trauma.

Even when British troops fought under conditions very similar to those under

which United States Army troops fought, their incidence of cold injury was

negligible (p. 198).

The purpose of this chapter is wofold; (1) To tell the complete story of cold

injury as it was encountered in ETOUSA during World War IT, and (2) to

attempt, as far as possible, to explain why cold injury occurred in this

theater in what was truly an epidemic form.

There are great many explanations for what happened, some of them

more valid than others. If, however, the premise be accepted that cold injury

is largely preventable, there is no real excuse for what happened. This is

neither new nor an unreasonable pouit of view. It was the considered opinion

for instance, of the General Board, United States Forces, European theater

(p. 208), which concluded its study of cold injury in that theater as follows:

29. Cold injury, ground type, is to great extent preventable.

30. The relatively high incidence of cold injury in the European Theater of Operations was due to inadequacy of clothing and footgear of types suitable for winter operation,

unfavorable operational conditions and to the delay of many units in instituting program

with emphasis on and close supervision of the measures to be taken by the individual soldier.

Of the three factors listed by the General Board in their report entitled

“Trench Foot” (Medical Section Study No. 94), as responsible for the incidence of cold injury in the European theater in the winter of 1944-45, only one,

unfavorable operational conditions, is not susceptible to reasonably complete

control, and even this condition is susceptible of some modification (p. 425).

If, however, there is no absolute excuse for the epidemics of cold injury

which occurred in Europe, there are number of reasons for them which will be

set forth in more detail in the course of this chapter. It might be useful, for

orientation purposes, to list and discuss briefly certain of these reasons in this
128 COLD INJURY, GROUND TYPE

introductory section, after stating that the fundamental and all-pervading

reason was that the lessons of the past had not been learned or heeded.

There were three major immediate reasons for these epidemics: (1) Operational conditions, (2) inadequacy of clothing and footgear, and (3) delay

in instituting program for the prevention of cold injury, ground type.

As has been pointed out many times in this volume, the experiences of the

Aleutians (p. 83) and of the Mediterranean Theater of Operations (p. 101) either

were not understood or were not considered applicable to the European theater.

Furthermore, early experience in the European theater was ignored. The highaltitude cold injuries which had originally beset the Eighth Air Force (p. 130)

were well under control by D-day, but the lessons implicit and explicit in them

were not passed on to the Ground Forces, chiefly because there was as yet no

general realization that all varieties of cold injury are of the same general

etiology and are subject to the same general considerations of prevention and

control.

The winter of 1944-45 was the coldest and wettest in years, and the

wet cold, combined with the tactical situation (p. 136), created precisely the

conditions most favorable for the development of trenchfoot and frostbite.

Moreover, two points of view prevailed about the possibility of winter campaign in Europe, neither of them conducive to preparations for the prevention

of cold injury. Historically, decisive military campaigns had not been fought

in western Europe during the cold winter months. On the other hand, it was

the opinion, at least in certain circles, during the summer and early fall of 1944,

that the war would end before winter. Thus, staffs were not psychologically

attuned to the need for large supplies of special combat clothing, footgear,

and other winterizing equipment (p. 147), or to the necessity for an extensive

program for the prevention and control of cold injury when there was time.

calculated risk also was taken by command decision to bring forward ammunition, gasoline, and other combat requirements to the exclusion of winter

clothing and footgear.

For number of reasons, clothing and footgear, which play an important

part in the prevention of cold injury, therefore were not in adequate supply

and were of inadequate design, as it turned out. When adequate supplies were

finally received, they came too late to be entirely useful, and they were not

always used efficiently because troops had not been trained in their use (p. 160).

For some of the same reasons, the program of prevention which eventually

was instituted comprehensively and effectively in the European theater was

instituted too late to be as useful as it should have been (p. 169). Troops

locked in mortal combat are concerned with saving their lives, not with learning

how to take care of their feet.

Other factors inherent in the rapid buildup of strength, the organization

of theater and field forces, and the development of operational plans contributed to lack of attention to preparedness for cold trauma. On 31 May 1942, for example, there were only 34,350 United States Army troops in Europe;

when the war ended, on May 1945, the United States Army strength in the
EUROPEAN THE BR 129

European theater totaled over 3,000,000 men under arms. This tremendous

increase in strength involved hundreds of units, both large and small and in both combat and support roles. Efficient command and staff function to direct these units required repeated reorientation and sometimes reorganization

of the higher theater headquarters, the integration of the several army headquarters into command structure, and the activation of lesser headquarters of

the Communications Zone in the United Kingdom and, later, on the Continent.

Inevitably, such expansion brought with it shifting of key personnel and

responsibilities.

The medical organization and personnel staffing understandably and

necessarily underwent, in general, the same mushroom growth. As an example, from the meager nucleus of one medical officer who went to England with the Special Observers Group in May 1941, before the United States

entered World War II, the total strength of the Medical Department in the

PAiropean theater increased to 268,798 officers and men present in the theater

on 30 April 1945. No expansion of such magnitude could fail to have its

weaknesses as well as its strengths.

Medical planning for the invasion of the Continent did not include extensive planning for the prevention of cold injuries. The Manual of Therapy,

issued shortly before D-day, mentioned them only casually, and the precautions suggested after exposure to cold and moisture were somewhat impractical

for men in combat or about to be engaged. They included foot bath with

soap and water, massage of the feet for 20 minutes, dry socks, and change of

shoes. The medical officers who were responsible for the medical planning for

the invasion and for the preparation of the Manual of Therapy had almost

without exception never seen cold injury, and few of them, for that matter,

had had any medical combat experience.

It is against this background that the history of cold injury in ETOUSA

must be read and evaluated. Other things seemed, and indeed were, far more

pressing than possible trauma from cold. As the troop strength of the theater

increased, repeated reorganizations of various headquarters were necessary.

multiplicity of staffs were involved. There was constant preoccupation with

urgent military and over-all medicomilitary needs, including tactical planning,

training, supply, and other matters connected with the normal support of the

largest military operation ever to be undertaken. Priorities of effort had to be

devoted to day-by-day problems, most of them, or so it then seemed, of far

greater urgency than the prevention of trenchfoot. Finally, there was general

inexperience, on the part of all concerned, with both the medical and the

military aspects of cold trauma.

All of these considerations must be borne in mind in the reading and

evaluation of the unfortunate story of trenchfoot and frostbite in ETOUSA in

the fall and winter of 1944-45. The lessons then learned greatly influenced

the planning and preparations for combat in cold and wet weather in Japan

Strength of the Army, May 1945. Prepared for War Department General Staff by Machine Records Branch

Office of the Adjutant General, under direction of Statistical Branch.
130 COLD INJURY, GROUND TYRE

and other parts of the Far East (p. 216). The European experience should

always serve as meaningful and instructive warning of the responsibility of

staff, command, and medical and other technical services in preparation for all

future military operations.

HIGH-ALTITUDE COLD INJURY IN THE EIGHTH AIR FORCE

Until the epidemics of cold injury occurred in the European theater in the

fall and winter of 1944, frostbite among flying personnel had constituted the

only important problem of this kind. Ground troops stationed in Ireland had

encountered extremely cold weather, but under noncomhat conditions, which in

no way paralleled the conditions confronting troops on the Continent in the

winter of 1944-45. The dangers which confronted the Army Air Forces were

also not parallel to those which ground troops encountered, but certain aspects

of the experience are sufficiently instructive to make it worthwhile to tell the

story briefly.

Incidence

From the beginning of operations in Europe, in 1942, until the end of the

fighting on the Continent, in May 1945, varying proportions of all casualties

in airborne personnel of the Eighth Air Force could be attributed to highaltitude frostbite. It was pointed out in the August 1944 issue of Health that,

during the fiscal year 1943-44, more crew members returning from operational

missions had sustained cold injuries than had sustained wounds from enemy

action. These losses were serious. third of all frostbite casualties required

hospitalization, and, even when the injuries were mild, flying personnel had to

be grounded for to 14 days. surgeon, speaking on the subject at general

hospital staff conference, warned that the situation constituted real emergency,

since many of the men hospitalized would not return to duty for months, if ever.

Annual reports for the years 1943, 1944, and 1945, by Col. (later Maj. Gen.)

Malcolm C. Grow, MC, Surgeon, Eighth Air Force, contain analyses of the

casualties from cold injuries, as follows;

For the 14-month period ending in December 1943, 1,634 men were removed

from flying duty because of cold injuries incurred on high-altitude operational

missions. Over the same period, 1,207 men were removed from flying duty

because of injuries incurred inaction against the enemy. In 1943, each casualty

from cold injury lost an average of 10.5 days from flying duty, and percent,

according to an analysis of sample of 200 consecutive casualties from this

cause, were permanently lost to airborne crewmen.

In 1944, although the numbers of casualties from all causes increased as the

rate of combat was stepped up, the situation in respect to cold injury was considerably improved; 1,685 men were lost from this cause in total of 3,158 men

Monthly Progress Report, Army Service Forces, War Department, 31 Aug. 1944, Section 7: Health.
EUR()PEAN THEATER 131

removed from flying duty. The average number of days lost from duty because of cold injury fell to 4.7.

In 1945, the situation was still further improved. Between January and the end of the fighting on May, there were only 151 injuries from high-altitude

cold in 149 crewmen, compared with 3,852 injuries from combat missiles.

Causes of Cold Injury

The occurrence of high-altitude cold injury was found, on analysis, to be

related to number of considerations. Some of them were obvious, such as the

season of the year and the altitude. Most of the missions were carried out

about 25,000 feet above sea level, where the free-air temperature, using December 1943 as an illustration, ranged from —22.4° to —45.4° F. 30.2° to

43.6° C.). In 1944, temperatures as low as —60° F. (—51.1° C.) were

encountered.

The position of the crew members in the plane had much to do both with

their chances of contracting cold injury and with the location of the injury. In

heavy bombers, waist, tail, and ball-turret gunners were particularly vulnerable.

The two waist gunners occupied the most exposed position. Injuries from wind

blast were frequent for several reasons. The wind entered through openings

for gun mounts. The gunners removed the gun-cover assembly because it

interfered with the operation of their guns. They left the waist hatch open for

the same reason, as well as to reduce chances of surprise by enemy bombers.

The radio operator also left the hatch open to avoid surprise.

In 1943, waist gunners and radio operators sustained considerably more

frostbite of the face, neck, and ears than men in other positions, though injuries

in these locations influenced losses from duty less than did injuries of the hands

and feet. The upper-turret and ball-turret gunners were particularly likely

to sustain injuries of the feet. Tail gunners suffered heavily from frostbite of

the hands and feet but more often sustained frostbite of the face, neck, and ears.

Ball-turret gunners suffered equally from frostbite of the hands and face but

more heavily from injuries of the feet. Gunners in any position who removed

their gloves to clean jammed guns or to change ammunition belts were instantly

frostbitten when they touched cold metal with their bare hands.

During 1943, gunners in the waist, tail, ball turret, and upper turret of

bombers, together with the radio operator, sustained 75 percent of all injuries

from frostbite in the United States Army Air Forces in Europe. Gunners

whose position was not stated in the reports sustained another percent of

cold injuries. Waist gunners and tail gunners sustained 64 percent of all cold

injuries. The number of casualties was reduced as time passed, but their proportionate distribution among crewmen did not alter materially during the war.

Data on frostbite casualties were secured from the Weekly Careof the Flyer and Statistical Eeport rendered by group

surgeons, who were required, as faras was practical, to state the cause of the injury, the part of the body affected, and the

position of the injured man on the plane. Only frostbite severe enough to cause removal from flying duty was considered

in these reports.
132 COLD INJURY, GROUND TYPE

In 1945, the waist, tail, and ball-turret gunners sustained 99 of the 151 separate

cold injuries which were reported, roughly two-thirds of the total number.

Up to July 1943, injuries of the hands accounted for more than half of all

cold injuries in the Eighth Air Force (table 7) and injuries of the face, neck,

and ears to less than fifth. Thereafter, the proportions were reversed, and

injuries of the face, neck, and ears accounted for the majority of these injuries.

This was decided improvement, since, as has been pointed out, injuries in

these areas were less serious in terms of manpower losses.

Table 7. Changing bodily sites of high-altitude frostbite, 1942-45, Eighth Air Force

The largest single cause of high-altitude frostbite was wind blast, which

was responsible for 39 percent of all cases in the 14-month period ending in

December 1943 and for almost 55 percent of all cases in 1944. The remaining

cases were due chiefly to lack of equipment, failure of equipment, and removal

of equipment which should have continued in use. The first few months of

aerial warfare in Europe clearly revealed that Air Force personnel, including

medical personnel, had not been adequately trained in the prevention of cold

injury. They had been fully alerted to such dangers as flak and air collisions,

but most of them did not know how to protect themselves against the dangers

of cold, nor, because they had not been instructed in its use, did they know the

proper use of the equipment supplied to them. The highest incidence of cold

injury occurred in new groups and in replacement crews in older groups; these

men had not been trained in prevention and did not understand the use and

maintenance of protective clothing.

Corrective and Preventive Measures

When once the factors contributing to the severe losses from high-altitude

frostbite were understood, corrective measures were promptly instituted. An

intensive investigation was carried out in March 1943, after sharp increase in

casualties from this cause had occurred in February. One of the principal

causes was found to be shortages of electrically heated boots and gloves. Until

additional American equipment could be supplied, the difficulty was tempoSite of Injury

December 1942-June 1943 July-December 1943 1944 1945

Cases Percent Cases Percent Cases Percent Cases Percent

Face, neck, ears 58 17. 779 53. 1, 145 65. 79 52.

Hands, fingers 188 56. 425 28. 298 16. 39 25.

Feet, toes 87 26. 278 18. 304 17. 32 21.

Buttocks, groin 1. 1. 19 1.

Total 337 100. 1, 489 100. 1, 766 100. 151 100.
EUROPEAN THEATER 133

rarily relieved by modification of gloves and boots used by British airmen to

permit their use with American flying suits. The investigation in March 1943

also revealed that failure of electricity in the planes was responsible for some

failures of equipment, that large numbers of injuries were occurring because

portions of the face and neck were unprotected, and that casualties in heavy

bombardment aircraft were suffering from cold injury after wounding because

of lack of warm blankets. It was also found that crewmen who occupied protected positions not infrequently suffered cold injuries from wind blast after

damage to the plane by enemy missiles.

After these discoveries, number of new items of equipment were devised

by the Air Surgeon’s Office and other service departments, working in cooperation. Among these new items were the following:

1. Protectors for the face and neck, so designed as to cover the oxygen

mask. The crewmen had previously complained that the face masks supplied

interfered with the use of the new type of oxygen mask and were also impractical

because they allowed the goggles to cloud over.

2. small, mufilike heated unit into which hands and feet could be

inserted if the standard gloves and boots became useless because of failure of

the plane’s electrical system.

3. Electrically heated canvas bags, several of which were supplied to each

heavy bomber, to keep the wounded warm, reduce shock, and prevent further

cold injury.

4. Electrically heated blankets for the wounded to use if their electrically

heated flying suits had to be cut away to control hemorrhage or if the heating

system of the plane was destroyed by enemy action.

5. Warm, light, and flexible gloves (devised by the surgeon of the Eighth

Air Force), which did not have to be removed to release jammed guns. The

men were warned that their hands would be frostbitten if they removed their

gloves, and it was demonstrated to them that locked gun could usually be

released just as readily with gloved as with ungloved hands.

During 1944, personal equipment was generally satisfactory, though early

in the year there were some shortages in particular sizes, both large and small,

of heated gloves and shoes, and not all the items supplied w’ere satisfactory in

either design or durability.

The investigation carried out in March 1943 revealed, as has been noted,

many shortages, inadequacies, and failures of protective equipment. Originally,

the maintenance of protective equipment had been among the numerous duties

of the assistant squadron operations officers, who had neither the time nor the

training for this task. On 19 March 1943, directive was issued authorizing

the assignment of equipment officers in each combat unit. These officers were

trained by the Central Medical Establishment, Eighth Air Force, in 2-week

courses. The first class, for officers, was completed on 29 March; by the end

of 1943, 275 officers had been trained in 23 classes.

The duties of these officers, who worked in close cooperation with medical

officers, were as follows: (1) To provide facilities for drying, testing, and storing
134 COLD INJURY, GROUND TYPE

all flying clothing; (2) to provide means for checking oxygen masks and systems;

(3) to assist in all matters pertaining to procurement and alteration of protective

flying equipment; and (4) to train airborne personnel in the correct use and

maintenance of personal protective equipment.

After each command, division, group, and squadron had appointed equipment officers and these officers had been trained, problems arising from deficiencies and failures of protective equipment promptly decreased. During the

latter part of 1944, demand arose for special training of the enlisted men who

assisted the equipment officers. Courses for them were organized at the Central

Medical Establishment and were continued until eight enlisted men had been

trained in each combat group.

Certain changes were also made in the aircraft themselves. By March

1944, most operational planes had been equipped with modified closed radio

room and modified gun hatches and waist window. Since the number of men

who could wear electrically heated suits depended upon the amount of electricity available from the plane generators, the capacity of the generators was

increased. The heating systems in bombers were also improved.

Educational training.—Lectures and demonstrations were given on

regular schedule to cover deficiencies in training. The subjects included first

aid and methods of preventing cold injuries and anoxia. The proper use offlying

clothing, especially electrically heated clothing, was explained and demonstrated.

Educational charts to show the various stages of high-altitude frostbite, its

symptoms and signs, and methods of management were prepared by the

Medical Department and equipment officers under the general direction of the

theater senior consultant in neurosurgery,Lt. Col. (later Col.) Loyal Davis, MC.

These charts were distributed to all divisions, groups, and squadrons likely to

be exposed to cold injury and were given routinely thereafter to all new units

as they arrived in the theater.

There was considerable discussion concerning whether or not photographs

showing the end results of high-altitude cold injury (that is, gangrene and

amputation) should be used in the educational program. Eventually, the distribution of these photographs was limited to medical officers.

Special Investigations

In memorandum dated 15 February 1943, Colonel Davis called the attention of Brig. Gen. (later Maj. Gen.) Paul R. Hawley, Chief Surgeon, ETOUSA,

to preliminary study of 14 cases of high-altitude frostbite which had been

conducted on the neurosurgical service of the 2d General Hospital between

30 January and February 1943. General Hawley sent this report to Colonel

Grow', and arrangements were made to assign neurosurgeon from the 2d

General Hospital to temporary duty at one of the airfields, to permit immediate

study of cold injuries in returning flying personnel.

Letter, Lt. Col. Loyal Davis, MC, Senior Consultant in Neurological Surgery, to Brig. Oen. Paul R. Hawley,

Chief Surgeon, ETOUSA, 15 Feb. 1943, subject: Damage to the Extremities From Cold Among Flying Personnel of

United States Army Air Forces.
EUROPEAN THEATER 135

Somewhat later, arrangements were made to transfer high-altitude cold

injury casualties directly to the 2d General Hospital for special studies. It is

both interesting and significant that it was necessary to call the attention of all

concerned to the fact that Circular Letter No. 12, dated 20 January 1943, Office of the Chief Surgeon, ETOUSA, although it dealt specifically with immersion foot, applied equally to injuries from high-altitude cold to Air Force

personnel. Until this concept was appreciated and other details were clarified,

transfers of cold injury casualties to the hospital were delayed, and, because

of the delay, many of the opportunities for investigation, particularly early

investigation, of these injuries were nullified.

By 31 August 1943, studies had been carried out on 93 high-altitude cold

injuries in 86 patients; 57 injuries were on the hands and 25, including caused

by immersion, were on the feet. The investigations covered the circumstances

of injury, the factors contributing to the injury, complete clinical details, skintemperature studies, capillary microscopy, oscillometry, studies of sweating,

and sensory reactions to injury. complete photographic record, including

colored photographs, was made in each case, and each patient was personally

observed by Colonel Davis, who had himself gone on practice raid mission to

study the clinical effects of cold at 13,000 feet.

By May 1943, it was noted that the number of casualties being admitted

to the 2d General Hospital for high-altitude frostbite were beginning to decline,

presumably because of insistence upon examination of equipment before

missions and the enforcement of other preventive measures.

The clinical observations made in the course of this study and other considerations of cold injury sustained at high altitudes are discussed elsewhere

(p. 13).

Summary

Because of the analysis of the situation and the various preventive and

educational measures instituted, the problem of high-altitude cold injuries in

the Eighth Air Force was well under control by the time that France was

invaded on June 1944. The lessons thus learned, however, were not passed

on to the Ground Forces in the European theater, apparently chiefly because

of the general failure to appreciate the fact that cold injuries sustained in highaltitude flights could have any relation to cold injuries sustained in ground

fighting. The fundamental error was failure to appreciate that all cold injuries are merely separate phases of single pathologic process, differing from

each other in severity and rate of development but in no other way. Both

high-altitude frostbite and the ground type of cold injury which occurred later

were caused by the same etiologic factors and were brought under control b}

Memorandum, Maj. J. E. Scarff, for Chief, Professional Services Division, Office of the Chief Surgeon, ETOUSA,

22 Dec. 1943, subject: Hospitalization of Cases Suffering from High Altitude Frostbite.

Memorandum,Lt. Col. Loyal Davis for Chief Surgeon, ETOUSA, 31 Aug. 1943, subject: Incidenceof Cases of Cold

Damage to the Tissues.

Letter, Lt. Col. Loyal Davis, MC, Senior Consultant in Neurological Surgery, to Brig. Gen. Paul R. Hawley,

Chief Surgeon, ETOUSA, 14 June 1943, subject: Cold Damage to Extremities.
13G COLD INJURY, GROUND TYPE

the application of much the same epidemiologic principles. Hence, had the

lessons of the Air Force experience been properly disseminated and utilized,

they might have prevented many of the cold injuries which caused such heavy

losses during the ground fighting in the winter of 1944-45.

TACTICAL AND ENVIRONMENTAL CONSIDERATIONS

The story of the ground type of cold injury in ETOUSA in 1944-45 begins

just about the time that the pursuit of the German armies across France after

D-day ended at the Siegfried Line and combat conditions had become more or

less static. This was the middle of October 1944. Occasional cases of cold

injury had been reported before this time (p. 138), but they were sporadic and

their possible significance was not generally appreciated.

Up to November, the front was comparatively quiet. On that date, the Third U. S. Army began heavy drive to the east, in environmental circumstances highly favorable for the development of the ground type of cold

injury. The weather on the Continent, which had been almost ideal from the

beginning of the invasion until the end of September, then began to change.

It proved to be the wettest winter, as well as the coldest, that Europe had

experienced in 30 years. The heavy rains which began early in October conU. S. Army photos

Figure 31.—A. Infantrymen pushing jeep and trailer along muddy road in France, November 1944. B. Infantryman bailing out his dugout.
EUROPEAN THEATER 137

tinned throughout the month. On the Third U. S. Army front, it rained 28

of the 31 days.

The offensive was conducted in large part over wet and Hooded terrain

(fig. 31) and required the crossing of major rivers. The Moselle and other

rivers were high because of the immoderate rains. By November, flood conditions had become general in all army areas. Fields and roads were water

soaked, and irrigation ditches and small streams as well as rivers were all overflowing. The weather was always cold, and cold injuries, in the form of trenchfoot, occurred in great numbers.

major counterattack was begun in the Ardennes by German forces on

16 December. For the preceding several days, the weather had been extremely

cold, and the intense cold, combined with heavy fighting, often under adverse

circumstances (fig. 32), produced second major outbreak of cold injury, this

time with more injuries in the form of frostbite.

U. S. Army photo

Figure 32.—2d Division infantrymen, 9th Regiment, First U. S. Army crouch in

snow-filled ditch, seeking shelter from German artillery barrage during the Battle of the

Bulge.

United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies,

September 1944-May 1945, vol. II. [In preparation.]
138 COLD INJURY, GROUND TYPE

With the termination of the Battle of the Bulge, in January 1945, the

German threat to the Western Front was, for all practical purposes, at an end.

Thereafter, the tactical situation, as the result of an Allied counteroffensive,

could best be described as the renewed pursuit of the German armies across

Europe into the heart of Germany, the pursuit continuing until V-E Day,

May 1945.

Between 19 December 1944 and 31 January 1945, the average maximum

temperature on the fighting front in Europe was 33.5° F. (0.83° C.),and the

average minimum temperature 22.6° F. (—5.2° C.). The element of wetness,

which had been responsible for the initial outbreak of cold injury in November,

was absent during this period.

The cold began to moderate during the last days of January, and the thaw

which set in on February again altered the environment. Wetness now predominated, and the ground type of cold injury which occurred at this time was,

as in the first outbreak, chiefly trenchfoot.

INCIDENCE

As the preceding brief summary of tactical and climatic conditions shows

the development and prevalence of cold injury in ETOUSA in the winter of

1944-45 were clearly related to the degree of combat activity and to the environmental circumstances and changed as these conditions changed.

Cold injury did not become epidemic until the middle of November, though

sporadic cases had been reported earlier. The first case of trenchfoot appeared

on 27 August 1944, in hospital unit attached to the Third U. S. Army. By

12 October, 25 or 30 cases were reported in the 35th Infantry Division, Third

U. S. Army. 10 Some of them, which were attributed to lack of overshoes, had

occurred as early as October. Col. (later Brig. Gen.) Elliott C. Cutler, MC,

Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA, noted in

his official diary on 14 December that there had been no report of cold injury

during the week ending on 27 September but that 140 cases had been reported

for the week ending on October and 320 had been reported for the following

week.

For the week ending on November, 17 cases were reported in the First

U. S. Army, in the Ninth U. S. Army, and 184 in the Seventh U. S. Army,

the total number recorded for this week being 202. 11 Fifty percent of the cases

in the Seventh U. S. Army were recurrences in men who had suffered from

cold injury in Italy the previous year.

The total number of cases for the week ending on 10 November was 823

and for the following week 5,386. This was the peak of the epidemic, and for

Reported in Annual Report, Medical Activities in the First U. S. Army, 1944. 10 Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley,

Surgeon, Third U. S. Army, 12 Oct. 1944. 11 Administrative and Logistical History of the Medical Service, Communications Zone, ETOUSA, vol. 14, ch

16. [Official record.]
EUROPEAN THEATER 139

the next several weeks there was progressive decline in the number of cases.12

The Third U. S. Army, which had had the largest number of cases, experienced

the most precipitous decline. In the First U. S. Army, which had had the

second largest number, the curve was also downward, but the decline was more

gradual. In the Seventh and Ninth U. S. Armies, the pattern of the curves

was similar to that of the other armies but was generally much lower. Early in December, the rates for the theater as whole were only fifth of the maximum rates, and it was thought that the situation was under control. 13

When the Germans attacked in the middle of December, in what came

to be known as the Battle of the Bulge, the number of cases of cold injury

again increased sharply. The peak incidence, 3,213 cases, occurred in the week

ending on 29 December 1944. 14 The maximum number of cases in the December

outbreak occurred in the First and Third U. S. Armies, which were most heavily

engaged. In the Seventh and Ninth U. S. Armies, the upward swings were less

sharp. 15 Neither in this epidemic nor in the later outbreak in January did the

number of cases per week approximate the 5,386 cases which occurred during

the week ending on 17 November.

In contrast to the November outbreak of cold injury, which had taken

the form of trenchfoot, in the December outbreak many cold injuries were in

the form of frostbite. The cold was intense and the ground frozen, so that

wetness was not factor. This was new and different experience, which the

troops were not fitted to cope with. The men in all sectors of thebattlefield

had less time to care for themselves, and particular factors operated to increase

the incidence in particular divisions and special smaller units. Even the best

trained divisions had trouble during this period.

The decline in incidence which followed the epidemic in December 1944

was followed by another sharp upswing, beginning in the week ending on 12

January, when the weather again became extremely severe, with freezing

temperatures and heavy falls of snow. 16 Again, many of the cold injuries took

the form of frostbite. During this epidemic new factor entered the situation;

namely, the large number of raw and inexperienced replacements (p. 171) who

had to be thrown into battle because of the manpowerlosses which had occurred

during this critical period.

The incidence of cold injury continued high, with only minor variations,

between the week ending on 12 January and the week ending on February,

though, after the thaw that began on February, the character of the epidemic

changed and trenchfoot again became predominant. At no time during this

period were fewer than 3,000 cases reported each week.

12 Coded Message CM-IN-E82072, Office of Chief Surgeon, Headquarters, Communications Zone, ETOUSA, to

War Department (signed Eisenhower to Kirk from Lee). Jan. 1945. 13 (1) Diary, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, Dec. 1944, subject Incidence

of Trench Foot. (2) Coded Message, CM-IN, Headquarters, Communications Zone, ETOUSA, to War Department

(signed Eisenhower to Surles for Houston from Lee), 18 Dec. 1944.

11 See footnote 11, p. 138. is Gordon, JohnE.: History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45,

vol. II, pt. 10, p. 46. [Official record.]

See footnote 11, p. 138.
140 COLD INJURY, GROUND TYPE

As the weather began to moderate and combat activity became lighter,

the incidence of cold injury again began to decline. This time the decrease was

permanent. There were 1,643 cases in the week ending 16 February but only

596 the following week. The peak incidence during March, 888 cases, was in

the week ending on March. In the week ending on 30 March, there were

only 108 cases, and the total number of cases in April was only 230. Except

under special, local circumstances, almost all of the cases which occurred after

the middle of February 1945 were instances of trenchfoot.

What happened in the European theater during the winter of 1944-45

has been variously described. It is nowhere better summed up than in

comment in the annual report of the Surgeon, VII Corps, dated 26 January

1945. “Trench foot,” he wrote, “appearing sporadically around the first of

November, has become like plague over the First Army front.” His description was applicable to the entire frontline.

Variations in incidence.—Although cold injury was always almost exclusively problem of armies in the field, there was considerable difference at all

times during the winter in the incidences reported by armies, divisions, and

smaller units. Generally speaking, the Third and First U. S. Armies, which

had extremely heavy and difficult combat assignments, had the greatest amount

of cold injury. On the other hand, combat activity did not tell the whole

story. This was particularly evident when the records of smaller units were

examined. Some divisions always had good records; this, however, does

not necessarily mean that they were always free from cold injury. The 30th

Infantry Division, First U. S. Army, for instance, was an old, seasoned unit,

with well-developed system of foot discipline, and its command had long

appreciated the significance of the possible occurrence of cold injury in combat

infantrymen. 17 Only when tactical circumstances were entirely beyond control

did this division have an appreciable amount. Some divisions, in contrast,

had records that were almost consistently bad, regardless of the degree of

combat activity. Investigation of the situation in these divisions almost

invariably brought to light conditions which could be improved. It was in

this sort of investigation and counseling that trenchfoot-control teams (p. 177)

had their greatest field of usefulness.

Variations between units were apparent when the trenchfoot incidence

was low as well as when it was high. The Ninth U. S. Army, for instance, had

relatively little cold injury because it was less actively engaged than the First

and Third U. S. Armies, but its units nonetheless showed the same types of

variations as were apparent in those armies.

Incidence according to services.—Because cold injury is so overwhelmingly

disease of frontline infantrymen, it is not always realized that it can also

occur in other troops when conditions are favorable for its development. Col.

John E. Gordon, MC, Chief, Preventive Medicine Service, Office of the Chief

17 See footnote 15, p. 139.
EUROPEAN THEATER 141

Surgeon, ETOUSA, noted in Ids report of 22 November 1944 that the hulk of

the cases reported up to that time (1,167) had occurred in the Infantry but

that cases had occurred also in the Engineer, Field Artillery, Tank Corps,

Quartermaster Corps, Cavalry Reconnaissance, Antiaircraft, Tank Destroyer,

Ordnance, Antitank, Signal, and Military Police units. On 30 November,

cold injury was reported in troops staging in rear areas, presumably because of

their lack of overshoes and shoepacs.18 In February 1945, there was an alarming

number of cases at large staging area in the Channel Base Section. 19 'The

outbreak was promptly halted by the provision of proper footgear and other

equipment and by strict enforcement of preventive measures.

Cold injury among replacements (reinforcements) furnished special

problem, which is discussed later, under separate heading (p. 171).

Impact of cold injury.—The impact of cold injury in combat theater is

discussed in detail elsewhere, but few facts may profitably be repeated

here because the details are, in many respects, even more overwhelming than

the total incidence. The data have been gathered from correspondence,

official diaries, and formal and informal memorandums of various kinds.

In November 1944, for instance, the 79th Infantry Division, Seventh

U. S. Army, had 1,400 battle casualties and 210 casualties from trenchfoot.

For the week ending 25 November, for every 100 battle casualties evacuated

from the Third U. S. Army, 60 soldiers were evacuated for cold injury. The

medical officer who conveyed this information to Lt. Gen. (later Gen.) George

S. Patton, Commanding General, Third U. S. Army, noted that trenchfoot

was doing quite as much damage to the Allied cause as was the enemy because

of the duration of the disability and its tendency to recur when exposure

was again experienced.

Losses of 10 and 15 percent, or more, of the strength of single units were

not unusual. During the Lorraine campaign, 20 in November 1944, the 328th

Infantry Regiment had to evacuate more than 500 men as casualties from

trenchfoot and exposure during the first days of one engagement; this number

exceeded the number of battle casualties. During the drive into Metz, one

company of the 11th Infantry Regiment had only 14 men available for duty

chiefly because of losses from trenchfoot. During the 3-day battle to penetrate the Orscholz Line, the mounting toll of trenchfoot casualties, combined

with battle casualties, made it impossible for the 358th Infantry Regiment to

continue the attack. In all, it lost about 60 percent of its effective strength.

The 357th Infantry Regiment was also so weakened from the same causes that

it had to be withdrawn. At one time, the 1st Battalion was in such precarious

state that men whose feet were too swollen from trenchfoot to permit them to

walk had to be carried by their comrades to forward foxholes.

18 Essential Technical Medical Data, Headquarters, ETOUSA, for October 1944, p. 17. 19 Semiannual Report, Channel Base Section, Communications Zone, ETOUSA, Jan. 1945-1 July 1945.

20 United States Army in World War II. The European Theater of Operations. The Lorraine Campaign. Washington: U. S. Government Printing Office, 1950.

438404'—58—11
142 COLD INJURY, GROUND TYPE

During November and December 1944, the total number of cases of cold

injury on the Western Front was more than 23,000. In terms of numbers, this was about an infantry division and half. In terms of combat riflemen

(4,000 to the division), the loss amounted to about 5% divisions.

In his book, Soldier’s Story, Gen. Omar N. Bradley, Commanding General, 12th Army Group, presents the military interpretation of these losses.

By the end of January 1945, lie wrote, cold injury had seriously crippled the

United States fighting strength in Europe. The malady had come upon the

armies unawares, partly because the possibility of its occurrence had been ignored. By the time the troops had been disciplined in the care and treatment

of wet feet, trenchfoot had the effect of plague. Previous combat had shown

that casualties from this cause occur chiefly in rifle platoons, the handful of

troops who must advance under fire and who have less chance of survival

than men in any other of the combat arms. Before the invasion, it had been

estimated that the infantry would incur 70 percent of the combat losses. By

August 1944, that estimate had been raised to 83 percent. Actually, because

of every casualties occurred in rifle platoons, the rate ofloss in them exceeded

90 percent. Trenchfoot, though listed as nonbattle loss, exacted its heaviest

toll among riflemen in the line, where every casualty sapped assault strength

and thus weakened the offensive.

Medical officers had estimated, General Bradley added, that by far the

greatest number of the thousands of soldiers with trenchfoot who were evacuated from the frontlines could never return to combat, and they had also predicted that some of these casualties would be incapacitated for life.

The impact of trenchfoot upon hospitals and hospitalization was also extremely serious. Between 10 October and 28 November 1944, 11,348 trenchfoot

casualties were admitted to general hospitals in the Paris area from the First,

Third, Seventh, and Ninth U. S. Armies. 21 For the 4-week period ending 24

November, for every 100 battle casualties admitted to these hospitals the weekly

number of trenchfoot admissions was, respectively, 5, 10, 55, and 54. These

admissions represented, over the same period, 1.3 percent, percent, 20 percent,

and 24 percent, respectively, of the total hospital admissions. On one occasion,

trenchfoot accounted for 602 (38 percent) of 1,581 medical admissions to the

23d General Hospital. 22 It is not necessary to point out what such figures

mean in terms of bed occupancy, medical attention, and nursing and other

care. The situation, in fact, was generally much worse than it seemed on the

surface.

certain proportion of hospital admissions for trenchfoot were incorrect,

though ordinarily the diagnostic error was well under 10 percent. Psychogenic

causes explained some cases, but malingering, although it sometimes occurred,

was surprisingly infrequent.

21 Essential Technical Medical Data, Headquarters,ETOUSA, for December 1944. 22 Essential Technical Medical Data, Headquarters,ETOUSA, for November 1944.
EUROPEAN THEATER 143

CLOTHING AND FOOTWEAR 23

Aside from any other considerations, the protection of the extremities

against cold and wet cold depends upon two practices. One of these is general,

the use of warm clothing which will keep the entire body warm. The other is

local, the use of proper footgear which will keep the feet warm, without constriction. Combat necessities require that all items of clothing and footgear

be of such construction that they do not interfere with rapid, unhampered

movement of the soldier who is wearing them. These statements concern such

elementary principles of protection against cold and wet cold, and thus of protection against cold injury, that they need not be elaborated upon. In addition, these principles are so closely connected with the medical aspects of exposure that they indicate why no apology is needed for the inclusion of rather

detailed discussion of clothing and footgear in chapter dealing with cold

injury in the European Theater of Operations in World War II.

The general situation with respect to clothing and footgear in this theater

during the winter of 1944-45 may be summarized about as follows:

1. The clothing which had been introduced into the Mediterranean theater

after the trenchfoot experience there in the winter of 1943-44 had been fully

combat tested at the Anzio beachhead early in 1944, and detailed, favorable

report on it was available in the European theater by the end of June 1944.

Observers from the Office of the Quartermaster General had been in the European theater for several weeks before this time and had the clothing available for

demonstration. Their advice that it be adopted for use in the theater, to

replace standard types of winter clothing, was not accepted by the theater

chiefquartermaster (p. 145). Although change ofmind finally occurred, stocks

of the new models did not reach the theater until January 1945, and distribution

was not accomplished until long after the urgent necessity had passed.

2. Orders for standard types of winter clothing were entirely inadequate

because the strength of the field armies had not been correctly anticipated

(p. 146).

3. Requisitions on the Zone of Interior for winter clothing were placed

too late. The first bulk requisition did not leave the European theater until

15 August 1944. Sufficient consideration was never given to the timelag

between submission ofrequisitions and eventual delivery of articles. timelag

is always inevitable, even in peacetime when the supply and delivery systems

can be conducted with the greatest efficiency. It is far more prolonged in

wartime when both production and transportation difficulties exist. Transportation difficulties prevailed in 1944 and 1945 not only between the Zone

Except as otherwise indicated, all data concerning clothing and footwear in the European Theater of Operations

are derived from the following three sources: (1) United States Army in World War II. The Technical Services. The

Quartermaster Corps: Operations in the War Against Germany. [In preparation.] (2) United States Army in World

War II. The Technical Services. The Quartermaster Corps: Organization, Supply, and Services. Washington; U. S.

Government Printing Office, 1953, vol. I. (3) United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies, September 1944-May 1945, vol. II. [In preparation.]
144 COLD INJURY, GROUND TYPE

of Interior and the European theater but also from area to area on theContinent,

where for several months ammunition and gasoline had first priority.

4. The multiplicity of styles and sizes in American battlegear made for

difficulties of supply (p. 149). In spite of its complexity, however, the tariff

of sizes, which was based on World War estimates, was inadequate, particularly

in the large sizes, in stocks of slices and overshoes.

5. The belief current in some quarters in the late summer of 1944 that

the war would be over before winter campaign was necessary undoubtedly

played part both in the delay in ordering adequate winter supplies and in the

acceptance of the new types of clothing and footgear.

What all of this added up to was that United States soldiers were improperly clothed and shod during the fall and winter of 1944-45 and that the

epidemics of cold injury which occurred must be attributed, at least in part, to

those deficiencies. The “pipeline obstacles” were numerous, but the shortages

themselves “were in large part the result of poor planning and wishful thinking

in the ETO and production difficulties in the Zone of Interior.”

Clothing

Planning.—The Quartermaster General, as was his routine, sent Capt.

(later Lt. Col.) William F. Pounder, Jr., QMC, to the European theater in

March 1944 as an observer. Captain Pounder had the additional function

of presenting the new winter M-1943 clothing, with view to its use in the

European theater. This clothing had been developed the previous year and

had been thoroughly tested in the Mediterranean theater. As already mentioned, the report on the testing of this clothing at the Anzio beachhead was in

the hands of the Chief Quartermaster, ETOUSA, by 25 June 1944. This

was just about the time active planning was beginning for the provision of

winter clothing for troops in the theater.

At this time, the clothing planned for the winter months (exclusive of

footgear, which is discussed under separate heading) was to consist of heavy

wool underwear, olive-drab wool trousers and shirt, high-neck sweater, and

wool ETC) jacket. Service troops in rear areas would be provided with overcoats. Combat troops would wear herringbone-tweed jacket and trousers over

the wool uniform. Although this equipment was intended for fighting in France

and the Low Countries—areas notably wet, cold, and muddy—it was conspicuously lacking in water-repellent items. 24

The uniform and equipment which Captain Pounder proposed, in line

with his instructions from the Quartermaster General, consisted of heavy wool

undershirt and underdrawers, wool field trousers, cotton field trousers, olivedrab wool shirt, high-neck sweater, wool ETO jacket, M-1943 jacket, olive-drab

cotton field cap with visor, gloves consisting of leather shell with wool insert,

synthetic-resin poncho, wool sleeping bag with water-repellent case, and shelter

24 Letter, Capt. Wm. F. Pounder, Office of the Chief Quartermaster, ETOUSA, to Col. Georges F. Doriot, Military

Planning Division, Office of the Quartermaster General. 30 June 1944.
EUROPEAN THEATER 145

half tent. In order to use up the large stocks then in the theater, it was recommended that wool overcoats be used if sufficient quantities of the M-1943

field jacket should not become available.

Theater personnel, in refusing these suggestions, stated that available

stocks of herringbone trousers would take the place of the proposed cotton

field trousers, which would be an additional rather than an essential item, and

that the synthetic poncho would take the place of the M-1943 jacket, for which

the supply situation was unfavorable. It was decided that the following

items would be presented to Maj. Gen. Robert M. Littlejohn, Chief Quarter- master, ETOUSA, for his approval for continental winter operations: Heavy

wool undershirt and underdrawers, high-neck wool sweater, ETO wool jacket

or olive-drab field jacket, field cotton cap, gloves with leather shell and wool

insert, wool sleeping bag with water-repellent case, and wool muffler. Items

not then in stock in the theater were to be requisitioned. Combat troops

would wear herringbone jacket and trousers over the wool uniform. Service

troops in rear areas would be equipped with overcoat or mackinaw.

Captain Pounder’s request for permission to go to France to make observa- tions of clothing and footgear in actual use in combat was not granted by

General Littlejohn, and Captain Pounder returned to the United States.

The Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, also concerned itself with the question of winter clothing.25 In May 1944, at

the suggestion of Colonel Gordon, conference was held with the chief of the

Research and Development Branch, Office of the Theater Chief Quartermaster,

at which it was learned that the theater quartermaster considered that the

problem of cold injury had been solved, as far as the feet were concerned, by the

use of combination of heavy socks and shoepacs. Both items were in production and would be ready in sufficient time to meet winter needs. The only

additional item needed would be windbreaking clothing to wear over the

regular winter clothing. The substance of this interview was reported to

Colonel Gordon.

In July 1944, in communication addressed to the theater chief quartermaster, Colonel Gordon pointed out the part which lack of proper winter

clothing had played in the trenchfoot epidemic in Italy the previous winter. 26

Correct clothing and footgear, he stated, would provide for maximum conservation of natural body warmth; would protect against wetness, which influences

the conservation of general and local warmth; and would be without constriction. Immediate action was urged to agree upon details of procurement of the

new and superior clothing and footgear which had been developed by the

Quartermaster General after the Italian experience and otherwise to get the

program under way.

23 Memorandumfor Record, Lt. Col. Paul Padget, MC, Preventive MedicineDivision, Office ot the Surgeon General,

26 Apr. 1945, subject: Early Interview Concerning Trench Foot Problem and Footwear—Contact With QM.

23 Under date of June 1944, Captain Pounder was informed by the Military Planning Branch, Office of the Quartermaster General, that the Mediterranean theater had already submitted requisitions for the new winter clothing to be

used in operations the following winter.
146 COLD INJURY, GROUND TYPE

The reply from the Office of the Chief Quartermaster on 10 August was to

the effect that procurement had been initiated to provide clothing designed for

maximum conservation of body warmth. There would be general issue to all

troops of the high-neck sweater and the olive-drab wool field jacket to be worn

over it. Overcoats, raincoats, and the other usual items of clothing would be

available, including wool sleeping bags with water-repellent cases for all personnel. For typical field army, which then was estimated at 325,000 men,

there would also be provided olive-drab cotton field trousers, windproof and

water-repellent garment to be worn outside the wool trousers, ponchos, mittens

with inserts, and field caps.

Requisitions. —The first requisition from the European theater was sent to

the New York Port of Embarkation on 15 August, the day southern France

was invaded. The requirements for the initial issue and 90-day replacement

were based on one field army and the attached troops. Half of the requisition

was to be delivered in September and half in October. The Chief Quarter- master, ETOUSA, gave definite assurances that no further requirements would

be made. On 21 August, the Office of the Quartermaster General questioned

the low requirements which had been submitted and stated that, if they were

correct, they would force immediate cutback in the production schedules of the

supply program. On September, the original requisitions were confirmed.

In Europe, meantime, there had been growing appreciation of the possibility of cold injury during the forthcoming operations and of its possible consequences. Requests for winter clothing and complaints about deficiencies in

supply were beginning to be received from armies in the field. The port of

New York was advised of the increasing seriousness of the supply situation.

The reply was that half of the 15 August requisition had been approved for

immediate shipment but that the items could not be shipped for another

weeks, at least. The theater chief quartermaster was requested to review all

woolen-clothing requirements, to make as many reductions as possible, and to

support all further requirements by complete justification, the data to include

lists of all stocks on hand. This request was based on the 1944 policy of the

Army Service Forces, which was to cancel contracts for all items of which more

than 60-day supply was on hand.

To understand some of the clothing deficiencies which developed in

ETOUSA, it is necessary to go back several months. When the strictly

functional M-1943 sateen field jacket, which had been tested in the Mediterranean theater, was exhibited in the European theater, the chief quartermaster

was not interested in it for number of reasons. He doubted that sufficient

number could be produced in 1944. He was anxious to have all troops in the

theater uniformly dressed, which would not be possible if his doubts about

production were justified. Finally, all echelons in the theater, from high command down, had strong preference for something like the British battle jacket,

which was used for both field and dress purposes and which came to be known as

the Eisenhower jacket. It was not the quartermaster’s policy “to force these

new items down the throat of troops.”
EUROPEAN THEATER 147

The M-1943 field jacket was therefore accepted in the theater for paratroops only, in spite of the War Department’s insistence that this jacket, with

the high-neck wool sweater, had been devised to replace the “limited standard

field” jacket. The Quartermaster General doubted that without the new

M-1943 jacket the troops would be adequately protected against cold weather and supported his statement by study showing the advantages of this jacket

over the wool overcoat for field troops. The commanding generals of the 12th

Army Group and the First U. S. Army considered, however, that the overcoat

was necessary for adequate warmth and that the Eisenhower field jacket with

sweater was preferable to the M-1943 jacket and sweater combination. This

decision was concurred in at SHAEF (Supreme Headquarters, Allied Expeditionary Force).

On 17 March 1944, requisition was cabled to the War Department for

4.259.000 wool field jackets of the Eisenhower type, to be delivered in the

course of 1944. Arrangements were later made for the phased shipments of

2.600.000 in the last quarter of 1944. The theater chief quartermaster and the

combat commanders in Europe were all so eager to have this battle jacket that

they were reluctant to submit requisitions which would slow down its production. During the summer, they continued to accept substitutes for it, including

the old Parsons style of field jacket and the wool-serge service blouse. Many

difficulties, however, were encountered in the production of the Eisenhower

jacket. Although 500,000 were supposed to leave New York in September, by

13 September only 116,000 had been shipped to the port, and only 14,000 had

been dispatched to the European theater. The deficiency in the theater was

estimated at more than million jackets when cold weather began. Large supplies of the Eisenhower jacket eventually reached the theater in January

and February 1945, but few of them were issued for combat use.

Even when shortages became apparent in the European theater, General

Littlejohn did not, at first, include the M-1943 jacket in his requisitions for

substitutes for the Eisenhower jacket. Final arrangements were not made to

accept the M-1943 jacket until 10 November 1944, after it had become evident

that the overcoat, which field commanders as well as the Office of the Chief

Quartermaster had insisted was essential for combat troops, was not satisfactory. It was bulky, it was not water repellent, and troops in combat frequently discarded it in fast-moving situations. The M-1943 jackets which

finally reached the theater arrived too late to be useful during the winter.

One reason for the slow pace of planning and requisitioning in the European

theater was the belief in some quarters that the war would end before combat

uniform would be needed for winter operations. This feeling of optimism,

although it was far from universal, began to develop even before the fall of

Paris, and it increased during the late summer. The need, it was felt, would

be for dress uniform for the army of occupation. There seemed to be more

concern with the appearance of the troops than with their protection from the

weather. It was suggested that the troops of the First and Third U. S. Armies,

which would occupy Germany, be outfitted first. Even after trenchfoot had
14S COLD INJURY, GROUND TYPE

appeared on the Continent, instructions were issued by the Supply Division, Office of the Chief Quartermaster, ETOUSA, to store in the United Kingdom

the cold-climate clothing which arrived before the end of the year and to use

Le Havre for whatever arrived later. As late as 31 October 1944, instructions

were to pack light and dark trousers separately, so that they would not be

issued indiscriminately, and the million ETO jackets received in the theater

by the end of 1944 were held in the United Kingdom because the trousers

which matched them (shade 33) were not available.

The situation on the Continent.—The tactical situation during the early

stages of the invasion required that troops should carry as little as possible on

their persons when they were landed on the far shore; the missing items of

personal equipment were to be supplied later. The supply system for clothing

and accessory equipment which had been planned was promptly put into

operation and operated efficiently, but, while the needs of the troops were met,

no surpluses of any consequence could be accumulated. Although clothing

and personal equipment had class II priority, it was not long before, for

number of reasons, difficulties began to develop. Illustrative of such difficulties

were the following:

1. Because of the rapidity of the advance, all the attention was originally

concentrated on the pressing demands for food, gasoline, and ammunition.

What General Bradley described as calculated risk (p. 209) was therefore

taken with respect to clothing and other winter equipment. It was not, in

fact, until the swift pursuit of the Germans was halted and the weather began

to change that demands were made for winterizing items. Earlier, class II

priority requisitions had been filled only when they were accompanied by

special authorizations,

2. The first requisitions from the theater were far too low. They were

based on authorized allowances and replacement factors which proved entirely

unrealistic, even though the Quartermaster General considered the later

theater estimate—that replacement rates must be 2K times those prescribed

by the War Department—to be somewhat exaggerated. Unquestionably,

however, nothing lasted as long as had been expected.

3. Shipping shortages played large part in deficiencies of clothing and

personal equipment. In August, only 29,000 tons of quartermaster supplies

were received on the Continent, against an allocation of 55,000 tons. Port

discharge deficiencies accounted for additional shortages. At the end of September, with only 14 berths available, 75 ships were offshore. At the end of October,

with only 18 berths available, 80 ships were waiting to be unloaded.

4. An additional complication arose from the fact that the clothing was

distributed over number of ships, instead of having been loaded in single

ships, as had been requested. Distribution was therefore impossible until

balanced loads had been accumulated. During the interval, there was considerable loss from pilferage because warehouse facilities were inadequate,

and there were also losses from damage by the elements. The picture, according
EUROPEAN THEATER 149

to one account, was “one of vessels lying at anchor and backlogged supplies

piled on piers in quantities which could frustrate the best logistical plan.”

5. The opening of the Channel ports and of the port of Antwerp improved

the situation but did not solve the problem of moving supplies inland. Rail

and truck transportation continued in short supply. On September, for

instance, one division of the Third U. S. Army was more than third short in

clothing, especially shoes, shirts, trousers, underwear, socks, and overcoats,

which were still in duffle bags on the landing beaches.27 It would have required

200 trucks to move these supplies, and the division could not provide the

transportation. Up to 13 September, practically 80 percent of issues of clothing

and equipment for the Third U. S. Army had been renovated salvage. The

army quartermaster was warned by the army surgeon that if these shortages

were not rapidly rectified, in view of the recent cold weather and continued

rains, “a rapid and explosive increase” in the noneffective rate from trenchfoot

and respiratory ailments could be expected.

Even after the port of Antwerp had been in operation for months, the

First U. S. Army had to send its own trucks to pick up winter clothing. Vehicles

were in short supply, and 50 tons of supplies had to be left behind. It was not until well into 1945 that these and similar difficulties were

completely overcome. An attempt to solve the problem of supplies by airlift

from the United Kingdom had not been effective. Of more than thousand

planeloads of emergency supplies brought to the Third U. S. Army airstrip

at Briey during August and September 1944, only 44 carried clothing and

personal equipment.

6. Still another difficulty had to do with sizing. The tariff provided for

shoes in 90 sizes, the M-1943 field jacket in 25 sizes, trousers in 34 sizes, and

shirts in 27 sizes. When the Army clothing was issued in November 1940 to

the first selectees to be inducted, it was found that, in spite of the apparent

liberality of the tariff, there were not enough items of the larger sizes to provide

for the present generation of soldiers. The original tariff had been based on

the World War experience. Revisions in August 1941 and July 1942 improved

the situation but did not fully correct it. In the fall and early winter of 1944,

both high level reports and reports of individual units showed continuing shortages of certain popular sizes. This was particularly true of field jackets, olivedrab wool clothing, herringbone-tweed clothing, and footgear. These errors

were not completely corrected until early in February 1945, too late, again,

to influence the tienchfoot situation in the European theater.

7. Deficiencies in other cold-weather items paralleled the deficiencies in

personal clothing. The authorized issue of four blankets per man, for instance,

had been reduced to two, in the expectation that the improved sleeping bag

would take the place of the other two. For this reason, no blankets were

shipped from the Zone of Interior to the European theater in either August

or September 1944. Two million sleeping bags had been expected in the

27 (1) Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley,

Surgeon, Third U. S. Army, Sept. 1944. (2) After Action Report, ThirdU. S. Army, ETOUSA, Aug. 1944-9 May 1945.

438404'—58 12
150 COLD INJURY, GROUND TYPE

theater by the end of September. By the middle of the month, only 57,721

had been delivered. On 17 September, when it became evident that requirements for sleeping bags could not be met, General Littlejohn called for every

blanket in the United Kingdom to be sent to him by every available vehicle on

the ground that he had 400,000 prisoners of war to supply, as well as field

armies. In all, he requested 4,000,000 blankets in September. The New York

Port of Embarkation resumed shipments in October, and in the last quarter

of 1944 more than million blankets and 2,000,000 sleeping bags reached the

European theater, though only after delays at every phase of the supply pipeline

and again too late to prevent much of the cold injury which occurred.

The situation in respect to clothing in the European theater in 1944-45

can be summarized in few sentences. Production snarls and transportation

difficulties all along the line accounted for many shortages. The major responsibility, however, must be placed upon delays in planning for and requisitioning

necessary items, underestimates of needs, and refusal to accept new, efficient,

field-tested items of winter clothing. If these items had been requisitioned in

time, they could have been provided in sufficient quantities. The Quarter- master General repeatedly warned the theater that its requisitions were not

adequate either in quantity or in the proper kind of wind-resistant, wetresistant winter clothing. The mistaken belief that the war would end promptly

and thatwinter clothing would be needed for an army of occupation and not for

troops engaged in combat explained some shortages. As result, when the

new clothing became available in adequate quantities, the acute need for it

had passed.

The only army in the European theater which was properly equipped

for combat in the winter of 1944-45 was the Seventh U. S. Army, which fought

in southern France and which had been equipped with the new uniform and with shoepacs through Mediterranean theater supply channels. This army

had great deal of cold injury, it is true, but large part of it could be explained

by recurrences in men who had suffered from cold injury the previous winter (p. 382).

Footgear

The course of events in regard to footgear during the winter of 1944-45

followed the pattern just described for clothing. Neither the combat boot

nor the service shoe proved satisfactory. Shoepacs, which were recommended, were not accepted at all in the beginning and were ordered too late in the end.

Overshoes (galoshes) were not provided in sufficient quantity nor in sufficiently

large sizes and were not made on the proper lasts. Wool socks wore not available in sufficient supply.

Boots and shoes.—-Combat boots or service shoes were worn by almost all

of the troops in the field, except the Seventh U. S. Army, until shoepacs became

generally available late in January 1945. The Seventh U. S. Army, as already

noted, had been equipped with them in the Mediterranean theater. The

Quartermaster General’s clothing representative in the European theater had
EUROPEAN THEATER 151

written to the chief of the Research and Development Branch, Office of the

Quartermaster General, before D-day, of the general dissatisfaction with both

the combat boot and the service shoe. It was decided, however, to make no

changes until there had been more field experience with these items. In the

meantime, action was to be directed toward improving the fitting of the

footwear at staging areas in the Zone of Interior.

Among the complaints made about the service shoe, in connection with

cold injury, were the following: 28

1. It had to be worn with leggings and was therefore difficult to remove for

foot care. In this respect, the combat boot, although it was open to many of

the objections raised about the service shoe, was superior to it.

2. It was so constructed that even when it was fitted loosely, as it usually

was not, there was very little room in the vamp. Because of the shape of the

last, there was pressure across the top of the foot when heavy socks were worn,

since there was no space between them and the overlying leather. The uppers

were cut so scantily that even shoes which were fitted correctly could not be

brought together by lacing without harmful constriction; this defect was

exaggerated when extra socks were worn. General Hawley had examined

patients with trenchfoot and had found marks of the shoelaces deep in the

swollen tissues. This could not have happened with the British field boot, which was cut so generously that the uppers could be brought together from the

time the shoe was first put on.

3. Both service shoes and combat boots were fitted too snugly, partly from

the general desire to keep the feet trim in appearance, partly because only three

widths were available, and partly because of carelessness in fitting. General

Hawley remarked in this connection that in 30 years of Army service he had

seldom seen shoes fitted with the care and expertness the function deserved.

4. Attempts to improve the situation were not very successful. Additional shoes were usually issued in the same size as the original pair, partly as

matter of routine and partly because of shortages of larger sizes. As with

clothing, so with shoes, the tariffs were inadequate for the new generation of

soldiers. By the middle of October, the First U. S. Army was complaining of

shortage of wide, large-sized combat boots. The committee appointed by the

Chief Quartermaster, ETOUSA, to study the tariff reported that the existing

War Department tariff should be revised to provide for more than twice as

many E-width shoes and more than three times as many EE-width shoes as

were then provided. These deficiencies occurred in spite of the fact that shoes

were provided in 90 different size variants.

5. Shortages prevented replacement of shoes originally fitted, and repairs

were slow. When the first trenchfoot outbreak occurred, many of the men had

oidy single pair of shoes, and some were still wearing the ones issued to them

before D-day.

28 (1) Report, GeneralBoard, United States Forces, European theater, Medical SectionStudy No. 94, subject: Trench

Foot. (2) Report, Col. A. G. Duncan, QMC, Office of Chief Quartermaster, ETOUSA, to Maj. Gen. Paul R. Hawley,

Chief Surgeon, 16 Apr. 1945, subject: Footwear and Socks for Use in the European Theater of Operations.
COLD INJURY, GROUND TYRE 152

6. The fact that shoes were originally fitted too snugly gave rise to

number of other consequences. The soldier’s feet spread during combat

training, and shoe which had fitted him in civilian life no longer fitted him now.

When the shoes became wet, the fit, because of shrinkage of the leather, was

even snugger than it had been originally. No provision at the original fitting

had been made for the wearing of extra socks or heavier socks during cold

weather, and the shoes were therefore too tight when these socks were used.

When the shoes were removed for foot care and to change the socks, the feet

swelled and it was difficult to replace shoe which had been fitted snugly to

begin with. The practical consequence, in the European theater, was that men

were unwilling to remove their shoes to care for their feet.

7. Neither the combat boot nor the service shoe was waterproof or water

resistant. The welt sole leaked, there was leakage at the seams, and the

leather was permeable.

8. Dubbing was no solution to the problem, although it was supplied in

lavish quantities. It did not make boots and shoes waterproof, and the men

complained that it made their feet perspire because it shut out air and therefore

kept their feet cold.

When in February 1945 special investigation of the whole footgear

situation was undertaken in the theater, the observer, who was an official of

one of the large shoe companies, made substantially the same criticisms as

those just listed.

Socks.—The sock difficulties in the European theater took two chief forms:

The socks which were provided did not contain enough wool, and they were

not available in sufficient quantities for men in the frontlines to receive clean,

dry socks daily, requirement which implied provision for washing and drying

soiled socks, as well as an efficient system of exchange.

In March 1944, Col. (later Brig. Gen.) Georges F. Doriot, QMC, Chief,

Research and Development Branch, Office of the Quartermaster General,

wrote his observer in the European theater that Table of Equipment 21 then

authorized one less pair of woolen socks per man than the experience in the

Mediterranean theater had shown to be necessary. Another warning about

the type of socks provided for United States troops came in April 1944. The

theater chief quartermaster was then notified by the Professional Services

Division, Office of the Chief Surgeon, that the chief consultant in surgery for

the Norwegian Army in the United Kingdom considered that the socks worn

by United States Army troops were fitted too tightly and did not contain

sufficient quantity of wool.

It has been related elsewhere (p. 63) that when War Department Circular

No. 312 was published in July 1944, there were several references to wool socks

in it; the soldier was supposed to carry extra pairs on his person and to wear

this type of sock in combat. Provision was to be made for daily supply of

clean, dry socks in each unit. It has also been noted (p. 65) that the Commanding General, Army Service Forces, at the request of the Quartermaster General, notified all commanding officers at ports of embarkation that this
EUROPEAN THEATER 153

circular was not to be construed as justification for an increase in the authorized

allowances of wool socks. It is significant, in the light of the events of the

following winter, that the European theater did not consider that the terms of

the circular would have any effect upon the initial issue of this type of sock.

War Department Technical Bulletin (TB MED) 81 and the circular on

foot care published in the European theater in October 1944 (p. 164) prescribed

that heavy woolen socks be worn, that an extra pair be carried, and that

others be made available by daily exchange when troops were on duty for

more than few’ days in wet, cold regions. Cotton socks were to be used only

for garrison duty.

When the footwear representative of the War Production Board surveyed

the situation in the theater in February 1945, he was even more specific in his

recommendations. 29 He thought that neither light wool socks nor cotton socks should be issued at all to combat troops, though he granted that, until

shortages of heavy ool socks could be overcome, the light wool socks, which

were in oversupply, would have to be used, as matter of expediency. He

recommended that, as soon as it was possible, supplies be limited to heavy

wool socks, cushion-sole ool socks, and ski socks. He also stressed the

point, already discussed, that the wearing of two pairs of socks was useful

only if the shoes were fitted with this in mind. Otherwise, the practice was

actually harmful because of the constriction produced and the resulting

embarrassment of the circulation in the lower extremity.

Early in October 1944, Colonel Gordon’s office and preventive medicine

officers who were with field armies began to work with the Quartermaster Corps to establish some system, similar to the British system, whereby clean

socks could be supplied regularly to frontline troops. 30 The program could

not be put into effect immediately because socks were not in sufficient supply

and enough laundry units were not available. By the middle of November, these deficiencies had been at least partly corrected and daily sock exchange

had been instituted. It was found that the best plan in all armies was to

bring the fresh socks forward with the daily rations (p. 182). Each man, when

he received his rations and his dry socks, woidd turn in his wet, soiled socks

for exchange. When the tactical situation or other circumstances interfered

with the daily sock exchange, the men were instructed to remove their wet

socks, wring them out, and dry them inside their shirts or sleeping bags while

they were wearing the extra socks which they had been carrying on their

persons.

Statistics from the 108th General Hospital, wdiere special investigation

of trenchfoot was conducted, showed how the tactical situation could influence

the supply of socks and, in turn, the incidence of trenchfoot. For the week

ending 27 November 1944, 96 of each 100 men admitted with diagnosis of

39 Memorandum, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, ETOUSA, to Quartermaster General,

War Department, 23 Mar. 1945, subject; Footwear and Socks for Use in the European Theaterof Operations.

30 Memorandum, Maj. W. P. Killingsworth, MC, Office of the Surgeon, Third U. S. Army, for Colonel Hurley,

Surgeon, Third U. S. Army, 12 Oct. 1944.
154 COLD INJURY, GROUND TYPE

trcnchfoot had adequate supplies of socks (at least pairs per man). For the

week ending 21 December, at the beginning of the Battle of the Bulge, only 46

in each 100 men were adequately supplied. By the following week, the number

of men adequately supplied in each 100 had fallen to 42. 31 These figures, of

course, do not tell the whole story. In the stress of combat, many of the men

who had dry socks were unable to put them on.

Early in the trenchfoot epidemic, it was found that many of the men seen

in the aid stations with apparent cold injuries really needed nothing more than

an opportunity to warm their feet and put on dry socks. It was eventually

arranged to provide supplies of dry socks in all aid stations, and, as result,

many frontline soldiers who otherwise would have been evacuated and lost for

combat duty could be returned directly to duty.

Overshoes (galoshes).—Even before the November epidemic of trenchfoot,

there had been warnings by medical and other officers from various units that

high incidence of cold injury could be expected if adequate supplies of galoshes

were not available. As early as July, the acting quartermaster of the Advanced

Section Communications Zone, ETOUSA, asked that shipments to France from

D-day plus 150 should be sufficient by October to equip every soldier with an

initial issue of various items of winter clothing and equipment, including arctic

overshoes. Maj. Gen. Albert W. Kenner, Chief Medical Officer, SHAEF,

after he had visited the 6th Army Group on 12 October 1944, included this

matter in his memorandum on the subject to the Chief of Staff, SHAEF. In

the report, Essential Technical Medical Data, ETOUSA, for October 1944, it

was stated that, in view of the shortage of overshoes, which then affected 60

percent of the total troop strength, and the shortage of shoepacs, the situation

was “viewed with apprehension.”

In spite of these warnings, by the middle of November only the Seventh

U. S. Army, which had been equipped through Mediterranean theater supply

channels, was completely equipped with overshoes and shoepacs, and only three

divisions from other armies were similarly equipped. At this time, the Third

U. S. Army had only one pairfor each four men. 32 In December, nine divisions

were still only partly equipped, and in January seven divisions still did not have

overshoes for all personnel.

Although there were number of reasons for these shortages, the over-all

explanation was the policy of taking overshoes away from soldiers at ports of

embarkation in the Zone of Interior. The plan was that the men would be

reequipped upon their arrival overseas. This was War Department policy,

founded on the difficulties of effective distribution and the laudable objective

of reducing the large amounts of equipment and clothing which the individual

soldier necessarily had to carry with him. In practice, the plan of reequipment

in the European theater proved thoroughly impractical. 33 It worked so badly,

31 Report, Headquarters, 108th General Hospital, 1944, subject; Progress Reporton the Etiological Factors ofTrench

Foot.32 See footnote 30, p. 153. 33 Essential Technical Medical Data, Headquarters, ETOUSA, for October 1944.
EUROPEAN THEATER 155

in fact, that some troops developed cold injuries while waiting for their galoshes

in staging areas. 34

The facts of the matter were repeatedly pointed out to authorities in the

United States as follows:

1. Supplies of overshoes in the theater or on current requisition were adequate merely for maintenance of troops already in the theater.

2. The supply lines were by this time spread all over Europe, and the distribution of overshoes after they had been received took weeks because of transportation difficulties. 35

3. Large sizes were in short supply.

4. There was clear-cut relationship between the development of trenchfoot and the shortage of overshoes. On 15 November 1944, General Hawley

wrote the theater chief quartermaster that hundreds of cases of trenchfoot had

already occurred and thousands more could he expected “if something drastic is

not done.” TheWar Department was not impressed by any of these arguments,

and the policy of sending troops overseas without overshoes continued unchanged until the end of the war.

Improper sizing played the same part in the overshoe situation as in the

clothing and other situations. There was an undersupply of large sizes, so

serious that at one time one corps was short 11,000 overshoes in the larger sizes

(from size 10 up).36 Although 90 sizes of boots and shoes were available, only 10

sizes of overshoes had been provided. Enough large sizes were not available

until March 1945.37

Another reason why it was difficult to match up shoes and overshoes was

that many of the overshoes available had been purchased in trade channels

and the lasts on which they were made did not fit the lasts on which boots

and shoes procured on military specifications had been made.38

To increase their mobility, troops were occasionally ordered to discard

their overshoes before an attack. Armored infantry could have them brought

forward later, in halftracks, but regular infantry had no such means of transportation, and their overshoes, once discarded, were usually irretrievably

lost and had to be replaced. More often, the troops were not ordered to discard

their overshoes. Instead, they simply threw them away because they were

difficult or awkward to wear and nuisance to carry.

When the footgear representative of the War Production Board surveyed

the theater in February 1945, he recommended that thereafter (1) all overshoes be made of rubber; (2) all troops be equipped with overshoes except

infantrymen, who would wear shoepacs, and troops on garrison duty, who

would wear the regulation combat shoe; (3) sizes and lasts conform with sizes

34 Technical IntelligenceReport, Col. B. C. Jones, GSC, Chief, Intelligence and Security Division, Army Service

Forces, 17 Feb. 1945, subject: Medical Corps Personnel and Trench Foot. 35 Letter, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, Headquarters, Communications Zone, ETO, to

Maj. Gen. R. L. Maxwell, G-4, War Department, 18 Nov. 1944. 36 See footnote 9, p. 138.

37 Report, Maj. Paul A. Siple, QMC, Technical Observer, for Commanding General, ETOUSA, 12 Apr. 1945. 38 See footnote 29, p. 153.
156 COLD INJURY, GROUND TYPE

and lasts of Army service shoes; and (4) all overshoes be plainly stamped with

their size, to permit prompt reissue and to avoid the wastage which had occurred

during the previous winter for lack of such identification.

Finally, overshoes originally available in the theater were often made with

canvas tops because of the rubber shortage. These tops, which were not

waterproof, tore readily, and the life of this type of galosh was short.

Supplies flown in from the United Kingdom Base helped to ease the

shortage of overshoes in November 1944, when it first became apparent. 39 It

was not then realized that overshoes should have been provided for the theater

on hundred-percent basis. Priorities were, properly, given to combat troops,

but galoshes were also needed by service units, which often had to work continuously in rain and mud, and by such troops as Military Police and antiaircraft units, which had to stand immobile for long hours, regardless of weather

and terrain.

The course of events left little doubt of the relationship between the

incidence of trenchfoot and the lack of overshoes. During November, for

instance, the 9th Infantry Division, 2,426 of whose strength was without

overshoes, had 183 cases of trenchfoot. By the end of November, 99 percent of the 28th Infantry Division had secured overshoes, but in the meantime

there had been 738 cases of trenchfoot. In the 3d Armored Division, there

were 56 cases of trenchfoot in 450 troops without overshoes. In the Ninth

U. S. Army, the highest trenchfoot rates in the November epidemic occurred

in the 84th and 102d Infantry Divisions, only 35 percent of which had overshoes. 40 These divisions accounted for 62.25 percent of all the cases of trenchfoot in this army up to 22 November.

Statistics secured by questioning casualties with trenchfoot admitted to

the 108th General Hospital supplied the following significant data about overshoes; 41

For the week ending 27 November, 82 of 100 men with trenchfoot had

lacked overshoes or had not received them in time to be effective, 52 had not

received overshoes, 28 had received them after sustaining cold injuries, and

had discarded their overshoes before combat.

For the week ending 21 December (the first week of the Battle of the

Bulge), 60 of 100 men had lacked overshoes for the reasons just stated. Of

this group, 38 had not received overshoes at all, 10 had received them too late, and 12 had discarded them before combat.

For the week ending 28 December, the total number of men without overshoes was 55; of these, 36 men had not received them at all, had received

them too late to be useful, and 15 had discarded them before combat. The

number of men who discarded their overshoes before combat, while too small

to be of any statistical significance, was significant to medical and other officers

familiar with the tactical situation and the character of United States troops.

39 Annual Report, Preventive Medicine Division, Office of Chief Surgeon, ETOUSA, 1944. 40 Annual Report, Surgeon, Ninth U. S. Army, ETOUSA, 1944. 41 See footnote 31, p. 154.
EUROPEAN THEATER 157

The troops generally felt that overshoes hampered their mobility in active

combat, and the fighting in the last of the weeks included in this survey,

during the Battle of the Bulge, was very heavy indeed.

There are, of course, other facts behind these figures. During each of

these weeks, number of men who had been provided with overshoes had wet

feet most of the time. The canvas tops, already commented on, leaked and tore.

Rain or snow also destroyed the effectiveness of sound protective footgear, or

water came over the tops when rivers had to be crossed. Sometimes, all of

these causes were effective. Actually, only 18 of the 100 men surveyed the

first week had been able to keep their feet dry, only in the second week, and

only 11 in the third week. The figures, again, reflect the tactical situation.

Shoepacs.—xis already mentioned (p. 145), in May 1944, representative of

Colonel Gordon’s office was informed by representative of the theater chief

quartermaster that the cold-weather problem in regard to the feet would he

solved by combination of heavy socks and shoepacs and that both items would

be in production in time to meet the winter needs. Shoepacs were also discussed at the meeting on winter clothing held in the theater in June 1944 (p. 144),

at which Captain Founder had stated the objections of the Quartermaster General to the items of winter clothing proposed. The footgear planned for

winter combat was to include service shoes, overshoes, leggings, and light

wool socks. Captain Pounder pointed out that this combination of footgear would not be satisfactory in country which was particularly cold, wet, and

muddy in winter. He proposed, instead, that winter footgear consist of shoepacs, with pairs of felt insoles and pairs of ski socks per man. Although it

was agreed that, in order to use up stocks presently in the theater, the combination of service shoes, leggings, and overshoes might be issued as substitute

for shoepacs, it was agreed also that shoepacs with felt insoles and ski socks

should be included in the list of items recommended to the theater chief quartermaster for use during winter operations on the Continent.

On 10 August 1944, in response to an inquiry made on 23 July concerning

footgear (p. 145), General Hawley’s Preventive Medicine Division was informed

by the Supply Branch, Office of the Chief Quartermaster, ETOUSA, that among

items of footgear for troops expected to fight in wet-cold conditions on the Continent would be new type of shoepac, made in three widths, with correct

orthopedic support. These shoepacs were to be fitted over cushion sole or

over heavy British woolen socks and ski socks. Allowances would be made for

extra socks for each soldier. If this footgear was used correctly, adequate foot

protection would thus be provided in the minimum temperatures expected in

northern France and southern Germany—10° F. (—12.2° C.) —during the

winter.

The Seventh U. S. Army, as already mentioned, had been equipped with

shoepacs through Mediterranean theater supply channels. The first requisition

for shoepacs from the European theater, on 15 August 1944, was for 446,000

pairs. This was small number, and the timing was late, in view of the limited

shipping available and the low priority for clothing and footgear.
158 COLD INJURY, GROUND TYPE

War Department Circular No. 312 listed criteria for winter footgear but

did not specifically mention shoepacs. TB MED 81 stated that shoepacs best

met the requirements of insulation and ventilation except on rough, mountainous terrain. When it was distributed in the theater as circular letter, in place

of the circular letter originally planned (p. 164), and in the theater medical

bulletin (p. 164), all mention of shoepacs had been eliminated at the request of

General Littlejohn’s office, since it was then known that shoepacs would be

available only for limited number of personnel in the theater.

On December, when it had become evident that the footgear provided in

the theater (the service shoe and the combat boot) would not furnish adequate

protection against trenchfoot, request was cabled from the theater for 500,000

additional pairs of shoepacs, over and above the 446,000 already shipped and

the 90,000 pairs issued to the Seventh U. S. Army. The theater was informed

on 16 December that this requirement could not possibly be met because of

limitations of production which could not be overcome for or months. An

attempt to fill the requisition would disrupt the shoe and wool production of the

whole country. It was noted in this reply that the issue of shoepacs, about

which the troops themselves had many reservations, would not solve the primary problem, which was strict compliance with the provisions of War Department Circular No. 312 and TB MED 81. In the light of these facts, it was

requested that the requisition be reconsidered. On 23 December, the theater

repeated the original request, using as justification the fact that extraordinary

cold and wet conditions were being encountered at the time. None of the shoepacs requisitioned arrived in the European theater until after the middle of

January 1945, and those which were received were not distributed in sufficient

numbers until it was too late for them to exert airg significant influence on the

incidence of cold injury.

Unfortunately, the shoepacs originally issued to the Seventh U. S. Army

in Italy and those which went to the European theater were of the old type and

were open to many objections. Because of the lack of ventilation, the feet,

even in the coldest weather, perspired when the men were active. Later, the

felt innersoles froze, and the feet became excessively cold. In warmer weather,

excessive perspiration caused maceration of the skin. cycle was often set up

ofperspiration, maceration, the development of so-calledshoepac foot, hospitalization for 10 to 15 days, return to duty, and repetition of the cycle. 42

The shoepacs issued in the European theater were the 6-inch type, too

low to offer much protection in deep mud, swampy ground, and flooded foxholes.

They offered no protection at all when streams had to be crossed. They lacked

arch supports and heels. The soft rubber soles wore out quickly. It was for

these reasons that the theater chief quartermaster had rejected the recommendation of the Quartermaster General that they be substituted for the

combat boot (p. 157).

The shoepacs supplied were also, for the most part, too large. This made

them unsatisfactory for marching, and men had to be evacuated for blisters

42 Essential Technical Medical Data, ETOUSA, for December 1944.
EUROPEAN TREATER 159

on their heels. No provision had been made for the wearing of additional socks with them.43

Finally, shoepacs cannot be worn efficiently unless their use is understood.

The supply for the European theater had to be distributed almost literally in the

midst of battle, and instructions for their use were often given after they had

been worn. As result, shoepacs in the European theater were seldom as

efficient as they should have been.

In spite of these and other objections, men who learned to wear shoepacs

correctly came to prefer them to service shoes and combat boots. At the end

of the cold season, it was generally agreed that in spite of their deficiencies the

shoepacs were the most satisfactory footgear for fighting in cold, wet weather.

This was the opinion of the conference on clothing held in March 1945 and the

footgear representative of the War Production Board (p. 155). It was also the

opinion expressed by the General Board, United States Forces, European

Theater of Operations, in its report on trenchfoot (p. 208) and of Maj. (later

Lt. Col.) Paul A. Siple, QMC, an observer from the Office of the Quarter- master General, who had been in the Antarctic with Admiral Byrd and who

studied the whole clothing and footgear situation in the theater in the late

winter of 1945.

Improvisations.—When the shortage of adequate footgear first became

acute, many units resorted to improvisations to secure additional protection

from rain and snow. Some units wore the white plastic powder bags provided

with 155-mm. projectiles inside or outside of their shoes. These bags were

extremely effective, but they were in short supply. Some units made boots of

four thicknesses of blanket and wore them inside their overshoes, without

shoes. Some troops which fought in Holland wore felt slippers and overshoes

with two pairs of socks. The incidence of trenchfoot was reduced in all the

units which used these and similar improvisations, one reason probably being

the free movement of the toes and feet possible when constricting footgear

was omitted.

Summary

more detailed account of the clothing and footgear used in the European

theater in the winter of 1944-45 does not properly belong in this volume.

Enough has been related to show the important role which inadequate clothing

and footgear played in the causation of trenchfoot. The items issued were

basically unsatisfactory because of deficiencies in insulation or ventilation,

or in other respects. The clothing was not windproof or water repellent.

The footgear did not protect against cold and wetness and had other defects.

Even these unsatisfactory items were in short supply. More efficient clothing

and footgear, which had been tested both in and out of combat, were available,

but the theater chose not to accept the new models, in spite ofrepeated warnings

from the Quartermaster General and his observer in the theater that the

troops would not be properly protected in combat operations during the

See footnote 37, p. 155.
160 COLD INJURY, GROUND TYPE

winter. The director of the Research and Development Branch of the Office

of the Quartermaster General had predicted that if the European theater persisted in using uniform already shown to be inadequate, the Italian experience with cold injury would be repeated. His prediction, unfortunately, was

oidy too correct.

When supplies of the improved clothing and footgear were finally ordered, cold injury was already widely prevalent, and the supplies were not received

until it was too late to alter the course of events.

Finally, neither the old nor the new models were correctly worn because

the troops had not been trained in their use. The United States soldier, as

Major Siple stated after he had surveyed the situation in February 1945

(p. 431), was better trained in the care and use offighting equipment than in the

care and use of his clothing.

These conclusions were, in substance, the conclusions of the General

Board, United States Forces, European theater, set up later in 1945 to study the whole cold injury situation in the theater.

DEVELOPMENT OF THE TRENCHFOOT-CONTROL

PROGRAM

Activities in 1942-43

The first recorded mention of cold injury in the European theater was

apparently made in letter dated August 1942, in which the Chief Surgeon,

on the request of the Office of the Surgeon General, transmitted information

on the management of frostbite as recommended by the British Medical

Research Council, together with some observations on immersion foot.

The first theater publication dealing with cold injury concerned immersion

foot. It was Circular Letter No. 12, Office of the Chief Surgeon, 20 January

1943. It was stated in this letter, “A condition which closely resembles the

trench foot of the last war may affect the extremities exposed to cold without

immersion provided the degree of cold is insufficient to cause frostbite.”

Medical Bulletin No. 1, Office of the Chief Surgeon, 18 March 1943,

reproduced the contents of Medical News Letter No. 1, Office of the Surgeon

General, which was published January 1943. The material on which this

letter was based was assembled under the auspices of the Committee on Information, Division of Medical Sciences, National Research Council, with the

cooperation of the American Medical Association and the Surgeons General of

the Army and the Navy. The letter also reproduced the substance of the

article on frostbite by Raymond Greene, which had appeared in Practitioner in

January 1942, and the substance of an article on immersion foot published

by Webster, Woolhouse, and Johnson in the Journal of Bone and Joint Surgery for October 1942.
EUROPEAN THEATER 161

\ctivities Before the Outbreak of Cold injury in 1944

In analyzing the cold injury epidemics in ETOUSA in World War II, it

must be borne in mind that there was little official information in the theater

concerning the serious losses from this cause in the Mediterranean theater in

the winter of 1943-44 and there was no continuous official medical liaison

between the two theaters. As one instance of the lack of liaison, the official

report on trenchfoot in the Mediterranean theater, which was submitted to the

Surgeon, MTOUSA (Mediterranean Theater of Operations, United States

Army), in January 1944, did not reach the European theater until year later,

when the urgent need for the data in it was practically over. It seems to have

arrived then only because Colonel Cutler requested it directly from the Surgeon of the Mediterranean theater.

There was, of course, considerable informal correspondence between

medical officers in the two theaters, though none specifically for the purpose of

studying cold injury. Curiously, it was dermatologist who was most impressed by the potentialities of this condition. On 10 November 1943, Lt.

Col. (later Col.) Donald M. Pillsbury, MC, Senior Consultant in Dermatology,

Office of the Chief Surgeon, ETOUSA, reported to General Hawley concerning

his tour of medical installations in the North African theater. He described

the epidemic of what he termed immersion foot in Italy and recounted his

discussions of the problem with medical officers in the North African theater,

including Maj. Fiorindo A. Simeone, MC, who was then making special study

of this condition (p. 101). Colonel Pillsbury stated that the treatment to date

was unsatisfactory, but that several approaches toward prevention were

practical. It was his opinion that the problem was great enough to warrant the use of every facility of General Hawley’s office in its solution and that the

Surgeon, MTOUSA, should be informed promptly of the results obtained.

Colonel Pillsbury’s recommendations concerning dermatologic conditions and

venereal disease were duly initialed by the theater venereal disease control

officer and the chief of the Professional Services Division, Office of the Chief

Surgeon, but no action seems to have been taken on his recommendations

concerning an energetic program for the prevention of cold injury.

Colonel Cutler, when he visited Italy in November and December 1943,

observed number of cases of trenchfoot. He was not then impressed with

them because of his experience in World War I, in which cold injury took the

form of “terrible swollen feet with ulcers and blue color.” Major Simeone

did not believe that more than quarter of the men affected would be able to

return to duty, but Colonel Cutler was then of the opinion that these soldiers

were utilizing the pain very hard as way out of fighting.

On his return to England, Colonel Cutler discussed cold injury with the

chief consultant in surgery to the Norwegian forces in the United Kingdom.

This officer, who had also just returned from Italy, had participated in the

Russo-Finnish War, and in Colonel Cutler’s opinion had had as wide an ex-
162 COLD INJURY, GROUND TYPE

perience in cold wet feet as any medical officer living. As result of these

discussions and after reflection upon his own observations in Italy, Colonel

Cutler transmitted the following (summarized) remarks to the theater chief

quartermaster, through channels, April 1944:

1. The socks furnished United States Army troops did not have sufficient

wool content.

2. Rigid discipline must be enforced within combat companies, so that

socks would he changed daily, even if this meant nothing more than wringing

them out and putting them on again.

3. United States Army soldiers were invariably fitted with shoes that

were too small.

Colonel Cutler added his own impressions of the enormous loss of manpower caused by cold injury in Italy and the importance of its prevention,

since no effective method of treatment had been discovered.

This memorandum was forwarded to the theater chief quartermaster

from General Hawley’s office 11 April 1944, with notation that his office

had in preparation proposed circular on the proper care of the feet. On

the same date, this information was sent to the Chief Surgeon’s Professional

Services Division, with the request that draft of the proposed directive be

prepared with the least practical delay.

Therequested draft, entitled “Prevention of trench foot (immersion foot),”

was forwarded to the executive officer of the Office of the Chief Surgeon, 25

April 1944. It emphasized the incapacitating character of the injury, the lack

of specific therapy for it, the possibility of prevention, and the preventive

measures which could be employed. These measures included keeping the

feet warm and dry, wearing properly fitted shoes and tw pairs of all-wool

socks, removing shoes and socks daily, rubbing the feet lightly with lanolin or

petrolatum after they were dried, and making every effort to encourage movement and maintain mobility.

No further action was apparently taken on this proposed circular at this

time, other than referring it to the Preventive Medicine Division of the Chief

Surgeon’s Office.

Preparations for the invasion of the Continent.—Cognizance was taken of

the danger of cold injury in the preparations for Operation OVERLORD, the invasion of the Continent. In Standing Operating Procedure 15, Medical

Service on the Continent, which was drawn up in March 1944, as part ofPolicies

and Procedures for Mounting the Invasion, and which w’as published 29 July

1944, paragraph 53 read as follows:

Trench foot (Immersion foot). Emphasis will be given to the care of the feet and to the

provision of proper clothing and footwear. Special attention will be given to these details

for combat troops operating under wet, cold conditions.

Annex No. 8, which was the medical plan for mounting the invasion, did

not mention cold injury. Annex No. to the Operations Plan, Communica-
EUROPEAN THEATER 163

tions Zone, for NEPTUNE, the assault phase of OVERLORD, contained the

following paragraph:

Section VIII, 40. “Trench Fool”—(“Immersion Foot”).—The cold wet weather prevailing during the winter season in the area will predispose combat troops to this affection.

Supplying seasonal changes of clothing opportunely, giving particular attention to the furnishing of proper footwear, are important measures for preventing casualties due to trench

foot.

The Manual of Therapy, issued by the Chief Surgeon, ETOUSA, on

May 1944, contained section on foot hygiene, which emphasized the importance of (1) cleanliness, (2) keeping the feet dry, (3) using foot powder, (4)

changing the socks frequently, (5) wearing properly fitted shoes and socks,

(6) avoiding trauma, (7) caring for the feet after long marches, and (8) caring

for the shoes and socks. It was again advised, as in other publications, that

the shoes be laced tightly.

Section XIV, paragraph 7, of the Manual of Therapy read as follows:

The importance of foot bath with soap and water cleansing, vigorous massage (20

Min.), dry socks, and change of shoes in the prophylaxis of foot disability resulting from

exposure to cold and moisture cannot be overemphasized.

The manual contained rather extensive description of fungous infections

of the feet, but there was no further mention of cold injury.

Preceding letters on the subject of cold injury were rescinded on 10 June

1944,44 and attention was directed to the Manual of Therapy, which, it was

stated, contained the principles of therapy to be followed in the theater.

Postinvasion Activities

On 22 June 1944, Colonel Gordon’s office recommended publication of

command directive entitled “Care of the Feet” for distribution to army groups,

armies, air forces, base sections, and analogous commands. This directive

included principles of fitting, care, and use of shoes; the choice and use of socks;

and general instructions on foot hygiene. It emphasized that company commanders were responsible for the correct fitting of shoes and that instructions to

fit them over light wool socks should be modified, if necessary, to permit them

to be fitted over heavy wool socks or two pairs of light wool socks. Instructions were given for the breaking in of new shoes, and tight lacing (contrary to

previous advice) was warned against. Specific instructions were given how to

lace shoes when the uppers fitted too snugly. Instructions were given for

changing of socks regularly and for drying socks by improvised methods if

fresh pair was not available. Finally, instructions were given for the care of

the feet, including cleanliness, conditioning, care of the nails, care of blisters

and abrasions, avoidance of excessive sweating, and prompt report of infections

or other disabilities to the medical officer.

44 Circular Letter No. 80, Office of the Chief Surgeon, Headquarters, ETOUSA, 10 June 1944. subject: Policies and

Procedures Governing Care of Patients in the European Theater of Operations.
164 COLD INJURY, GROUND TYPE

Paragraph (4) read as follows:

External Conditions. The feet are subject to all of the common injuries due to external

causes, but there is one type to which they are particularly prone. Slightly different forms

of this injury are known as Immersion Foot, Trench Foot, Shelter Foot, etc., but all are

fundamentally the same. The condition results from long exposure to combination of

wetting, cold (which need not be extreme) and stagnation of circulation due to inactivity or

constricting clothing or boots. Prevention depends upon avoidance of wetting and chilling

if possible and where these are unavoidable the preservation of circulation by exercise, relief

of constricting clothing and as last resort general manipulation. After the condition is well

established, with numbness, swelling and change of color of the feet, walking and even massage are to be avoided.

This publication was disapproved by the Adjutant General, ETOUSA,

on the ground that existing manuals covered the subject and that the problem

was the responsibility of subordinate commands. Colonel Gordon thereupon

forwarded the content of the proposed publication informally to the surgeons of

major commands.

In September 1944, Colonel Gordon’s office began work on circular letter

dealing with the care of the feet and intended for publication to all commanding

officers, including those of smaller units. After the proposed letter had been

concurred in by other divisions of the Chief Surgeon’s Office, it was sent to the

Adjutant General, ETOUSA, 11 October, with the statement that publication

was urgent and should be expedited because of the possibility of trenchfoot in

the theater. When it appeared on 24 November as Circular No. 108, Headquarters, ETOUSA (appendix E, p. 525), heavy losses from cold injury had already been sustained.

Meantime, as already noted, other publications had become available.

War Department Circular No. 312, dated 22 July 1944 (p. 63), was distributed

in the theater on September 1944. TB MED 81, dated August 1944

(p. 65), was received in the theater later that month. When it arrived,

circular letter containing substantially the same material was in process of

preparation. TB MED 81 was substituted for the material in preparation and

was published 18 October 1944, as Circular Letter No. 126, Office of the Chief

Surgeon, ETOUSA. As already mentioned (p. 158), statement in this bulletin

dealing with shoepacs was deleted at the request of the Chief Quartermaster,

ETOUSA, because it was now evident that they could be supplied only to

very limited number of personnel in the theater.

In order to give additional and faster circulation to the information contained in TB MED 81, this bulletin was reproduced in the theater medical

bulletin for November 1944. It was preceded by statement by General

Hawley to the effect that the Italian experience had shown that cold injury could disable men as suddenly and with as little warning as severe wound,

that many of those affected would remain permanently unfit for duty under

conditions of cold and moisture, and that all medical personnel should familiarize themselves with the contents of TB MED 81 because it indicated the

possible extent and severity of cold injury and the paramount importance of

preventive measures.
EUROPEAN THEATER 165

Meantime, there had been numerous informal warnings of the possibilities

and potentialities of cold injury. On October 1944, Colonel Cutler informed

Col. James K. Kimbrough, MC, Chief, Professional Services Division, Office

of the Chief Surgeon, ETOUSA, that Lt. Col. (later Col.) Joseph A. Crisler,

Jr., MC, Consultant in Surgery, Office of the Surgeon, First U. S. Army, had

sent word to him that he was fearful of trouble with trenchfoot in the coming

weeks and months and that he (Colonel Cutler) shared these apprehensions. 45

All experience, the memorandum continued, justified the statement that there

is no sound treatment for trenchfoot and that prevention is all important.

It further stated that the Medical Department should insist that woolen socks

be worn and that shoes be properly fitted, since all Americans wear their shoes

too small. Unless these warnings were heeded, Colonel Cutler concluded,

“there will be disaster.” The memorandum also called attention to the habit

of Norwegians, especially Laplanders, of putting straw in their big shoes

during the winter, thus providing both ventilation and insulation, and to the

Russian custom of changing from leather to felt shoes and binding the feet

instead of wearing socks in cold weather. Neither Russians nor Norwegians

suffered from cold injury.

In report, Health of the Command, 12th Army Group, for August 1944,

the possible increase ofrespiratory diseases during cold weather was mentioned,

but the report contained no mention of cold injury. In the report for September 1944, dated 11 October, respiratory diseases were again mentioned,

and paragraph was devoted to trenchfoot:

b. Trench Foot. Attention is also directed to the great loss of time and the noneffectiveness of personnel experienced in the Italian Campaign last winter and spring from

“trench foot,” “immersion foot,” and similar injuries due to cold and wetness. Not only

should emphasis be placed upon the early issue of winter foot-gear, but also upon fitting of

shoes and socks, cleanliness of the feet, and early treatment of foot conditions. The command function of educating and training combat troops in this problem if diligently carried

out, will go far toward reducing non-effectiveness from these causes.

This report, which was intended for the 12th xVrmy Group commander,

as well as for subordinate commanders, recommended (1) that winter clothing

be issued at the earliest practicable date and (2) that commanding officers of

all echelons take the necessary steps to insure that all men in their commands

were properly instructed in the care of their feet under winter combat conditions and were adequately supplied with properly fitting socks and shoes. Army publications.—On the army level, the first directive concerning cold

injury (Professional Memorandum No. 5, Trench Foot), which was issued

before the outbreak, appeared on October 1944, from the Office of the Surgeon, First U. S. Army. All commanding officers and all medical officers

assigned or attached to corps, division, and separate medical units were warned

of the possibility of cold injury, especially in wet and damp weather and even

when the temperature was above freezing. Causes of trenchfoot and meas-

<5 Informal Routing Slip, Chief Consultant in Surgery, to Chief, Professional Services Division, Oct. 1944, subject:

Trench Foot, Immersion Foot.
166 COLD INJURY, GROUND TYPE

ures of prevention were outlined, and the importance of teaching troops to

protect themselves as individuals was stressed. It was pointed out that the

First U. S. Army was then operating in terrain ideal for the development of

trenchfoot and in weather that was also ideal for its occurrence.

When Colonel Cutler received this memorandum, he commented that it

was an excellent summary of Circular Letter No. 126 (p. 164) but that he regarded it as unfortunate that two separate memorandums should be issued on

this important subject. He hoped proper authorities would advise the First

U. S. Army to use Circular Letter No. 126 instead of their own publication.

Colonel Kimbrough added note to this comment to the effect that, since

the Chief Surgeon’s circular letter was entirely adequate, it would be unfortunate if each army were to put out separate circular on the subject. In

effect, that is what each army did and what many lower units also did. Many

of these circulars were unduly long, and some of them combined matters, such

as how to prevent trenchfoot and how to wash wool socks without shrinkage

(p. 167), which might better have been handled separately.

On October 1944, the Ninth U. S. Army headquarters issued Memorandum No. 68, entitled “Medical Instructions.” In it, the possibility of

trenchfoot in the climatic conditions then present and the areas then occupied

was stressed, and attention was directed to War Department Circular No. 312.

On December, after trenchfoot had already caused thousands of casualties

in this and other armies, second communication was issued by the Ninth

U. S. Army in which the effective methods of prevention used by theBritish were

summarized.

In the Seventh U. S. Army, Circular No. 20 was issued as command

directive on October 1944. In it, attention was called to the losses suffered

the previous winter in Italy. The causes, symptoms, and treatment of trenchfoot were outlined, and methods of prevention in combat as well as in reserve

were described. It was emphasized that cold injury is preventable condition and that its prevention is the function and responsibility of command.

This circular also pointed out that commanders must learn how to prevent

cold injury and must see that their orders were carried out. The Seventh

U. S. Army originally consisted of divisions which had fought in the Mediterranean theater the previous winter. Many of the troops had suffered from

cold injury then, and there were numerous recurrences as soon as the weather

in France became cold (p. 382).

The warning that commanding officers must inform themselves concerning

cold injury was very necessary. It was repeatedly found in all armies during

the coming weeks that commissioned officers, like noncommissioned officers

and enlisted men, did not understand the real nature of cold injury. 46 Some

of them, in fact, believed that the condition was similar to severe athlete’s

foot.

The Third U. S. Army issued its first directive on the subject of trenchfoot

46 Letter, Headquarters, Third U. S. Army, Office of the Surgeon, to Commanding General, Third U. S. Army,

19 Apr. 1945, subject; Activities of Third U. S. Army Trench Foot Control Team.
EUROPEAN THEATER 167

(Circular No. 76) on November 1944. During the weeks prior to the issuance

of this circular, numerous informal discussions between medical and other

personnel at army headquarters and in subordinate echelons were held. Although trenchfoot was serious problem in the army when Circular No. 76

was issued, the directive merely stated officially and in writing, policies and

plans which were already in effect.

In this circular, troop commanders were directed to familiarize themselves

with War Department Circular No. 312 and to comply with its directions.

Commanders were given the direct responsibility of preventing cold injury.

The following unequivocal statement was made: “The excessive development

of trenchfoot in an organization will be considered as indicative of inadequate

supervision and control.” This circular also contained numerous details concerning the cause and prevention of cold injury and included detailed set of

instructions for laundering socks and instituting sock exchange.

Measures Taken During the Epidemics of Cold Injury

On 17 November 1944, by which time thousands of cases of trenchfoot

had already occurred, General Kenner addressed memorandum on the subject to the Chief of Staff, SHAEF. In it, he discussed the incidence of trenchfoot and the causes, with particular emphasis upon cold weather, wet feet, and

constriction about the feet. He also outlined the action being taken to check

the epidemic. The control of cold injury, he stated, had been placed in command channels, since foot discipline was command responsibility. He emphasized proper footgear, including overshoes, and the use of dubbing. He

reported that definitive action had already been taken on his recommendations

that the unit issue of heavy wool socks be increased, that high priority be given

to forward movement of socks, and that concise brochure on trenchfoot, for

universal distribution, be prepared and published by the Chief Surgeon,

ETOUSA.

General Kenner’s memorandum was approved at SHAEF and forwarded

to the Commanding General, Communications Zone, ETOUSA, for his information and guidance.

On November 17, field directive on the subject of trenchfoot was prepared

by the chief of the Preventive Medicine Section, Office of the Surgeon, 12th

Army Group, and was hand carried by Col. Alvin L. Gorby, MC, Surgeon,

12th Army Group, to the commanding general. In this memorandum, the

whole situation in the field was surveyed.

General Bradley immediately ordered the material issued as command

directive (Circular No. 19). In addition, he sent personal letters to the commanding generals of all field armies in the 12th Army Group. In these letters,

he pointed out the heavy loss of manpower caused by cold injury, the permanence of many of these injuries, the particularly heavy losses in the infantry,

the fact that cold injury was largely preventable by the proper assumption of

responsibility by command, and the apparent absence of all assumption of
168 COLD INJURY, GROUND TYPE

responsibility by command at that time. General Bradley also noted that in

many units galoshes had been left behind by direction, spare socks had not been

required, and in some instances men had not removed their shoes for to 10

days. He requested that all army commanders give these matters their immediate personal attention.

Immediately upon the receipt of these letters, the commanding generals

of the First, Third, and Ninth U. S. Armies prepared and distributed to corps

and division commanders letters embodying the information contained in

General Bradley’s letter and ordering immediate measures to control the

trenchfoot epidemic.

The letter from General Patton, dated 21 November 1944 (appendix F,

p. 529), is typical of the substance ofall these letters. In it, attention was called

to the gravity of the situation. The causes of cold injury were outlined.

Specific control measures were listed, including the use of overshoes, the proper

fitting of shoes, the use of dubbing, the provision of extra socks, and daily foot

care. It was stated unequivocally that control was function of command,

and distinction was made between control measures for which the individual

soldier was responsible and the support which command could provide. The

letter began with the blunt statement, “The most serious menace confronting

us today is not the German Army, which we have practically destroyed, but

the weather which, if we do not exert ourselves, may well destroy us through

the incidence of trench foot.” 47

On 23 November 1944, General Hawley sent identical letters to the surgeons of the 12th Army Group, First U. S. Army, Third U. S. Army, and

Ninth IT. S. Army, pointing out to them that, if ideal methods ofprevention of

trenchfoot could not be accomplished, simple measures to keep the circulation

active in the feet would result in the disappearance of most cases. He recommended removal of the shoes and socks once day and massage of the feet until

the circulation was completely reestablished. He also pointed out that, while

dry socks were desirable, wringing water out of wet socks and then replacing

them was preferable to leaving the shoes and socks on continuously. The

letter concluded:

3. The ratio of trench foot to battle casualties is so high that, by failing to solve this

problem, we are doing practically as much damage to our own troops as the enemy—and, by “we,” do not mean the Medical Department. This is disciplinary problem, particularly one of leadership in small units.

In spite of his recognition that the prevention of trenchfoot was command

problem, General Hawley was not entirely satisfied with the activities of the

47 On 19 November, Col. CharlesB. Odom. MC, simrical consultantto the Surgeon, Third U. S, Army, had addressed

memorandum to GeneralPatton in which he outlined the seriousness of casualties from cold injury amongUnited States

troops, the far better situation among German troops, and the inadequacies of the footgear supplied to United States

soldiers. The shoes, he said, were badly fitted and the qualityof the socks was poor. After analyzing the major factors

in the causation of trenchfoot and the discouraging outlook for the man who sustained it, the memorandum concluded:

“It is apparent from talks with our soldiers that they do not realize the importance of caring for their feet, norare they

properly instructed and disciplined in this regard.”
BUR()PEAN THEATER 169

Medical Department. On 25 November 1944, he wrote to Colonel Gorby,

as follows:

am not sure that the Medical Department has been aggressive enough in this

situation. We have published long dissertations on the prevention of trench foot which are

too long for anyone to read. Furthermore, they lay down so many requirements that,

unless the soldier can fulfill all of them, he does nothing. Apparently no one has ever told

the small unit commander that the very essence of prevention of trench foot is the prevention

of stagnation of circulation for periods greater than 24 hours.

General Hawley concluded his letter by again laying down his own concept

of prevention. He stated that he thought that if the shoes were removed once

every 24 hours, if the feet were massaged briskly, preferably while were

higher than the hips, and if the water was wrung out of wet socks before they

were replaced, cold injury could be prevented in 75 percent of all cases.

High command also made it clear, though somewhat belatedly, that

control was the responsibility of command and that prevention was both

feasible and practical. letter, dated 24 January 1945,48 stated:

While appreciative of the adverse climatic factors existing in combat areas, he [General

Eisenhower] desires to emphasize that this condition [cold injury] may be controlled by the

proper exercise of Command, particularly by officers of company grade. It is desired, therefore, that higher unit commanders impress upon all ranks the necessity for unremitting attention to this command responsibility.

There was similar acceptance of responsibility, though frequently equally

belated, in most individual units. The annual report of medical activities in

the XIII Corps, Ninth U. S. Army, dated 31 January 1945, read, in part, as

follows:

It [trench foot] was the most important and most prevalent condition that could have

been prevented *. There are several reasons for high incidence of this disease. First

neither the line officer nor the medical officer is sufficiently aware of the condition

prior to the time the troops are exposed to the hazards of unfavorable weather and terrain

conditions. Second, neither the line officer nor the medical officer stresses sufficiently proper

care of the feet. Third, the footgear and clothing issued by the U. S. Army is not adequate

for wear under conditions apt to result in trench foot. Fourth, commanding officers often

fail to relieve their front-line units sufficiently frequently. Fifth, commanding officers fail

to provide facilities for the drying of shoes, socks and clothing; fail to give adequate instructions to their men; fail to realize that the care of the feet of their troops is command

responsibility. All of the above reasons, except the third, could be eliminated by adequate

instruction and indoctrination of officers and noncommissioned officers in the training

phases.

Individual Instruction and Indoctrination

One of the major problems in the control of trenchfoot in the European

theater was the necessity for instructing the individual soldier how to take care

of his feet. Almost none of these troops had had any previous training in foot

hygiene in cold wet weather. All personnel had to be instructed; line officers,

as has already been mentioned several times, knew no more of the matter, for

49 Letter, SHAEF, to Commanding Generals, 12th Army Group, 6th Army Group, First Allied Airborne Army, and

Communications Zone, European theater, 24 Jan. 1945, subject: Control of Trench Foot.
170 COLD INJURY, GROUND TYPE

the most part, than the men for whose well-being they were responsible. The

instruction had to be given in highly unfavorable circumstances, in combat,

when the soldiers were concerned with other matters that seemed of much more

importance than taking care of their feet. One of them was saving their lives.

Yet, in some manner, they had to be impressed with the urgent necessity of

taking care of their feet. Although they should have been taught these things

earlier, it is nonetheless fair to say that the effort, even if made late, was extremely effective.

Formal instruction was obviously impractical under the circumstances,

and the facts of the trenchfoot situation and methods of preventing it, particularly in the individual soldier, were conveyed to the men in variety of ways.

Before the invasion, it had been planned that trenchfoot would be one of

the subjects to be considered in series of articles on health to be published in

Stars and Stripes, in which it would be discussed in the article on footgear.

After the first general epidemic of trenchfoot, in November 1944, publicity

was intensive. News articles, editorials, and feature notes appeared in Stars

and Stripes, including news summaries on 10 November and 29 November and

editorials on December 1944 and 19 January 1945. Articles appeared in

Ears on and December and in War Week on December. short article

appeared in Combat Tips for December and 4-page spread (half of the issue)

in the 16 December issue. Material was placed in division publications, such

as the Invader of the 28th Infantry Division. In these publications, the language of authority was translated into the language of the GI:

1. Keep your feet as dry as possible. With all the mud, this is easier said than done

but you gotta do it anyway.

2. Elevate your feet at intervals, every two or three hours, whenever your feet get cold

and wet. Just flop on your derriere and do push-ups with your legs.

3. Modernize your slit trench, if possible, by putting in flooring. Pine boughs make

nice GI color scheme but don’t use any floor wax.

4. Wear overshoes. That is, if you have them.

Radio publicity was employed intensively. Mobile broadcasting facilities

made it possible for the messages on trenchfoot to reach frontline troops in

areas in which printed matter was not practical.

Posters in preparation in the United States (p. 72) were not ready in time

to bo useful in the European theater, but poster was prepared in the theater

for general distribution, and the use of posters prepared in individual units was

encouraged. Some of them were very effective.

In his memorandum (p. 167) to the Chief of Staff, SHAEF, on 17 November 1944, General Kenner had recommended that the Chief Surgeon,

ETOUSA, publish concise brochure on trenchfoot for distribution to the

troops. Colonel Gordon set this project in motion, although his own experience

indicated that articles for newspapers, magazines, and periodicals, which could

be repeated, were more purposeful.

With the cooperation of the Public Relations Division, ETOUSA, the

preparation of brochure was expedited, and distribution was begun the second
EUROPEAN THEATER 171

week in January 1945. Two and half million copies were printed, so that

each soldier in the theater could receive one. Those used in the United Kingdom were printed in London and those used on the Continent were printed in

Paris, where distribution was delayed because of strike of printers. When

the copy was sent to the Assistant Chief ofStaff, G-3 (operations and training),

ETOUSA, December, it had been noted that early printing was more important than an elaborate effort delayed beyond the present period of urgent need.

When an inquiry to The Surgeon General produced the information that the

film on trenchfoot being prepared in that office was not yet ready, an educational

film on the subject was prepared in the First U. S. Army. Clinical material

was obtained at First U. S. Army medical installations, medical supervision was

supplied by an officer of that army, and the technical work was done by

photographic section from SHAEF. The official film on trenchfoot (FBI80,

p. 73) did not reach the theater from the Zone of Interior until 24 February

1945.

The clinical pictures of trenchfoot made by the 2d Medical Arts Detachment at the 108th General Hospital were used for instructional purposes,

although only after some debate about their value for nonmedical personnel.

Still photographs were also made to illustrate preventive measures as practiced

by men in the field.

Training of Reinforcements 49

The problem of trenchfoot in reinforcements assumed three forms in the

European theater;

1. It occasionally occurred in the Ground Force Reinforcement Command,

while the men were still undergoing training. When this happened, it could

usually be accounted for by special circumstances, such as the lack of overshoes.

In February 1945, 22 of 449 reinforcements received by the 47th Infantry Regiment were found, on inspection by representative of the G-3 Section, Headquarters, ETOUSA, to be suffering from trenchfoot. 80 The explanation was

that they had stood in the wet for hours at time during training.

2. Most of the cold injury which occurred while troops were in the Reinforcement Command was secondary, in the form of recurrences in troops

recently released from the hospital after treatment for primary cold injury.

In November 1944, there were almost no cases in the Ground Force Reinforcement Command, but in December, for the reason just stated, there was an

appreciable number.

48 The name of the Ground Force Replacement Command was changed on 28 December 1944 to Ground Force Reinforcement Command, the reason being that some officers believedthat the British term “reinforcement” was more suitable,

because of the morale factor, than theoriginal term “replacement.” The implementingletter instructed all concerned to

inform new men that they were combat reserves orreinforcements, not replacements for men who had been killed or

wounded. As matter of convenience, the term “reinforcements” is used uniformly throughout this section, regardless

of date.

50 Letter, Lt. Col. Richard P. Fisk, AGD, Headquarters,ETOUSA, to Commanding General, Ground Force Reinorcement Command, 23 Feb. 1945, subject: Trench Foot Among Reinforcements.
172 COLD INJURY, GROUND TYPE

3. Most of the cases of cold injury in reinforcements occurred in troops

sent into the field without proper training in its prevention. The plan in the

European theater provided for 2- to 3-week period of training for all replacements arriving from the United States before they were assigned to combat

units. Military exigencies did not permit the uniform application of this plan.

The training period frequently had to be cut short because of the urgent need

for manpower in the frontlines. During the Battle of the Bulge, for instance,

very little time intervened between the arrival of troops in the theater and their

assignment to units in combat.

The program of training in the Reinforcement Command included course

in first aid and field sanitation, in thepreparation of which the Surgeon General’s

Office had participated. 51 Foot hygiene was part of this course. Greater

emphasis was placed upon this subject after the distribution ofWar Department

Circular No. 312 and TB MED 81. When the original program proved inadequate and recently arrived reinforcements were found to be suffering heavy

casualties from trenchfoot, the program of indoctrination was further intensified,

action being initiated both inside and outside the Reinforcement Command.

Colonel Gorby wrote General Hawley on December 1944 that he had

asked all army surgeons to take the necessary steps to see that reinforcements

were properly indoctrinated in the facts of cold injury before their assignment

to combat units. On December, General Patton recommended to the Commanding General, ETOUSA, that before their release from the Ground Force

Reinforcement Command each officer and each enlisted man be given intensive

individual instruction in measures to prevent cold injury, including the correct

fitting of shoes, combat boots, and overshoes. It was also recommended that

command responsibility for cold injury be emphasized to officers and that the

importance of rotation be particularly stressed. These recommendations were

designed to decrease “the probability that they [officers and enlisted men] will

become casualties soon after arrival in combat areas.” 52

Two circulars on the subject of cold injury were issued by the Ground

Force Reinforcement Command, No. 55, dated 13 December 1944, and No. 3,

dated 10 Januar} 1945. Later, all depots were instructed that no reinforcements were to be reassigned until they had received the proper instruction in

cold injury and until that fact had been duly noted on each man’s WD AGO

Form 20.

As the dates indicate, in this as in other commands, the action taken to

prevent cold injury was correct, but it was taken too late to influence the

epidemics which occurred in the European theater in the winter of 1944-45.

Training and Schools

It was midsummer of 1944 before the prevention of cold injury came to

be regarded as one of the essential considerations in the infantry training

Annual Report, Surgeon, Ground Force Reinforcement Command, European theater, dated 30 Sept. 1945. 52 Letter, Headquarters, 12th Army Group, to Commanding General, ETOUSA, Dec. 1944, subject: Training of

Replacements in Prevention of Trench Foot and Care of the Feet.
EUROPEAN THEATER 173

program in the Zone of Interior (p. 74). By the time the program had been hilly implemented and the troops trained under it had reached the European theater, the trenchfoot epidemics were practically ended. In other words except for the divisions of the Seventh U. S. Army which had been trained in the Mediterranean theater, the troops which fought in Europe through the winter of 1944-45 had had only the most casual training in the prevention of cold injury, if, indeed, they had had any at all. This lack of knowledge and training was not limited to enlisted men. With few exceptions, line com- manders had equally little understanding and appreciation of the risks of cold injury and of methods of preventing it. Finally, and again with few exceptions, medical officers were almost equally ignorant and untrained, since cold injury is an entirely unknown condition in most parts of the United States. Even in the coldest portions it is observed only occasionally, practically always in the form of frostbite. Although numerous opportunities existed for instruction of medical officers in the European theater, study of the record does not indicate that they received an\ special training in the subject before cold injury began to occur. The Medical Field Service School was established at Shrivenham, England, as part of the American School Center operated by the Services of Supply, on 27 February 1943 (Circular No. 22) for training medical officers in aspects of military practice not ordinarily encountered in civilian practice. Before it discontinued operations on 15 October 1944, about 900 officers had been trained in 21 classes. The field of instruction was wide, but the curriculum apparently did not include cold injury, at least as special subject; it may have been mentioned incidentally. Cold injury also does not seem to have been included in the instruction in Medical Department training methods provided by demonstration platoon at the school. Between courses, this Platoon toured base sections, putting on demonstrations for the hospitals’. Courses in such subjects as plaster technique, laboratory technique, anesthesia, oxygen therapy, and the making of artificial eyes were given for officers and enlisted technicians at various station and general hospitals in the theater, and selected medical officers attended courses at British hospitals and schools. In all of these courses, as at Shrivenham, the range of interest was wide, but cold injury was apparently not covered in any of them.

OTHER CONSIDERATIONS OF PREVENTION

AND CONTROL

Rotation

During the cold injury season in the European theater, fighting was always too desperate and combat manpower was always in too short supply to permit unitrotation to any considerable degree. This was war of movement, and troops were almost always continuously engaged. Because of the tactical 438404'—58 13
174 COLD INJURY, GROUND TYPE

situation and the limited manpower available, therefore, major commanders

seldom found that any large-scale rotation of troops was possible.

Absence of regular rotation practices was one of the major handicaps of

the control program. In spite of the serious difficulties connected with it,

however, rotation might still have been accomplished if there had been any

stated theater policies concerning it. There were none,53 and, until the end of

combat, such unit rotation as was practiced was according to the orders of

individual subordinate commanders. This was not desirable state of affairs.

Individual rotation was difficult and was not practiced uniformly, though

it was employed irregularly and to some extent almost everywhere along the

front. Since experience has shown that trenchfoot does not, as rule, develop

until after more than 24 to 48 hours of relative immobility, rotation, when it

was correctly practiced, had the objective of taking small groups, of squad

size or larger, out of the lines for few hours within these periods.

Many times, conditions in the rear were almost as severe as in forward

areas, but usually tent, dugout, ruined building, or some similar protection

was available. Here, soldiers could care for their feet, change their socks,

and have warm food and drinks. Drying facilities were provided whenever

possible.

In spite of the irregular practice of rotation, units which employed it to

the limits of the possibilities found it an extremely useful method of preventing

trenchfoot. The possibilities, of course, frequently depended, more than

anything else, upon the will and resourcefulness of the unit commander.

Tentage and Shelter

In April 1944, when planning for the invasion of the Continent was under

way, an elaborate program was outlined (Standing Operating Procedure No. 5, ETOUSA) for the shelter of the invading troops. 54 The idea was that all

camps and depots should be changed over, in phases, first from canvas coverage

to wood and metal huts and then to buildings.

The theater chief quartermaster was not optimistic about the use of

existing buildings, because of heavy bombings, and did not regard new construction as practical. It was his idea that tentage should be provided for

2,500,000 troops, about 90 percent of the total number then envisaged, and

for their supporting personnel. This planning ran counter to the experience

in North Africa, barren area, where heavy tentage for 50 percent of the

troops had proved adequate. No allowances were made in the European theater for barracks and hospital buildings, which would have provided—and

later did provide—for certain proportion of the shelter needed.

The requisitions for tentage made in the summer of 1944 were not filled.

Indeed, the requisitions were never more than halfway met, and when the

53 Report, Office of Chief Surgeon, ETOUSA, to The Surgeon General, 16 May 1945, subject: Trench Foot—Revised Report No. 9. 54 See footnote 23 (1), p. 143.
EUROPEAN THEATER 175

field forces called for tentage it was unavailable. At first, the troops did not

fully explore the possibilities of houses, barns, and other structures, as European armies had always done, and this omission resulted in certain amount

of unnecessary exposure. Later, as their experience increased, the men began

to protect themselves in existing buildings and eventually found them better

than tents.

Salves and Ointments

In World War I, British medical officers at first laid much stress upon

the use of salves and ointments in the prevention of trenchfoot (p. 202). In

1917, this practice was discarded in favor of the use of foot powder, and it was

not reverted to in World War II. Salves and ointments were part of the preventive routine used by American troops in World War (p. 48), and they" were

also used by some of the troops who participated in the Attn campaign (p. 310).

During the summer of 1944, number of inquiries concerning the use of

salves and ointments were made of the Professional Services Division, Office

of the Surgeon General, as well as of the Professional Services Division, Office

of the Chief Surgeon, ETOUSA. The substance of the replies, which stated

the official policy concerning these agents, was as follows; 55

1. Tests by both ground and air forces had shown salves and ointments

to be of no value.

2. The National Research Council had arrived at the same conclusion

after studies of work that had been done in Canada. The only exception to

this opinion was that oil-impregnated socks might be of some value in the

prevention of immersion foot.

3. The use of oils and salves might engender false sense of security and

lead to carelessness in the strict application of such essential preventive measures

as cleanliness, frequent changes of socks, and general foot discipline.

4. The application of grease to the feet before the shoes were put on might

cause so much sweating, especially in men with tendency to hyperhydrosis,

that state of chronic local immersion might be produced with vasodilatation

and perhaps the formation of small vesicles.

5. The Russians, who had conducted extensive tests with various salves and

oils, had also concluded that this was not useful form of prophylaxis.

The epidemic of trenchfoot in November led to number of inquiries

concerning the preventive value of this practice, but the Professional Services

Division, Office of the Chief Surgeon, ETOUSA, invariably replied that the

use of those agents had been carefully considered and was not recommended.

Although this was official policy, number of units in the theater used

various agents to massage the feet, some in the hope that the lubricants might

have some preventive effect, others frankly for the psychologic effect and to

55 (1) Memorandum, Lt. Col. A. L. Ahnfeldt, MC, Director, Sanitation and Hygiene Division, Preventive Medicine Service, Office of the Surgeon General, to Major Walker, Preventive Medicine Service, May 1944, subject:

Use of Oil as Preventive in Frostbite, Freezing, and Trench Foot. (2) Informal Routing Slip, Professional Services

Division, to Preventive Medicine Division, Aug. 1944, subject: Trench Foot.
176 COLD INJURY, GROUND TYPE

insure massage of the feet. One unit used shaving cream. One division surgeon ran tests on the relative value of massage alone, massage with lanolin,

and massage with petrolatum. In another division, aidmen carried mixture

of mineral oil, cod liver oil, and oil of peppermint, which they gave the men

to use on their feet. One medical officer had the supply officer make up

anhydrous lanolin with 10 percent beeswax for this purpose. So far as is

known, none of these practices proved effective and all of them were quietly

dropped, though not before number of men suffered maceration of the feet

from the collection of excessive perspiration under the oils and greases which

they had used.

EPIDEMIOLOGIC SURVEY AND CONTROL

Even before cold injury had become serious problem in the European

theater, officers representing General Hawley and Colonel Gordon had visited

major commands of the 12th Army Group. Their surveys began in October.

As result, they were able to observe the November outbreak of trenchfoot at

first hand and to evaluate the efficacy of the various measures taken to control

it. On their return to 12thArmy Group headquarters at the end of November, they were able to corroborate, from firsthand observation, what experienced

observers already knew; that is, that the major means of prevention of cold

injury is proper command control. They could also emphasize, from their

personal experience, that, even when the tactical situation is most difficult and

terrain and environmental conditions most unfavorable, units in which foot

care is correctly supervised command responsibility could maintainreasonably

low rates.

The field surveys undertaken in October and November had not been

specifically directed toward cold injury. In December, formal survey of the

cold injury situation was undertaken. The observers, all experienced officers

who had seen cold injury in the Mediterranean and European theaters, were

accompanied by medical inspectors of the various armies. They surveyed the

field armies, division by division, collecting accurate data on the incidence and

prevalence of trenchfoot in each unit; unit combat experience; weather conditions; terrain; status of clothing supplies; rotation policies and practices; the

quality of unit and foot discipline; and whatever other host and environmental

factors were known, or were presumed, to influence the development of cold

trauma. Conferences were also held with army, corps, and division surgeons

and with as many senior commanders as possible. The wealth of material

secured in this survey is discussed in detail under the heading of epidemiology

(p. 363), and only the main points need be summarized here:

1. The winter of 1944-45 was the worst Europe had experienced in years.

2. The terrain which was fought over was chiefly open country, easily

flooded, and crossed by many rivers in flood because of heavy precipitation.

3. Clothing and footgear suitable for the environmental situation and the
EUROPEAN THEATER ITT

terrain were in short supply and were still inadequate at the end of December

1944.

4. The tactical situation could take no account of the unfavorable weather, terrain, and supply situations. The November offensive by United States

ground forces and the German counteroffensive in December placed very heavy

demands upon combat troops. It was necessary that they expose themselves

in the performance of essential duties, and the isolated position of many units,

as result of enemy action, greatly increased the risks of exposure.

5. In spite of these adverse circumstances, considerable degree of command control was perfectly practical, the proof being that in many units it

had been accomplished. Efforts at general indoctrination of troops and at

preventive measures by command were increasing and were becoming increasingly effective.

Trenchfoot-Control Teams

The recommendation of the Paris Conference on Trench Foot, that trenchfoot-control teams be established at army level (p. 183), was implemented by

the directive published on 30 January 1945 (appendix G, p. 531). Each control

team consisted of line officer and an officer of the Quartermaster Corps. The

function of these teams was to visit corps, division, and regimental headquarters

for two chief purposes: (1) To assess the past and present cold injury situation

and (2) to teach unit trenchfoot-control officers practical measures for preventing outbreaks of cold injury and for controlling them if they occurred. It was

the duty of these unit control officers, in their turn, to train trenchfoot-control

officers and noncommissioned officers in battalions, companies, and platoons.

The functions of control personnel in the smaller units were to check on individual foot discipline in their units; to encourage obedience to instructions and

better performance by means of personal instruction and force of example; to

determine shortages of clothing and equipment; and to institute programs of

discussions and demonstrations among small groups, so that all personnel would be familiar with the need for, and the details of, the special measures necessary

to prevent cold injury.

Trenchfoot-control teams were set up too late to exert any substantial

influence on the incidence of cold injury in the European theater during the

winter of 1944-45. By the time they had become fully operational, weather

conditions were improving, German resistance was deteriorating, and the Allied

forces were moving swiftly and victoriously forward toward the Inner Reich.

In spite of the late institution of the program, it was nonetheless the consensus of those who watched the program in operation that it provided an extremely effective means of combating cold injury. This was the opinion of the

personnel of the teams from all five armies which met at the Office of the Chief

Surgeon on 21 April 1945, together with medical inspectors of the various United

States field armies and representatives of Headquarters, 12th Army Group. 56

56 Report, Medical Section, 12th Army Group, to the Adjutant General, 12th Army Group, May 1945, subject

Monthly Summary of Medical Section Activities.
178 COLD INJURY, GROUND TYPE

The general feeling was (1) that this was the best method of bringing preventive

measures to units of company grade and (2) that squad leaders were essential

components of the control program, since they were in close contact, day and

night, with their squadmates and could encourage and guide individual foot

care and discipline.

It was also the unanimous feeling of those present at this meeting that,

should operations be required during the next winter, these control teams should

be reorganized and reactivated before the trenchfoot season began. Finally,

it was decided that trenchfoot-control officers or teams could profitably be

established on divisional as well as army levels.

The full potentialities of the trenchfoot-control program are discussed in

the chapter on prevention (p. 484).

CONFERENCES

Regular conferences were held by General Hawley with base section surgeons. The agenda covered wide range of subjects of both administrative

and clinical significance. Other conferences were held with senior consultants,

and still others with bis division chiefs. Inter-Allied conferences on war

medicine were also held during 1942, 1943, 1944, and 1945. Cold injury,

however, was scarcely mentioned at any of these conferences until after it had

become serious problem in the theater.

At conference held in London on 21 July 1944, attended by various

professional and administrative personnel, General Hawley stated that The

Surgeon General was greatly concerned about the possibility of cold injury

during the coming winter. He emphasized that the causes were well known

and that prevention was the important consideration. The Surgeon General,

General Hawley continued, thought that sock with high wool content

would prevent cold injury, and Colonel Gordon’s division, with assistance from

the Professional Services Division, would at once take up the matter with the

theater chief quartermaster. Three million pairs of pure-wool socks were on

hand in the theater, but the troops did not like them. The alternative might

be to request the Quartermaster General to develop an 80-percent-wool sock.

At this conference, Colonel Gordon stated that material on the subject of cold

injury had been put together and was ready to be published. General Hawley

observed that it would not be of much value if the necessary socks were not

available.

At meeting of his division chiefs on October 1944, General Hawley

stated that he could not himself think that the end of the war was in sight and

that he thought that plans should he made for all eventualities before they

developed. Cold injury was not specifically mentioned as one of the eventualities he had in mind.

On October, at another meeting of his division chiefs, General Hawley
EUROPEAN THEATER 179

stated that in recent visits to various evacuation hospitals of field armies he had found nurses living in cold tents surrounded by water and mud and that respiratory disease rates were increasing. At the meeting of division chiefs

held on 26 October, Col. William S. Middleton, MC, Chief Consultant in

Medicine, Office of the Chief Surgeon, ETOUSA, also reported an upward

trend in respiratory disease in the First and Third U. S. Armies.

conference held in Paris from 14 to 16 October was attended by professional consultants to the British, Canadian, and United States Army forces on

the Continent. Although cold injury was beginning to be evident by this time, the agenda did not include any mention of it. Other conferences were also

held on the Continent, but later, after trenchfoot had already become serious

problem.

At the 10 November meeting of General Hawley and members of his staff,

trenchfoot was mentioned for the first time since the 21 July meeting in London. It was now becoming problem. The shortage of overshoes and the quality

of the socks being issued to the troops were discussed. It was brought out that

the theater quartermaster had said that the supply of socks was more than ample.

At the 30 December meeting of the Chief Surgeon’s consultants committee, in Paris, trenchfoot occupied much of the agenda. The discussion covered

both the clinical manifestations of cold injury and its management, with special

emphasis on the value of prompt exercise. The idea then prevailed that 50

percent of casualties from this cause coidd be returned to duty and that anywhere from to 35 percent of the patients hospitalized in the Communications

Zone could be returned to duty. The experience in the Mediterranean theater

had already shown that the optimism indicated by the figure of 35 percent was

unwarranted. Colonel Middleton remarked that the lack of clinical coordina- tion was shown by the fact that every new unit which encountered cold injury

had to go over the same therapeutic trials and errors that had already been explored by units farther forward.

The February 1945 Inter-Allied Conference was devoted to cold injury. Papers on the subject were presented by Maj. Leiv Kreyberg, Royal Norwegian Medical Corps, Professor of Pathology, University of Oslo; Col. C. S.

Ryles, Professor of Hygiene, Royal Army Medical College; and Raymond

Greene, physician, Emergency Medical Service. Cold injury does not seem to

have been discussed at any of the earlier meetings of this group.

The other conferences held on cold injury and on cold-weather clothing

were not convoked until the problem had become extremely serious.

Conferences on Trenchfoot

In January 1945, just as the epidemiologic survey of trenchfoot in the

European theater was nearing completion, cold injury again began to increase

in frequency. The disappointing increase, the large numbers of hospital beds
180 COLD INJURY, GROUND TYPE

already occupied by casualties suffering from trenclifoot, and the findings of

the epidemiologic survey pointed to the need for pooling of experiences and

general review of the situation. The Chief Surgeon therefore authorized

conference on trenclifoot, which was held in Paris on 24 January 1945. It was

participated in by representatives of the Medical Department, Quartermaster Corps, and G-l (personnel and administration), ETOUSA, the preventive

medicine officers of the several field armies, the officers who had conducted the

epidemiologic survey (p. 176), and the medical and surgical consultants in the

theater. Combat commanders were represented by Col. (later Brig. Gen.)

Sterling A. Wood, commanding officer of the 313th Infantry Regiment, 79th

Infantry Division, who had shown particular interest in, and comprehension

of, the trenclifoot problem.

The discussions and conclusions of this conference in regard to the pathologic process, clinical manifestations, therapy, and prognosis of trenclifoot are

presented elsewhere in this volume, under the appropriate headings. The

opening presentation by Colonel Gordon was comprehensive analysis of the

situation from the standpoint of control. The substance of his remarks was

as follows:

Epidemic cold injury may be compared with waterborne epidemic of

typhoid fever. In such an epidemic, general measures would first be taken,

including the chlorination of water and the institution of general control

program. Then specific measures would be instituted. Focal points of local

outbreaks would be sought for and would be eliminated by the application of

the general epidemiologic principles of focal attack. This procedure had been

followed in the attack on cold injury. Commanding officers in all echelons

had made an energetic effort to educate troops and perfect their discipline.

The chief quartermaster had invoked all the resources of his office to provide

and distribute winter clothing. Finally, the Medical Department had conducted an intensive campaign of instruction in preventive measures for both

units and individuals. In this presentation, the epidemiologic similarities between the trenchfoot situation in Europe and the malaria situation in the

Southwest Pacific were also pointed out.

The analysis of the epidemic of cold injury had revealed decided variations

from unit to unit, whether the unit was an army or battalion. These variations made it clear that future steps in prevention must be directed toward the

smaller units. The small unit did not necessarily require additional general

education and indoctrination. It did not even require more assiduous application of general measures of control. The essential point was that every

company, and even lesser units, must understand the special conditions which

were producing cold injury within their own ranks. These conditions were

not necessarily the same in all units. Frequently, in fact, they were quite

different. If the individuality of the special causative factors were realized,

rotation, for instance, would not be overemphasized in unit in which the

cause of cold injury was the lack of proper clothing or failure to enforce foot

discipline.
EUROPEAN THEATER 181

Special experiences.—Of number of special experiences described in the

course of the discussion, the following are of special interest:

1. When it was found in the Seventh U. S. Army that reinforcements

coming into one division through regular channels or from hospitals were not

acquainted with the facts of cold injury, it was decided, about November

1944, that the convalescent hospital and the replacement depot were good

spots in which to initiate preventive training. At this particular time, it was

the custom in replacement centers to give the troops 30-minute lecture on

their general health, only 10 minutes of which was devoted to the care of the

feet. Trenchfoot was either not mentioned at all or was discussed within

minutes. The lecture period was lengthened to 60 minutes, and at least 30

minutes of the time was devoted to cold injury.

The educational program instituted at the convalescent hospital consisted

of short, informal discussions; radio programs; and the use of articles on the

subject in Stars and Stripes. representative of the Quartermaster Corps

was assigned to the hospital to teach methods of utilizing winter equipment.

Among other things, he demonstrated how easy it was to get out of the sleeping

bag, once the trick was known. This officer, together with Medical Corps

officers, worked down to battalions, companies, and smaller units. As result

of these efforts, the Seventh U. S. Army had become extremely foot conscious.

The same speaker (Lieutenant Colonel Gowan) who reported this effort in

the Seventh U. S. Army also reported the value of individual efforts at instruction. When he visited the 36th Infantry Division, he found that medical

aidman, who was later killed, while serving in lost battalion, had made the

men remove their shoes at intervals, wring out their socks, exercise their feet

and toes, and employ other simple measures to prevent trenchfoot. His work

paid large dividends. Although the tactical and environmental circumstances

were highly favorable for the development of large number of cases of trenchfoot, the number which occurred was very small.

2. The second experience was related by Colonel Wood. In his notes

on the conference, Colonel Cutler stated that this officer’s remarks were “more

effective than any of the professional discussion.” Later, General Hawley

passed on to the surgeons of the field armies Colonel Wood’s suggestion that

every regimental commander could profitably be taken on tour of hospitals

caring for trenchfoot casualties, so that they would comprehend the real

seriousness of the injury.

Colonel Wood knew nothing of trenchfoot until he observed it, as patient

with another condition, in the 40th General Hospital. There he saw enough

of it to make him very much aware of it. Before he returned to his own regiment,

he was able to have conferences on the subject with the Chief Surgeon and

Colonel Cutler.

His remarks concerning his actions thereafter deserve extended quotation:

went in and asked my division surgeon, “What are you doing about trench foot?

He said, “On the 22nd of November we got up circular.” said, “Let’s get it out and

see what it is.” It had come to my regiment when we were in the middle of fighting

438404'—58 -14
182 COLD INJURY, GROUND TYPE

battle. There was one copy to the regiment and there had been no follow-up on the part

of the higher command to see what had happened to it. The regimental commanders did

not know about the dangers of trench foot. worked to have them [the

posters] issued and displayed in every conspicuous place around the area. had ten

basic factors about trench foot printed up and required that every single individual have

one and have the company commanders check to see that they have them personally. Then

talked to the division commander and he sent me to tell all the other regiments in

the command all that had seen. At that time we had no trench foot. We did not know

what we were going to get into. We were fortunate in that we had the shoepac. [In another

connection the speaker said that his own men preferred the shoepac to the combat shoe

and could march 18 to 20 miles in it.] We had ski socks, so that we did have basic equipment.

There was one thing we immediately found. we had never been trained in this type

of foot discipline over here. Colonel Gordon was talking about the original training and

education. We never had any training about trench foot. Command control and

discipline were also mentioned. Now the difficulty as see it is that of command control. peaks [of trench foot] are going to happen because during month’s time in

our organization the noncommissioned officers and officers are casualties and going back.

[They are] the people that will normally handle the supervision to see that the man does

what he should do *.

think the commanding officers have to receive some definite orders, not suggestions.

One of my objections to all these medical bulletins is that you use too long words and that

we don’t know what you are talking about, and that they are too lengthy. They should

be just as brief as possible. We should get them in quantities, so that we can give them

to the man who has to carry them into effect.

Because of the high rate of replacements, in actual practice it means you have to start

to educate people all over again. None of the early training we had even two months ago

will ensure that the individual man does what he is expected to do. We have broken it

down to the noncommissioned officers. Actually have more stable rate of noncommissioned

officers in my regiment than commissioned officers; often the company commander is

second lieutenant who has recently come in. Each man carries one of the papers and he is

checked. They are erased for consideration for Paris pass if they are caught without one.

Then if you can get those leaders to force the men to change their socks, you are doing

great deal in the right direction. That is command responsibility, but in the way we are

scattered up there, the company commander is busy planning what he is going to do next.

It has to be broken down. The regimental commander has to ask the battalion commander

for report of what he is doing on trench foot, which is exactly the same as he must ask if the

men are being fed and supplied. Then he has to insist that the battalion commanders do

the same thing with company commanders, but the men who actually made the men put

on the dry socks have to see them put on *.

One thing we require is that as soon as man gets into any shelter at all, he is to lie down

on his back, elevate his feet and remain there just as long as he can, and wiggle his feet as

much as he can. We have tried to convince them that if for period of thirty minutes time

during twenty-four hour interval, blood can be made to pump into the toes, we can eliminate

great deal of trench foot *.

We have drawn extra duffle bags for every company. All the socks are in the

duffle bags. It doesn’t make much difference in size. All our requisitions are for size

twelve socks. The ration detail comes up at night and takes back with it the duffle bags of

wet wool socks. They come up then with one dry pair of socks for every man in the company. After forty-eight hour period we are getting duffle bags and dry socks for

every man in the company. That is the rotation system and we are able to use it most of the

time. If you can gel food to the men, you can also get socks to the men. It can be done if it

is ordered, and the same thing applies about wearing socks. When we are ordered to do

something, we do it without any question, but if the division surgeon comes up and says,

“I think it would be good idea to get dry socks every day,” it just doesn’t get done, and
EUROPEAN THEATER 183

would like to recommend that the recommendations from here go down through command

channels. By that way the line officer does what he is told automatically without thinking

whether it can be done; if we leave it to him, it won’t be done. think it would be much

simpler just to tell him to do it.

In reply to questions, the speaker stated that one man, preferably the mess

sergeant, should be made responsible for the dry socks. He also lecommended

that education on trenchfoot be given in the reenforcement depot, to make

company officers conscious of the problem before they went forward. Second

lieutenants were often company commanders within few days after they had

joined the regiment, and, if they had not been previously instructed concerning

cold injury, it was necessary to wait for break before the matter could bo

taken up with them.

Conclusions and recommendations.—The general responsibility for trenchfoot was particularly emphasized in the discussions at the conference. It was

distributed among (1) the individual soldiers, who had to take care of their

own feet; (2) command, which had the responsibility of training the soldiers

and seeing that they did what they were told to do; (3) the Quartermaster Corps,

which had the responsibility of providing clothing and footgear suitable for

winter combat; and (4) the Medical Corps, which had to keep the various

command and quartermaster echelons informed about cold injuries, without at

the same time letting the individual soldier believe that he was going to lose

his legs from this cause.

The most universal fault, the conference concluded, was poor foot discipline, and the timehad arrived for firm and definitive action within units in which

this deficiency was evident. The similarities between the trenchfoot situation

in Europe and the malaria situation in the Southwest Pacific suggested that

improvement could be accomplished in Europe by the same approach that had

been effective in the Pacific; that is, the use of control teams for individual

inspection, education, and discipline.

recommendation embodying the concept of control teams was supported,

and the necessary steps were taken later to form such team in each of the field

armies (p. 177 and appendix G).

After the trenchfoot teams had been appointed in accordance with the

directive authorizing their establishment, Col. Tom F. Whayne, MC, preventive

medicine officer of the 12th Army Group, suggested that it would be profitable

for members of the teams from the various armies to meet with preventive medicine officers from the armies as well as representatives of the theater and the

army groups, in order to discuss the functions of the teams and methods of procedure. This conference was held in Paris on 16 February 1945.

Quite properly, because of the command and training implications of the

cold injury problem, the conference was opened with general discussion of the

whole problem by representative of G-3, ETOUSA. The medical aspects of

the problem were then discussed by General Hawley. resume of causative

factors, the present status of the cold injury situation, and the principles of the

control program were presented by Colonel Gordon. This (morning) session
184 COLD INJURY, GROUND TYPE

was concluded by roundtable discussion in which members of the trenchfootcontrol teams and others participated. Many practical aspects of the problem

were covered. The afternoon session, which was entirely clinical, was held at

the 108th General Hospital, at which special study of patients with trenchfoot was in progress. After an opening clinical lecture on the nature of cold

injury, patients were presented and methods of treatment were demonstrated

and discussed.

The over-all effectiveness of the trenchfoot-control program could not be

evaluated in the European theater because, at about the time the control teams

went into action, the weather ameliorated and, with the thaw that occurred,

cold injury began to decrease. It was, however, the consensus of all who had

participated in the first conference that second conference, attended by essentially the same personnel, should be called to review the activities of the teams

and of the officers and noncommissioned officers who had been responsible for

the implementation of the program. It was hoped that enough information

could be brought out to permit some sort of evaluation of the operations of the

control teams. This conference was held in Paris on 21 April 1945.

The program of the second conference, after the opening remarks by

Colonel Gordon, was devoted to discussions of foot discipline, weather, clothing

and equipment, operational conditions, and similar matters. The experience

of certain divisions of the Seventh U. S. Army which had previously been

exposed to cold injury was compared with that of other divisions which had

had no previous experience in winter combat. It was the consensus of those

present (1) that the plan of using control teams provided an effective and

profitable means for the control of cold injury; (2) that it greatly enhanced

the training of the individual soldier and the small unit in their own responsibilities in the matter; and (3) that it also utilized the elements of command,

supply, and medical personnel in well-coordinated and interlocking combination.

It is highly significant that the majority of the members of this second

conference (13 of 15), all of whom had observed trenchfoot under combat conditions, concluded that, in the control of trenchfoot, the most important of all

considerations was individual foot care, followed, in order of importance, by

adequate clothing and equipment and sound rotation policies. Bad weather,

although it is the fundamental cause of all cold injury, was given the place of

least importance by all the officers voting.

Conferences on Winter Clothing

The conference on winter clothing which the chief quartermaster had

planned to call for late December 1944 was necessarily postponed because of

the German breakthrough in the Ardennes which occurred at that time. The

conference was eventually held in Paris on 29 January 1945, and followup

conference was held in the same city, with much the same personnel in attendance on 17 March,
EUROPEAN THEATER 185

detailed record of these conferences is not the proper concern of this

volume, but certain general facts may be stated. 57 It had been the hope of the

chief quartermaster that the conference would recommend simple, basic

uniform, suitable for all branches of the Army and planned in accordance with

limitations of transportation and production. As he pointed out, the United

States Army had 70 items of basic winter clothing, against 11 basic items for

the British Army. The British Army had made its plans for simple uniform at the beginning of the war and did not change them; as result, it did not

experience the shortages and inadequacies of various items which constantly

plagued the United States Army.

The two conferences did not accomplish the goal which the chief quartermaster had set for them, but they did improve matters by reducing

the 70 basic items of clothing by 21, the number of sizes by 29, and the number of fabrics required in the manufacture of the uniform from 10 to 4.

As to clothing, it has been correctly said that the items finally decided

upon represented weighing of preferences rather than meeting of minds.

This was because the clothing recommended by the Quartermaster General

had been thoroughly tested only in the Fifth and Seventh U. S. Armies, which

had used it with satisfaction for two winters. The 12th Army Group, which

expressed preference for the obsolete armored force uniform, had scarcely

tested the new items which it was voting against. On the whole, the conclusions finally arrived at were much the same as those arrived at by members

of the trenchfoot-control teams who had observed cold injury at first hand in

the field. On one point, at least, there was unanimity, that the shoepac was the

most acceptable footgear for frontline troops to wear in winter.

CLINICAL INVESTIGATIONS

Mention has already been made of the study of cold injury in Air Force

personnel undertaken in 1943 at the 2d General Hospital in the United Kingdom

(p. 134). number of other studies were undertaken when cold injury became

prevalent among ground troops in the European theater in November 1944, but most of them were informal and concerned only small series of cases. One

of them was study of therapeutic methods at the 110th Station Hospital.

Another was study of negative pressure therapy at the 7th General Hospital.

Still another was an investigation at the 92d Medical Gas Treatment Battalion,

Third U. S. Army, to determine what type of casualty could be retained in the

army area for treatment with the expectation of return to combat duty. Incidentally, several hundred men were returned to duty under this plan.

In view of the excellent results obtained by the formal study of influenza

and empyema undertaken in World War I, it is unfortunate that trained investigators were not sent from the Zone of Interior to the European theater to

57 Letter, Maj. Gen. Robert M. Littlejohn, Chief Quartermaster, ETOUSA, to the Quartermaster General, May

1945, subject; Winter Uniform.
186 COLD INJURY, GROUND TYPE

set up similar studies for cold injury. Not great deal could be done by personnel in the European theater. All facilities were heavily involved in the care

of patients. The clinical material, paradoxical though it may seem, was much

too abundant to permit extensive, properly controlled studies to be set up

generally.

Early in October 1944, Colonel Crisler of the First U. S. Army had suggested

to Colonel Cutler that hospitals for specialized care of trenchfoot should be

set up in each army and should be staffed by medical officers experienced in this special field. Colonel Cutler transmitted the suggestion to Colonel

Kimbrough, but events, unfortunately, moved too fast for this excellent plan

to be carried out. The exchange of information at the trenchfoot conference in Paris in January 1945 (p. 179) permitted the evaluation of various diagnostic and therapeutic techniques, but it was then too late to institute formal investi- gations.

The single formal study of trenchfoot in the European theater was made

at the 108th General Hospital, under the direction of Capt. (later Maj.) Octa

C. Leigh, Jr., MC. Consultants on the project included Col. Johan C. Holst,

consultant in surgery to the Norwegian Army in the United Kingdom, and

Major Krejffierg. The specific objectives of the study were to provide

simple, workable classification for rapid triage; to study various methods of

therapy; and to accumulate as much practical data as possible concerning the

duration of exposure, the duration of immobilization, the kind of footwear

worn at the time of injury, and similar matters. The details of this investigation are cited in appropriate places throughout this volume. The investigation, unfortunately, was not as complete as it might have been because the

special equipment required, including skin temperature thermocouples and

capillary microscopes, was received too late to be entirely useful.

Plans for study of anticoagulant therapy (heparin) in cold injury were

proposed by the Medical and the Surgical Consultants Division, Office of the

Surgeon General, but for variety of reasons this project could not be carried

out. The rationale of this type of therapy is discussed elsewhere (p. 326).

REPORTING AND NOMENCLATURE

War Department Technical Bulletin (TB MED) 92, issued 15 September

1944, provided that War Department MD Form 86ab, though intended for

use in reporting communicable diseases, should also be used to report trenchfoot, immersion foot, and frostbite under special heading. The reason

for the use of this form was that reports made on MD Form 52 would be too

late to accomplish one of the most important purposes of the Statistical Health

Report namely, to furnish current information on the incidence of communicable diseases.
EUROPEAN THEATER 187

When trenchfoot became epidemic in the European theater, it was found

that Form 86ab was not providing statistical data quickly enough to be useful, and Form 323 was substituted for it.

Form 323 was daily report prepared by all medical units in the theater

primarily for use by the Office of the Chief Surgeon; it permitted the reporting of epidemic conditions without loss of time. Reports made on this form,

however, were less exact than reports made on Form 86ab. For this reason

and as result of different methods of reporting, the first statistics secured for

cold injury contained some inaccuracies, chiefly in the form of overreporting.

The errors, which were sometimes substantial, were finally all corrected. Because of necessary wartime classification of medical casualty reports,

higher headquarters at times encountered some difficulty in associating the

casualties from trenchfoot with the exact unit in which they occurred and the

location of the unit on the battlefront. From the standpoint of Colonel

Gordon’s office in Paris, the secrecy with which military operations were being

carried on delayed the evaluation of the reports of trenchfoot as they were

submitted, first weekly and then daily. The condition appeared suddenly,

and the number of casualties increased rapidly. Colonel Gordon apparently

had difficulty, from the reports which he received at first, in determining the

exact units which were most affected and their location. Division, corps, and

army surgeons, who were closer to the trouble, of course did not have this

difficulty.

Other problems, however, were not settled during the entire war. The

first was the category in which cold injury belonged in statistical reports.

The second was the nomenclature to be employed for it. The third, which

arose out of the confusion in the nomenclature, was the award of the Purple

Heart for cold injury (p. 189).

Because oflack of clarity in directives, trenchfoot and immersion foot were

at one time or another included in medical statistical reports both as nonbattle

injuries and as diseases, while frostbite was variously considered as both

battle and nonbattle injury, depending upon the interpretation of the individual command. As long as cold injury was not major problem in the

theater, the confusion did not make too much difference. In November 1944, with the outbreak of what proved to be true epidemic, the confusion became

serious. It resulted in both underreporting and overreporting, and it added

further to the administrative difficulties which arose in connection with the

award of the Purple Heart.

As pointed out elsewhere, the terms “high-altitude frostbite,” “immersion

foot,” “trench foot,” and “frostbite” were developed as matters of expediency,

when the now generally accepted concept of cold injury, that all of these

conditions represent varying degrees of the same fundamental pathologic

process, did not exist. The distinction between these conditions is not of

major importance and is often artificial. In World War II, in fact, trench-
188 COLD INJURY, GROUND TYPE

foot was often, in effect, immersion foot, and the distinction between trenchfoot and frostbite was usually made according to the environmental temperature at the time the injury was sustained. If the temperature was

above 32° F. (0° C.), the diagnosis was trenchfoot; if the temperature was

below this level, the diagnosis was frostbite. When weather records were

lacking or incomplete in any area, as they frequently were, this entirely artificial

distinction broke down, and the diagnosis rested with the individual medical

officer.

The principal source of the confusion was administrative. Circular Letter

No. 156, Office of the Chief Surgeon, ETOUSA, dated 20 October 1943, directed

that cold injury be designated as (1) high-altitude type, (2) ground type, and

(3) immersion foot. When TB MED 81 arrived in the theater the following

year, it left the theater Chief Surgeon and The Surgeon General at variance

over the nomenclature of cold injury. The opinion was rather freely expressed

that the term “trenchfoot” would persist, which it did, although formal recognition was not given to the popular nomenclature until 18 November 1944, when Circular Letter No. 156 was rescinded with the issuance of Circular

Letter No. 134, Office of the Chief Surgeon, ETOUSA. Nothing seems to have

come of the sensible suggestion of the senior consultant in orthopedic surgery,

Col. Mather Cleveland, MC, that the term “foxhole foot” would be better than

“trenchfoot,” since this type of cold injury seldom occurs in large, roomy

trenches, in which men can move about, but does develop in foxholes, where

they are very often almost completely immobilized.

Circular Letter No. 94, Office of the Chief Surgeon, ETOUSA, 31 August

1944, directed that patients admitted for cold injury and retained more than

24 hours (that is, for more than food and rest) should be classified as battle

casualties. This regulation was frequently violated, with the result that

hospital registrars were confused, and statistical reporting was becoming

inaccurate. On 30 November 1944, Col. David E. Liston, MC, Deputy

Surgeon, ETOUSA, directed that for the time being all cases of trenchfoot

should be classified as nonbattle injuries. Shortly before, Colonel Kimbrough

had recommended to General Hawley’s executive officer that the relevant

portions of Circular Letter No. 94 be altered and that disabilities due to exposure be listed as diseases.

Because of the mounting confusion, General Hawley’s office requested

War Department ruling on the classification of trenchfoot, immersion foot, and

frostbite incurred in combat areas. The reply, dated December 1944, directed

that these injuries should not be classified as battle casualties. This ruling

was reaffirmed in April 1945.

The reports indicate that trenchfoot and frostbite were both reported as

trenchfoot up to the end of 1944. Thereafter, they were reported separately,

although the distinction, as already mentioned, was artificial in the extreme.

Many medical officers experienced in this type of trauma always thought that

the three categories (immersion foot, trenchfoot, and frostbite) would better

have been considered under the generic heading of cold injury, if only because
EUROPEAN THEATER 189

more correct concept ol the etiologic factors and pathologic process would

thus have been obtained. The terms of the award of the Purple Heart, however, made it necessary to continue the separate classifications.

AWARD OF THE PURPLE HEART

One of the byproducts of cold injury, which arose principally in the

European theater, was the troublesome, entirely administrative, problem

created by the award of the Purple Heart. At least part of the difficulty arose

from the confusion in the nomenclature of cold injury, which has just been

summarized.

This award, which had been established by Gen. George Washington at

Newburgh on August 1782, during the War of the Revolution, and which

had lapsed shortly afterward, was revived on 22 February 1982, on the 200th

anniversary of his birth, “out of respect to his memory and military achievements,” in War Department General Orders No. 3. The award was to be

given to members of the United States Armed Forces wounded either in action

against an enemy of the United States or as direct result of an enemy act,

provided that the wound thus incurred required treatment by medical officer.

For purposes of the award, wound was defined as “an injury to any part of

the body from an outside force, element or agent sustained as the result of

hostile act of the enemy or while in action in the face of the enemy.” The

word “element,” it was specified, “refers to weather and permits award to

personnel severely frostbitten while actually engaged in combat.” It was

stated, equally specifically and entirely illogically, that trenchfoot did not

merit the award.

Army Air Forces.—The question of awarding the Purple Heart for cold

injury first arose in World War II in connection with cold injury in flying

personnel. In September 1943, the Preventive Medicine Division, Office of

the Chief Surgeon, ETOUSA, concurred in the opinion that this type of cold

injury justified the award. few weeks later, however, the inconsistencies of

this policy were pointed out to G-l, ETOUSA, by General Hawley in line of

argument to be repeatedly advanced in connection with this award. The

Purple Heart, the Chief Surgeon pointed out, was command, not medical,

problem. Frostbite was disability produced by the hardships of service, not

by enemy action, and it was usually preventable. While it could result from

defects in equipment, it was more likely to result from individual carelessness.

Protective clothing might be damaged by enemy action, but, if the principle

upon which the Purple Heart was being given for cold injury in flying personnel

were applied consistently, it was hard to see where the line was to be drawn;

the award might as reasonably be made for pneumonia, tonsillitis, and cold

in the head, all of which might develop after exposure. Furthermore, if men

in the Eighth Air Force were given awards for frostbite, every soldier on the

ground who had sustained cold injury also deserved it. Awards were not
190 COLD INJURY, GROUND TYPE

given for cold injury in the Royal Air Force. On the contrary, each injury

was investigated, to determine whether damage to protective clothing had

occurred by enemy action or by negligence.

In May 1944, when changes were made in Army Regulations (AR) 600-45

(Changes No. 4) concerning the terms of the award, reference to cold injury

in flying personnel was deleted and the term “element” was defined, without

restriction, as referring to the weather. It was again specified that, while severe

frostbite sustained in combat justified the award of the Purple Heart, trenchfoot did not.

Residua of the Aleutians campaign.—The Purple Heart was apparently

never serious administrative problem in the Mediterranean theater either in

the winter of 1943-44 or in the following winter. Questions concerning it next

arose in June 1944, in connection with the residua of cold injury in the Aleutians

campaign. Immersion foot, as cold injury incurred in that area was called,

was not mentioned in the regulations for the award, and the commanding

general of the 7th Infantry Division, whose troops had suffered heavily from

cold injury during that campaign, recommended that the Purple Heart be

given for immersion foot.

When the correspondence on the subject was referred to the Surgical

Consultants Division, Office of theSurgeon General, thereply sent on 15 September 1944 agreed that the current regulations were unfair for number ofreasons:

1. Many soldiers incur trenchfoot while actually in combat and are more

seriously injured than some who incur frostbite, even if it is severe.

2. They may lose one or both lower extremities as result of their injury.

3. Although immersion foot, trenchfoot, and frostbite develop under

different circumstances, the basic pathologic process and the clinical manifestations are similar, the difference being in degree, not in kind.

In view of these facts, it was recommended that, since all three types of

injury might be incurred in actual combat, the disputed paragraph (16A)in

AR 600-45 should be altered to read: “In connection with the definition of the

‘wound’ above, the word ‘element’ refers to weather and permits award to

personnel severely Frostbitten or incurring Immersion Foot or Trench Foot

while actually engaged in combat.”

In subsequent weeks these arguments were reiterated and expanded in

the Surgeon General’s Office. On October 1944, the Surgeon General’s executive officer wrote to the Decorations and Awards Branch, Office of the Adjutant

General, that specifications as to the severity of cold injury were not regarded

as practical, partly because injuries without loss of structure might be graver

than those in which tissue is not lost.

On October 1944, Brig. Gen. (later Maj. Gen.) Russell B. Reynolds,

GSC, Director, Military Personnel Division, Headquarters, Army Service

Forces, recommended to G-l, War Department, that the regulations be altered

to permit the award to personnel who had incurred trenchfoot or immersion

foot as well as frostbite if they were actually engaged in combat, if theyrequired

amputation of part, or if the injury required hospitalization. The changes
EUR()PEA THEATE 191

proposed were not made, but, on 21 October 1944, the deputy chief of staff

settled the question which had arisen in connection with cold injury in the

Aleutians campaign by authorizing the 7th Infantry Division commander, who had raised the question, to make the award to members of his division who had sustained immersion foot during the Attu operation if the injury had

been incurred in actual combat and if it had resulted in amputation of part

or in other permanent injury.

European theater.—Meantime, the matter was again coming to head in

the European theater, this time in connection with the ground type of cold

injury. As the weather became colder and wetter, and as cold injuries increased in numbers, the situation became more and more confused and unsatisfactory,

especially from the administrative standpoint.

On 25 November 1944, Colonel Gorby, the 12th Army Group surgeon and

an experienced field medical officer, pointed out to G-3 of the army group that

itwas not at all fair to limit the award to amputees since more lasting incapacity

might be incurred without any loss of tissue. His own opinion, however, was

that the award should not be given for any type of cold injury, Trenchfoot

was preventable. It was the responsibility of the individual soldier and of his

commanding officer to prevent it. Its occurrence usually indicated poor training, poor command, and poor soldiering. The medical officer was in no position

to determine whether it was or was not preventable in any given case, and it

would be more logical to award it for diseases which could not be prevented.

If word got about that the Purple Heart was to be awarded for cold injury, an

immediate increase in hospital admissions could be expected; it would be

good way out for potential S. I. W. (self-inflicted wounds). The Russians,

although they were fighting in an environment productive of cold injury, had

very little of it because in every instance, no matter what the circumstances,

disciplinary action was taken against the injured man and his commanding

officer. In Colonel Gorby’s opinion, disciplinary action rather than awards

would reduce the personnel losses due to cold injury. No definitive action

resulted from these sound arguments.

Still other complications were arising. Line officers, out of consideration

for their men, naturally wanted liberalization of the regulations, to permit

the Purple Heart to be awarded for trenchfoot. On the other hand, just at

this time, the concept of command responsibility for cold injury was beginning

to be comprehended, and those charged with the prevention of the injury

objected, with logic, to making nominations for an award to be presented for

the very condition which they were ordered to prevent. The conflict of interests, centering around the criteria for awarding the Purple Heart and

complicated by the confusion of nomenclature just described, actually tended

to affect the Adjutant General’s accounting of battle casualties.

The Purple Heart came in for considerable discussion at the conference

on trenchfoot held in Paris in January 1945 (p. 179). It was pointed out

that in view of the terms of the award, which required distinction between

frostbite and trenchfoot, the nomination of the man for the award really
192 COLD INJURY, GROUND TYPE

rested with the medical officer who first saw the patient, since lie was aware

of weather conditions and duty status. It was therefore an error, which

should not be permitted to continue, to change the diagnosis in evacuation

hospitals in any case of cold injury unless there was sound clinical evidence

of diagnostic error. If this plan were followed, the award would at least be

made consistently, for the diagnosis would be consistently right or consistently

wrong. General Hawley said that, over his opposition, the award had been

extended to such absurd lengths that it might as well be issued with rations.

No change in Army Regulations was made during the epidemic phase of

cold injury in the European theater. The award continued to be matter of

administrative controversy, with the Medical Department, because of its

exclusive power to determine diagnoses, squarely in the center. On February

1945, General Hawley wrote The Surgeon General that the wording of the

regulation (severely frostbitten) could be interpreted to apply only when the

lesion was so extensive that cells were killed and there was an actual loss of

part, or slough through the whole thickness of the corium. He said that,

as practical matter, it was not possible to distinguish between frostbite

and other forms of cold injury. The hospital wards, he said, were full of embittered infantrymen who had sustained trenchfoot, often of serious degree,

but who were not entitled to the Purple Heart. The Medical Department

was being required to administer policy which it had not set up and which it

could not administer fairly. Forward units were conferring the Purple Heart

and were not being too strict about it, under pressure from frontline commanders who demanded liberality in the award to keep their troops reasonably

mollified. As the situation now stood, General Hawley added, men with

simple blisters caused by frostbite were receiving the Purple Heart while men

with incapacitating lesions from trenchfoot were not getting it.

On 26 February, General Hawley pointed out to the surgeons of the other

armies in the European theater that the Third U. S. Army did not authorize

the award because of the difficulty of determining the degree of severity of

the injury within the period established for holding these casualties in the

theater. He felt that the same step could well be taken in other armies in the

theater.

The last War Department message on the subject received in theEuropean

theater did nothing to resolve the difficulties connected with the award. In

April 1945, in response to second inquiry from the theater concerning the

classification of cold injuries, the Adjutant General’s Office replied that

trenchfoot, immersion foot, frostbite, and injuries similar to them would not

be reported for statistical purposes as battle casualties but that the award

of the Purple Heart to personnel severely frostbitten while actually engaged

in combat would not be affected by this ruling. This meant, in effect, that

although cold injuries were not to be classified as battle casualties the Purple

Heart, which is an award for an injury sustained in battle, would continue to be

given for one type of cold injury but not for the other two.
EUROPEAN THEATER 193

The General Board, United States Forces, European theater, trenchfoot

(cold injury, ground type).—The General Board which investigated, among

other matters, the subject of trenchfoot in the European theater later in 1945

(p. 208) stated that just and equitable award of the Purple Heart for cold

injury was possible only if it was authorized for all casualties who sustained

cold injuries while actually engaged in combat, and only if the injuries were

of sufficient severity to require treatment by medical officer. The Board

recommended that the current policies be reviewed and that the award either be

granted for both trenchfoot and frostbite or not be granted for either. Before

the award was recommended in any instance, consideration should be given to

such factors as combat and weather. It should also be determined whether

or not the injury was due to negligence or to deliberate intent or was avoidable

and to what degree it was attributable to enemy action.

Action in the Zone of Interior.—When casualties from overseas began to be

returned to the United States, the problem of the award of the Purple Heart

for cold injuries came to the fore in this country. For example, in February

1945, the commanding officer of the United States Army General Hospital,

Camp Carson, Colo., which was trenchfoot center, wrote to The Adjutant

General 58 that the great majority of the patients under his command had received their cold injuries while fighting for their lives, under very unfavorable

conditions of combat. Many had been pinned down for days in water-filled

foxholes, continuously raked by machinegun fire and periodically subjected to

tank assaults. Some had been kept for days on outposts and patrols and could

not possibly remove their shoes. Some had been in combat for as long as 30

days without extra socks. There could be no question of personal neglect in

such cases. Moreover, many of these casualties were likely to have serious

sequelae, ranging from severe paresthesias and hyperhidrosis to gangrene,

possibly with amputation of half the foot.

In fairness to these casualties, as well as in the interests of uniformity, the

letter proposed that policy be established whereby the Purple Heart would

be given for trenchfoot on two criteria: (1) That the disability be acquired in

combat and (2) that it be sufficiently disabling to require evacuation to the

Zone of Interior. It was further proposed that the award be accomplished in

Zone of Interior hospitals, after thorough investigation of the records in each

case. These proposals were concurred in by the commanding general of the

Seventh Service Command.

When this communication was referred to The Surgeon General by The

Adjutant General for comment and recommendations, The Surgeon General

expressed complete accord with the views of the basic communication and

reiterated the recommendations made by his office on October 1944 (p. 190).

It was specified again that if soldier was to receive the award, his injury must

have been incurred during actual combat and that its severity must have been

58 Letter, Col. T. E. Harwood, MC, Commanding Officer, U. S. Army General Hospital, Camp Carson, Colo., to The Adjutant General, 12 Feb. 1945, subject: Award of Purple Heart.
194 COLD INJURY, GROUND TYPE

sufficient to require hospitalization. Evaluation of the severity of the injury

was considered impractical. It was pointed out again that injuries without

loss of tissue might prove to he graver than those in which tissue was lost.

In memorandum dated April 1945, addressed to Maj. Gen. George F.

Lull, Deputy Surgeon General, Lt. Col. Hoy H. Turner, MC, acting director

of the Medical Consultants Division, Office of the Surgeon General, pointed

out that Army Regulations 600-45, Changes No. 5, dated 11 November 1944,

permitted the award of the Purple Heart for severe frostbite, while trenehfoot

was not considered to merit the award.

At the time this change was made, Colonel Turner pointed out, frostbite

was limited almost entirely to flying personnel. In April 1945, however,

large number of patients at the United States Army General Hospital, Camp

Butner, N. C., were suffering from trenehfoot, and the clinical picture in these

cases could not be differentiated from that of patients in the hospital suffering

from frostbite. Existing regulations about the award of the Purple Heart

were cause of impaired morale and unfavorable criticism of the Medical

Department, and it was suggested that consideration be given to change in

the regulations, so that severe trenehfoot would also merit award of the Purple

Heart.

In the third endorsement of the basic communication, dated 14 April 1945,

Maj. Gen. Norman T. Kirk, The Surgeon General, recommended to Gen.

Brehon B. Somervell, Commanding General, Army Service Forces, that AR

600-45, paragraph 16a (2), be either amended to include immersion foot and

trenehfoot or rescinded insofar as it authorized the award of the Purple Heart

for frostbite. In doing so, General Kirk also mentioned the memorandum

submitted by his office on October 1944 to The Adjutant General (p. 190).

In memorandum addressed to the Professional Administrative Service

of the Surgeon General’s Office on 18 May 1945, Brig. Gen. Fred W. Rankin

proposed that the regulations governing the award of the Purple Heart be

changed either to exclude the award altogether for cold injury or to authorize

the award for all nonpreventable cold injuries actually sustained in combat if

the injury necessitated hospitalization while in service. It was noted that the unfair regulation differentiating between frostbite, for which the award was

authorized, and trenehfoot, for which it was not, had just been perpetuated

in Changes No. 6, AR 600-45, dated May 1945.

When the War Department G-l concurred in this suggested change with

the proviso that the award be made only if the cold injury resulted in amputation or partial amputation of member, the action reopened the question

which had already been so warmly debated. The Surgeon General’s Office took exception, on the ground that amputation was not suitable criterion of

injury. soldier severely frostbitten on the cheek, chin, or forehead would

not receive the award by this criterion; neither would casualty with serious and perhaps permanent impairment of the local vascular tree, though he would

be left with major disability. Furthermore, the great emphasis placed by
EUROPEAN THEATER 195

the Army upon the preventable nature of cold injury had to be taken into

consideration, even while it was remembered that circumstances beyond individual control might be responsible for any gradation of the injury. It was

therefore recommended that if the Purple Heart were to be given at all for cold

injury, three criteria must be met:

1. The injury must be severe.

2. It must require hospitalization.

3. It must be ascertained that the circumstances of the injury were not

preventable and were beyond human control.

The president of the War Department Decorations Board did not look with

favor upon proposal that the whole matter be dropped on the ground that

there woidd probably be few instances of cold injury in the future. He took

the position that since the question had been raised it should be settled. He

suggested that the criteria of award should include proviso that the injury

had not been incurred as the result of the soldier’s own negligence or misconduct.

To some extent, this woidd take care of possible malingerers and would put the

responsibility on medical officers. little later, G-l of the War Department

concurred with the suggested changes, on the ground that if the award was

made for one injury it should be made for all.

In July 1945, the Adjutant General, Army Ground Forces, recommended

that the award should not be given for frostbite. He wished wound to be

defined as “*

physical injury to any part of the body from an outside

force, or from noxious agent used as weapon, sustained as result of hostile act of the enemy or while in action in the face of the enemy.” He considered that any substantial departure from this definition was confusing and

detracted from the prestige of the Purple Heart, which should be maintained.

This letter also repeated the arguments that the award was no more logical

for cold injury than for pneumonia, malaria, and other medical conditions;

that there was no point at which to stop if any single type of nonbattle casualty

were to be considered basis for the award; and that the problem was complicated by the fact that cold injury might or might not be preventable.

While this correspondence was in progress, Changes No. 7, All 600-45, was

issued on 14 July 1945, with the disputed paragraph as it had appeared on

May 1944 (Changes No. 4), before the most recent argument about it had

arisen. This meant that personnel severely frostbitten while actually engaged

in combat might continue to be awarded the Purple Heart, but that the award

would be withheld from soldiers who acquired trenchfoot under precisely the

same circumstances. 59

59 The paragraph in question remained unchanged until May 1951, when the recommendation was revived that the

Purple Heart should not be awarded for frostbite. In the notation from Q-l for the Chief of Staff, United States Army,

it was pointed out that the Air Force and Navy had eliminated the award for cold injury, and that the Army, to provide formore uniform standardsofawards, should also eliminateit. This recommendation was concurred in on all levels,

and the Chief of Staff on 23 August 1951 approved the elimination of frostbite and trenchfoot as reasons for the award of

the Purple Heart (Changes No. 4, AR 600-45). The award was therefore not made again during the remainder of the

ar in Korea.
196 COLD INJURY, GROUND TYPE

PUBLIC AND CONGRESSIONAL REACTIONS TO THE

TRENCHFOOT SITUATION IN EUROPE

During the entire period in which trenchfoot was epidemic in the European

theater there was intense public interest in the situation in the United States.

Full cooperation was given to newsmen working in the theater; they were supplied with as much information as military security permitted. Numerous

stories appeared in the lay press. Much of the material was accurate and

was fairly presented. Much of it, however, was not, and even the most accurate

accounts usually failed to make clear that the trenchfoot problem was complex

one and that it was not possible to simplify it by incriminating any single

factor or any single set of circumstances.

How completely the situation could be misunderstood is apparent from

the following extracts from letter which was received by Senator Robert A.

Taft from one of his constituents. 60 After noting published reports of the

widespread incidence of trenchfoot and “frozen feet,” the writer continued:

have also noted the statement attributed by Gen. Lear that the cause was more

question of discipline rather than adequate foot wear. Knowing Gen. Lear’s passion for

discipline, suppose he would say the soldiers could fight in their shirt tails as long as they

were properly disciplined.

That may be all right on sunny golf course in the South but would hardly apply to

the fighting front during an European winter. Inadequate foot wear may be the reason

but reason is not an excuse for the proper army authorities failure to provide proper foot

gear. With the benefit of the knowledge obtained by the experience of our Allies both

British and Russian, there appears to be no excuse for overlooking this important matter.

Why not hand out little discipline to the disciplinarian who failed?

Senator Taft sent the letter to General Kirk. In his reply, General Kirk

pointed out that trenchfoot was many-sided problem, with many causative

factors, one of which was discipline. The Senator’s correspondent had apparently misinterpreted the meaning of the word discipline, which in connection

with trenchfoot meant the enforcement of foot care and other measures designed

to prevent the soldier from contracting trenchfoot through carelessness. Combat troops were correctly trained in these precautions, but, unless the regulations were rigidly enforced, they would not prevent cold injury.

On March 1945, the Mead Committee, formally known as the Special

Committee for the Investigation of the National Defense Program, requested

the commanding general of the Army Service Forces to make an inquiry into

all phases of trenchfoot in Europe, with special reference to medical reports

and the performance of procurement and supply agencies charged with furnishing proper equipment. After several conferences, and the submission on 15

March 1945 of written report on the activities of the Surgeon General’s Office

in connection with cold injury, 61 it became evident that to secure all the material

60 Letter, H. J. Hamlin, to Sen. Robert A. Taft, Feb. 1945. 61 Memorandum, The Surgeon General, for Mr. Julias H. Amberg, Special Assistant tor Secretary of War. 15 Mar.

1945, subject: Trench Foot Control—MedicalDepartment Action.
EUROPEAN THEATER 197

which tiie committee had requested would require an on-the-ground investigation in the European theater itself.

The investigation was carried out by Lt. Col. (later Col.) Mason Ladd,

JAGD, director of the Legal Division, Office of the Surgeon General. His

formal report, which was submitted to The Surgeon General on June 1945,62

covered the following subjects: (1) Action of the Chief Surgeon and surgeons

of army groups and armies, European theater, to prevent the development of

trenchfoot; (2) factors causing trenchfoot; (3) observations of the British

experience with trenchfoot; (4) trenchfoot as fixed hazard in fighting of the

type experienced in the winter of 1944-45; and (5) miscellaneous comments.

The report contained copies of the circular letters and other material

issued on the subject of trenchfoot, interviews with various observers in the

European theater, extracts from official diaries, statistical data, data on amputations for trenchfoot; and reports of conferences with The Surgeon General

and officers of the British Army.

The conclusions arrived at by Colonel Ladd as result of this investigation

were as follows:

1. Efforts in the prevention of trench foot in the Office of the Chief Surgeon, ETO,

and in the medical service in this theater, are considered to represent an efficient and thorough

dealing with the problem. The work was commenced timely, but became effective only

after the initial outbreak of cold weather injuries. When the problem became appreciated

generally as serious threat to military operations, complete cooperation was given by the

entire theater command. Although training in foot discipline had been carried on in the

ZI and in this theater, its significance in the prosecution of the war on the Continent was not

fully appreciated by the troops until the incidence arose. An army-wide education program

on the control of trench foot was initiated and successfully carried out.

2. The reduction of trench foot is believed to involve the following controllable factors

in order of significance as listed below;

a. Discipline in care of feet.

b. Footgear and clothing.

c. Rotation of troops (short and long term).

3. Among those contacted the shoepac with ski socks, one or two pairs, was

regarded as the most suitable footw ear for cold, wet weather in combat operations, although

the necessity of discipline in its use, and the need for proper fitting were emphasized. For

ordinary use, an improved, water-proofed combat boot with the smooth surface of the leather

on the exterior was believed desirable. system by w'hich exchange of types of shoes

according to weather conditions, as practiced in some units of the army last winter, was

also favored.

4. The subject of supply of winter footwear and winter clothing is matter pertaining

to the Office of the Chief Quartermaster, and is not covered in this report. Based upon

opinions expressed by Medical Officers, the matter would appear academic for this theater,

as the ordinary winter clothing of the type issued generally during last fall should be fully

adequate for ordinary winter conditions and action of the Army of Occupation. The production of new supplies will undoubtedly include improvements realized out of the winter’s

experiences. The later types of cold weather clothing used in the ETO are regarded as of

utmost importance for Pacific operations where many of the wet and cold hazards encountered

in combat action in the ETO may be reasonably anticipated to reappear.

62 Report, Lt. Col. Mason Ladd, JAQD, Director, Legal Division, Office of the Surgeon General, dated June 1945, subject; Report of Study of Records and of Investigation Relative to Incidence of Trench Foot, With Special Reference

to its Course and the Activities of Army Medical Service Within ETO in Preventive Measures.
198 COLD INJURY, GROUND TYPE

5. In attempting to evaluate the various factors giving rise to the incidence of trench

foot in the ETO during the winter of 1944-45, it was the unanimous opinion of all persons

contacted, or groups of persons, that any one cause cannot be designated as the single

cause, but that all factors were interrelated, and each of different force under the varying

circumstances under which it operated. It is practical impossibility to single out any one

cause. There is no magic cure or prevention—trench foot control involves combination

of all relevant factors. Under the type of warfare, during the conditions experienced last

winter in the ETO by the American Armies, trench foot in substantial amount is believed

to have been an unavoidable hazard of war. The incidence may be reduced but not eliminated under the adverse conditions faced in Europe last winter. Under less severe conditions where fighting is less active, it may be possible, with careful discipline, rotation and

suitable supplies, to reduce trench foot to the point of almost complete elimination.

Colonel Ladd’s report was presented to General Kirk on June 1945.

On August 1945, two copies were delivered to Brig. Gen. Kenneth C. Royall,

Special Assistant to the Secretary of War, in accordance with request from

his office that the report be delivered to him directly rather than through

channels.63 The understanding was that one of these copies was to be forwarded to the Mead Committee for use in its consideration of the trenchfoot

problem in the European theater.

This report, while an excellent summary of the cold injury situation in

the European theater, contained little material not already available in the

Zone of Interior. When it was presented to General Kirk, the war in Europe

had been over for month. The war in the Pacific ended week after it was

delivered to General Royall, for transmission to the Mead Committee.

The investigation inspired by the Mead Committee unquestionably

helped to focus attention upon the whole trenchfoot problem. Any Congressional investigation would demand respect and attention from the agency

which was being investigated. On the other hand, by the time the investigation was requested (5 March 1945), cold injury had almost ceased to occur in

Europe, and the severity of the epidemics had been so great that the attention

of all responsible agencies of the War Department was already focused upon

the problem. The dates of the delivery of the report to The Surgeon General

and to General Royall for the Mead Committee explain why the investigation

exerted no influence upon the planning in the Pacific and had no special impact

elsewhere.

EXPERIENCES OF OTHER ARMIES

British Armies

The British and Canadian troops fighting in Europe in the winter of 1944-45

had an extremely low incidence of cold injury, 206 cases as compared with the

63 Memorandum, The Surgeon General, for Brig. Gen. Kenneth C, Royal], Special Assistant to Secretary of War,

Aug. 1945. subject; Report of Study of Records and of Investigation Relative to Incidence of Trench Foot.
EUROPEAN THEATER 199

United States Army experience of approximately 46,000 cases. 64 The discrepancy was in line with the discrepancy observed between British and United

States troops in Italy during the winter of 1943-44 (p. 103). On the surface,

the circumstances under which British and United States Armies fought on

the Western Front seem substantially the same. closer investigation shows

that in number of respects they were quite different. These facts are best

analyzed by presenting summaries of three separate reports made by Maj.

William L. Hawley, MC, Major Siple, and Colonel Ladd.

Major Hawley, the epidemiologist from the Preventive Medicine Division

of General Hawley’s office who observed conditions in the British 21st Army

Group, reported that factors responsible for the superior British record were,

in order of importance, as follows:

1. The smaller number of divisional combat days engaged in by British

and Canadian troops.

2. The tactical handling of troops. On an advancing front, provision

was always made in the British and Canadian Armies for periods of alternating

activity and reserve. During periods of extreme cold, all elements of forward

units were withdrawn from the line every day for rest and warming.

3. Weather, in the sense that the American troops did greater amount of

fighting in the snow than British troops.

4. Clothing and footgear. The British battle dress was warmer, the sock

had more insulation when it was wet, and the shoe had slightly more insulation

and fitted the foot much more loosely than similar United States footgear.

5. The daily consumption of hot food and drink in forward areas. British

and Canadian troops were issued hexamine cookers for use in the frontline and

thus were able to indulge their national tea-drinking habits no matter where

they were.

6. Discipline and morale. The average British soldier was more likely

than the United States soldier to do exactly what he was told to do. If, therefore, he was directed to carry certain number of extra pairs of socks on his

person, he carried them. Similarly, he took care of his feet as directed. The

United States soldier was frequently careless in such matters. Under direct

fire, neither United States nor British troops displayed much interest in their

feet.

The most important of the factors just listed, in Major Hawley’s opinion,

were the smaller number of combat days engaged in by British and Canadian

troops and the more favorable climatic conditions under which they fought.

On the other hand, the preventive measures practiced in these armies were

undeniably better and were better enforced than the United States Army

practices, especially in the early fall and winter of 1944-45. When combat

situations were parallel, as they were in at least four instances in which United

64 Ashas been explained elsewhere, the figureof 46,000 forcold injury in the European theaterwas laterraised to71,000

when all reports were available and when the eases in which cold injury was not the primary cause of the casualty were

included. The figure of 46,000 isretained in this connection becauseit is the one used in the earlier reports from which

much of the discussion in this chapter is taken.
200 COLD INJURY, GROUND TYPE

States and British or Canadian troops occupied adjoining areas in battle, the

British and Canadian records were better. “It cannot be denied,” said the

report, “that where comparisons seem valid the incidence in British-Canadian

troops is much less than in the Americans.”

Major Siplc, who was sent from the Office of the Quartermaster General

to the European theater in April 1945 to study various phases of cold injury,

arrived at the following conclusions concerning the low incidence of cold injury

in British and Canadian troops: 65

1. The constant wet-cold conditions in the British Isles during the winter

months, combined with the heavy losses sustained by the British from cold

injury during the first winter of World War (p. 43), made the British Army extremely foot conscious. The immediate cessation of losses from this cause in

World War when the proper control measures were instituted showed clearly

that cold injury is preventable. The lessons of the earlier experience were therefore incorporated into the training of British soldiers on the Western Front in

World War II, just as they had been incorporated into the training of those who

fought in Italy. Foot discipline in the British Army was the responsibility of

the unit commander; if he failed to carry out the foot inspections and other

preventive measures required, he could be subjected to court-martial. The

situation in the United States Army was, of course, essentially the same, but

American officers did not assume their full responsibility and authority in

this matter and did not exercise their full powers of discipline.

2. The British and Canadian Armies fought holding campaign during

most of the winter months and therefore had much less exposure in combat

than American troops, who were pushing forward actively during the same

period.

3. The areas of Holland and northern Belgium, where the British and

Canadian Armies did most of their fighting during the winter of 1944-45, have

good deal of sandy soil, in which drainage is rapid. As result, these troops

did not spend so much time in mud and standing water as did American troops.

Furthermore, these areas are somewhat warmer and drier than the more

mountainous areas where American troops fought during the winter of 1944-45.

4. When British and Canadian troops were found to be wearing leather

boots not adequate for the cold-wet conditions they were encountering, they

were provided with completely waterproof boots.

5. The British militia boot had certain advantages over the American

combat boot. The range of sizes was greater, and the higher toe and deeper

forequarter permitted the use of additional socks during extremely cold weather.

It was impossible to lace the boot tightly because the uppers already met when

it was first fitted. The British boot was also somewhat more waterproof than

the American boot because of the construction of the sole.

6. Throughout the winter fighting, it was British and Canadian policy not

to keep any man in the frontlines more than 48 hours at time if it was at all

65 See footnote 37, p. 155.
EUROPEAN THEATER 201

possible to relieve him. The few cases of trenchfoot which appeared in these

armies occurred when this precaution could not be carried out.

7. During the periods British and Canadian troops were out of the line

during the winter, they could usually be billeted in buildings, where they were

able to dry their clothing and footgear and otherwise care for themselves.

Colonel Ladd, during his investigation of trenchfoot in Europe in the

spring of 1945 (p. 197), held conferences with the Director General, British

Army Medical Services, and certain key officers on his staff. While the

emphasis placed upon the importance of various causative factors naturally

varied somewhat from officer to officer, the substance of these conferences with

British medical officers was as follows:

1. The answer to trenchfoot could be summed up in single word, “discipline.” Assuming that troops had reasonably good equipment and encountered

ordinary cold-wet conditions, they would not contract trenchfoot if they took

care of their feet. The medical services of the British Army advised upon foot

care and discipline, but execution of the advice was the function of line officers,

whose personal responsibility it was to see that the men gave their feet proper

care.

2. Troops should have month or more of training, with the care of the

feet an important part of the program.

3. All-leather boots and heavy wool socks provided for British troops were

important in the program of prevention. Soldiers seldom liked the boots when

they first began to wear them, but, by the end of the month of training, they

were usually well satisfied with them. Some British officers regarded the

British boot as the most important single factor in preventing trenchfoot. It

fitted more loosely than the American boot, was made of heavier leather, and

could not be laced tightly, since it was so cut that the uppers came together

when the soldier first put it on. Its loose fit made movement of the feet

possible even when the boot was soaked through, and the circulation of the

lower extremities could therefore be maintained.

4. Every British soldier who fought in cold weather was provided with

long, loose, sleeveless leather jerkin, which he wore constantly. In general,

British clothing was warmer than American clothing and was more loosely

fitted.

5. British soldiers also kept themselves warm by their habit of drinking

hot tea. They carried their own equipment and brewed tea many times during

the day, even during brief halts in marches.

6. The differences in temperament between British and United States

soldiers accounted for the fact that British troops did what they were told to

do, without asking questions. Habits of obedience were not deeply ingrained

in United States soldiers.

7. All British frontline troops were frequently rotated as individuals.

They were given brief rest periods, in places provided behind the lines, where

they could take care of their physical needs and care for their feet. This
202 COLD INJURY, GROUND TYPE

practice, while it depended upon the resourcefulness of the individual unit

commanders, was almost universally carried out.

8. British and United States troops fought over different terrain, with the

differences in favor of the British. Weather and combat activity were also in

favor of British troops.

9. United States troops had moved fast and aggressively, and trenchfoot

was one of the prices paid for their victory.

At the Inter-Allied Conference on War Medicine held in February 1945,

Col. C. S. Ryles, Professor of Hygiene, Royal Army Medical College, said that

the magic that had practically eliminated trenchfoot in the British armies in

World War was contained in the General Routine Orders issued 28 November

1915. These orders provided (1) that every man must carry second pair of

socks on his person; (2) that arrangements must be made for drying the socks

and reissuing them during tours in the trenches; and (3) that the boots and

socks must be taken off in the trenches from time to time, as circumstances

permitted, to dry the feet and rub them well, and to put on dry socks.

The only difference between the orders issued in 1915 and those issued in

1917 was that, in the second orders, greases and lubricants were discarded in

favor of foot powder. The orders under which the British armies operated in

World War II were essentially the same as those issued in 1915 and 1917.

Lt. Col. (later Col.) Theodore L. Badger, MC, Chief Medical Consultant,

Normandy Base Section, thought that there was fundamental difference

between British and United States soldiers in regard to their feet. Americans, he said, for the most part walk only when they cannot ride. The British, on

the contrary, walk constantly, not only about their business but for recreation.

They spend their weekends and vacations on hikes. As result, they are foot

conscious. They take care of their feet. They are careful about the fit of

their shoes. These civilian habits were carried over into military life. As

result, British troops understood the necessity for caring for their feet in service,

learned promptly from training and experience, and practiced what they already

knew about foot care even before they were told what to do.

French Army

Troops of the First French Army fought in the same general territory as

the Seventh U. S. Army, engaged in much the same operations, and were

exposed to much the same environmental conditions. The bulk of the forces

operated in the Vosges Mountains, where rain and snowfall were heavy. Each

man had been issued pairs of service shoes, but the allotment of 150,000 pairs

of galoshes was not sufficient for the issue of pair per man.66 The program of

education was good; it was based on that of the Seventh U. S. Army, and the

principle of command responsibility for the care of the feet was the same as the

United States Army principle.

66 Coded Message, Communications Zone, European Theater of Operations, to War Department, signed Eisenhower

from Lee to Kirk, 15 Jan. 1945.
EUROPEAN THEATER 203

During the week ending 12 October 1944, there were 110 cases of trendifoot reported in the First French Army. Between that week and the week

ending 28 December, cold injury was epidemic; 662 cases were reported for the

week ending 16 November, and 907 cases for the following week. After

brief period of improvement, there was second outbreak, in which 574 cases

were reported for the eek ending 21 December and 582 for the follow ing week.

The highest weekly rates per 1,000 men for this period were 3.089 for

the week ending 16 November, 4.223 for the following eek, 2.648 for the weeks

ending 14 December and 21 December, and 2.717 for the week ending 28

December. The smallest number of cases during this period, 105, was reported

for the week ending November, and the lowest rate, 0.573, was reported for

the week ending November.

German Armies

German troops fought under the same circumstances and in the same areas

as United States troops during the winter of 1944-45, and comparison of their

experiences is therefore of some value. The best information concerning the

incidence of cold injury among them was derived from the direct testimony of

prisoners of war, whose physical condition usually furnished concrete proof of

their statements. great deal of the prisoners’ evidence was contradictory,

but this could easily be explained by variations in the circumstances of weather

and combat. The material is best presented according to the sources from

which it was derived, with no further attempt to explain the contradictions.

Records of German units opposing the Third U. S. Army contain no

references to trenchfoot, which was apparently no problem among the enemy

troops at time when it was serious problem in United States troops. 67 For

this, there were apparently two reasons. The first was that many of the troops

facing the Third U. S. Army were seasoned veterans of the previous campaigns

on the Eastern Front. German troops had suffered severely from cold injury during the winter of 1941-42, and they had learned their lessons well. The

second reason was that German soldiers in late 1944 lacked the mechanized

transport (and the freedom to use it when it was available) which characterized

the Allied armies. They were, therefore, necessarily inured to long marches on

foot and were physically prepared to withstand cold injury.

Up to 15 December 1944, the number of cases of cold injury observed in

all German troops was apparently limited. Thereafter, the numbers were

larger. Most German noncommissioned officersreported seeing only occasional

cases, but few reported that up to 10 percent of the strength of their units, or

more, had been affected in varying degrees. corporal who had been captured

on 14 January 1945 and who had been with paratroop regiment in the field

since January, reported that all 34 men in his platoon suffered from frozen

feet, as the Germans called trenchfoot. battalion surgeon captured on 13

87 See footnote20. p. 141.
204 COLD INJURY, GROUND TYPE

January by the Third U. S. Army had seen no trenchfoot in Ids unit before

November 1944; since that time, about percent of the men had contracted it.

In the infirmary in the prisoner-of-war enclosure, 150 German soldiers had to

be hospitalized because of severe trenchfoot and frostbite; gangrene was sometimes present when they were captured. Lack of bed space did not permit

hospitalization of prisoners with milder cold injuries.

United States medical officer in charge of the dispensary in another

prisoner-of-war enclosure in the First U. S. Army area said that, between

January and 11 January 1945, 5,061 prisoners had passed through this cage; of

the 437 who reported on sick call, at least half were treated for trenchfoot or

frozen feet. Of the 44 who were hospitalized for this cause, 21 had serious

injuries. Thirty of the 76 prisoners hospitalized between 11 January and 17

January also had cold injuries.

Colonel Cleveland noted in his official diary for the week ending 21 February 1945 that, in tour of 11 hospitals, he had observed about thousand

German prisoners with frostbite, about third of it serious because of gangrene

of the toes, the forepart of the foot, or the entire foot. He thought that

practically all of these men would eventually require amputation of some

portion of the foot.

At the 196th General Hospital, Colonel Cleveland saw 127 prisoners,

about 20 percent of the prisoner-of-war admissions, with frostbite of various

degrees. At the 180th General Hospital, there were 100 cases, many severe,

among 622 German prisoners. At least one man was likely to lose the whole

foot. At the 168th General Hospital, which was serving as the parent organization of large prisoner-of-war hospital to be staffed by prisoner-of-war personnel, admissions for cold injury totaled 665; 222 cases were mild, 167 moderately severe, and 276 severe. It was believed that several of the patients in

this hospital would probably require amputation of the entire foot.

At the 189th General Hospital, there were 146 cases of cold injury on the

medical service, 76 mild and the remainder moderately severe. On the surgical

service, 16 prisoners had mild cold injuries, 63 moderately severe injuries with

superficial gangrene, and 120 severe injuries, with deep gangrene of the toes or

of portion of the foot. Twenty-seven amputations had already been performed, of the forepart of the foot and 13 of the entire foot. In all of the other hospitals mentioned, Colonel Cleveland observed German

prisoners with cold injuries who had already undergone amputation in forward

hospitals. The general practice in the fixed hospitals was to delay amputation until mummification had occurred unless infection required it more promptly,

as it did in many instances. At this time (February 1945), it was thought that

the frequency of moist gangrene was increasing in prisoners of war.

The prisoners themselves stated that cold injuries had been far more

prevalent in the winter of 1943-44 than they were during the winter of 1944-45.

Some men who had fought on the Russian front in previous winters had already

had one or more of their toes amputated.

The German medical officers, as well as the United States Medical Corps
EUROPEAN THEATER 205

officers who interrogated them, commented on the greater susceptibility to cold

of men who had suffered previous cold injuries. German officer captured in

October 1944 thought that cold injury was less likely to occur in younger men, who were well fed. United States medical officer thought that, on the contrary, it was more likely to occur in younger men because they had not learned

to take care of their feet. Some German medical officers emphasized the factor

of poor circulation. One regarded the constitutional makeup of the parasympathetic and sympathetic system as possible predisposing factor. One thought

that men who were pale and who tired quickly were more likely to suffer from

cold injury. He also thought that heavy smokers were more susceptible.

Interrogation of German medical officers and corpsmen produced fairly

consistent statements concerning equipment and discipline. It was apparently

not the practice to issue special equipment before the onset of cold weather,

though some men reported receiving extra socks, shoes two sizes larger than

those worn during the summer, and rags for their feet. few said that they

had received chemical pocket heaters.

German clothing was, on the whole, very good. Every captured prisoner

wore an overcoat. The German field boot (fig. 33), which had years of development behind it, seemed very satisfactory item. It was made of excellent

quality cowhide and was loosely fitted, without lacings. It extended to just

above the calf (just below the head of the fibula). It had no pressure points.

U. S. Army photo

Figure 33. —Winter footgear used by German troops captured during fighting

in Ardennes.

438404'—58 15
206 COLD INJURY, GROUND TYPE

The leather was thoroughly impregnated with waxy substance, applied after

the use of oil, and was practically water resistant. This was partly because one

of the first duties of German recruit was to spend an hour or more daily in

rubbing and polishing his boots. Few of the soldiers had overshoes, but with

this type of boot they did not need them.

German socks were of heavy wool. Men who did not wear two pairs were

given flannel or othei cloths which they wrapped around their feet outside of

their socks. The socks were loosely fitted, sometimes so loosely that the toe

could be doubled back under the foot.

The preventive program practiced by German troops was similar to that

employed in the United States Army, except for the great emphasis placed upon

the daily application of salve to the feet. Presumably, the massage implicit

in the application was responsible for the apparent good results, Aden who

had received basic training in the care of the feet stated that the routine was

to keep the feet clean, with warm water followed by cold water; to use foot

powder regularly; to cut the nails square; to exercise the feet as much as possible;

to remove the shoes and rub salve into the feet whenever possible; to take care

of calluses; to rub shoe cream into the shoes every day; to carry pair of dry

socks in the pocket; and to dry wet socks inside the shirt.

Men who had received special, additional instructions against cold said

that they had been advised to wear American overshoes; to wrap the feet in

blankets if the night had to be spent in the open; to select dry foxholes, or to fill

wet foxholes with straw or wood, so that it would not be necessary to stand

directly in water or mud; to put straw in the shoes, or to wrap paper around the

feet inside the shoes; and never to let the metal part of the shoe touch the foot.

Alen who had served on the Russian front were well aware of the importance

of these precautions.

The majority of the prisoners stated that no provisions had been made

during the extremely cold, wet weather for issuing dry socks or for rotating

personnel to places where heat was available and their clothes could be dried

while they rested. Smoking was restricted during cold weather because of its

depressant effect on the temperature of the extremities. Alcohol was advocated

for its vasodilating effect.

No single person in unit was responsible for foot discipline. It was only

occasionally reported that medical corpsmen examined the soldiers’ feet and

made suggestions for their care. There was no evidence of any sort of control

organization. The individual soldier understood, however, that he was responsible for the condition of his feet and that he must report any trouble with them

to the corpsman at once. The soldier who contracted trenchfoot was not

punished unless it could be proved that he had deliberately exposed himself, to escape service. Then punishment was severe; court-martial could mete

out prison sentences of or years, or, occasionally, death sentence. document, taken from German prisoner during interrogation and dated 28 December 1944, confirmed these statements. It had been prepared by battalion
EUROPEAN THEATER 207

medical officer, to be read to all members of the unit. Note was taken of two

cases of frostbite, the occurrence of which made it necessary to remind the personnel that anyone suffering from this condition could be charged with selfmutilation, an offense subject to court-martial and punishable with imprison- ment or the death sentence.

Russian Armies

Russian armies did no fighting on the Western Front at any time during

World War II, and their experiences are therefore not comparable to United

States Army experiences. Their armies have always operated in regions of

extreme cold, and they have long known how to combat these conditions.

Furthermore, since the Russian Army is conscript army, with long and intensive training, they are acclimatized and are trained for combat in cold weather.

Russian clothing during World War IT was loose, warm, and efficient.

Russian soldiers usually wore fur gloves. Their footgear was usually very

loose-fitting felt boot (the valenki) without heel and with single seam.

Each man had pair of felt boots and another pair of leather boots, which

were also very soft and pliable and which were to be worn wdiile the felt boots

were drying. Both felt and leather boots were free from constriction at any

point.

Soviet troops did not wear socks. Instead, they were supplied with

linen or woolen cloths, 36 centimeters long and from 16 to 20 centimeters

wide, which they wrapped around their feet in prescribed fashion. When

this bandage was properly applied, it was without seams or wrinkles. Each

man had or of these cloths; boots were issued in only sizes, and differences

in sizing were compensated for by differences in the thickness of the wrappings.

If the bandage became wet, it as removed and reversed, the dry portion

originally about the leg now being used for the foot. Newspapers were sometimes wrapped around the feet to furnish additional insulation.

The platoon commander routinely inspected the feet at the end of each

march. The soldier was not permitted to go to sleep until his feet and footgear

had been inspected. In effect, this meant that, unless the combat situation

absolutely prevented it, the boots were taken off daily, the wrappings around

the feet were reversed, and the feet were dried and rubbed.

The chief reason why the incidence of cold injury was so low in Soviet

troops was that it was regarded as preventable condition, the responsibility

for which lay with the individual soldier, the small-unit commander, and the

medical officer. The soldier was held accountable for the occurrence of disability, and punishment was meted out according to the neglect presumed

to have caused the injury. In severe cases, the offense was looked upon as

sabotage, since it deprived the army of man-hours which should have been

spent on essential duties, including combat duty.
208 COLD INJURY, GROUND TYPE

STATEMENT BY THE GENERAL BOARD

The definitive statement on trenchfoot in the European Theater of Operations is contained in the report of the General Board, United States Forces,

European theater, 68 set up by General Orders No. 128, issued on 17 June 1945, to prepare factual analysis of the strategy, tactics, and administration

employed by the United States Armed Forces in this theater. 69 The following

points were covered

1. Between October 1944 and April 1945, 46,107 cases of cold injuries

of all types required hospitalization. This loss of manpower amounted to

more than three combat divisions and comprised 9.25 percent of the total

hospital admissions for all causes during the entire campaign in western

Europe.

2. The causes of cold injury were listed as wet and cold, immobility,

lack of shelter, lack of regular warm food and drink, and wet footgear. Contributory factors were listed as impaired peripheral circulation caused by inactivity and constriction, general body cooling from inadequate clothing and

exposure to the elements, and lowering of the metabolic rate due to fatigue

and lack of warm food and drink.

3. The pathologic process was described.

4. The practical considerations and administrative difficulties of the award

of the Purple Heart were discussed (p. 189).

5. The specific causes of trenchfoot in the European theater included

extended supply lines and inadequate stocks ofproper types of winter clothing

and footgear, combined with the onset of wet, cold weather; the footgear

worn by the troops, which was unsatisfactory in many respects and which

was not waterproof or water resistant; the lack of galoshes for large proportion of the troops when protection for the feet was most needed; the lack of

shoepacs when they were most needed; the lack of proper socks in adequate

supply.

6. Operational conditions were regarded as second in importance to inadequacy of clothing and footgear. Weather and terrain were also listed as

possible etiologic factors. Infantrymen had been particularly affected, but

cold injury had also occurred in reinforcements packed into trucks and railroad

cars going forward to combat areas and in military police who had stood for

long periods at traffic intersections.

7. program of prevention had been employed, beginning with the

issuance of Circular No. 312 on 22 July 1944 and the measures of education

and prevention which followed. At the onset of the outbreak of cold injury,

many men had only vague idea of its possible seriousness, and practical

68 This study was prepared by Col. L. Holmes Qinn, Jr., MC, Chief, Medical Section, Chairman;Lt. Col. Edward J.

Whiteley, MC, Deputy Chairman; and Col. W. E. Wilkinson, MC. The principal consultants were Col. Horace McP.

Woodward, Jr., Commanding Officer, Field Forces Port Detachment; Col. Samuel G. Conley, Commanding Officer,

274th Infantry Regiment, 70 InfantryDivisioh; Lt. Col. John I. Ladd, Assistant 0-1, Headquarters, 12th Army Group,

and Maj. George T. Aitken, medical member of the trenchfoot control team, Headquarters,Fifteenth U. S. Army.

69 See footnote 28 (1), p. 151.
EUR()PEAN THEATER 209

methods of preventing it were not understood. After the epidemic had reached

serious proportions, more intensive program was instituted. The various

phases of this program included indoctrination, command responsibility, provision of clothing and footgear suitable for intensely cold, wet weather, sock

exchange, rotation individually and by units, and the establishment of trenchfoot control teams.

8. The European experience showed that an effective program to combat

and control cold injury must be instituted in the War Department and must be

based on the premises that soldier must be provided with clothing and footgear

suitable for fighting in cold, wet weather; must be given regular warm meals and hot drinks; and must have opportunities provided to warm and dry himself at least once daily. Supplies must be available when they are needed.

Commanders in all echelons must be aware of the seriousness of cold injury

and must take the necessary steps to insure the timely application of appropriate

preventive measures. Unit surgeons must be thoroughly trained in triage and treatment. Indoctrination and training in preventive measures must be

instituted in the Zone of Interior.

There was no doubt of the effectiveness of the control program that was

finally instituted, even though the results could not be completely evaluated because the weather moderated just as the program became fully operative.

Units which had employed vigorous preventive programs before the institution of the general program had consistently lower rates than units which had not

instituted such programs, even when conditions were unfavorable.

9. The incidence of cold injuries in French, British, German, and Russian

Armies was summarized.

10. It was recommended that more effective combat boot be developed;

that more adequate socks be developed and that they be provided in sufficient

numbers; that the award of the Purple Heart be reviewed and more consistent

policy be developed; and that officers of the Medical Corps be given the same

training in trenchfoot as they received in burns.

11. It was concluded by the General Board (1) that cold injury is largely

preventable; and (2) that the relatively high incidence of cold injury in the

European theater (9.25 percent of all casualties) was the result of inadequacy

of clothing and footgear suitable for winter operations, unfavorable operational

conditions, and the delay of many units in instituting program with emphasis

on, and close supervision of, measures that must be taken by the individual

soldier to protect himself.

THE CALCULATED RISK

thoughtful reader of this chapter on cold injury in the European Theater

of Operations in World War II cannot fail to emerge from it with number of

impressions, such as the following;

1. There was very heavy loss of manpower from this cause.
210 COLD INJURY, GROUND TYPE

2. The losses chiefly affected the most critically needed of all troops, the

combat infantrymen, at the very time in the fighting when their services were

most necessary and reinforcements were in shortest supply.

3. The fundamental cause of the epidemics of cold injury was, of course, the wet, cold weather, which could not be altered and which had to be endured.

4. Combat was heavy and could not be postponed or altered.

5. The terrain over which the fighting occurred also could not be altered.

Against this array of facts must be set number of other factors, including

human factors, which could have been controlled and the control of which would

have materially modified the factors which could not be altered per se:

1. Clothing was inadequate and improperly selected.

2. Footgear was inadequate and improperly selected.

3. Troops had not been trained to care for their feet and to protect themselves against cold, wet weather.

4. Planning for all of these contingencies came too late.

5. An effective program was finally put into operation, but when it became

fidly operative losses from trenchfoot had begun to decline and within matter

of weeks had become insignificant.

Unquestionably, one of the reasons for failure to prepare more adequately

for the prevention of cold injury in the European theater was the expectation,

at least in certain high quarters, that Germany would fall before winter fighting

became necessary. This belief developed after the breakthrough in Normandy

in July 1944, and it continued for number of weeks thereafter, during the

rapid advance of the First and Third U. S. Armies across France. This belief proved entirely erroneous. What happened with respect to cold injury was

therefore, at least in part, the unhappy result of calculated risk.

General Bradley wrote after the war: 70

When the rains first came in November with blast of wintry cold, our troops were

ill-prepared for winter-time campaigning. This was traceable in part to the September

crisis in supply for, during our race to the Rhine, had deliberately by-passed shipments of

winter clothing in favor of ammunition and gasoline. As consequence, we now found

ourselves caught short, particularly in bad-weather footgear. We had gambled in our

choice and now were paying for the bad guess.

70 Bradley, Omar N.; Soldier’s Story. New York: Henry Holtand Co., 1951.
211

CHAPTER VIII

The Pacific

Part I. Cold Injury in the Tropics

Although trenchfoot was recognized as one of the probable risks of combat

in the Pacific in World War II, this condition, as it is ordinarily envisaged, did

not occur among United States troops in these areas. The war ended before

fighting was necessary under circumstances which would produce the classical

type of wet-cold injury. However, in addition to the numerous skin diseases,

including diseases of the feet, which developed in tropical environment

highly favorable for them, there was brief experience in the Philippine Islands,

chiefly on Leyte, with disability of the feet caused by long exposure to wet terrain under combat conditions (fig. 34). This disability, for lack of better

term, was originally described as tropical immersion foot. It can more logically

be described as type of cold injury low on the gradient (p. 20).

Lack of complete information on all details of this experience makes it

somewhat difficult to analyze it. Precise climatic records are not available for

October, November, and December 1944, the period in which the disability appeared. Records for the preceding years showed that during these months

temperatures on Leyte had ranged from 74° to 88° F. (23.3° to 31.1° C.). It

is not known whether they were lower than this in the fall of 1944, especially

at night. Furthermore, it is still not known at what temperature level cold

injury can occur when it is associated with long exposure, fatigue, insufficient

food, and combat stress.

Information about rainfall in the fall of 1944 is somewhat more adequate.

During the preceding years, it had ranged between 8.5 and 14.2 inches per

month in three areas on Leyte (Tacloban, Palo, and Dulag) during the period

in question. Weather records showed that, as rule, rain fell on 20 days per

month during the October-January period, against 10 days per month during

the remainder of the year. Readings available for 1944 show rainfall greatly

in excess of what might have been expected in the light of these data. Engineers, who worked around the clock, recorded that 69 percent of the time lost

on construction between 11 November and 18 November 1944 was caused by

heavy rains, against only 11 percent lost because of air raids. Between 19

November and December, the measured rainfall in three separate areas on

(1) Letter, Maj. Frank Qlenn, MC, Surgical Consultant, Office of the Surgeon, Headquarters, Sixth U. S. Army,

to the Surgeon, Sixth U. S. Army,27 Nov. 1944, subject: Trench Foot. (2) Letter, Brig. Gen. J.I. Martin,Chief Surgeon,

United States Army Forces, Western Pacific, to Director, Army Institute of Pathology, 19 Oct. 1945, subject: Immersion

Foot.
212 COLD INJURY, GROUND TYPE

U. S. Army photo

Figure 34.—Tropical environment favorable to numerous skin diseases, including disability of the feet. A. Infantrymen from 7th Infantry Division wading across Maraby

River, Leyte, October 1944. It was this sort of exposure in tropical climate which produced so-called tropical immersion foot. B. Infantrymen of 43d Infantry Division moving

along muddy road on Luzon, May 1945.
THE PACIFIC 213

Leyte (Tacloban, Palo, and Dulag) varied between 11.08 and 14.8 inches. Between 10 December and 14 December, 16.62 inches was recorded at Buwi

Drome; 7.6 inches fell in single day. There seems no doubt, therefore, in

spite of the lack of complete information, that constant wetness played decided

role in the intensification of heat loss, especially through the feet, in this experience.

From the time that fighting began in the jungles of New Guinea in the

summer of 1942, large numbers of soldiers suffered from excoriations of the

feet and from some degree of infection, which was often superimposed on

previous epidermophytosis. These lesions were, however, quite distinct from

the variety of cold injury observed during the Leyte campaign (a total of 167

cases), and observed later, in scattered cases (55 in all), on the Visayan Islands

during the first months of 1945. The second outbreak was much milder than

the first.

The incidence of this type of cold injury was comparatively low. Prompt

recovery occurred in all but few of the most severe cases when once the men

were able to stay clean and dry. There was no similar experience on Luzon, because the dry season had commenced when combat operations were undertaken there (p. 221).

CLINICAL ASPECTS

On 23 November 1944, two evacuation hospitals on Leyte received some

120 soldiers with swollen, painful feet, all of which had been injured under the

same circumstances. These men had been in combat on the frontline for periods

ranging from to 17 days. During this time, rains and typhoons had been

almost continuous. Combat troops lived in foxholes or crawled through the

jungles. Many were completely isolated. They had no dry socks or footwear, and there would have been no opportunities to change them if they had

been provided with them.

Maj. (later Lt. Col.) Frank Glenn, MC, Surgical Consultant, Office of

the Surgeon, Headquarters, Sixth U. S. Army, observed and examined these

patients within 12 hours after they had been hospitalized. Their stories were

all substantially the same, and their physical findings differed only in degree.

Most of them reported that, after to days of existence under the conditions

described, they began to experience burning sensations in their feet, first on

the dorsum, later on the soles and over the toes. Movement at first gave some

relief. Later, walking was progressively more painful. When rescue finally

came, the men had to be carried by litter through swamps and over difficult

terrain, which they all agreed they could not possibly have traversed by themselves. In some units, as much as 50 percent of the personnel was affected.

When they first removed their shoes, the men said, their feet appeared

pale and swollen. Shortly afterward, the skin of the feet became flushed and

warm. The burning sensations increased, and tingling and pain were soon

experienced. Elevation of the feet gave some relief. Within 30 minutes after

438404'—58 -16
214 COLD INJURY, GROUND TYPE

the shoes had been removed, it was impossible to replace them because the feet

were so intensely swollen. Some soldiers volunteered the information that

these symptoms and signs did not appear until after it became impractical to

remove the shoes every night. When the tactical situation prevented this, the

disability described quickly followed.

At first, the feet were not ulcerated and there was no loss of skin. As time

passed, however, pain and swelling increased, and ulcerations appeared, first

on the dorsum, and then about the toes. Cracks on the soles were frequent,

but ulceration in this area was uncommon.

When the men were first observed in the evacuation hospitals, it was

striking to note that, although all of them were obviously fatigued, only an

occasional patient seemed to be resting. Some sat with their feet elevated.

Some let them dangle over the edge of the cot. Some clasped their ankles and

lower legs. Most of them changed position frequently. Those who attempted

to stand seemed helpless and distressed and were obviously in pain. When

they walked, they moved with “hesitant deliberation/’ putting the weight of

the body on the feet only after the feet were put down, like “a cat walking on

flypaper.” The most frequent complaint was burning sensation, associated

with “deep” aching of the dorsum and sole of the foot. Neither socks nor

dressings could be endured.

Examination of the feet usually revealed uniform erythema, which was

frequently intense. The skin of the dorsum was tense and shining, and the

soles were so swollen that they seemed to bulge. Blebs and ulcerations from

which weeping serum exuded were often observed at the margins of, and between, the toes. In the most serious cases, there were scattered areas of ecchymosis, and the distal portions of the toes were blue, white, mottled and

cold, in contrast to the swollen, erythematous aspect of the other portions of

the feet. After the feet had been cleaned and dried, line of demarcation was

usually evident at shoe-top level. Only occasionally did edema extend above

this level.

Ulcerating lesions were most numerous on the toes and over the dorsum of the foot. These lesions were blotchy, and their appearance suggested that

they had been produced by pressure and abrasions. They varied in degree

from patient to patient. Some were only superficial. In others, the destructive

process extended down to, or through, the true skin. Some lesions were well

demarcated, with zone of necrotic tissue along the margin, as in decubitus

ulcers or gangrenous process. The skin between the lesions, especially over

the dorsum of the foot, was pale, cold and inert. Secondary infection was

strikingly infrequent.

Lymphangitis was present in few cases, in all of which there was

previous history of troublesome epidermophytoses. When the men were

directly questioned, about 15 percent admitted to some discomfort in the groin;

all of this group were found to have enlarged and sensitive regional lymph

nodes. There was no correlation, however, between the presence of lymphadenopathy and the degree of pain and swelling in the feet.
THE PACIFIC 215

Pressure over the affected areas caused pain. Erythematous areas blanched slowly, and the return flush was delayed. In no instance were pulsations

absent, nor in any instance were variations in the pulsations beyond the range

of normal. Sensory changes were not clear cut. Areas of numbness and tingling

could be demonstrated by light touch and pinprick. Areas of diminished sensation seemed to be increased when the feet were elevated. Attempts to

outline areas of paresthesia and anesthesia were not satisfactory, perhaps

because the patients were all uncomfortable and fatigued.

Temperature and pulse were invariably within normal range. Fatigue

and inability to sleep were the only systemic reactions.

Treatment was based on keeping the patients off their feet as much as

was possible in crowded forward hospital. If the shoes had not already been

discarded, they were cut off. Most of the patients had long since discarded

them, and no pictorial or other record, unfortunately, was made of the condition of the few pairs available for examination. The feet were washed with

cool water and mild soap, which brought only temporary relief; the discomfort

returned as soon as the feet were dry. At the most, only light, dry dressings

could be endured, and the patients were more comfortable with no dressings

at all. Applications of mineral oil were not well tolerated. Lanolin was not

tested. General supportive measures were instituted, such as would be employed

for men who were extremely tired physically and who had been without food

and sleep for long periods of time. Sedatives were given as necessary to insure

sleep and rest.

Contrary to the usual course in trenchfoot or immersion foot, recovery

in these cases was fairly rapid. Most of the casualties were evacuated by ship

to hospitals in Hollandia within 36 hours of their admission to evacuation

hospitals on Leyte. When they arrived in Hollandia, most of them were almost

entirely free from symptoms and signs of the injury. Pain, swelling, excoriations

and vasomotor manifestations had, for the most part, disappeared during the

voyage, apparently as the result of rest, and healing was usually complete by

the time the men were admitted to general hospitals in New Guinea.

Gangrene did not occur in any of these cases, and no recurrences of sequelae

were recorded. The uniform absence of thrombosis and gangrene was believed

due to the relatively high temperatures in which the injuries occurred.

The additional cases of cold injury which occurred on Leyte in December

1944 and which brought the total number on that island up to 167 were similar

in all respects to those already described. The 55 cases which occurred in the

Visayan Islands, most of them in January and February 1945, were considerably

milder but were otherwise similar to those which occurred on Leyte.

It should be noted how closely the symptoms and signs of the variety of

cold injury observed in the Philippine Islands resembled those of cold injury

as it was observed in both the Mediterranean and the European Theaters of

Operations, where the classical type of trenchfoot occurred. On Leyte, the

degree of injury appeared, at least superficially, to be mild, but all of the men

affected required hospitalization. They could not walk, let alone put on their
216 COLD INJURY, GROUND TYRE

shoes, and they could not sleep because of discomfort. The most important

difference between the cold injuries in the Pacific and those in other areas

was that in the Pacific, in contrast to the course of events in both the Mediterranean and the European theaters, virtually all of the men affected could be

returned to duty after being hospitalized, and there were no recorded recurrences. In other theaters, large proportion of the trenchfoot casualties were

lost permanently to combat duty, and there was high percentage of recurrence

in the soldiers returned to full and limited duty (p. 327).

The Surgical Consultants Division, Office of the Surgeon General, in

commenting on February 1945 on the report of this experience in Essential

Technical Medical Data, United States Army Forces, Far East, dated 23

December 1944, took occasion to point out the gravity of the United States

experience with trenchfoot inEurope in the winter of 1944-45 andrecommended

that any additional information on this extremely important medicomilitary

subject be compiled.

Part II. The Wet-Cold Program

The actual experience with cold injury in the Pacific was limited to the

type just described. There was general realization, however, that the invasion

of the Japanese islands, which was planned for the fall of 1945, would again

require combat operations in cold-wet environment, and at temperatures

which had produced the classical type of trenchfoot in the Aleutian Islands

and in the Mediterranean and European theaters. By the time that planning

for the invasion of Japan was undertaken, the lessons inherent in the serious

losses from cold injury which had occurred in other theaters had already been

well learned. Moreover, the successful prevention and control programs which

had eventual!}- been formulated and implemented in Italy and in Europe had

shown that such losses were in large part neither necessary nor inevitable.

It was therefore taken into consideration early in the planning for the

invasion of Japan that if similar misfortunes were to be avoided the fullest

advantage must be taken of the knowledge which had been gained in the

Mediterranean and European theaters. considerable part of the losses from

cold injury in the Mediterranean theater could be explained by the fact that

the experience gained in the Aleutians had not been transferred to it.

considerable part of the losses from this cause in the European theater could

be explained by the fact that the experience gained in Italy had not been

transferred to it. Those errors were notrepeated in the Pacific theaters. The

wet-cold program there was planned against the background of what had been

learned in other theaters. The program of prevention and control was worked

out with the joint cooperation of the Office of the Surgeon General, the Office of the Quartermaster General, and the various levels of command in the Pacific.

The war, fortunately, ended before it was necessary to test the program in

combat, and the story of wet-cold injury is therefore story of planning and
THE PACIFIC 217

prevention and not, as in other theaters, story of the actual occurrence of

trenchfoot. The planning was thorough and precise, and there is every reason

to believe that the program would have been highly effective, and that losses from cold injury would have been reduced to an irreducible minimum, had it

been necessary to put it into operation.

As matter of convenience, and to simplify the account, the programs of

planning for the prevention and control of cold injuries are described under

number of separate headings, without any attempt at the integration which was

in progress when the war ended.

OFFICE OF THE SURGEON GENERAL

The first formal recognition by the Office of the Surgeon General of the

possibility of cold injury in the Pacific appeared in an article prepared in that

office and published in the February 1945 issue of Health. In it number of

facts about future fighting in the Pacific were emphasized:

1. Warfare in this area would extend northward during the fall and winter

months, and range of temperature particularly favorable to the occurrence of

cold injury would therefore be encountered.

2. The terrain of the lowlands, where most of the fighting in Japan would

probably take place, was also favorable to the development of cold injury, since

drainage was poor and the numerous rice paddies made much of the ground little

more than swampland.

3. The same general conditions would also be. encountered iffighting should

be necessary in the northern provinces of China.

4. Trenchfoot would not occur in the mountainous regions of Japan and

the north Asian mainland, where dry cold rather than wet cold would be encountered, but frostbite was possibility seriously to be considered in these

areas.

5. Attention was directed to the recorded experiences with cold injury

among Japanese troops during the Russo-Japanese War.

For the next several months, the Preventive Medicine Division and the

Surgical Consultants Division, Office of the Surgeon General, continued, in

various ways, to emphasize the potential dangers of cold injury in the Pacific

theaters and the necessity for the prompt institution of preventive measures.

Among the specific actions taken were the following:

On 12 February 1945, Brig. Gen. Stanhope Bayne-Jones, acting chief of

the Preventive Medicine Service, initiated the preparation of communication

for the signature of The Surgeon General, to be sent to the commanding general

of the Array Service Forces. This communication was sent to General Somervell, in the form of memorandum, through the Quartermaster General on

24 March 1945.

Monthly Progress Report, Army Service Forces, War Department, 28 Feb. 194.5, Section 7: Health.
218 COLD INJURY, GROUND TYPE

This memorandum, to which was attached copy of the article on cold

injury which had appeared in the February 1945 issue of Health, contained

meteorologic data to support the strong probability that cold injury would be

encountered in Japan. It recommended the use of the shoepac (12-inch

height), with two pair of wool ski socks, as well as the use of other modern cold

weather protective garments and equipment developed by the Quartermaster General. The memorandum also recommended that all troops taking part in

operations in cold climates receive training in foot hygiene, in accordance with

Section IV, War Department Circular No. 312, and War Department Technical

Bulletin (TB MED) 81.

On April 7, memorandum prepared by Maj. Gen. (later Lt. Gen.) LeRoy

Lutes, Acting Chief of Staff, Army Service Forces, was sent to the director of

Plans and Operations, Army Service Forces, directing that the Planning Division initiate study on trenchfoot immediately. This study was to include all

available data on incidence, causes, preventive measures, and similar matters.

As soon as the study was completed, it was to be sent to the commanding

general of the United States Army Forces in the Pacific, with covering letter

to be prepared for the signature of the Chief of Staff. The memorandum concluded: “It is General Somervell’s belief that the language of this letter should

be so couched that General MacArthur would understand that there should be

no excuse for trench foot developing in the Far East due to the ample warning

given to him on this subject.”

On April 11, memorandum containing the material to be included in the

proposed letter to General MacArthur was sent by General Kirk to General

Somervell, for the attention of the director of Plans and Operations, Army

Service Forces. In this memorandum, the unfortunate experience of the

United States Army in the Mediterranean and European theaters was recounted, and it was emphasized that it was urgently necessary to institute

prompt and energetic program of prevention for the United States Army troops

in the Pacific. It was also pointed out that the far better record of the British

Army in respect to cold injury in both the Mediterranean and the European

Theaters of Operations seemed to be the result of the far more effective measures

of prevention employed in this army.

On 27 April, communication from the War Department on the subject of

trenchfoot was addressed to General MacArthur. It contained the following

information:

1. Large numbers of troops had been incapacitated by trenchfoot during

the winter campaigns in the Mediterranean and European theaters.

2. The majority of these losses could have been avoided if troops had been

properly indoctrinated concerning the cause and effect of cold injuries and the

measures necessary to prevent them.

3. The Pacific fighting was about to advance into areas in which conditions

conducive to trenchfoot would exist during certain seasons of the year.

Letter, TheAdjutant General, War Department, to Commanderin Chief, UnitedStates Army Forces in the Pacific,

27 Apr. 1945, subject: Trench Foot.
THE PACIFIC 219

4. The disastrous losses suffered in other theaters need not be duplicated in

the Pacific if the risks of the situation were recognized and the necessary preventive measures taken.

Since the role of the Medical Department in the prevention of cold injury is entirely advisory, it was specifically stated in this communication that the

control of trenchfoot “is primarily command problem that can only be solved

by proper indoctrination of troops prior to entering the combat zone and continuous follow-up supervision backed up by strict disciplinary policy during

the period in which the troops are exposed to the condition. Troops must be

made trenchfoot conscious.”

Enclosed with this letter was resume of all available information on

trenchfoot secured in the study made in the Office of the Surgeon General on

General Lutes’ instructions (p. 218). graphic training aid (8-16) was also

enclosed. The letter noted that Film Bulletin No. 180, training film on trenchfoot (p. 223), had already been sent to the commanders of the Pacific Ocean Areas and Southwest Pacific Area.

This letter was received at General Headquarters, SWPA (Southwest

Pacific Area), on May 1945 and was forwarded for necessary action to the

Commanding General, USASOS, SWPA (United States Army, Services of

Supply, Southwest Pacific Area), on 12 May 1945. It was received on 15 May

1945.

On 30 June 1945, memorandum addressed by General Rankin to The

Surgeon General again stressed the seriousness of cold injury and the importance

of its prevention. It was suggested that the programs conceived and in process

of execution for the prevention of cold injuries in the Pacific should be critically

reviewed by all divisions in theSurgeon General’sOffice, so that past experiences

could be utilized to the fullest advantage in future planning.

conference for the purposes suggested in this memorandum was held on

July 1945 under the chairmanship of General Bayne-Jones. The clothing

and equipment then in production and planning for troops in the Pacific were

fully discussed, and it was noted that representatives from the Office of the

Quartermaster General were already in the Pacific theaters giving instruction

in the wearing and use of the winter outfit, including shoepacs (p. 226). The

training of troops in foot discipline was discussed, and plans were made for the

full utilization of such aids as films, film strips, graphic portfolios, posters,

manuals, and pamphlets which would call the attention of the soldiers to their

individual responsibility for the care of their own feet.

Efforts had been begun on 14 June 1945, by the Preventive Medicine Division, Office of the Surgeon General, to obtain the release from the European

theater of certain medical officers who were thoroughly experienced in cold

injury, so that they could be assigned to the Southwest Pacific for supervision

The consolidation of the United States Army Forces in the Pacificunder General MacArthur was occurring just as

the planning for the prevention of cold injury in that area was getting under way. His appointment, in fact, was made

after team from the Office of the Quartermaster General had already begun to operatein the Pacific Ocean Area.

second team from this office was latter assigned to General MacArthur’s headquarters (p. 228).
220 COLD INJURY, GROUND TYPE

of the program of prevention to be instituted in that area. The first request,

which was sent formally on 19 June, was refused by the theater on 23 June. In

retrospect, it was thought that the reason for the refusal was that the radiogram

requesting the release was weakly worded and provided no explanation of the

urgency of the need for these officers for this assignment. second, more

strongly worded radiogram to the European theater was drafted on 24 June and

sent on July. When no reply to it had been received by 19 July, tracer

radiogram was sent. The consent to the transfer of these officers was finally

received on 23 July.

The original request had been for the release ofLt. Col. (later Col.) Richard

P. Mason, MC, and Maj. William L. Hawley, MC, both of whom had had considerable experience in the European theater. Later, Colonel Gordon’s release

was requested. On their arrival in the Zone of Interior, these officers were

temporarily assigned to the Office of the Surgeon General and participated in

the conference on medical matters in the Pacific held 30 July-1 August 1945.

On July 1945, General Kirk wrote personally to Brig. Gen. (later Maj.

Gen.) Guy B. Denit, the Surgeon,AFPAC (United States Army Forces, Pacific),

to inform him of the expectation that the officers whose release from the

European theater had been requested would be sent to the Pacific to aid in the

setting up of the cold injury prevention program. It was hoped, General

Kirk wrote, that General MacArthur would see these officers himself, to secure

firsthand information of the seriousness of the experience in the European

theater. The activities of the teams from the Office of the Quartermaster

General, which were already in the Pacific, were discussed, and all the material

then available on trenchfoot was enclosed. The letter ended with another

reminder of the seriousness of the problem in the European theater and with

the statement that it would be equally serious in the Pacific if preventive

measures were not taken. Trenchfoot, it was pointed out again, is an essentially

preventable military hazard.

similar letter to General MacArthur was prepared in the Office of the

Surgeon General, for the signature of the Chief of Staff, but does not seem

to have been dispatched.

MEDICAL PLANNING IN THE PACIFIC

The first published mention of cold injury in the Pacific theaters took the

form of memorandum (Technical Memorandum No. 10) issued from the

Office of the Surgeon, USASOS, SWPA, on July 1943. This memorandum,

which was entitled “Immersion Foot,” was obviously prepared with shipwrecked persons in mind. The causes of the injury, the clinical picture, and the

management were discussed. Preventive measures were listed as removal of

constricting footgear, which would be of no use for warmth if the feet were in

water; exercise of the feet and legs, to maintain vascular and muscular tone;
THE PACIFIC 221

and the application, when possible, of thick coating of grease. The affected

parts were not to be rubbed, and heat was not to be applied to them.

The problem of wet-cold injury did not arise in the hot jungles of New

Guinea, New Britain, the Admiralty Islands, and the Schouten Islands, where

all the fighting occurred in this area before the invasion of Leyte in September

1944. The outbreak of form of cold injury which occurred in Leyte has already

been described (p. 211). Col. I. Ridgeway Trimble, MC, Consultant in

Surgery, Office of the Surgeon, USASOS, SWPA, who was familiar with the

losses from trenchfoot in the Aleutians and in the Mediterranean theater,

reacted to this outbreak in two ways:

1. He wrote Major Glenn on December 1944, suggesting that the men

with these injuries be considered for sympathetic block. When this suggestion

reached Major Glenn, the patients had already recovered.

2. Colonel Trimble also prepared technical memorandum on the subject

of trenchfoot, based on War Department Circular No. 312, to be issued by

Headquarters, USASOS. This memorandum, which was not issued, recognized

that the disability sustained by number of troops on Leyte, although it had

occurred in the Tropics, was actually form of cold injury or trenchfoot. With

proper preventive measures, the number of men disabled from this type of

trauma could be held to minimum. It might not be possible, the memorandum

continued, to carry out, during the exigencies of jungle warfare, all the preventive measures recommended, but every effort should be made to follow the

directions outlined. Particular emphasis was placed on the provision of extra

dry socks for each man.

With the concurrence of General Denit, Colonel Trimble also discussed

with the Surgeon, Sixth U. S. Army, Brig. Gen. William A. Hagins, the indoctrination of troops in the prevention of wet-cold injuries, in view of the impending fighting on Luzon. In General Hagins’ opinion, which events proved

to be correct, this was an unnecessary precaution at this time, since conditions

on Luzon during therainy season would not be comparable to those encountered

on Leyte.

Between 30 April and 16 July 1945, Colonel Trimble, on General Denit’s

instructions, prepared number of memoranda and drafts and revisions of

circular letters on the subject of cold injury. They were chiefly exploratory

and preparatory and were designed to keep the Office of the Theater Surgeon

informed on this matter, and to have all the necessary material in readiness

when the time came to issue circular letters and technical memoranda. In these

various drafts the following points were made:

1. Trenchfoot could be expected to become problem of great seriousness

as fighting developed in colder climates.

2. In spite of the experience in the Aleutians in 1943 and in Italy in

1943-44, some American units went into combat in biurope without proper

footgear. As consequence, they suffered seriously from cold injury.

Check Sheet, Surgical Consultant, Headquarters, United StatesArmy Forces, Western Pacific, to the Chief Surgeon,

16 July 1945, subject: Trench Foot, Summary of Program to(Date.
222 COLD INJURY, GROUND TYPE

3. The rate of cold injury under similar circumstances varied from unit to

unit, depending upon the efficiency of commanding officers in enforcing preventive measures.

4. British and Russian troops, who had better winter footgear than United

States troops and who had been better schooled in foot hygiene, had almost

no trenchfoot.

5. Strenuous measures must be taken in the Pacific to avoid repetition

of the previous United States Army experience, most of which was preventable.

6. Appropriate memoranda should be published at once, through technical

and command channels, concerning these preventive measures, which were

command and not medical responsibility.

7. It was urgent thatrequisitions be placed at once with the Office of the

theater chief quartermaster for sufficient supplies of shoepacs, wool socks,

and other winter equipment. In the memorandum dated May 1945, it was

noted that these supplies were already on order and that teams trained to give

instruction in the proper use of the new winter clothing would arrive in the

Southwest Pacific Area in August.

Colonel Trimble, with General Denit’s concurrence, also held conferences

with representative of the theater chief quartermaster concerning the protection of ground troops in cold, wet weather. Originally, the use of white clothing for camouflage had not been contemplated, but, after Colonel Trimble

had raised the question, his suggestion was approved and 10,000 suits, enough

for two regimental combat teams, were put on order.

The new items of clothing and footgear were demonstrated for Colonel

Trimble who wrote in memorandum to General Denit on 16 July 1945:

“The temperature then in Manila was 105° F. in the shade. It was rather

painful to observe the demonstrating soldier put on in layers pair of Jong

Johns,’ wool shirt, two pairs of wet resistant pants, two pairs of wool ski

socks, an Eisenhower jacket, an M-1943 jacket, cap with ear muffs, and

high shoepac.”

On 27 June, Colonel Trimble submitted recommendation to General

Denit that all United States Army officers and enlisted men of ground combat

elements be given special foot examination by their unit medical officers, to

determine the status of the two main arteries of the foot. Men in whom the

pulsations in these arteries were absent would have further examinations,

including roentgenologic studies, to detect or exclude insufficient circulation

due to arteriosclerosis and other causes. The rationale of this recommendation

was the peculiar susceptibility of this (small) group of soldiers to cold, and

the possibility that they would contract trenchfoot under conditions in which

those with normal circulation would suffer no disability whatsoever. This

recommendation was approved by General Denit.

On 12 July 1945, General Denit received from General MacArthur’s headquarters letter incorporating the information about cold injury which had been

Check Sheet, SurgicalConsultant, United States Army, Western Pacific, to the Chief Surgeon, 27 June 1945, subject:

Comments on Indoctrination Program Cold-Wet.
THE PACIFIC 223

sent to the latter by the War Department on 27 April 1945 (p. 218). On General Denit’s instructions, Colonel Trimble prepared circular letter on the subject, to be issued as command directive from General MacArthur’s headquarters.

Various changes were made in this letter as it passed through various

hands. One change was the deletion of the recommendation that all soldiers

should have an investigation of the pulsations in the pedal arteries as part of

their physical examination. Another was the deletion of paragraph in which

it was stated G) that the great majority of cold injuries in other theaters could have been avoided if troops had been properly indoctrinated concerning the

cause, effect, and prevention of cold injury and (2) that the disability rate in

armies subjected to the same climatic conditions varied enormously with the

efficiency of their commanding officers.

Had the war continued and had it been necessary to issue technical memoranda and circular letters on the subject of cold injury, their preparation would

have been simple matter, since the material had been thoroughly worked

over and was readily available for use. Instruction on the prevention of trenchfoot and the training of troops in foot hygiene was included in the medical

planning for the impending OLYMPIC and CORONET operations against

Japan,and provision had also been madefor shoepacs and other winter footgear.

On 17 July 1945, Col. Charles W. Mayo, MC, who had been placed on

temporary duty in the Office of the Chief Surgeon, AFWESPAC (United States

Army Forces, Western Pacific), as special consultant in cold injury, prepared

memorandum for General Denit, in which he made the following suggestions;

1. That wet-cold indoctrination program, similar to the program already

instituted in other parts of the Pacific, should be carried out in the Philippines.

The Quartermaster Corps would provide the program on instruction in the use

of winter clothing, and there would be related medical program on the care

of the feet.

2. That training film 180 should be made compulsory viewing for all personnel and officers, on the ground that it would probably be the greatest single

aid available in persuading troops to carry out the preventive measures advised.

It was recommended that it should not be combined with films shown for entertainment, and that there be no comment upon it afterward unless an exceptionally able medical speaker was present, since it was sufficiently informative

and impressive in itself.

The war in the Pacific ended before these plans could be put into effect.

Colonel Gordon and Major Hawley, who had been released from the

European theater for service in the Pacific (p. 219), arrived in Headquarters,

MIDPAC (United States Army Forces, Middle Pacific), on 11 August 1945.

They held conferences with the surgeon and members of his staff, representaCircular Letter (draft), Office of the Commanding General, AFPAC, 12 July 1945, subject: Trench Foot.

Cheek Sheet, Surgical Consultant, Office of the ChiefSurgeon, Headquarters, United States Army, Western Pacific,

to the ChiefSurgeon, 24 June 1945, subject; Outline of Studies Being Conducted on Medical Supportfor Next Operation,

Memorandum, Col. John E. Gordon, MC, Headquarters, MIDPAC, to General Willis, 17 Aug. 1945, subject

Trenchfoot Control.
224 COLD INJURY, GROUND TYPE

lives of the quartermaster, representative of the surgeon of the Central

Pacific Base Command, and others, to review the entire wet-cold program and

related subjects. One day was spent at Headquarters, 98th Infantry Division. Extended conferences were held with medical officers of the marine

forces, the Pacific naval force, and the United States Navy, Pacific. Two

general conferences were held with medical units alerted for service in Japan.

At all of these conferences, the principal topic of discussion was the medical

aspects of cold injury and the epidemiologic features of its control. It was the

opinion of Colonel Gordon and Major Hawley that adequate attention had

been given by Headquarters, M1DPAC, to the probability of cold injury in

forthcoming military operations, and that sound measures had been taken for

its prevention. The excellent training of the 98th Infantry Division furnished

proof of these statements.

When Colonel Gordon and Major Hawley reached Manila, they were

informed by General Denit that he desired the trenchfoot program to be carried out as planned, but with such modifications as would make it suitable

for an army of occupation. The scope of the mission was extended to include

considerations of acclimatization. Later, it was decided to defer indoctrination

until all troops in the Philippines had been moved to Japan, since the confusion

attending their deployment made the institution of formal program impractical at this time. For various reasons, the medical phase of the program was

never instituted, although the instruction of the troops in the use of winter

clothing went forward as planned (p. 228).

ACTION BY COMMANDERS IN PACIFIC

The training directive issued on 20 January 1945 from Headquarters,

Army Ground Forces (p. 76 and appendix B), was received by General MacArthur’s headquarters and was transmitted for informational purposes to the

commanding general of USASOS, on 21 March 1945.

On 27 April 1945, communication from the War Department to General

MacArthur (p.218) pointed out that the prevention of trenchfoot is primarily

command problem and directed that adequate indoctrination of troops be

undertaken before they entered combat zones. This communication was

transmitted by General MacArthur’s headquarters to the commanding general of USASOS, SWPA, on 12 May 1945, for necessary action.

On 18 July 1945, letter directive from General Headquarters, AFPAC,

(appendix H, p. 533), to the various headquarters in the Pacific announced the

wet-cold indoctrination program and placed the responsibility for its technical

and administrative control on the commanders logistically responsible for the

troops in the Western and Middle Pacific areas. The commanding generals

of the Sixth and Eighth S. Armies and of the Far East Air Force in turn

were charged with responsibility for the indoctrination of personnel in their

commands. Direct contact between the various commands was authorized
THE PACIFIC 225

for the purposes of the program. Appropriate directives containing pertinent

information were issued to all subordinate echelons.

second communication on the subject of cold injury was in preparation

in General MacArthur’s headquarters on 12 August 1945, the day of the Japanese surrender, for distribution to the various commands in the Pacific. In

it the following points were discussed:

1. Attention was called to the earlier letter on the subject, in which

the responsibility for the training program was placed specifically upon command, with unit commanders responsible for the dissemination of information

and for enforcement of preventive measures.

2. The European experience with cold injury was briefly reviewed, and it

was emphasized that only the strict application of correct preventive measures

could forestall repetition of that experience in Japan.

3. The importance of rotation of troops was stressed.

4. It was again directed that the wet-cold indoctrination program be included in all training programs.

This letter was accompanied by an outline intended for the guidance of

officers responsible for the training of troops. Details of the required preventive measures were described.

The rationale of these measures was stated as follows:

1. Men who have lived in the Tropics for approximately years are

physiologically attuned to weather varying from warm to extremely hot and have probably all but forgotten modes of living imposed by cold weather.

They must therefore be prepared for sustained out-of-doors life in circumstances of extreme cold.

2. The mere provision of suitable winter clothing is not sufficient. The

experience in Europe clearly demonstrated that troops must also be taught

how to wear such clothing and how to maintain it. Knowledge of the proper

fit and sizing of garments is also essential.

3. Protection of the soldier in winter combat is the responsibility of all

echelons of command, from senior commander to squad leader. The experiences

of United States Army troops on Attu, in Italy, and in Europe clearly showed

the importance of this attitude and achievement, as did the British experience.

Because their officers and leaders were aware of their responsibility, the incidence of trenchfoot in British troops was negligible.

4. Trenchfoot is chiefly disease of infantrymen. It causes actual losses

among men who carry the fight to the enemy; also, soldiers who become chilled

beyond the point of comfort are neither mentally nor physically fit for efficient

combat.

To implement the program planned for the prevention of cold injury, it

was directed

1. That the wet-cold indoctrination program be given top priority in all

echelons and be incorporated into the requirements of all training programs

for operations contemplated in temperate climates.
226 COLD INJURY, GROUND TYRE

2. That the implementation of training doctrines be made the responsibility of command in all echelons.

3. That individual organizations be held responsible forfurther indoctrination of troops in various echelons, the basic program being designed only to

orient, as fully as possible, all command and staff officers and key enlisted men

in these echelons.

4. That the program be limited to ground combat and service elements of

the Army and to Military Government personnel. Other provision would be

made for the instruction of Marine Corps and Air Forces personnel.

5. That the program occupy approximately weeks, with an additional

weeks allowed for the dissemination of the doctrines of the preliminary

courses to organizational personnel by individual commands. The officers

detailed to the area by the Office of the Quartermaster General, who were

already in the area, would be available for consultation. Courses of instruction were outlined for higher headquarters and for ground combat and ground

combat service support echelons.

6. That indoctrination be provided at the latest date practical before

staging, the program being phased to meet this objective. refresher course

in living and fighting in wet-cold areas should be included in shipboard orientation programs, but, as far as practical, should be delayed until convoys had

passed out of the tropical zone, so that normal cold weather conditions would

help to emphasize the doctrines to be employed at the target area.

THE QUARTERMASTER CORPS

The Quartermaster General employed in the Pacific areas the same

policy which he had employed in other theaters of operations. Observers

were sent into the area to introduce new equipment and to lay the basis for

future requisitions. 10 The action taken in the Pacific was greatly influenced

by the serious consequences of the failure in the European theater to accept

the advice of his office concerning the best type of clothing and equipment.

Long-range planning was essential in the Pacific because the long distances

would make procurement and transportation difficulties more serious than in

either the Mediterranean theater or the European theater.

The observers sent to the Pacific from the Quartermaster General’s Office

also had the responsibility of indoctrinating the troops in the correct wearing and care of the new winter clothing. The same general routine was followed

that had been followed in other areas, but the observers in the Pacific area

had two advantages: They had seen the results of training in the Mediterranean

10 (1) Report, Capt. William F. Pounder and Capt. Clarence J. MacManus, Military Planning Division, Research

and Development Branch, Office of the Quartermaster General. (2) Report, Col. Charles P. Bellican, QMC, Senior

Member Quartermaster General Liaison Group in Pacific Areas, Nov. 1945, subject: Quartermaster General Liaison

Indoctrination Program in Wet-Cold Clothing Concepts, also Cold Weather.
THE PACIFIC 227

theater in the winter of 1944-45, and they had also seen the serious situation

which developed in the European theater because requisitions for the proper

kind of clothing and footgear had been placed too late for the material to be

delivered when it was needed for the winter campaign.

When the first observer from the Office of the Quartermaster General,

Capt. (later Lt. Col.) William F. Founder, QMC, arrived in the Hawaiian

Islands (then MIDPAC) on April 1945, the logistic responsibility for the

assault operations on Japan had not yet been firmly established. Almost as

soon as the requisitions for winter clothing and equipment had been completed

and approved by the supply staff of MIDPAC, these responsibilities were

assigned to AFPAC. The requisitions prepared in MIDPAC, which were

thus left without authorization, were forwarded to the Office of the Quarter- master General, to serve as guide for the specific amounts of individual

wet-cold winter items considered necessary for the invasion.

The team headed by Captain Pounder eventually consisted of seven other

officers from the Office of the Quartermaster General and two Quartermaster Corps officers who were attached to it locally. Its mission was threefold, to

plan the quantities of supplies needed for the forthcoming winter operations,

to train the troops in the use and care of their personal winter equipment, and

to observe the functional adequacy of individual items of wet-cold clothing

and equipment. Ml previous operations in the Pacific had required only

tropical clothing and equipment, and the change from supplies of that type of

clothing to supplies of clothing and equipment suitable for winter combat

would represent, in itself, major logistic operation. The advice of the representatives of the Quartermaster General, contrary to the experience in Europe,

was accepted at once. When the war ended, large amounts of winter clothing

and equipment were already on hand in the various commands in the Pacific,

and more were en route. It is certain that, if the war had continued into the

winter, all the troops would have been properly protected for combat in cold

environment. The first demonstration of the new clothing was given on Oahu

on 12 April 1945.

Training Memorandum No. 11 for the United States Army Forces,

Pacific Ocean Areas, was issued on 16 May 1945. In it, the date for the completion of all unit training in MIDPAC was set for September 1945. Training

was practically completed in the Hawaiian Islands by 20 June, when the team

left Oahu for the training of other units elsewhere.

Work carried out elsewhere by this team was as follows:

1. Establishment of the program of indoctrination at Fleet Marine Headquarters for all Marine units in the Pacific areas.

2. Indoctrination of troops on Johnson Island, Kwajalein, Saipan, Tinian,

Guam, Iwo Jima, and Okinawa.

3. Assistance to the second team working on Mindanao and Luzon by two

members detached from the first team.
228 COLD INJURY, GROUND TYPE

4. Indoctrination of troops in Korea and Japan and in Kyushu (Sasebo),

Honshu (Yokohama), and Shanghai, after V-J Day. Indoctrination was

expedited in Korea, where it grows steadily colder after the first part of October.

Each major unit was helped in the planning of requisitions and the distribution

of clothing, and the actual distribution was supervised by two officers from the

team attached to the XXIV Corps.

The final phases of the work of Captain Pounder’s team were carried out

under the direction of the liaison group from the Office of the Quartermaster

General, which had arrived in the Pacific on 21 May 1945. The initial activities of this team, on Oahu, consisted of conferences with the first team and

additional planning for wet-cold clothing and equipment for Operation OLYMPIC.

The second team, which was headed by Col. Charles P. Bellican, QMC, operated in four sections; namely, planning section assigned to the Commander in Chief, AFPAC, for coordination purposes, an operating section in

M1DPAC, and two operating sections in AFWESPAC. The planning section

was later assigned to the administrative control of the Commanding General,

AFWESPAC, who then had general logistic control of Operations OLYMPIC

and CORONET. After command responsibility had been approved by the

Commander in Chief, AFPAC, and general directive had been prepared dealing

with the capabilities and limitations of wet-cold clothing, supply problems connected with its issue, and similar matters, the entire program was placed in the

hands of the liaison group.

Training directives were first prepared for the various separate commands.

Teams were then dispatched from the operating sections of the group to the

lowest tactical elements of the various commands, to insure that all soldiers

received proper individual instruction. This phase of the work lasted from

June until the middle of August.

When the Japanese surrendered, the indoctrination program was at once

modified to fit the needs of an army of occupation, and plans of instruction were

modified to meet the needs of the changes of tactical units within the several

commands and assignments in the areas of occupation. The program was

hampered by delays in the delivery of winter clothing, due to the shortage of

ships; by the shortage of port facilities, due to the destruction caused by bombing during the war; by the necessity for using harbors which were still mined;

and by the very bad weather. As late as 28 September, only small amounts of

winter clothing had been received in the Tokyo area.

In spite of these difficulties and delays, Colonel Bellican was able to report

to General MacArthur on November 1945 that as of November, the original

target date for the completion of the program, approximately 96 percent of the

army of occupation had been indoctrinated and that the program had been completed 100 percent in the XXIV Corps and the Eighth U. S. Army. Arrangements had been made for the training of the elements of the Sixth S.

Army not yet indoctrinated.
THE PACIFIC

PRACTICAL CONSIDERATIONS OF THE WET-COLD

INDOCTR[NATION R0(i AM

It was originally estimated that the program of wet-cold indoctrination for

troops in the Pacific would cover total of 1,500,000 men. The necessity for

program of such magnitude is readily explained: The training program instituted in the Zone of Interior (p. 74) had been in operation too short time to

affect most of the troops in the Pacific. Many of the troops deployed to the

Pacific from the European theater had arrived late in that area, had had little

combat experience, and had also had little training in the prevention of cold

injury. Finally, troops which had fought only in the Pacific had had no

indoctrination at all, and without it they would have been completely unprepared for combat in wet-cold weather. Training en masse was far more efficient

than an endeavor to isolate the groups and individuals making up the small

minority which had already been trained.

There were number of factors which complicated the indoctrination

program:

1. All the military bases in the Pacific were islands, and there were therefore enormous distances between the groups of men to be indoctrinated.

2. Xo specific organization was in existence for meeting the special problems posed by the prevention and control of cold injury. Command, staff,

technical personnel, and enlisted components alike had to undergo comprehensive indoctrination on all phases of this type of trauma at the same time that

administrative facilities for organization and implementation of the program

were being developed.

3. The varying character of the troops in each command required the

setting up of number of special programs. Combat troops, service troops,

and the various organizations of the Army Air Forces all had to be instructed

differently.

4. Facilities for instruction ranged from indoor theaters and classrooms on

Oahu to demonstrations in makeshift areas deep in mud. Extreme heat and

frequent drenching rains added to these difficulties.

5. The size of the class was often determined by the availability or lack

of availability of public address system.

6. Language difficulties also arose. Instruction had to be given to soldiers

of several nationalities, including Chinese and Filipinos. When Film Bulletin

No. 180 was shown, the sound track was translated as the showing progressed.

7. The program was timed to permit completion just before the invasion,

so that the troops would not forget what they had learned about cold weather

during the additional period they had to spend in tropic temperatures.

8. Written records required from commanders concerning the progress of

indoctrination within their units proved essential but were sometimes produced

unwillingly.

9. Training aids had to be of convenient size to be carried no matter how
230 COLD INJURY, GROUND TYPE

the instructor might be traveling. Large, heavy, bulky materials, no matter

how valuable, were not practicable.

Training directives.—Although class schedules had to be widely varied

according to the extent of the area of each base, the complexity of commands,

the type of personnel to be instructed, and other considerations, training directives could be practically uniform. The training directive for the Pacific

Ocean Areas (Training Memorandum No. 11) was issued on 16 May 1945 (p.

227). It was reproduced with only minor changes as Training Memorandum

No. AFWESPAC, August 1945. This latter directive furnished the authority for the indoctrination of all troops in the Philippine Islands and all adjacent

areas under the administrative control of AFWESPAC. separate directive

was issued on August for service troops.

These directives covered the following points:

1. The indoctrination of all individuals liable for service under wet-cold

conditions; the training of supply personnel in supply, storage, care, maintenance, proper fitting, and issue of clothing and equipment; effective instruction

in the use of these items; command responsibility for the training; specified

dates for the completion of the program.

2. Description of the new wet-cold clothing and equipment.

3. Details of the training courses, which were hours for officers and enlisted personnel; hours for instructors; hour for supply personnel; and

refresher course when the winter clothing was to be issued.

4. The function of the indoctrination teams from the Office of the Quarter- master General.

5. Training aids and references (p. 231).

6. Provision for unit status-of-training reports to be submitted to headquarters before operational commitment of troops or before transfer of units

between major echelons, the date to include the hours of training accomplished

per individual and the commander’s estimate of the unit’s proficiency.

Three courses of instruction were provided in the wet-cold program, one

for officers and enlisted men for indoctrination purposes, one for instructors

who would conduct future courses, and one for supply officers and enlisted

supply personnel. The best results were obtained if the instructor took for

granted that his audience had never seen the new winter clothing and equipment, as indeed most of them had not.

The material was usually presented as follows:

1. Explanation of the purpose of the course.

2. Necessity for the course, because of past experiences in wet-cold climates.

3. Statement of cold injury casualties in the Aleutians and in the Mediterranean and European theaters, with discussion of the responsible climatic

factors.

4. Brief descriptions of trenchfoot, frostbite, and the respiratory diseases,

with special references to their relationship to the incorrect use of uniforms and

equipment.
THE PACIFIC 231

5. Showing of Film Bulletin Xo. 180 on trenchfoot.

6. Explanation of the difference between wet-cold and extreme cold.

7. Clirnatologic data on Japan and the coast of China. Information was

also included on Russia, to provide for all contingencies.

8. Principles of living in cold and wet-cold.

9. Demonstration of the winter combat unit, with special reference to the

layering principle.

10. Explanation of the importance of the correct fit of garments, methods

of ventilation, washing of woolens and cottons, provision of dry socks and insoles, and similar matters.

11. Display of posters on the proper use of clothing.

12. Demonstration of the correct use of special equipment, including the

sleeping bag with water-repellent case, the poncho, the pack, and the mountain

cook set.

Each course of instruction was concluded with summary, question

period, and inspection of the items of clothing and equipment by the audience.

Training aids and references.—The chief training aid was the combat

uniform itself, which troops in the Tropics had never seen before. There was

some delay in the receipt of the first sets to be used for teaching purposes, but

eventually sufficient numbers were available to be shipped ahead to all the

islands on which instruction was to be given.

In addition to material of interest only to supply personnel, the following

training aids were employed:

TM 10-275, Principles of Cold Weather Clothing and Equipment.

FM 70-10, Mountain Operations.

FM 70-15, Operations in Snow and Extreme Cold. This manual was

not of very great value, since extreme cold was only relatively important in

the Pacific.

Trenchfoot, Cause and Prevention (Sect. IV, WD Circular No. 312, 1944).

Prevention of Trenchfoot and Frostbite (Letter, Headquarters, Army

Ground Forces, 20 Jau. 1945).

FB-180, Trenchfoot. As noted elsewhere, it was the general opinion

that this film bulletin was the greatest single aid in the prevention of cold

injury because it showed so vividly the possible consequences of cold injury;

namely, gangrene and amputation. When the technicolor Navy film on

trenchfoot became available, it was shown to medical officers and

other personnel who might be interested. Film strips on cold weather

operations were of little value and were seldom used.

Posters, radio announcements, and publicity in Yank, Stars and Stripes,

and other Army publications were utilized to keep the indoctrination program

in the minds of men who had received instruction but who were still in tropical areas and who would be inclined to think of clothing and personal hygiene

accordingly.
232 COLD INJURY, GROUND TYPE

Instruction After V-J Day

Inquiry at theater headquarters after the surrender of Japan revealed

that combat maneuvers and patrols would be discontinued at once and that

the chief task of the troops would be policing. It was expected that forces

in both Japan and Korea would be billeted in heated quarters and would not

be subjected to extraordinary exposure to cold-wet conditions.

At the desire of the theater commander, the program was continued after

V-J Day, with modifications in the emphasis and the content of the courses.

The film bulletin on trenchfoot was no longer shown, but the correct fitting

and use of the winter combat uniform were still emphasized. To maintain

the interest of the troops, which naturally decreased as the acute need for

protection against wet and cold was lessened, the usefulness of this special

clothing for hunting and fishing in civilian life was stressed. The 2-hour

period formerly allotted for the course was now reduced to hour.

Acclimatization Program

The Chief Surgeon, AFWESPAC, 30 June 1945, concurred in the proposal made earlier by the theater quartermaster to G-4 of the theater concerning the institution of an acclimatization program for all troops who were

to move from tropical to cold climates in the forthcoming operations against

Japan. 11 In his concurrence, General Denit stated that medical officer

would be delegated to collaborate with the theater quartermaster in setting

up the technical aspects of the program and to assist in the correlation of

its technical and administrative control. It was suggested that the program

be so phased that instruction would be given at the latest feasible time, which

would not be before 15 July 1945.

Shortly after this proposal was accepted, Maj. (later Lt. Col.) Paul Siple,

QMC, an experienced climatologist who had been in the Antarctic with Admiral

Byrd and who had made an extensive study of the clothing used in the European theater during the trenchfoot outbreaks the preceding winter (p. 431).

was temporarily assigned to the Office of the Chief Surgeon, AFPAC, as

representative of the Quartermaster General. His special mission was to

devise plans for the proper, gradual acclimatization of troops who would

suddenly be transferred from tropical to colder climates. 12

It was estimated that under these circumstances men would be considerably

below peak efficiency for about weeks, at least that period of time being

required for the establishment of compensatory vasomotor controls. It was

believed that the time could be shortened if training were instituted during

the journey on the transports from southern bases to the target areas farther

north. It was therefore recommended that during this journey, particularly

11 Check Sheet, Chief Surgeon, AFWESPAC, to G-4, 30 .Tune 1945, subject: Indoctrination Program, Wet-Cold. 12 Letter, Col. Charles P. Bellican, QMC, Quartermaster General Liaison Group, Headquarters, AFWESPAC, to

Brig. Gen. Georges F. Doriot, Military Planing Division, Office of the Quartermaster General, Aug. 1945.
THE PACIFIC

during the last weeks, troops should be encouraged, as they entered cold

waters, to expose themselves to the cold as much as possible, by remaining on

deck for long periods with minimum clothing. It was expected that they

would object to being uncomfortable, but it was considered more desirable

to impress upon them the value of acclimatization while they could still get

warmed up occasionally than to let them suffer the rigors of getting used to cold weather in the midst of combat.

The acclimatization program came to an end with the end of the war, before

the theories on which it was founded could be put to the test. One of the

indirect results expected from it was the saving of tons of shipping space; it

was estimated that men who had been acclimatized would require for efficient

comfort at least one layer of clothing less than men who had not been trained

to withstand cold weather.

INDOCTRINATION OF OTHER SERVICES

In June 1945 representatives of the Office of the Surgeon General made

contact with the Bureau of Medicine and Surgery, United States Navy, to

inform the appropriate officers of the Army experience with trenchfoot in the

European theater and of the plans for its prevention and control in the Pacific. 13

Transmission of this information was considered essential, since the Navy had

had little experience with the ground type of cold injury which would be

encountered in the Pacific, where large numbers of Marines would be involved

in forthcoming operations. Medical officers of the Navy were informed on

all phases of the Army program, and the Army officers, in turn, were given

print of the Navy film in technicolor on cold injury. This film later proved

useful in the indoctrination program in the Pacific.

When demonstration classes were held on Oahu for Army officers, at the

beginning of the indoctrination program, they were also attended by Marine

officers, who were much impressed with the potential dangers of winter warfare

to Marines whose entire previous combat experience had been in tropical areas. 14

These officers were also greatly concerned about the possible efficiency of their

winter uniform, which was still an unknown quantity under wet-cold combat

conditions. Marine equipment did not include such items as shoepacs, overshoes, trigger-finger mittens, water-repellent jackets with hoods, and sleeping

bags. When the Army uniform and equipment were demonstrated to the

Marine Corps Command on 22 May 1945, the comparison was so greatly in

favor of the Army items that the Marine Corps immediately submitted requests

for many of them. After conference with the representatives of The Quarter13 Memorandum for Record, Lt. Col. A. L. Ahnfeldt, MC, Director, Sanitation and Hygiene Division, Preventive

Medicine Service, Office of the Surgeon General, 30 June 1945, subject: Conference on Trenchfoot at Bureau of Medicine

and Surgery, Navy.

14 See footnote 10 (1), p. 226.
234 COLD INJURY, GROUND TYPE

master General on 11 June, 15 Navy officers also decided that Army clothing

would be better for their land-based personnel than their own uniforms for

their seagoing personnel.

As soon as it was realized that wet-cold indoctrination was essential for

all Marine personnel who would participate in future winter operations, the

necessary directives were issued. On Okinawa, which was combat area,

direct instruction was given to Marine contingents by members of the army

quartermaster team. 16 Elsewhere, the general plan was to train Marine officers

as instructors who would serve as instructors for other officers, who were then

responsible for the indoctrination of their own units.

SUMMARY

The most important conclusion to be derived from the story of the wet-cold

program in the Pacific is that for the first time in World War II the problem of cold injury was attacked in advance of its occurrence, and was attacked by

all the elements whose responsibility it was to be. Command, staff, Quarter- master Corps, and Medical Corps all participated in the endeavor to prevent it. It is true that coordination of the separate efforts had not yet been fully

accomplished when the war ended, but the originally divergent lines of action

were clearly beginning to converge. There seems no doubt that, had the

fighting continued, the program as set up and implemented would have proved

an effective means of preventing the cold injuries which had been responsible

for such heavy losses in theaters of operations earlier in the war.

15 Letter, Oapt. William F. Pounder, QMC, to Brig. Gen. Georges F. Doriot, Military Planning Division, Office

of the Quartermaster General, 11 June 1945. 16 (1) Letter, Capt. William F. Pounder, QMC, Q-3 Section, Headquarters, Army Garrison Forces, Okinawa, to Brig. Gen. Georges F. Doriot, Military Planning Division, Office of the Quartermaster General, 27 July 1945. (2) Letter, Captain Pounder, Q-3 Section, Headquarters, Army Service Command I, to General Doriot, 12 Aug. 1945.
235

CHAPTER IX

Pathogenesis and Pathologic Process

PATHOGENESIS

Generally speaking, both the clinical manifestations and the pathologic

process in cold injury depend upon two mechanisms: (1) The duration of the

exposure to cold or wet cold, and (2) the degree to which the temperature of

the tissues is reduced. The comparison has frequently been made and is valid

that cold injuries resemble thermal burns with one exception: in cold injury

there is no coagulation of the components of the blood serum.

The altered physiologic processes resulting from exposure to cold have

been described by number of observers,notably Ariev, Blackwood, Burdenko,

Lange and Boyd, Lewis, and Kreyberg and his associates. Of these descriptions, Lewis’ articles and the various contributions of Kreyberg best summarize

current concepts of the mechanisms involved in injuries caused by cold. As

matter of convenience, their material will be summarized separately.

Theories of Pathogenesis (Lewis)

discussion of the pathogenesis of cold injury necessarily begins with the

mechanism of simple cooling and its effects on the blood flow to the skin.

comfortably warm person, who sits unclothed, atrest, in room without

source of radiant heat, progressively loses body heat if the room temperature

is 61° F. (16.1° C.). In many persons, the cooling process begins at 64° F.

(17.8° C.), and in some persons it begins at 68° F. (20.0° C.). Progressive

Ariev, T. V.: Fundamental Outlines of Present Day Knowledge of Frostbite. Medgiz; Moscow, 1943.

Blackwood, W.: Injury from Exposure to Low Temperature: Pathology. Brit. M. Bull. 2(7): 138-141, 1944.

Burdenko, N.N.: The Effect of Frostbite on the Sympathetic Nervous System. Am. Rev. Soviet Med. I; 15-22,

October 1943.

(1) Lange, K., and Boyd, L. J.: Use of Fluorescein Method in Establishmentof Diagnosis and Prognosis of Peripheral Vascular Diseases. Arch. Int. Med. 74: 174-184, September 1944. (2) Lange, K., and Boyd, L. .1.: The Functional Pathology of Experimental Frostbite and the Prevention of Subsequent Gangrene. Surg., Oynec. Obst. 80:

346-350, April 1945.

(1) Lewis, T.: Observationson Some Normaland Injurious Effects of Cold upon the Skin and Underlying Tissues.

I. Reactions to Cold and Injury of Normal Skin. Brit. M. J. 2; 795-797, Dec. 1941. (2) Lewis, T.: Observations on

Some Normaland Injurious Effects of Cold upon the Skin and UnderlyingTissues. II. Chilblainsand AlliedConditions.

Brit. M. J. 2: 837-839, 13Dec. 1941. (3) Lewis, T.: Observations on Some Normal and Injurious Effects of Cold upon

the Skinand Underlying Tissues. III. Frost-bite. Brit. M. J. 2: 869-871, 20 Dec. 1941.

(1) Kreyberg, L., and Rotnes, L.: La Stase Expferimentale. Mcthode pour la Mettre en Evidence au Moyen de

Preparations Spficiales. Compt.rend. Soc. de biol. 106: 895-897, 21 Mar. 1931. (2) Kreyberg, L.: Some Notes and Considerations Regarding Injuries from Cold. Report to the Commanding Officer, 108th United States General Hospital,

12 Apr. 1945. (3) Kreyberg, L.: Tissue DamageDue to Cold. Lancet 1: 338-340, Mar. 1946. (4) Kreyberg, L.: Experimental Immersion Foot in Rabbits. Acta path, et microbiol. Scandinav. 27; 296-308,1949.
COLD INJURY, GROUND TYPE

cooling becomes apparent chiefly in certain parts of the body, particularly the

extremities and even more particularly the digits, in which the temperature

eventually approaches that of the surrounding air. The cooling process

varies according to the precise circumstances of exposure and also varies from

subject to subject. The result is naturally influenced by whether or not

clothing is worn, especially if the room air is in motion, since clothing holds

layer of warm air on the surface of the skin. Cooling occurs very much more

rapidly if the part is immersed in water.

Effect of cooling on blood flow.—The first reaction of the skin to cold is

vasoconstriction, which is manifested clinically by sensation of cold and

contraction of the smooth muscle of the skin (gooseflcsh). Vasoconstriction

resulting from cold, however, is not simple reaction. It involves three

separate components: (1) direct and persistent response of the superficial

vessels, in the form of local constriction; (2) transient general vasoconstriction

brought about by reflex action through the central nervous system; and (3)

persistent general vasoconstriction. This general vasoconstriction is caused

by the return of cold venous blood from the cooled skin and the consequent

lowering of the temperature of the general circulation. The cooled general

circulation acts, in its turn, upon central nervous mechanism which is extremely sensitive to cold. All surface vessels, including arteries, arterioles,

capillaries, venules, and veins, are involved in these mechanisms, and the total

response constitutes the general defense of the body against cold.

In the very act of conserving general body heat, the subcapillary plexuses

of the venules, which are so extensively involved in the process, may themselves

be sacrificed. As these vessels constrict to safeguard the organism against an

excessive fall of temperature, there is, necessarily, fall in the temperature of

the limb. As the limb cools, more and more of the regional vessels constrict,

so that eventually vicious circle is set up by which the temperature of the

limb gradually approaches the environmental temperature.

Local defense.—When the temperature has fallen to 50° F. (10° C.) or

lower, the clinical effects of cooling become manifest. The skin feels numb.

Touch sense and pain sense are lost. There are also certain muscular effects,

which Lewis describes as 'local defence.” This is process of alternate vasoconstriction and vasodilatation, by means of which the mean temperature of

the exposed part is raised several degrees. The mechanism depends upon axon

reflexes which are called into play by the cold injury and which are similar to

the reflexes called into play by burns, cuts, and other local injuries to the skin.

Lewis’ explanation is that all of these injuries cause the release of histaminelike substances from the cells of the skin. He has been able to show that

the production of pain is associated with actual damage to the skin. The

sensation of pure coldness begins to change to stinging or pain at about 59° F.

(15° C.). The defensive mechanisms just described are easily recognized

when the temperature is below this level, and in exceptional cases they can be

observed up to 64° F. (17.8° C.). The hypothesis of injury to the skin by cold

is further supported by the release of vasodilator substance, as the result
PATHOGENESIS AND PATHOLOGIC PROCESS 237

of cellular damage caused by supercooling, hypersensitivity to cold (in some

persons), and the swelling which follows prolonged cooling.

The maximum response to cold occurs in the vascular system. Vasodilatation and increased cellular permeability result in inflammation, which is

manifested clinically by redness, heat, and swelling.

Supercooling.—The supercooling property of the skin is attributable to the protective effect of its dry, horny layers. The dryness of these layers is the

important consideration. Wetness tends to destroy the supercooling property,

which is always more evident in skin that remains unwashed. Mechanisms of special cold injuries.—The predisposing cause of chilblains,

Lewis points out, is almost certainly habitually defective circulation, associaated with repeated exposure to cold. He also implies that erythrocyanosis,

trenchfoot, and immersion foot occur on the same basis. In the early stages,

all of these conditions present the common characteristics of itching, tenderness, coldness, and high vascular coloration. In more severe cases, swelling, blistering, and ulceration occur. Except in the extremely severe forms of frostbite,

necrosis of tissue occurs more frequently in trenchfoot than in other forms of

cold injury. The initial damage in trenchfoot may not appear to be as great

as in frostbite, but the injury is of the silent type, which means that trauma

continues over long period of time and anoxia is correspondingly prolonged,

while the temperature of the tissue is not sufficiently low to retard metabolic

or degenerative activity. The circumstances of the injury also play part.

In trenchfoot, it may be some time before the soldier realizes that he is injured,

or, if he does realize it, he may be unable to seek care or be unable to do anything for himself, because he is pinned down by enemy fire. Under these

circumstances, immobility and dependency begin to exert their influence.

Indolence and slow healing are characteristic of all cold injury. According

to Lewis’ theory, reduced blood supply permits greater cooling on exposure to

cold in chilblains, erythrocyanosis, and trenchfoot alike; and failure to prompt

healing, at least in chilblains and erythrocyanosis, is attributable to the same

cause. All three conditions may present the same acute inflammatory processes

observed in number of other injuries, such as those caused by heat.

In frostbite, in which there is actual freezing of the skin, the deeper tissues

may be involved. Although the freezing temperature of the skin lies between

32° F. (0° C.) and 28° F. —2.2° C.), the supercooling property of the skin

may prevent freezing until temperature of 23° to 14° F. —5° to —10° C.) is

reached. Once freezing has begun, however, the process is rapid, and large

areas of the skin surface mav become involved in verv short time.

As freezing increases in severity, Lewis’ triple-response phenomenon

appears, that is, local reddening, wheal formation over the affected area, and

surrounding bright-red flare. This reaction is the result of reflex vasodilatation, and in Lewis’ opinion it depends upon the release of histaminelike substances from skin cells injured by ice crystals. Later, after the wheal disappears,

local redness is persistent. Some edema is also persistent, and warming gives

rise to both pain and tenderness. Skin which is damaged to this degree shows,

438404 —58 17
238 COLD INJURY, GROUND TYPE

on microscopic examination, edema of both epidermis and dermis, together,

with perivascular infiltration of the superficial dermal layers with lymphocytes,

extravasated red cells, and some polymorphonuclear cells.

Theories of Pathogenesis (Kreyberg)

Lewis’ observations on the pathogenesis of cold injury, which have just

been summarized, were confirmed by the observations ofStray and of Kreyberg,

whose work was done independently. Kreyberg’s observations are in large

degree similar to those of Lewis, but he follows the various physiopathologic

processes more nearly to their ultimate conclusions.

Immediate reactions. —The immediate reaction of the skin to cold, as

Kreyberg describes it, is blanching, caused by contraction of the blood vessels,

including the minute vessels (the minute end organs or terminal loops of blood

vessels, in which the exchange of fluid and metabolic processes take place). At

skin temperatures of 77° to 59° F. (25° to 15° C.), cyanosis appears, as the

result of local oxygen deficiency, and the skin is cold to touch. As the temperature of the skin becomes progressively lower, series of other color changes

occurs. After the cyanotic stage, when the temperature is about 59° F. (15° C.),

the color of the skin is bluish red. At about 50° F. (10° C.), it is reddish purple

or red, and below that level it is bright pink. At this point, pain begins to be

felt. From the cyanotic stage onward, an increasing tissue anoxia accentuates

tissue damage. Paradoxically, however, the red stage is explained by surplus

of oxygen in the local skin areas, this being the result, according to Kreyberg,

of lack of consumption, and lowered dissociation, of oxygen. At this stage,

as well as at the blue stage, the sensations of touch and of pain are reduced.

Once the bright-pink stage is reached, the alternating constriction and

dilatation described by Lewis begin to occur, and there is resultant rise in the

skin temperature. The high color is the result of the presence of blood in the

minute regional vessels, which remain constantly dilated during this phase.

The sensation of cold is lost, and there is further reduction in touch and pressure

sense. With exposure to still lower temperatures, however, these minute vessels

contract, and there results second white stage, which must not be confused with the white appearance of frozen tissues containing ice crystals. There is

not, incidentally, full agreement with the theory of the formation of ice crystals,

and there is also considerable debate over whether or not, if they do occur, they

arc of great significance.

Up to this time, according to Kreyberg’s thesis, reactions which have

occurred as the result of exposure to cold are chiefly physiologic and are reversible if and when the environemntal temperature returns to normal. The position, however, is borderline, and prolonged exposure in any of the stages of cold

described may be sufficient for the process to pass over into actual pathologic

damage to the tissues. Further loss of body heat from protracted moderate

exposure thus may result in trenchfoot or immersion foot, with severe tissue
PATHOGENESIS AND PATHOLOGIC PROCESS 239

damage, while additional exposure to low temperatures may cause actual freezing of the skin and tissues.

Effects of cold on the vascular supply.—One of the effects of exposure to

cold, according to Kreyberg, is greatly increased permeability of the capillary

walls, which is most likely to occur during the red or hyperemic stage. As

result, there is transudation of plasma through the vessel walls, combined with slowing down of the flow of blood through the minute vessels. When

the injury is severe enough, all the plasma passes through the vessel walls, leaving the blood cells tightly packed in the lumen and preventing further blood flow by what amounts to mechanical occlusion of the vessel. Kreyberg regards

it as most important that this phenomenon be recognized as true stasis and not

be interpreted as intravascular coagulation. By the use of vital dyes, he and

Rotnes (one of his associates) were able to demonstrate both capillary permeability and blood cell stasis in the ears of rabbits which had been injured by

cold. Their observations were confirmed by Lange and Boyd, who demonstrated

transudation into injured tissue spaces by the use of intravenous injections of

fluorescein combined with examination by ultraviolet light. Reversibility of

the process was observed in frogs, but it remains to be proved that stasis in

man is reversible process.

Although the initial edema in cold injury can be explained as the result of

the imbalance between the outpouring and the drainage of tissue fluids, an

inflammatory factor enters the picture as capillary permeability increases.

Kreyberg, by using vital stains, was also able to demonstrate this phenomenon

in experimental animals which had been injured by cold.

From the cyanotic stage onward, as has already been pointed out, tissue

damage is accentuated by increasing anoxia of the tissues. In the more severe

types of injury, lack of oxygen brought about by the processes described leads

to necrosis, which may involve both the tissues and the packed, static blood

cells within the vessels. The final intravascular stage is the production of

hyaline mass from degeneration of the blood cells. Necrosis, in Kreyberg’s

opinion, is primarily the result of vascular stasis and anoxemia and is not

influenced by cold per se.

All the reactions thus far described are known to be the result of local

tissue damage in frostbite. Whether these same reactions result from long

exposure to moderate cold and wet, as in trenchfoot, cannot be so readily demonstrated. Kreyberg, however, is emphatically of the opinion that the end results

of exposure, with and without freezing to ice, differ only in degree and not in

principle. The reaction to severe or prolonged cold, he believes, is the result of

single factor; namely, acute aseptic inflammation from tissue damage caused

by the lowered temperature, the freezing to ice, and the deprivation of oxygen.

By the term “acute aseptic inflammation” he means the combined vascular and

cellular local reactions which occur after the introduction of an element foreign

to the tissues. Dead and damaged tissues and abnormal metabolic products

may act as the foreign elements. Either cellular or vascular type of reaction

may predominate.
240 COLD INJURY, GROUND TYPE

Two forms of tissue damage, according to Kreyberg’s theory, thus progress

during prolonged cooling, one caused by the cooling itself and the other by the

resultant lack of oxygen in the tissues. One of the first effects of prolonged

cooling is increased transudation and the development of edema. The passage

of plasma through the blood vessel walls is augmented by the increase in

hydrostatic pressure which may result from long standing or immobilization.

It is also the result of constriction, which increases venous congestion.

Kreyberg also believes that cardiac disease and poor physical condition,

whether from hunger, reduced protein intake, or reduced colloid pressure, may

increase transudation. Whatever the various causes may be, vicious circle

is soon set up, consisting of increased local tissue damage and increased permeability of the minute vessels. The shift of body fluid may be sufficient, in

some cases, to produce shock.

All of these reactions are retarded as long as the part is cold, partly because

of the slowing down of all activities and partly because of the prolonged contraction of the arteries and arterioles. These facts account in large measure

for the early clinical appearance of trenchfoot. They are of clinical importance,

for they indicate that the tissues are not dead. Therefore, unless the process

is of long standing wdien the patient is first brought under treatment, the

chances are that with properly applied treatment it will not go on to necrosis.

Theories of Pathogenesis (Ariev)

According to Ariev, the reaction of the tissues to cold is comparable to

chemical reaction in which the speed of the reaction is proportional to the

temperature at which it takes place. If the comparison is valid, the injury

from frostbite would occur early but would become manifest only when the

temperatures of the injured part had been raised. The behavior of cold injury

suggests that this hypothesis is sound. The predominant early clinical features

are pallor, edema, and numbness. When the part is warmed, the arterial

circulation increases rapidly, while in the later stages of hyperemia, which is

both reactive and inflammatory, blister formation, necrosis, and actual gangrene appear, according to the severity of the injury. These latter processes,

however, remain latent and do not become manifest, because of the retarding

effects of cold, until the injured part is warmed. If the injur} is superficial

and the underlying tissues are not dead, feet which seem to be seriously damaged

may go on to recovery. This process is what Kreyberg describes as the

“fulminating vascular reaction which precedes tissue necrosis.”

As the circulation is reestablished, there may also occur, in addition to

gross exudation, rupture of the minute vessels and bleeding into the tissues

and the skin, with resultant ecchymotic areas and blister formation.
PATHOGENESIS AND PATHOLOGIC PROCESS 241

PATHOLOGIC PROCESS

The pathologic change in all cold injuries is essentially the same, such differences as exist being explained by differences in the duration and severity

of the exposure. The process is essentially inflammatory and degenerative.

The skin, subcutaneous tissues, muscles, nerves, and blood vessels are chiefly

affected; but degenerative changes in the bod} structure and joint tissue have

also been observed.

World War Studies

The changes which occur in trenchfoot were first adequately described by

Smith, Ritchie, and Dawson, in 1915. After an intensive clinical study of 51

cases of “trench frost-bite,” they carried out series of experiments on rabbits, in which they were able to reproduce perfectly the edematous swelling characteristic of trenchfoot in man. The development of edema and its degree

depended upon the controlled degree of the cold, wet, and constriction by which

the condition was reproduced.

Microscopic examination of the affected tissues showed that the blood

vessels were chiefly affected. The changes included dilatation of the lumen, which contained certain amount of fibrin deposit; swelling of the endothelium

of the intima; vacuolation of the muscle fibers of the intirna; and an increase

in the number of cells in the perivascular tissue.

The lymph vessels were sometimes normal and sometimes dilated and

filled with masses of fibrin, but the walls were usually unaffected. The tissue

spaces were filled with copious deposit of threads and granules of fibrin.

The collagen bundles of the fibrous tissue were separated and swollen and

were undergoing solution in the exudate in whatever areas it was abundant.

When the edema was of long standing, the swollen tissues were diffusely

infiltrated with leukocytes. When the foot had been placed in warm water

after exposure to cold, the tissues were diffusely infiltrated with red blood

corpuscles, the infiltration in some areas amounting to actual hemorrhage.

The nerves of the affected area presented edematous swelling of the axis

cylinders, apparently as part of the general edema. Degenerative changes

were not present, as they are in true frostbite. In the voluntary muscles, the

staining was modified and there was loss of striation. In longstanding cases,

examination revealed leukocytic infiltration, edema, and deposit of fibrin

between the fibers. These changes were in contrast to the definite disintegration and regeneration seen in the muscles in true frostbite.

The sinuses of the regional lymph nodes were dilated and the lymphoid

follicles were hypertrophied. The sinuses contained deposit of fibrin threads

and granules, and red corpuscles, polymorphonuclear leukocytes and proliferated

endothelial cells were observed in the meshwork of fibrin.

Smith, J. L., Ritchie, J., and Dawson, J.: On the Pathology of Trench Frost-Bite. Lancet 2: 595-598,11 Sept. 1915.
242 COLD INJURY, GROUND TYPE

It was concluded by Smith, Ritchie, and Dawson that these changes

duplicated the changes of trenchfoot in man and that they were inflammatory

in origin, resulting directly from the action of cold on the tissues. The most

important pathologic change, in their opinion, was in the blood vessels, the

walls of which were so damaged that they could no longer function, with the

result that an excessive amount of fluid was poured out and accumulated

in the tissues. The deposition of fibrin followed, and the fibrous elements

of the tissues underwent more or less disintegration. Congestion of the damaged vessels, such as would occur from the application of warmth, caused

rupture of their walls, allowing the passage of red blood corpuscles into the

tissues. Recovery from such process, Smith and his associates pointed out,

would naturally be slow, because the swelling had to subside and the damaged

blood vessel walls had to be repaired sufficiently to withstand the strain of

normal circulation.

Excellent correlation was possible between these experimental observations and the clinical phenomena observed in human patients, and sound

regimen of therapy was therefore outlined on the basis of the investigation.

Two of the most important therapeutic observations were that the feet should

not be warmed in any manner that would cause congestion and that the return

of normal circulation in the part should be delayed and not hastened.

World War II Studies

During the early months of World War II, considerable attention was

devoted to immersion foot, and extensive studies were published by Blackwood, Ungley, White, and Warren, and others (p. 10). Later in the war,

the chief attention was centered on high-altitude frostbite (p. 13) and, still

later, on the ground type of cold injury.

Observations from the Aleutians.—Patterson, who treated wet-cold

casualties from Attn (p. 95), reported that pathologic studies of amputated

parts revealed diffuse, spotty fibrosis, thrombosis, and recanalization of blood

vessels. There was total demyelinization of nerves at the demarcating zone,

with regression to normal 10 cm. above this area. These changes were all

observed in specimens obtained by amputation about weeks, on the average,

after injury and were what might have been expected, Patterson concluded,

in casualties who had presented edema of the tissues, necrosis, and arterial

and venous thrombosis soon after injury. No tissues were available for study

immediately after exposure.

Observations from the Mediterranean theater.—In the Mediterranean

theater (p. 101), only limited opportunities occurred for histologic study of

the lesions of trenchfoot, but from the few specimens which could be examined

Patterson, R. H.; Effect of Prolonged Wet and Cold on the Extremities. Bull. U. S. Army M. Dept. No. 75, pp.

62-70, April 1944.
PATHOGENESIS AND PATHOLOGIC PROCESS 243

Simeone was able to reconstruct the following composite changes, which were

essentially inflammatory and degenerative:

Edema was observed in all the subcutaneous tissues and in the nerves

and muscles. Round-cell infiltration was noted in scattered areas throughout

the dermis and around the arterioles and capillaries. Acute inflammatory

changes were observed in one specimen, bursa thought to be from the proximal

metatarsophalangeal joint of the great toe.

Degenerative changes included atrophy of the epidermis, with decreased

thickness of this layer, smoothing of the rete pegs, and atrophy of the sweat

glands. Fat tended to disappear from the subcutaneous tissues. Fibrous tissue (collagen) was deposited subcutaneously about the nerves and blood vessels.

Elastic tissue was apparently not affected. Small blood vessels showed similar deposition of fibrous tissue, which

sometimes was almost sufficient to occlude the lumen. Fibrosis was also noted

in the walls of the large vessels, in which the patency of the lumen was less affected.

Wallerian degeneration was noted in the nerves and was most marked

peripherally. Regeneration of axis cylinders could be detected in specimens

obtained some months after injury. Nerve endings were found still noninnervated as long as year after injury. Fibrosis was observed in and about the

nerves.

Muscle fibers showed early degeneration of the Zenker type. Later,

atrophy and fibrosis of the muscles were found. Irregular areas of osteoporosis

and new bone formation were observed in bones of the affected parts.

Studies at the Army Institute of Pathology 10

As previous descriptions indicate, little material was available anywhere

for the histologic study of trenchfoot, which would be expected in condition

not in itself lethal and seldom requiring radical surgery. Friedman, working

at the Army Institute of Pathology in Washington, D. C., was able to overcome this difficulty and to reconstruct the pathogenesis of trenchfoot from

an intensive study of 14 specimens representing various stages of the disease.

Three of the specimens were secured at autopsy from patients who died to 10

days after exposure, from conditions other than trenchfoot. In the other 11

cases, gangrene ensued and amputation of portions of the foot and leg was

necessary from to months after injury. In of the 14 cases, the injury

had been sustained during the Attu invasion.

The findings in all 14 specimens permitted the conclusion that all injuries

resulting from exposure to low temperatures exhibit common pattern and

result from similar train of events. Friedman's conclusions concerning

Report, Lt. Col. Florindo A. Simeone, to the Surgeon, Fifth U. S. Army,subject: Trenchfoot in the Italian Campaign, 1943-45.

10 Friedman, N. B.: The Pathology of Trench Foot. Am. J. Path, 21: 387-433, May 1945.
244 COLD INJURY, GROUND TYPE

the pathologic changes in trenchfoot are practically the same as Kreyberg’s

(p. 238), the only real point of difference being the occurrence of thrombosis

in the damaged blood vessels. Kreyberg believes that thrombosis does not

occur. Friedman’s view is that the masses ofred blood cells seen in the minute

vessels are true agglutinative thrombi which are poor in fibrin.

The pathologic changes can be most conveniently summarized under the

heading of the areas in which they occur. It must be remembered that the

observations listed are composite and that all of the changes listed were not

found in all the specimens.

Skin and subcutaneous tissues.—The edema in trenchfoot involved the

skin and subcutaneous tissues as well as the nerves and muscles. Cellular

exudates appeared in the dermis and subcutaneous tissues but were less notable

than in the immediate vicinity of congested vessels. There was smoothing of

the rete pegs, and the sweat glands showed atrophy, degeneration, cystic dilatation, and vacuolation.

Changes in fatty tissue in early cases of trenchfoot consisted of infiltration

by leukocytes in the deeper subcutaneous tissue and in the tissue around the

appendages, even when the overlying layers were not involved; proliferation

of the adventitial cells of the prominent capillaries and smaller vessels in the

fat lobules; edema and leukocytic infiltration of the interlobular fibrous septa;

and fibrinous exudation in the deeper tissues.

Changes in the fat were marked in late cases. Fat lobules were diffusely

infiltrated with foam cells laden with finely divided fat (fig. 35). Occasional

accumulations of giant cells of the foreign body and Teuton types were observed in otherwise unaltered fat. In this study, actual fat necrosis with soap

formation was observed only in areas of gangrene in single specimen, which

was secured 143 days after injury. Oil cysts (fig. 36), most of which were

minute and which were lined layers of foam cells, contained scattered, free

fat globules. Fibrous replacement of adipose tissue was notable and seemed

to occur in two w'ays:

1. In some regions, serous atrophy or actual replacement by loose areolar

or mucinous connective tissue (fig. 37) left collapsed, atrophic structure in

which the original outline of the fat lobule was still preserved.

2. In other areas, thickening of the interlobular fibrous septa (fig. 38)

resulted in conspicuous depletion of the adipose tissue component in the subcutaneous layer.

Blood vessels.—Marked engorgement of the vascular tree was characteristically present in the early stages of trenchfoot. Extravasations of red blood

cells typically surrounded the engorged plexuses. Numerous vessels contained

agglutinative erythrocytic thrombi (fig. 39) of the type found in stagnant blood

rather than in freely moving blood stream. The thrombi usually filled the

lumen of the involved vessels completely, though some plugs were incomplete,

and occasionally mural deposits of hyaline material or fibrin encircled patent

central lumen. Endothelial damage was not striking. Mural hemorrhage
PATHOGENESIS AND PATHOLOGIC PROCESS 245

AFIP 78629, AFIP 81141

Figure 35.—A. Phagocytosis of fat in subcutaneous adipose tissue in late case of

trenchfoot. Foam cells are present throughout the lobule. Hematocylin and eosin stain.

(X 145) B. High-power view of the lipoid phagocytes shown in A. Masson’s trichrome

stain. (X 1360)

AFIP 78630

Figure 36.—Oil cyst, lined by foam cells in subcutaneous fat in late case of trenchfoot.

Hematoxylin and eosin stain. (X 205)

438404'—58 IS
246 COLD INJURY, GROUND TYPE

AFIP 81954

Figure 37.—Connective tissue elements replacing cells of subcutaneous fat lobule in late

case of trenchfoot. Hematoxylin and eosin stain. (X 145)

AFIP 81054

Figure 38.—Atrophy and inflammation of subcutaneous fat

lobules in late case of trenchfoot. The interlobular fibrous septa

are thickened. Hematoxylin and eosin stain. (X 30)
PATHOGENESIS AND PATHOLOGIC PROCESS 247

(fig. 40) and inflammation (fig. 41) could be observed in both patent and plugged

vessels. There was no instance of periangiitis in any of the 14 specimens.

While many vessels, especially if they were thrombosed or inflamed, were

dilated, marked vasoconstriction (fig. 42) was also observed. This was true

even of the main trunks, well above the line of demarcation, though it was

AFIP 82059

Figure 39.—Thrombosis of posterior tibial vein in early case

of trenchfoot. The thrombus consists almost entirely of agglutinated red cells. Hematoxylin and eosin stain. (X 65)

AFIP 81964

Figure 40.—Thrombosis of artery from gangrenous foot in late case of trenchfoot.

Organization of the thrombus and hemorrhage into the vessel wall are shown. Hematoxylin

and eosin stain. (X 50)
248 COLD INJURY, GROUND TYPE

AFIP 82186

Figure 41 —Mural angiitis in early case of trenchfoot. The wall contains

chromatin debris and is infiltrated by leukocytes. The muscular elements

are degenerated, and the media contain eosinophilic granular material.

Hematoxylin and eosin stain. (X 500)

AFIP 82518

Figure 42.—Construction of posterior tibial artery in early case of trenchfoot. Weigert’s elastica and van Gieson’s stains. (X 32)

not possible to say with certainty that the constriction was characteristically

present during life.

In one specimen (fig. 43), secured 32 days after exposure, transitions were

observed from the stage of thrombosis seen in early stages to stage of endarteritis obliterans. Connective tissue and capillaries exhibited proliferation,

and the development of mucinous stroma seemed related to the presumably

original thrombi, in which predominance of red blood cells and platelet agglutinations, together with lack of fibrin, was still evident.
PATHOGENESIS AND PATHOLOGIC PROCESS 249

AFIP 81950

Figure 43.—Longitudinal section of plantar artery in 32-day case of trenchfoot. Organization is underway at the head of thrombus. Hematoxylin and

eosin stain. (X 75)

Almost all thrombi observed within 40 days after exposure were organized.

Endangiitis obliterans was present in both arteries and veins, even in practically

normal tissue above the line of demarcation. The degree varied from slight

thickening of the intima to obliteration of the lumen. Arteries which were

slightly involved showed subintimal proliferation ot cells, often in mucinous

and edematous matrix (fig. 44). The intimal thickening was frequently eccentric but sometimes involved the entire circumference. In extreme cases, it

produced marked narrowing of the lumen. When the arteries were obliterated

(fig. 45), the lumen was filled with fibroblasts, round cells, and hemosiderinladen phagocytes. The central mass usually contained number of discrete

channels with definite muscular walls, which resembled arterioles (fig. 46).

Similar recanalization was noted even in small arteries and arterioles. The

proliferative reaction was central to the inner elastic membrane, which occasionally was destroyed (fig. 47) but which usually was intact and not reduplicated.

The veins, although they were less regularly involved than the arteries,

sometimes showed nodular intimal thickening caused by edema, mucinous

degeneration, and increase in cells, collagen, and elastica. The veins were

sometimes obliterated.
250 COLD INJURY, GROUND TYPI

Figure 44.—Proliferation of intima and mucinous degeneration in small

artery. Hematoxylin and eosin stain. (X 175)

Muscles.—In early cases, muscle tissues exhibited degeneration, necrosis,

and cellulitis, but atrophy was not observed. In later cases (40 days or more

after exposure), atrophy (fig. 48) was extensive in all of the specimens. Fibrils

could be identified, but the cytoplasm was usually shrunken and homogenized.

Cells laden with yellow pigment lay between atrophic fibers, which were occasionally separated from the endomysial network by spaces containing edema fluid.

The interstitial connective tissue of the muscle was the site of mucinous

degeneration. few truegiant cells were identified in areas which had undergone less marked atrophy. Necrosis and inflammation were observed in areas of

gangrene and cellulitis. In the zone of demarcation, and above, were circumscribed foci of necrosis, like infarcts. Hyaline degeneration and proliferation of

sarcolemmal nuclei were occasionally encountered in isolated fibers. Numerous

tendon sheaths exhibited severe exudative and proliferative lesions in which

masses of fibrin were more prominent than in the regions of inflammation present

elsewhere in the soft tissues.
PATHOGENESIS AND PATHOLOGIC PROCESS 251

AFIP 78631

Figure 45.—Obliteration of lumen of artery in late case of trenchfoot. The inner

elastic membrane is ruptured, and the media and adventitia are scarred. Hematoxylin

and eosin stain. (X 175)

AFIP 82190

Figure 46.—Recanalization of small, obliterated artery. Many new channels, some with

muscular walls, have formed. Hematoxylin and eosin stain. (X 280)
252 COLD INJURY, GROUND TYPE

AFIP 81139

Figure 47.—Organization and recanalization of artery in late case of trenchfoot. The

elastica is ruptured, frayed, and distorted. Weigert’s elastica and van Gieson’s stains.

(X 145).

AFIP 78633

Figure 48. —Atrophy of muscle in late case of trenchfoot. The shrunken fibers are

widely separated. Hematoxylin and eosin stain. (X 145)
PATHOGENESIS AND PATHOLOGIC PROCESS 253

Nerves.—In specimens secured soon after exposure, nerves which traversed

regions of inflammation were swollen and edematous, and, even at distance

from such areas, degeneration of both axis cylinders and myelin was observed.

Demyelinization was especially marked in the distal portions of the nerves.

The pronounced lipoid phagocytosis characteristic of late cases was not observed

in early cases. Only large myelinated fibers which presumably represented the

sympathetic components of the nerves were not significantly altered either in

the main trunks or the small branches (fig. 49), and small intraneural vessels

showed no essential abnormality.

In late cases, nerves in areas of gangrene and cellulitis were usually badly

damaged. Demyelinization (fig. 50) was observed at all levels but was more

Figure 49.—Cross section of

portion of posterior tibial nerve in

early case of trenchfoot. The

groups of small fibers are undamaged. Bielschowsky’s stain.

(X 500)

AFIP 77251

AFIP 77251

Figup.e 50.—Slight demyelinization of nerve above region of gangrene in late case of

trenchfoot. Frozen section. Spielmeyer’s stain. (X 125)
254 COLD INJURY, GROUND TYPE

extensive below the zone of demarcation (fig. 51). Between the nerve fibers

were many foam cells (fig. 52) containing sudanophilic material in fine droplets,

presumably fat from broken-down myelin. Many axis cylinders had disappeared

and those still present were irregular and ballooned (fig. 53). Damage was

usually spotty. Some nerve bundles showed edema and separation of the fibers,

AFIP 77253

Figure 51.—Marked segmentation, beading, and loss of myelin in nerve

from region of gangrene. This section is of the same nerve as is illustrated in

figure 50 but was taken at different level. Frozen section. Spiclmeyer’s

stain. (X 220).

AFIP 81956

Figure 52.—Lipoid phagocytosis in degenerated nerve in late case of

trenchfoot. Foam cells are scattered between the damaged fibers. Weigert’s

stain. (X 230).
PATHOGENESIS AND PATHOLOGIC PROCESS 255

AFIP 82524

Figure 53.—Degeneration of nerve in late case of trenchfoot. Many axis

cylinders have been lost, and those which remain are ballooned. Bielschow- sky’s stain. (X 550).

and in few instances it was thought that actual increase of the endoneural

connective tissue elements might be present. Perineural fibrosis (fig. 54) was

noted, with exaggeration of the epineurium and perineurium, and occasional

nerve bundles were partially or completely hyalinized. Many small blood

vessels in the nerves were thickened. The degeneration and phagocytosis

observed in the subcutaneous adipose tissue were also observed in the perineural

fat.

Panchenko 11 described characteristic changes in the perineural nervous

system, nerve trunks, and spinal cord of 12 patients with frostbite who died of

intercurrent disease. The changes included typical ischemic neuritis and signs

of intensive fibroblastic hyperplasia and hypertrophy. Some of the nerve

fibers were in state of wallerian degeneration, while evidences of regeneration

could be seen at the same time. Small axial islands of degenerative necrosis

were usually found close to blood vessels. Changes in the cells of the anterior

horn of the spinal cord and of the intervertebral ganglia varied from slight

chromatophilic granular degeneration of the central area to complete degeneration of the cellular structure. These changes were found only at the levels of

the spinal cord which corresponded to the innervation of the injured part.

The extent of the damage was related to the intensity of the exposure to cold.

Bruneau and Heinbeckcr 12 also showed that the nerve degeneration occurs

in dogs after prolonged chilling of an extremity.

11 Panchenko, D. I.: Retrograde Changes in the Spinal Cord in Frostbite of the Extremities. Am. Rev. Soviet Med.

1; 440-443, June 1944. 12 Bruneau, J., and Heinbecker, P.: Effects of Cooling on Experimentally Infected Tissues. Ann. Surg. 120; 716-726,

November 1944.
256 COLD INJURY, GROUND TYPE

AFIP 81957

Figure 54.—Sclerosis of nerves in late case of trenchfoot. The nerve bundles are embedded

in dense fibrous tissue. Hematoxylin and eosin stain. (X 175)

Bones.—The single specimen of bone, section of the middle phalanx of

toe, available for study soon after exposure revealed uo significant abnormality.

In specimens from late cases, areas of osteomyelitis were observed adjacent to

areas of cellulitis. The inflammatory exudate had occasionally undermined

and eroded articular cartilages, but, except in these areas, there was little

evidence of resorption or of osteoclastic activity. There was also no evidence

of sequestration. Necrosis of bone had occurred near the zone of demarcation,

and ostcocytes had disappeared from the lacunae. sharply defined layer of

viable bone surrounded the dead lamellae. In some areas adjacent to necrotic

trabeculae, numerous osteoblasts were actively laying down new bone (fig. 55).

In some of these areas, the bone marrow was necrotic or was involved in the

osteomyelitic process. In other areas, serous atrophy was present, with fibrosis,

hemorrhage, and infiltration of inflammatory cells. Occasional small oil cysts

were noted, and there were many foci of lipoid phagocytosis comparable to

those observed in the subcutaneous panniculus. The altered bone marrow

contained an increased number of thin-walled, dilated blood vessels.

Summary.—The essential early change in trenchfoot which Friedman’s

studies revealed was thus disturbance in the circulatory mechanism; namely,

the consequent stagnation of blood leading to thrombosis and, subsequently,

to gangrene. In many ways, the gangrene resembled ordinary peripheral

ischemic necrosis complicated by secondary infection. There were, however,
PATHOGENESIS AND PATHOLOGIC PROCESS

AFIP 81960

Figure 55. —Necrosis of bone. Dead trabeculae with empty lacunae have been sheathed

by viable bone. Osteoblasts line the newly formed trabeculae. The marrow is fibrotic.

Hematoxylin and eosin stain. (X 145)

certain unusual features. Particularly notable were the agglutinative thrombosis, the profound changes in the fatty tissues, and the interesting neuromuscular and osseous alterations. While Friedman regarded most of the changes, whether superficial or deep, as secondary to vascular occlusion, he

called attention to possible direct thermal effect on structures rich in lipoids,

especially adipose tissue and myelinated nerve fibers. The nerve fibers, he

thought, might have special susceptibility to cold.

Friedman suggested two essential lines of future morphologic investigation

to clarify the pathogenesis of trenchfoot: (1) Investigation of the early changes

in the myelin sheaths and the fat of the subcutaneous panniculus to determine

whether tissues rich in lipoid are especially sensitive to cold and (2) detailed

examination of the sympathetic fibers which supply blood vessels and of the

arteriovenous anastomoses to determine whether the initial lesion of cold injury

is vascular or neural.

259

CHAPTER

Clinical Picture and Diagnosis

GENERAL CONSIDERATIONS

The symptoms and signs of cold injury, while they have always been of the

same general character in all recorded wars, have varied in degree from area to

area and person to person in relation to the severity of weather conditions, the

duration of exposure, the extent of tissue damage, the length of time the man

has remained in the line after his initial injury, and the kind of treatment he has

received between the first point of triage and the first medical installation in

which he has received definitive therapy. It has been the universal experience

that, if the casualty could not be evacuated by litter or ambulance, the trauma

of walking, particularly over rough ground, has increased the severity of symptoms, the extent of tissue damage, and the period of incapacitation.

In general, the symptoms, signs, and clinical progress of cold injury may be

summarized about as follows:

The initial symptoms variously include numbness, tingling, and feeling

that the feet have become wooden. Walking may be impossible, or the man

may complain that he is unable to feel his feet moving when they touch the

ground as he walks. In other instances, there may be dull or severe drawing

pain in the feet and in the back of the legs. There is universal complaint

that the feet are cold. At this time, examination shows the skin mottled and

the color light bluish gray. Edema and blister formation may or may not be

present. This is the composite picture in the ischemic stage.

In the more severe cases, the next symptom is exquisite pain on touch or

on exposure to warmth. The feet are swollen, flushed, dry, hot, tense, and

shiny. The edema present is of the pitting variety. Blisters are frequent, and

intracutaneous ecchvmosis may be pronounced. This is the composite picture

of the hyperemic stage. Soldiers in World War II frequently called it the

“hot foot” stage.

As edema subsides, hyperthermia decreases. Blisters break. The surface

layers of skin begin to desquamate. The ecchymotic areas turn black and

become hard and mummified. The appearance of the lesions suggests dry

gangrene. This is the composite picture of the posthyperemic stage.

If ecchymosis has involved the deeper areas of the skin, particularly under

heavy callous formation, exfoliation may not be complete for month or more.

The nails are sometimes lost, and entire casts of the toes may be shed. As the

mummified layers peel off, the underlying skin appears normal but proves to be
260 COLD INJURY, GROUND TYPE

extremely delicate. The soldier is unfit for any kind of duty until the plantar

surface of the foot and other areas exposed to friction are covered with cornified

skin. It was the universal experience in World War II that when soldier had

lost the superficial skin on the sole of his foot, he was unlikely to return to duty

for considerable period of time, if ever.

In World War II, the incubation or lag period of cold injury, from the

beginning of exposure to the first clinical manifestations of damage, averaged

days. It varied, however, from person to person, and was greatly influenced by

what had happened during the period of exposure. If the soldier were pinned

down in state of immobility, exposure of even few hours might give rise to

extremely severe injury. If he were fully ambulatory and especially if he had

had opportunities to dry his feet, massage them, and change wet socks for dry,

his injury was likely to be mild, or he might escape injury altogether. Surprisingly, insignificant factors sometimes weighted the scale in one direction or

the other. Experiences are recorded in which the man who left the foxhole

daily to secure the rations for his comrades escaped intact while the other

soldiers in the same foxhole all sustained cold injury.

Although the clinical picture of trenchfoot was essentially the same wherever the condition was observed, there were certain variables in each theater

which influenced the symptoms and signs. It therefore seems worthwhile to

present the observations from each area separately, even at the cost of some

repetition.

THE ALEUTIANS

The first clinical description of cold injury sustained in combat in World

ar II concerned the casualties from the Attu campaign. The men, because

of the circumstances of this campaign, were cared for in field hospitals and were

then evacuated as soon as possible by hospital ships, chiefly to the 183d Station

Hospital and then to general hospitals in the United States. The following

description is composite of the data secured at the 183dStation Hospital, Fort

Richardson, Alaska; McCaw General Hospital, Walla Walla, Wash.; McCloskey

General Hospital, Temple, Tex.; and Letterman General Hospital, San Francisco, Calif.

Clinical manifestations were unusually prompt and often very severe in the

Attu campaign. Within 12 to 14 hours after exposure to wet cold, many of the

men affected began to complain of throbbing, tingling, and cramping pain in the

feet. There were also frequent complaints of cramps in the muscles of the calf.

Numbness became progressively more troublesome, and many soldiers said that

they felt as if they were walking on wooden feet. Some could not walk at all.

Only 40 soldiers in provisional battalion consisting of more than 350 men were

(1) Annual Report, 183d Station Hospital, 1943. (2) Lesser, A.; Report on Immersion Foot Casualties Iron the

Battle of Attu. Ann. Surg. 121: 257-271, March 1944. (3) Patterson, R. H.: Effect of Prolonged Wet and Cold on the

Extremities. Bull. U. S. ArmyM. Dept. No. 75, pp. 62-70, April 1944. (4) Orr, R. D.: Report on Attu Operations, May

11-June 16,1943.
CLINICAL PICTURE AND DIAGNOSIS 261

able to walk at the end of days; over the same period, the number of killed and

wounded in action amounted to only 30. Many of the men presented extensive

lacerated, ulcerated lesions of the knees that they had sustained from crawling

over the ground because the terrain and the tactical circumstances had made

litter evacuation impossible.

When the boots were removed, it was usually impossible to replace them, swelling of some degree being present in practically every case. The appearance

of the feet varied from man to man. Sometimes they were blue, or mottled

blue and white, and the soles were waxy white. Sometimes they were red and

hot. Sometimes they were blistered; in such cases, swelling was intense.

McCaw General Hospital. —Twenty-five men received at McCaw General

Hospital about weeks after they had been removed from combat presented

particularly severe clinical manifestations. Some of them (p. 93) had gone to

Attu by submarine and had averaged 10 days without change of shoes or socks.

They had been practically without food during their days in action, and they

had had no real physical rest or sleep. They became wet almost as soon as they

landed, and they were constantly exposed thereafter. Nine of them had battle

wounds of varying severity.

Aside from general fatigue, exhaustion, and numbness and discomfort in

their feet, these men had had little actual pain until their shoes were removed.

Then there was an immediate onset of pain and swelling, and, within to 12

hours, areas of blackish discoloration were observed, followed by gangrene,

which in some instances promptly became infected. When they were received

at McGaw General Hospital, all of these men seemed physically exhausted.

Both the red blood cell count and the hemoglobin level were lowered, and the

white blood cell count was sometimes moderate!}', and sometimes greatly,

increased. The most severe cold injuries were associated with septic temperature elevations. In the other cases, the temperature elevations were low

grade.

When the fingers were affected, numbness was seldom experienced earlier

than days after exposure, in contrast to the frequent onset of symptoms

within to 12 hours when the feet were affected. The longer timelag was

probably to be explained by the opportunities to exercise the hands, even when

the men were immobilized by enemy fire, and the consequent maintenance and

stimulation of the circulation. Hypesthesia was usual complaint. Physical

findings included desquamation of the fingertips, slight swelling, and hyperesthesia. The coloration was likely to be mottled and cyanotic. Gangrene

was exceptional. There was no record in the Aleutians of the type of case

reported from other theaters in which there were complaints of transient

paresthesia and hypesthesia of the fingertips but in which edema and color

changes did not develop.

McClosky General Hospital.—At this time, there was no standard system

of grading cold injuries, and the various hospitals developed their own systems. Some merely divided the cases into early and late groups, depending upon the
262 COLD INJURY, GROUND TYPE

time at which the patients were received. At McCloskey General Hospital,

which had received 121 casualities with trenchfoot from Attn by 10 July 1943,

four degrees of injury were recognized. First-degree injuries were characterized

by small patches of damaged skin, without peeling or blistering. Second-degree

injuries were characterized by damage to the superficial cutaneous layers, with

associated peeling or blistering. Third-degree injuries were characterized by

the loss of thick layers of skin and, occasionally, of subcutaneous tissues also.

Fourth-degree injuries were characterized by gangrene of part or the whole

of an extremity.

Letterman General Hospital.—At Letterman General Hospital, three

clinicopathologic groups were recognized, in addition to minimal, first-degree

injuries, for which hospitalization was not required;

Patients with second-degree injuries suffered from smarting, tingling, and

throbbing sensations in the feet rather than true pain. These sensations, while

chiefly limited to the toes, were often present in the ball of the foot also. Patients in this group were further classified into three clinical subgroups. About

45 percent had mild type of injury. The feet were only slightly swollen, or

were not swollen at all, and sensory changes were limited to hypesthesia.

Pulsations in the feet were good. About third of the men had cold, sweaty,

slightly swollen feet, with areas of anesthesia. One or more of the normal

pulsations was absent. The remaining patients, who represented about

quarter of the total number, presented extensive areas of desquamation. The

feet were dry, very warm, flushed, and edematous and became congested on

dependency. Most of the foot was anesthetic.

Patients with third-degree injuries presented areas of superficial destruction. Thick layers of skin and subcutaneous tissues became necrotic, nails

were frequently lost, and, in numerous instances, the tips of the toes were also

lost.

Patients with fourth-degree injuries presented true gangrene, with loss of

the greater part of one or more of the toes and, occasionally, loss of the whole

foot.

All the patients in the third and fourth groups complained of burning

pain, most severe at night and most often located in the toes. They also

complained of aching, pulling, or cramping sensations in the foot or in the

muscles of the calf. Hypesthesia was invariably present. It began at the

ankle and increased to complete anesthesia as the toes were approached. The

degree of anesthesia was usually, though not always, proportional to the degree

of tissue damage. In two instances of severe gangrene, in both of which the

entire foot had to be amputated, sensation was comparatively unaltered almost

to the line of demarcation. In contrast, many patients with only moderate

degrees of desquamation had almost complete anesthesia of all the toes. How

complete the loss of sensation was in these cases is evident from the fact that

in most of them it was possible to perform debridement and amputate the

gangrenous toes without any anesthetic at all.
CLINICAL PICTURE AND DIAGNOSIS

THE MEDITERRANEAN (FORMERLY NORTH

AFRICAN) THEATER

Simeone, who studied cold injury in the North African theater from the

time the first cases appeared in November 1943, recognized three clinical stages,

the preinflammatory, the inflammatory, and the postinflammatory. The

postinflammatory stage was further divided into an early and late stage.

Edwards and his associates recognized four classifications of injury in the 351

patients whom they observed at general hospital.

Special Investigation

In the preinflammatory (prehyperemic, ischemic) stage (plate 2A and B),

the soldier’s first warning of trouble was that his feet felt cold and numb.

Then he began to experience aching pain in the ankle and the arch of the foot,

with tingling, lancinating pains when he put his weight on his feet. Sometimes

these pains radiated to the groin. Later, the only complaint might be stiffness

and numbness of the feet, which made him feel as if he were walking on blocks

of wood. Ataxia might be severe and incapacitating, and only the soldier who

had not been instructed in the dangers of cold injury and whose pain was

minimal would be likely to continue on duty for several days longer before he

reported sick. During this time, irreparable damage to tissue might occur, as

the following case history indicates:

Case 1.—A 25-year-old soldier, who had lived in New Jersey all his life, had no previous

history of frostbite or circulatory disturbance. His company was exposed to wet cold on

hillside in Italy from December through December 1943. The ground was continuously

wet and muddy. There was no snow in the immediate vicinity, but the tops of neighboring

mountains were snow covered. There was frost on the ground every morning, and, during

one night, the water in his canteen became partly frozen. During the daytime, he moved

about as much as possible. During the night, he slept in foxhole, in cramped position.

He subsisted on rations, with nothing hot to eat or drink, during the 5-day period of exposure. At first, he wore two pairs of light-weight (35 percent) wool socks. They became

wet almost immediately, and, when he changed to dry socks on the third day, they also

became wet almost as soon as he had put them on.

When he changed his socks on the third day, there was nothing wrong with his feet.

On the fourth day, he first noticed numbness in the toes. On the fifth day, the greater part

of the foot was affected, and his knees, ankles, and toes were stiff. He noted that he was

unable to walk in straight line.

The company was relieved from duty on December at 0200 hours. When the bivouac

area was reached, the man went promptly to the kitchen, where he ate hot breakfast while

seated about feet from hot gasoline range. When he sat down, he had no complaints

except stiffness and numbness. When he rose from his seat to report to the dispensary

because of the condition of his feet, he was unable to walk and had to be carried to the

medical officer. At this time, the left shoe came off easily and could be replaced readily,

but the toes looked dark.

Report, Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, subject: Trenchfoot in the Italian

Campaign, 1945.

Edwards, J. C., Shapiro, M.A., and Ruffin, J. B.: Trench Foot. Report of 351 Cases. Bull. U. S. Army M. Dept.

No. 83, pp. 58-66, December 1944.
264 COLD INJURY, GROUND TYPE

The patient was removed by ambulance to clearing station, where both shoes and

socks were removed, and thence to an evacuation hospital. Here his feet became progressively more swollen. Within 24 hours, blisters were present on both feet, and the right

foot and leg were red and edematous to the knee.

When the man reached general hospital, 48 hours after leaving the line, both feet

were red, swollen, and blistered, and edema on the left side now extended above the knee.

Both feet felt numb. Pulses on both sides were bounding. On this day (11 December), the

morning temperature was 102.8° F. (39.3° C.) and the evening temperature 103.2° F. (39.6°

C.). The morning pulse rate was 108 and the evening rate 78. Sulfadiazine was begun

by mouth.

The following day, both morning and evening temperatures were 102.4° F. (39.1° C.)

and the pulse rates were, respectively, 144 and 120. The blood-glucose level was 162 mg.

percent. On 13 December, the morning temperature was 100.2° F. (37.9° C.) and the

afternoon level 102.2° F. (39.0° C.); the pulse rate was constant at 92; the blood-glucose

level was 125 mg. percent.

Edema began to subside on 14 December. The skin over both shins was shiny and

wrinkled (fig. 56). There were large blisters on the dorsal and plantar surfaces of both

feet (plate and D). The areas which were not blistered were hot and dry. Both dorsalis

pedis pulses were palpable. The toes were anesthetic, and motion in them was feeble.

The patient complained of very little pain. The blood-glucose level was 115 mg. percent.

phenolsulfonphthalein test of renal function on 15 December showed total excretion

for hours of 53.8 percent; no dye was excreted during the first 30 minutes after injection.

glucose-tolerance test showed decreased tolerance (147 mg. percent at the end of hours,

as contrasted with fasting level of 98 mg. percent). The nonprotein nitrogen of the blocd

was 30.4 mg. percent and the serum-protein concentration 9.8 gm. percent.

On 16 December, the non-protein-nitrogen level was 45.3 mg. percent. Urinalysis 17

December showed no abnormality. The serum-protein concentration was 8.96 gm. percent.

On 18 December, the white blood cell count was 6,200 per cubic millimeter. On 19 December, it was 9,950 per cubic millimeter, and the serum-protein concentration was 8.8 gm.

percent. The sulfathiazole blood level on 16 and 17 December was 1.3 mg. percent.

On 22 December, under Pentothal Sodium (thiopental sodium) anesthesia, the right

leg was amputated inches below the knee. The wound was sutured, but drainage was

instituted. There was no reaction to the operation, and on 27 December, under spinal

analgesia, five toes were removed from the left foot, by disarticulation at the metatarsophalangeal joints.

Plate 2.—Various stages of trenchfoot. A. Preinflammatory stage of trenchfoot

observed in clearing station, after days’ exposure to wet and cold near Rapido River, Italy,

and directly after removing wet shoes for first time. The feet are still wet and cold, but

edema has not yet begun to develop. Note coarse mottling of skin. B. Early inflammatory

stage of trenchfoot observed in field hospital near front after days of continuous exposure

to wet cold. The trousers and underwear are still wet. The feet are warm and dry. Edema

is beginning to develop in the left foot. C. Early inflammatory stage of severe trenchfoot.

Detail of blisters and gangrene. In this case, the pulses in both dorsalis pedis arteries were

bounding. This soldier had been exposed to wet cold, without snow, between and

December 1943. The water in his canteen partly froze during one night. D. Inflammatory

stage of severe trenchfoot in same case shown in view C. This photograph was taken after

weeks of hospitalization. Blisters are still present, along with gangrene. Only the toes

were lost on the left foot, but amputation of the right leg below the knee was required. E.

Late postinflammatory stage of trenchfoot without loss of tissue. Note cyanosis, probably

resulting fom venular dilatation and arteriolar constriction in area affected by cold. Note

also suggestive boot pattern. This foot is typical of the postinflammatory stage of trenchfoot from to months after injury.
Plate 2. (See opposite page for legends.)

CLINICAL PICTURE AND DIAGNOSIS 265

AFIP CA-43-57

Figure 56,—Subsiding inflammatory stage of trenchfoot. Note shrivelling of blister

over right great toe and wrinkling of skin. In this patient, the dorsalis pedis pulses were

bounding, and the skin was red, hot, and dry.

The white blood cell count on 22 December, just before the first operation, was 15,000

per cubic millimeter. The following day, it as 9,950 per cubic millimeter, and the serumprotein concentration was 8.8 gm. percent. On 27 December, just before the second operation, the white blood cell count was 15,000 per cubic millimeter. It was 17,300 on 23 December and at practically the same level on 24 December. Daily urinalyses showed no

abnormalities. On 27 December, the sulfathiazole level was 1.5 mg. percent and the serumprotein concentration was 9.2 gm. percent.

On 29 December, when the sutures were removed from the right stump, healing was

found to be fairly satisfactory. The heads of the metatarsal bones were exposed in the left

foot, and the dorsalis pedis pulse on this side was of greater than normal volume. The

patient’s physical status and the laboratory data were substantially unchanged when he

was evacuated to Africa on January 1944.

This was typical case of severe trenchfoot, except in one respect, that

pain was never major complaint. There was considerable systemic reaction, as evidenced by fever early in the course of the disease, but leukocytosis was

not observed until after amputation of the leg. The evidence of depressed

renal function is interesting, but the results of single test cannot be regarded

as significant. The non-protein-nitrogen concentration in the blood was within

the upper limits of normal. There is no apparent explanation for two unexpected findings; namely, hyperglycemia early in the illness, with depressed

glucose tolerance, and the increased concentration of protein in the serum. It

is possible that if amputation had been postponed longer in this case more of

the right leg might have been saved.
266 COLD INJURY, GROUND TYPE

Simeone’s first observations on trenchfoot were made in November 1943, in battalion aid station and in clearing and collecting stations on the Italian

Front. All of the men had been exposed to wet cold for periods ranging from

to 15 days, with an average of days. The weather at this time was not

unduly severe, and the opinion was expressed that, as rain and cold increased, symptoms would ensue within shorter periods of time. This proved true

during the following winter, particularly at times when the temperature was

near freezing between midnight and sunrise but rose to 50° F. (10° C.) during

the day, with consequent thawing of the ground.

On the initial inspection, the feet of these first casualties were wet, cold, and numb. Variable degrees of pallor and purple mottling were observed.

Edema, if it was present at all, was slight. Whether it was or was not present

at this time apparently depended, at least in part, upon whether or not the

feet had been warmed during the course of the exposure. Questioning of the

men revealed that the swelling was most likely to develop during the warmer

parts of the day. If the shoes were removed then or if they were removed

after swelling had already occurred, it was often impossible to replace them.

Not infrequently, casualties were unaware during the preinflammatory

stage of trenchfoot that there was anything wrong with their feet. In 125

cases studied by Boland and his associates during one period of the fighting

iii Italy, percent of the patients stated that they had not known that their

feet had been injured by cold until they reported to the aid station for treatment of wounds or other unrelated conditions. This lack of awareness of the injury

was sometimes serious matter, not only because treatment was delayed but

also because the man remained on his feet and thus sustained additional trauma.

The ischemic or preinflammatory stage of trenchfoot usually lasted only

few hours after the shoes had been removed and the feet had been dried. In an occasional case, in which there was severe spasm of the larger arteries or in

which actual thrombosis had occurred, it lasted considerably longer. In the

following (fatal) case, this phase lasted days in one leg and days in the other:

Case 2.—A 22-year-old soldier, on January 1944, was obliged to cross river that in

midstream was over his head. Just as he reached the opposite bank, at 0900 hours, he was

felled by shell-fragment wounds of both thighs and compound comminuted fracture of

the right femur. For the next 26 hours, until aidmen could reach him, he lay as he had

fallen, wet and cold. At the aid station, his right leg was splinted, and he was given 500 cc.

of plasma. AVhen he was received at an evacuation hospital on January at 1500 hours, the diagnosis was recorded as bilateral severe immersion foot, bilateral severe frostbite of

the hands, moderately severe penetrating wounds of both thighs due to shell fragments,

and severe compound comminuted fracture of the right femur.

Within the first hours after he was admitted to the evacuation hospital, the patient

received 1,500 cc. of blood, of which 250 cc. was mismatched; it was type and he was type O. There was no noticeable immediate ill effects from the error. Nine hours after

admission, the blood pressure was 130/90 mm. Hg and the pulse 110. The hands were cold, cyanotic, and edematous, but both radial pulses were palpable. The feet were cold, numb, and cyanotic, but were not swollen. The dorsalis pedis and posterior tibial pulsations were palpable in both feet.

Boland, F. K., Claiborne, T. S., and Parker, F. P.; Trench Foot. Surgery 17: 564-571, April 1945.
CLINICAL PICTURE AND DIAGNOSIS 267

At 0400 hours on January, the wounds were debrided, and long hip spica was applied.

The patient’s condition was excellent after operation.

The following day, the left foot was blue and ice cold, and mottling was present from

the toes to the malleoli. Edema extended up to the knee but was most pronounced in the

foot, in which no pulsations could be felt. The calf was moderately tense. On the right

side, the tips of the toes were blue. The forepart of the foot, to the midtarsal region, was

mottled and bluish white. Edema was moderate and did not extend to the leg, which was cool. The dorsalis pedis and posterior tibial pulsations were not palpable on this side.

The left hand was blue, and motion was feeble in the fingers, though they were warm.

There were large bullae filled with clear fluid on the dorsal aspect of the hand. The radial

pulse was normal. Both cyanosis and edema were more pronounced in the right hand.

The fingers, except for the thumb, were cold. There were bullae on the dorsal aspect of

the hand. The radial pulse was normal on this side also.

On 11 January, the left foot was warm, except for the toes, but continued to be edematous and cyanotic. Bullae were present on the plantar surface (fig. 57;. The patient

complained of pain when the foot was covered by blankets. The right foot also continued

to be cold, anesthetic, mottled, and cyanotic, and edema was more pronounced. The leg

was warm down to the malleoli. The calf still felt slightly tense. Both hands were warm

but were moderately edematous, cyanotic, and anesthetic and were covered with huge

bullae (fig. 58). The right hand was more extensively involved than the left. Both hands

and feet were protected by sterile dressings.

AFIP A-44-76

Figure 57.—Trenchfoot third day after exposure. Ischemia had persisted up to thi;

time, and the discoloration of the skin suggested impending gangrene, though the foot wa

warm and dry. Dorsal view. B. Lateral view. Note blister on plantar surface.

Urinalysis had been negative until 11 January. On this day, two specimens were

amber and contained albumin (1 to plus). The concentration of nonprotein nitrogen in

the blood was 174.8 mg. percent.

On 12 January, the toes on the right foot were somewhat less cyanotic, but they were

cold and motionless. Urinalysis showed plus albumin and to white blood cells per

high-power field. The color was clear amber. The following day, two specimens showed

plus albumin but were otherwise negative.
268 COLD INJURY, GROUND TYPE

AFIP CA-44-76

Figure 58. —"Trench hands” after days of hospitalization. Merthiolate (sodium ethylmercurithiosalicylate) has been applied to the skin about the blisters.

On 14 January, signs of heart failure were apparent, with gallop rhythm and CheyneStokes respiration. Three urine specimens, one of which showed an alkaline reaction, were

negative except for albumin (a trace to plus) and to white blood cells per high-power

field. The nonprotein nitrogen of the blood was 199.5 mg. percent. Two specimens

examined on 15 January showed, respectively, and plus albumin. The following day,

both specimens showed plus albumin. Throughout the period of hospitalization, the

daily urinary output had ranged from 1,200 to 2,000 cc., and the specific gravity had varied

from 1.014 to 1.021.

On 16 January, the patient became progressively drowsier and weaker. Physical

examination revealed hepatomegaly and pulmonary congestion. Digitalization was not

effective, and death occurred on this day. Autopsy revealed bilateral pulmonary edema,

hydrothorax, pneumonia of the left lower lobe, and passive congestion of the liver. Microscopic examination revealed pigment nephropathy. The pheripheral vessels revealed

multiple thrombi and acute inflammatory changes, and the anterior tibial muscle showed

degenerative changes and necrosis.

This case is of interest for several reasons. The cause of death, uremia

without anuria, can most reasonably be attributed to the transfusion of 250

cc. of mismatched blood, even though no untoward clinical reaction seems to

have occurred after it. The prolonged period of exposure, however, may have

played some part in the development of renal insufficiency, and prolonged

shock may also have played part. The case was additionally complicated

by ischemia of the left leg, which was sufficient to cause degeneration and
CLINICAL PICTURE AND DIAGNOSIS 269

necrosis in the anterior tibial muscle, as shown by histologic examination of

sections after death. It is possible that the muscle necrosis had the same effect

on the kidneys as crushing injuries which cause renal damage. Histologically,

it is impossible to differentiate these conditions on the basis of renal changes.

Finally, the patient lay on cold, wet ground for 26 hours, and the ischemic stage was unusually prolonged. The feet remained cold on the left side for

days and on the right side for days after hospitalization. Although it was

then general policy in the North African theater to employ active measures to

promote the circulation in the feet in cases such as this, these measures were

omitted in this particular instance.

Classification

Inflammatory stage.-—In some cases of cold injury observed in Italy, the

ischemic stage was mild and transitory, no detectable second or inflammatory

stage ensued, and casualties could be promptly returned to duty from the

clearing station or evacuation hospital. This was not the usual experience.

In most instances, the inflammatory stage was clear cut and lasted at least

week. In many cases, it lasted weeks, and it sometimes lasted as long as

month. In 25 of the 50 cases studied intensively early in the cold injury

experience in Italy, the inflammatory stage lasted about week. Practically

all of the 50 patients had passed into the postinflammatory stage by the third

week of hospitalization. In no patient in the group did the inflammatory stage

last longer than month.

Patients in the inflammatory or hyperemic stage of trenchfoot were sometimes seen in clearing stations (fig. 59) but were usually first seen in evacuation

hospitals. The story was generally the same. Within an hour or two after

the shoes had been removed and the feet had become warm and dry, the feet

began to swell, even though the patient was recumbent. Within the course

of the next few hours, they became hot, dry, red, and painful, thus presenting

all the classical signs of acute inflammation. At this time, the dorsalis pedis

pulse was easily palpable and was usually increased in volume.

The patients complained of tingling pain when the feet first became warm.

As they became warmer, burning, throbbing pain ensued, and discomfort was

extreme. External heat was intolerable, and the feet were most comfortable

when they were exposed to cold air. The affected parts were extremely sensitive and tender to palpation except for portions of the toes, particularly the

tips and the plantar surfaces, which were likely to show hypesthesia and

anesthesia. Often, however, hyperesthesia was present and might be so severe

that even light bed coverings could not be tolerated. Small, patchy areas of

ecchymosis appeared at pressure points (plate 3A).

Clinical progression could be correlated with the severity of the injury.

In the mildest cases, inflammatory signs reached maximum during the first

24 hours of hospitalization, then rapidly subsided (plate 3B). Areas of super19
270 COLD INJURY, GROUND TYPE

AFIP A-44-1F9

Figure 59.—Inflammatory stage of trenchfoot days after exposure.

Swelling was slight in the right foot and moderate in the left. Although

this man’s combat trousers and underwear were still wet, his feet were dry.

ficial thrombosis were sometimes seen. In the severe cases, symptoms and

signs were progressive for 48 to 96 hours. At the height of the inflammatory

reaction in the most severe cases, usually between the fourth and sixtli days,

edema extended to the knee and was sufficient to obscure the pulses in the foot.

When regression set in and edema began to disappear, the skin become finely

wrinkled. The color, which was originally bright red, first became brownish

Plate 3.—Various stages of cold injury. A. Inflammatory stage of mild cold injury,

weeks after exposure. The edema has almost entirely disappeared, but areas of ecchymosis

remain at points at which the feet and toes were presumably subjected to trauma by rubbing

against the shoes or by pressure from them. B. Early cold injury, in which inflammatory

stage was practically over by the end of the first eek after exposure. Edema had lasted

only days. Note superficial gangrene of left fifth toe, rather marked cyanosis over fifth

metatarsophalangeal joint, and slighter cyanosis over base of fifth metatarsal bone. These

areas of injury to the skin can be attributed to close contact wdth the shoe, wdiich rendered

cold more effective injurious agent than it was in parts of the skin in less direct contact

with the shoe and the environment. Exposure in this case as in the hills about Venafro,

Italy; the temperature was never below freezing. C. Early postinflammatory stage of cold

injury. Note especially desquamation of superficial layers of skin, with exposure of atrophic

skin beneath. D. Late stage of cold injury, about months after exposure to nonfreezing

cold. Note sequelae of injury in skin and nail of right fifth toe. The skin is very delicate,

soft, warm, and moist. Hyperhidrosis occurs in feet such as this, particularly after marching,

and maceration of the skin, wdth trichophytosis, is frequent complication. and F.

Plantar and dorsal views of feet during late inflammatory stage of cold injury month after

exposure. Gangrenous (partial-thickness) skin has separated, and islands of residual viable

skin remain to epithelize the surface. The toes gangrenous throughout and eventually

had to be amputated. The case illustrated, however, that even what appears to be extensive

gangrene may be only skindeep and that major amputation can usually be avoided.
Plate 3. (See opposite page for legends.)

CLINICAL PICTURE AND DIAGNOSIS 271

and then faded to normal. The dorsalis pedis pulse became less bounding.

Exfoliation usually occurred, revealing delicate underlying skin (plate 3C).

In the most severe cases of trenchfoot, blister formation and signs of circulatory insufficiency became apparent early in the second stage. They were

sometimes present when the shoes were removed. The blisters usually contained clear fluid, though it might be hemorrhagic. In some cases, small areas

of redness and induration appeared during the first week of the inflammatory

stage. Acute tenderness was complained of on palpation, and the whole

clinical picture was suggestive of cellulitis. Impending gangrene sometimes

progressed to frank gangrene within 48 hours.

The clinical progress of the 50 patients with trenchfoot included in the

initial survey can be summarized as follows:

At the end of the first week of hospitalization, 51 of the 100 feet were

edematous. The edema was pitting in slightly more than half of the extremities

and was slight in the remainder. Initially, it had been slight in nine cases.

At the end of the second week, 45 feet were still edematous, but the edema was

now slight in 37 of these. At this time, it was unilateral in cases and was

of the same degree on both sides in only of the bilateral cases (plate 3D).

At the end of weeks, pitting edema was not present in any case, but 18

patients still had slightly edematous extremities. Subsequent observations on

much larger numbers of patients showed substantially the same distribution

of edema.

After week of hospitalization, 46 of the 100 feet were warm. In 31

extremities, edema was associated with the warmth; 11 were moist and 20 dry. Of the 15 warm feet without edema, were moist and dry. Of the 54 cold

feet, 20 showed edema; of these were moist. Of the 34 cold feet which showed

no edema at this time, 14 were moist.

At the end of weeks, 44 of the 100 feet were warm. Of the 14 which

still showed edema, 11 were moist. Of the 30 without edema, 23 were moist.

Only of the 56 cold feet still showed edema; of the were moist. Of the

52 cold feet without edema, 40 were moist.

In mild cases of cold injury, acute pain often disappeared by the end of

the first week, leaving the patient quite comfortable thereafter. Much more

often, the burning pain originally present was replaced by deep-seated ache

in the ankle, in the transverse and longitudinal arches, and in the metatarsophalangeal joints, particularly the proximal joint of the great toe. It was

frequently observed that the intensity ofresidual pain was related to the degree

of previous edema. Edema almost always disappeared more rapidly than pain.

Abnormal heat disappeared fairly promptly. At the end of week, only

of the 50 patients first studied had extremely hot feet, and none of the feet

were abnormally hot at the end of weeks. Sometimes, however, there were

extraordinary variations in temperature. While the patients were actually

under observation, the feet would change in few minutes from warm and dry

to cold and wet, or vice versa. The variability was particularly marked at

night, both in the late inflammatory stage and the early postinflammatory
272 COLD INJURY, GROUND TYPE

stage. patient would complain that he had wakened with his feet “burning

up,” and, when the nurse or ward officer on night duty investigated, it would

he found that feet which had been cool during the day had become hot to

palpation.

Gangrene sufficient to require amputation of the toes or of larger areas

of the feet was uncommon (figs. 56, 60, 61, 62, 63, 64, 65) (plate 3E and F).

It was estimated that gangrenous changes occurred in from to 1.5 percent

of the cases of trenchfoot which occurred in Italy during the winter of 1943-44,

and in about 0.5 percent of the cases observed the following winter. Six percent of the 125 patients observed by Boland, Claiborne, and Parker presented

some degree of dry gangrene, including minor degrees in which loss of tissue

was superficial, but this figure must be interpreted in the light of the fact that

these patients were part of selected group returned to Communications

Zone hospital because of the severity of their injuries.

In his personal study of trenchfoot, Simeone observed only one patient

who required amputation of more than the toes (case 1), though another (case

2) would probably have required amputation of the leg if he had survived.

Investigation of the proceedings of theater disposition boards for 5-month

AFIP CA-44-188

Figure 60.—Postinflammatory stage of trenchfoot. Gangrene in this patient was superficial, and no amputation of tissues

was necessary. Note small areas of gangrene on instep and

anterior aspect of ankle; they represent points of pressure from

shoe.
CLINICAL PICTURE AND DIAGNOSIS 273

AFIP CA^4-120

Figure 61.—Late inflammatory stage of severe trenchfoot. Edema

has almost entirely subsided. The skin was warm, dry, and scaling.

Note location of gangrene, in tips of toes and over the prominence of the

base of each great toe. It was thought that these particular areas

represented areas of frostbite because they were in direct contact with the

shoe and might have sustained freezing temperatures. The appearance

of the remainder of the foot, however, was entirely typical of trenchfoot.

period in 1945 brought to light three other cases in which amputation of more

than the foot was required:

Case 3.—A soldier who became separated from his unit just after landing at Anzio beachhead on 22 January 1944 wandered about swamp for the next days, continuously

exposed to cold and wet. When he was finally hospitalized, both feet were seriously damaged.

Gangrene affected all the toes and the distal halves of the dorsal surfaces of both feet.

Alcohol packs were used to hasten demarcation. The lower third of the right leg was

amputated on 25 March, under spinal analgesia, and on April the lower third of the left

leg was similarly amputated. Both wounds were sutured primarily. When this man

appeared before the disposition board, which recommended evacuation to the Zone of Interior

for additional care and final disposition, he had already been hospitalized for 91 days.

Case 4. soldier was admitted to an evacuation hospital on 17 February 1944, after

having been exposed to cold and wet near Cassino for the preceding week. His feet first

became painful on 13February. When he was received in general hospital on 23 February,

both feet were swollen, blistered, and cyanotic (fig. 65). definite line of demarcation

gradually developed at the level of the malleoli in both legs. staphylococcic infection of

the gangrenous areas, which began to cause temperature elevations on 28 February, was

controlled by sulfadiazine. The fever recurred, however, and dead tissue began to slough

away as the result of secondary infection. bilateral guillotine amputation was done at

the junction of middle and lower thirds of both legs on 16 March, under ether anesthesia
274 COLD INJURY, GROUND TYPE

AFIP A-44-97

Figure 62.-—Postinflammatory stage of trenchfoot. Note dry,

scaly skin and dry gangrene, which was severest at tips of toes and

margins of the great toes and the fifth toes. The center of the transverse arch, which is less likely to come into contact with the shoes, was

affected less severely.

APIP CA-44-210

Figure 63.—Early postinflammatory stage of severe trenchfoot. Note

delicate skin beneath peeling, gangrenous superficial layer of epidermis,

weeks after exposure.
CLINICAL PICTURE AND DIAGNOSIS 275

AFIP CA-44-131, CA-44-176

Figuke 64.—Subsiding inflammatory stage of trenchfoot. The right foot, on which the process was more severe than on the left, was treated by the local application of ice cold

packs for few days. The left foot was used as control. A. Appearance of feet immediately after therapy. B. Feet shown in view weeks later. better result had been

expected, on the basis of the initial appearance of the feet. The wet ice treatment was

considered of no value.

Skin traction was applied. The postoperative course had been uneventful up to the time

the patient was returned to the Zone of Interior for further treatment and disposition.

Case 5.—This patient was admitted to an evacuation hospital on 15 February 1944,

after having spent most of the previous week in foxhole half filled with water. His feet

were swollen and painful when he was first seen. Later, he became extremely toxic, and,

when he was received in general hospital, there was wet gangrene of the left foot, with

line of demarcation just below the malleoli, and both wet and dry gangrene of the forepart

of the right foot. The lower third of the left leg was amputated on 27 February, and at the

same time the right foot was amputated distal to the talus. When the patient appeared

before the disposition board, which recommended evacuation to the Zone of Interior for

further care and disposition, he had already been hospitalized for 24 days.

Postinflammatory stage.—The postinflammatory (posthyperemic) stage of

cold injury began with the disappearance of signs and symptoms of inflammation. The foot, instead of being hot and dry, was now cool or cold and moist.

Cyanosis was common when the feet were dependent (plate 2E). The dorsalis

pedis pulse, instead of being bounding, was often not palpable at all. Patchy

areas of cyanosis frequently remained, suggesting local thromboses. Occasional patients complained of hyperirritability and spasm of the muscles of

the leg, the spasm being either spontaneous or readily invoked by ischemia.

Burning pain was replaced by deep-seated ache, much like the aching pain

ofrheumatoid arthritis. It was usually worse at night. It was most commonly

located in the metatarsophalangeal joints, particularly in the great toe, but
276 COLD INJURY. GROUND TYPE

AFIP CA-44-186

Figure 65.—Subsiding inflammatory stage of trenchfoot

12 days after hospitalization. The gangrene of the skin

appeared to be superficial, but the record described the

development of staphylococcic infection in gangrenous feet,

and bilateral amputations of the lower leg were done 16 days

after this photograph was taken. The outcome is surprising,

in view of the appearance of the feet in this picture.

might also be experienced in the transverse and longitudinal arches. Less

often, it was felt in the ankle. Ambulatory patients complained of pain in

the weight-bearing parts of the transverse and longitudinal arches. Less

often, it was felt in the ankle. Ambulatory patients complained of pain in

the weight-bearing parts of the foot. The pain sometimes radiated up to the

knee, and, occasionally, into the groin.

Hyperesthesia and paresthesias tended to disappear promptly. Anesthesia did not; it sometimeslasted months or more. In one of the first 50 cases

studied intensively, hyperesthesia appeared in the tip of the great toe when

sensation first began to return, after weeks of hospitalization.

The pain complained of in the postinflammatory stage was sometimes

associated with thickening and stiffness about the joint. More often, the only
CLINICAL PICTURE AND DIAGNOSIS 277

abnormality found on physical examination was deep tenderness. In some

cases, there was general atrophy of the structures of the foot. The arches

weakened, the tendons became prominent (figs. 66 and 67), contractures

appeared, and the joints stiffened (figs. 67 and 68). Roentgenograms sometimes revealed osteoporosis. In the cases in which the feet were entirely

normal on examination after the acute phase had passed, complaints of persistent pain provided major problems of management.

Figure 66.—Late postinflammatory stage

of trenchfoot. Note the delicate, waxy appearance of the skin, the absence of longitudinal and transverse arches, and the slightly

valgus position of the great toes. This soldier

was unable to do infantry duty because of

hyperhidrosis, maceration of the skin, and

pain in the feet.

AFIP A-44-416

Figure 67.—Postinflammatory stage of

trenchfoot. The feet were cold, sweaty,

and cyanotic. Note prominence of extensors of toes and dorsiflexion at the

metatarsophalangeal joints.

AFIP CA-43-57

20
278 COLD INJURY, GROUND TYPE

Figure 68.—Late postinflammatory stage

of trenchfoot. The skin was delicate, and

there was marked hidrosis. There is still

trace of edema in the right foot. Note relaxation of both longitudinal and transverse

arches and slight dorsiflexion of metatarsophalangeal joints.

AFIP CA 44-413

As time passed, it became more and more evident that the postinflammatory stage of trenchfoot was not matter of sharply defined chronologic limits.

It seemed likely, instead, that it could last for months and even years. Recovery was very slow. Sequelae were frequent (p. 284). An occasional man

malingered, but observations both overseas and in Zone of Interior hospitals

clearly showed that many of the men who had suffered from cold injury would

be left with genuine disabilities.

Other Studies

Edwards, Shapiro, and Ruffin, who observed 351 cases of cold injury

in general hospital in Italy, confirmed Simeone’s observations and described

much the same clinical picture. The first evidences of cold injury in their

cases were numbness and coldness of the feet. As result, the men hesitated

to exercise them. When the feet began to warm up after exposure, the toes

tingled and burned or ached. Pain sometimes radiated up to the knee as

vasodilatation began to occur in the damaged tissues of the feet. Then

sterile inflammatory reaction became evident, and blebs, some of which

contained bloody fluid, might cover the whole plantar surfaces. Sometimes

the symptoms and signs of injury were limited to coldness of the feet, perhaps

associated with stiffness, for several days. In other instances, the toes were

gangrenous and enormous blisters made normal walking impossible for weeks.

Edwards and his associates graded their cases as follows:

Grade 1.—The feet were cool and the great toes numb. The soldier complained of slight aching or stiffness, but there was no evidence of discoloration,

blebs, or swelling, and no decrease in the pulsations of the dorsalis pedis and

posterior tibia! arteries. Return to duty was possible in about weeks. In

another group of injuries, also graded as mild, the feet were cool, sometimes
CLINICAL PICTURE ANT) DIAGNOSIS

moist, and slightly cyanotic, but pain was not severe enough to interfere with

sleep, stiffness did not develop, and no blebs formed. Pulsations of the regional

arteries were normal. When the feet became too warm, there might be mild

aching. Return to duty was usually possible within weeks to months.

Grade 2.—The feet were cold, cyanotic, and sometimes moist. Aching

pain interfered with sleep for several days. The dorsalis pedis puslation was

decreased, or might be absent part of the time. There was tenderness to pressure over the metatarsal pads. Within week after the onset of symptoms, the feet might become warm, tender, and swollen. Return to duty was possible

within to months (4 months on the average), but future combat infantry

duty might be impossible.

Grade 3.—The feet were cold, mottled, and cyanotic, with large blebs or

areas of ecchymosis. Pain and aching were continuous, day and night. Pain

was always felt on motion of the toes or on pressure over the metatarsal pads.

The dorsalis pedis pulse was often absent, and posterior tibial pulsations were

feeble. Pulsations might disappear for several days, then reappear for several

days before they disappeared again. This phenomenon was particularly likely

to occur in the dorsalis pedis. After few days, the feet might become warm

and swollen, with little or no cyanosis. When this happened, the dorsalis pedis

pulse became bounding. Desquamation of thick layers of skin always occurred.

Return to duty was impossible for months or more, and as rule only limited

duty was possible.

Grade 4-—The clinical picture was similar to that described in grade 3, but, in addition, there were areas of gangrene over the toes. The nail beds were

black, and pitting edema was pronounced. Physiologic amputation of the toes

sometimes followed, though in surprising number of instances the blackened

dermis peeled off gradually, leaving granulation tissue underneath. Amputation

of an entire toe or of the whole foot was necessary in few instances of gangrene

and necrosis.

Edwards and his associates noted that, during the period of hospitalization,

the feet became purple or cyanotic when they were dependent and became

blanched when they were elevated, which suggested that the subcutaneous

circulation was slow in spite of dilatation of arteries in the foot, with increased

circulation in the deeper tissues. When the generalized swelling and sterile inflammation had subsided, the foot usually remained tender to pressure over the

plantar surface of the metatarsophalangeal area. The great toe was more often

affected by numbness, blister formation, and paresthesias than the other toes,

but ecchymosis and superficial burning were frequent in all the toes, especially

at pressure points in contact with the shoes. These symptoms and signs also

occurred over the dorsum of the foot and on the heel. In both moderately

severe and severe cases, even after sensation returned, the toes were likely to

remain stiff for weeks or months, and months or more might pass before

flexions were straightened out.

When hikes were resumed, patients with milder grades of trenchfoot

usually ceased to complain of aching pain after the first week, though in both
280 COLD INJURY, GROUND TYPE

grade and grade cases mild aching and tenderness on the plantar surfaces of

the metatarsal arch might persist for several months whenever the man walked

for any distance. Grade patients usually complained for months or more of

tenderness on walking, and few could return to full field duty within the holding

period permitted in the theater.

Vascular Changes

The vascular changes associated with trenchfoot impressed all observers in

the cases studied during the Italian experience. During the ischemic stage,

the skin was usually pallid as well as cold. Areas of pallor were mingled with

areas of purple mottling and blotching. It was assumed that pallor indicated

arteriolar spasm and mottling indicated blood stasis and paralysis of venules.

The dorsalis pedis and posterior tibia! pulsations were not ordinarily palpable

in feet which had this appearance.

In the early inflammatory stage, these pulsations were bounding, and the

blood flow, at least superficially, seemed maximal. This was frequently true

even when pitting edema was present. After few days, however, evidences of

increased blood flow became fewer and fewer, and later it might be impossible

to feel any pulsations at all in the dorsalis pedis. This was the situation in

11 of the first 50 cases of trenchfoot studied intensively. In of the cases in

which the pulsations were absent bilaterally, history of previous frostbite

was obtained. The dorsalis pedis of posterior tibial pulsations, or both, wera

absent in quarter of the cases studied by Boland and his associates. No

relationship was evident between these phenomena and the severity of the

injury, though it was observed that pulsations were always stronger in hot feet

and weaker in cold feet. In evaluating these figures, it must be remembered

that these pulsations are not always present in normal feet (p. 387).

As the inflammatory stage subsided, there was remarkable variability, as

already noted, in the ease with which the dorsalis pedis pulsation could be felt

at different times in the same foot. The observations sometimes varied from

hour to hour. When this happened, there were always associated variations in

the subjective sensation of heat or burning pain in the feet.

THE EUROPEAN THEATER

As part of the trenchfoot-study project initiated at the 108th General

Hospital in Paris, in November 1944 (p. 186), an intensive study was made of 500 of the 5,000 patients with trenchfoot admitted to this installation.

Clinically, the cases were classified into three groups, according to the severity of the injury, the size of all the groups being about equal.

Group 1.—In mild injuries, when the exposed foot was returned to

normal environmental temperature, bright-red flush developed, the appear-
CLINICAL PICTURE AND DIAGNOSIS 281

ance of the foot suggesting mild sunburn. Slightly increased pulsations

of the large vessels were observed for brief period. The skin temperature

was somewhat increased, and edema made the skin seem thicker than normal.

The duration of the edema was from to days and averaged days. The

chief complaints were itching, burning, or moderate pain.

Bed rest was necessary for from to 12 days and averaged 6.4 days.

In some cases, for as long as 10 days, walking in shoes caused painful reaction,

though in others walking was possible and painless as soon as the patient

became ambulatory. The average duration of discomfort from this cause was

4.2 days. Symptoms disappeared completely, and the feet resumed their normal

appearance in from to 21 days, or an average of 12.6 days.

Group 2. —When exposure had been more prolonged or the environmental

temperature had been lower, edema was fairly severe, blisters formed (figs. 69

and 70), and minute areas of intracutaneous ecchymosis were often present.

Exfoliation occurred in varying degrees after edema had subsided. The only

serious complaint was deep-seated pain, which was increased by heat and by

walking. It was especially severe in the first metatarsophalangeal joint and

across the plantar surface of the anterior arch of the foot.

In this group of cases, the edema lasted from to 14 days, or an average

of 10 days. Bed rest was necessary for from 11 to 46 days, or an average of

23.2 days. Walking in shoes without pain was possible oidy after an additional

period which varied with the patient from to 15 days and which averaged

8.4 days. After recovery had been sufficient for the man to resume marching,

the only sign of abnormality in most cases was profuse hyperhidrosis. Marching in cold weather was likely to cause recurrence of pain in the feet for

month or more. At the time this report was made, the final disposition of

this group of patients was still unknown.

Group 3.—In third-degree cold injury, the initial reaction was intense.

All the cardinal signs of inflammation were present, including burning pain,

heat, rubor, and marked edema. The peripheral arterial pulsations were

bounding. Large blisters appeared on the dorsal and plantar surfaces of the

feet. Superficial skin necrosis over areas of intracutaneous ecchymosis produced lesions with the appearance of impending gangrene.

In this group of cases, the duration of edema was usually from 10 to 15

days but might be as long as month or more. Superficial layers of skin

gradually mummified and finally desquamated, leaving underneath normal

pink skin, which was extremely sensitive. The extremity assumed dusky,

cyanotic color, on dependency or when placed in cold environment. Muscular weakness was considerable and as associated with atrophy and stiffness

of the joints. None of the casualties in this group were able to alk without

great pain and disability during the 3-month period they remained under

observation.

Only of the 500 casualties studied intensively at the 108th General

Hospital required amputation of the digits. Bilateral amputation for gangrene
282 COLD IX.l I’RY, GROUND TYPE

AFIP B-361-b, c, d,

Figure 69.—Second- and third-degree cold injury. A. Early changes. Multiple small

blisters are present and in some areas have coalesced to produce bullae. On the right foot,

only the great toe is involved, and the process is of moderate severity. On the left foot, the

changes are more advanced. B. Appearance of feet shown in view 28 days later. Gangrenous changes in the first and second toes of the left foot have produced spontaneous

amputations. The wounds are still open and unhealed. On the right foot, the changes are

superficial, and healing has progressed to scaling of the skin. C. Appearance of feet shown in

view days later. Healing has continued bilaterally. The open wounds on the amputated

stumps of the toes on the left foot show beginning epithelization. All blisters have disappeared, and most of the cutaneous lesions on the dorsum of the left foot have healed,

leaving only residual changes. D. Appearance of feet shown in view days later. Healing

is now almost complete on the right foot. On the left foot, the open areas are almost completely healed, and only some superficial cutaneous scaling remains.

was necessary in one case. This man had been trapped for days behind

enemy lines, where he escaped capture by feigning death. He spent the

entire time in snow and water-filled foxhole, in which his feet became encased

in ice. At the end of the time, by walking and crawling for several miles, he

reached friendly lines, and his shoes were finally cut off his frozen feet.
CLINICAL PICTURE AND DIAGNOSIS 283

AFIP B-387-a, b, c, e,

Figure 70.—Serial changes in trenchfoot. A. Early phase of severe cold injury, with

blister formation and beginning gangrenous changes in toes of both feet. Edematous changes

have begun to regress, and blister formation on the dorsal aspects of both feet has begun

to subside. B. Plantar view of feet on same date as view A. C. Appearance of feet shown in

view days later. Regressive changes are evident on the dorsal aspects of both feet.

Blisters have almost disappeared, and the skin is superficially wrinkled and dry. Mummification has begun in the toes. D. Appearance of feet shown in view days later. Note

the cracked, scaly appearance of the skin, following disappearance of blisters, and the

slowly progressive dry gangrenous changes in the toes on both sides. E. Plantar aspect

of feet shown in view on same date. The changes present in the dorsal view are also

evident in this view. Most of the digits on both feet will inevitably be lost by spontaneous

separation.
284 COLD INJURY, GROUND TYPE

OVERSEAS COMPLICATIONS AND SEQUELAE

Trenchfoot, as already pointed out several times, is type of injury which

is likely to continue to give trouble long after acute manifestations have

subsided. Experiences in all theaters of operations in World War II bore out

this generalization.

The Aleutians Experience

The experiences of casualties from Attu in Zone of Interior hospitals

paralleled, in point of time after injury, experiences of other casualties in

overseas hospitals. Some of them complained, often for many months after

exposure, of pains deep in the foot, superficial burning, and aching, all increased

by walking. Pain was particularly likely to occur in the metatarsophalangeal

joints, whence itradiated into the ankle and sometimes into the calf muscles.

In some cases, hypersensitivity persisted, and the slightest touch or the lightest

pressure caused discomfort.

Osteoporosis was observed in 16 of the 93 patients treated at the 183rd

Station Hospital, where it was observed between the 6th and 12th weeks

after exposure, in the course of the diagnostic endeavor to find the cause of

the deep-seated pain of which these patients complained. The pathologic

process, which was moderately advanced in all of these cases, involved the

distal half of the metatarsals and the proximal three-quarters of the phalanges,

usually in the first and second toes. The changes were particularly marked

when there was preexistent deviation from the normal foot structure, as in

two cases of preexistent arthritis, or when there was evidence of fault} weight

bearing of longstanding. The immediate factors which produced this complication were probably the result of prolonged disuse of the feet, which, in

turn, resulted in nutritional and circulatory changes. It was least in evidence

in the cases in which early supervised exercise had been instituted.

At Letterman General Hospital, deformities of the feet were observed in

the majority of the patients, even those in whom the injury was only of second

degree. Most often, the deformity was of claw-foot type, with varying

degrees of pes cavus (fig. 71). The great toe was pulled downward into plantar

deformity, and the spaces between all the toes were increased. The spread

was especially prominent between the great toe and the second toe. study

of available pathologic specimens clearly explained the mechanism of the

deformity. Varying degrees of inflammation and degeneration were observed

in the nerves and vessels, the supply to the short muscles being more seriously

affected. Long muscles usually escaped, probably because they receive their

nerve supply farther up the leg, more distant from the involved zone. When

smaller muscles of the feet were badly damaged, the large muscles took over

their function. Since the long flexor to the great toe is stronger than its long

See footnote (1), p. 260.

See footnote (3), p. 260.
CLINICAL PICTURE AND DIAGNOSIS 285

AFIP 56-3927

Figure 71.—Severe flexion contractures of toes, for which amputation was subsequently

necessary. On the right foot, amputations have already been performed proximal to the

heads of the first and second metatarsals. On the left foot, amputation has been done at

the head of the first metatarsal and through the proximal phalanx of the second toe.

extensor, the great toe was pulled downward, while the reverse mechanism in the small toes caused them to be pulled upward.

In many of the cases observed at McCaw General Hospital, the gradual

development of claw-toe deformities was troublesome complication. The

explanation was thought to be an exaggerated deposition of collagenous and

fibroblastic material in the tissues following injury. Lumbar sympathetic

block and surgical lumbar sympathectomy had no effect on the progress of this

deformity, and, when rigid contracture occurred, with friction irritation from

the shoes, surgery was necessary to straighten the toes.

The persistence ofpain in the toes and feet, which was principal complaint

in many cases, was thought to be related to the extensive perineural fibrosis

demonstrable in tissue sections. The delayed onset of pain was probably due

to the late, progressive contracture of fibrotic tissues.

Psychoneurosis was observed in many of the patients at the 183d Station

Hospital, where it was attributed to the lack of any specific means of therapy

and the corresponding slow recovery. Some of the men were seriously concerned about possible permanent damage to their feet. Others were more concerned with their participation in an active engagement, in which they had

become casualties, and because of which they felt they had done their share

of fighting.

The Mediterranean Theater

Sequelae of trenchfoot became evident in the Mediterranean theater in the

course of the 1943-44 experience (plate 3D). They included persistent pain and

edema, hvpesthesia and anesthesia, and vasospasm. The skin was delicate and

See footnote (2), p. 260.
286 COLD INJURY, GROUND TYPE

waxy after desquamation, and weight bearing was impractical until calluses

had formed (fig. 72), process likely to be long delayed. The patients were

sensitive to cold but were also incapacitated by heat. Hyperhidrosis and associated trichophytosis resulted in maceration of the skin (figs. 66, 67, 68, 72, 73,

74, 75, 76).

AFIP CA-44-411

Figure 72.—Late postinflammatory stage of trenchfoot. This photograph was taken

in June, after the soldier had been unable to remain with his infantry unit because the skin

of the feet was so delicate and perspiration was so excessive that maceration ensued. Note

absence of calluses on weight-bearing surfaces.

Figure 73.—Late postinflammatory

stage of trenchfoot. Note delicate, waxy

skin. This man’s transverse arches were

relaxed, but the longitudinal arches ere

within normal limits. This photograph

should be compared with figure 66, which

shows absence of both transverse and longitudinal arches.

AFIP CA-44-415
CLINICAL PICTURE AND DIAGNOSIS 287

Figure 74.—Late postinflammatory

stage of trenchfoot. After months of

hospitalization, the feet were still cold and

sweaty and were blue on dependency.

The patient complained of deep aches in

the metatarsophalangeal joints and in the

longitudinal arches.

AFIP CA-44-21I

Figure 75.—Early postinflammatory

stage of trenchfoot. After months of

hospitalization, edema had subsided. The

skin was delicate, and the patient complained of aches in the metatarsophalangeal

joints, particularly in the joints of the great

toes. Note scanty amount of subcutaneous

fat about these toes.

AFIP CA-44-95

During the summer and early fall of 1944, many patients were admitted to

hospitals in the Peninsular Base Section, Mediterranean theater, for what was

termed recurrent trenchfoot, though actually the present condition was quite

different from the original condition. Most of these men were returned from

units which had participated in the drive north of Rome to the Gothic Line,

because they could not keep up with the troops. Others were received from
288 COLD INJURY, GROUND TYPE

Figure 76.—Late postinflammatory stage

of trenchfoot. This patient was unable to

do infantry duty during the summer months

because of excessive sweating and trichophytosis, with secondary infection, on the insteps.

AFIP CA-44-414

units undergoing amphibious training for the invasion of southern France.

Still others came from replacement depots and rehabilitation centers.

In detailed report by Toone and Williams on these men (p. 330), it was

pointed out that the feet appeared weak and atrophic and were painful on light

pressure. The toes were numb and stiff. The skin was thin, of delicate texture, and bore scars of recently healed excoriations as well as new lesions.

Plantar calluses were entirely lacking or were grossly inadequate. The men

complained of excessive hyperhidrosis, and many had been incapacitated by

recurrent episodes of trichophytosis. Earlier in the summer, Long had observed an apparently increased incidence of epidermophytosis and allied foot

disorders in Peninsular Base Section hospitals, and had found that much of it

was in patients who had suffered from trenchfoot the previous winter. He

considered the complication sufficiently serious to warrant setting up new

criteria for the disposition of patients with trenchfoot.

Edwards and his associates believed that this type of complication was

preventable. Correspondence with number of their patients who had returned

to full duty showed them to be fully aware of proper foot hygiene and to be

following instructions as faithfully as possible under combat conditions. Even

when they could not bathe their feet, they removed their shoes, massaged their

feet, and applied the foot powder issued by the quartermaster. As result,

they had minimum of trouble with hyperhidrosis and epidermophytosis.

Ragan and Schecter, whose study covered only casualties with early

trenchfoot, observed them for too brief period for muscle atrophy or other

sequelae to develop. In two cases, however, both instances of moderately

severe trenchfoot, the following curious sequence of events was observed: The first patient presented nothing out of the ordinary when he was hosRagan, C. A., and Schecter, A. E.: Clinical Observations on Early Trench Foot. Bull. U. S. Army M. Dept.

4; 434-440, October 1945.
CLINICAL PICTURE AND DIAGNOSIS 289

pitalized for cold injury. On the 14th day, it was found that all the toes of the

right foot, including the great toe, were so firmly held in dorsiflexion that even

after considerable force had been exerted the contraction could be overcome

only partly. This man stated that, in civilian life, years before his induction

into the Army, his feet had been frozen and that similar contraction of the

toes had occurred at that time.

The following day, the patient in the next bed, also on the 14th day of

hospitalization, presented the same type of contraction, also on the right side,

but without involvement of the great toe.

The circumstances naturally suggested hysterical contraction in both

cases, but in each instance the contraction was held so firmly and so constantly

throughout the day that the suggestion lost some weight. That night, both

patients were heavily sedated and their feet were examined after they were

soundly asleep. In each instance, the contracture was still present.

The next day, both patients were given ether anesthesia, under which complete relaxation of the contractures occurred. When Novocain was injected

into the belly of the extensor hallucis longus of the first patient, the distal

phalanx of the great toe relaxed but the proximal phalanx remained in dorsiflexion. In both patients, similar dorsiflexion could be induced in the unaffected

(left) feet by occlusion of the circulation by inflation above arterial pressure of

blood pressure cuff placed around the thigh. The dorsiflexion was relaxed

when the cuff was deflated. This phenomenon could not be induced in the

first patient when he was under ether anesthesia. Dorsiflexion by the same

method was induced in control patient on the first attempt but could not be

induced 48 hours later.

The first patient was kept under observation for 10 days after the appearance of the contracture. When he was evacuated, dorsiflexion was still present

but was less firm. The second patient was observed for 23 days. At the end

of this time, the contracture, although still present, could be readily overcome

by minimal pressure. The phenomenon induced in the left leg by varcular

occlusion could no longer be elicited.

possible complication of trenchfoot or, more accurately, of measure

adopted to prevent trenchfoot was so-called shoepac foot, which was observed

in both the Mediterranean and European theaters. This was an irritation of

the feet caused by the continuous wearing of damp socks within shoepacs, by

the heat generated within the shoepacs as the result of friction of wool socks

on the wool inner soles, or by the poor ventilation inherent in shoe made

partly of rubber. The ball of the foot was most often affected, but the irritation also extended to the heel in some cases. Sometimes cleanliness, clean

socks, and brief period of rest cleared up the trouble. Sometimes, however,

hospitalization was required for as long as 10 or 15 days. The soldier could

usually be returned to full duty, but, if the causative conditions were permitted

to recur, recurrence of the trouble could be expected.

Continued observation of patients with trenchfoot in the Mediterranean

Theater of Operations showed only slow disappearance of residual complaints
290 COLD INJURY, GROUND TYPE

of pain and tenderness. Complaints were fewer in warm than in cold weather,

but long marches were still not possible. During the winter of 1944-45,

year after their injuries had been sustained, many men still complained of

spontaneous aching whenever the weather was cold and damp, and the ability

to walk and march was decidedly diminished, though the original level of

incapacity was not again reached.

In February and March 1945, Paddock studied intensively number of

soldiers who had contracted trenchfoot in the Apennines from to weeks

earlier. All had injuries of mild to moderate severity, the damage being, on

the whole, less severe than in the similar cases observed during the previous

winter. At this time, acute edema, gangrene, and pseudogangrene had disappeared, and the chief residual complaint was pain, with tenderness of the

soles of the feet. The men could be divided into two main groups, those with

complaints of vascular origin, with tendency to coldness and cyanosis, and

those with complaints of neural origin, including pain on firm pressure over the

soles, superficial hypalgesia, loss of proprioception, diminution of temperature

discrimination, hyperhidrosis, and poor toe-flexion ability.

After employing variety of tests and making numerous observations,

Paddock reached the following conclusions:

1. The capillaries and venules in the injured feet were apparently normal,

but there was increased arteriolar tone, apparently secondary to increased

sympathetic stimulation. There was no evidence of arteriolar obstruction.

2. In addition to superficial hypalgesia, there was frequently diminution

of temperature, vibration, and position sense in the affected feet. Poor toe

flexion was not the result of any obvious structural abnormality. Deep-seated

sensitivity to cold was usually absent.

3. In trenchfoot of moderate severity, it seemed reasonable to conceive

of involvement of all the most superficial tissues of the foot, with quantitative

variation from patient to patient with respect to special tissues affected. The

disabilities encountered in the later stages of mild to moderate cold injury were

apparently more dependent on neural changes than on vascular changes. Microscopic evidence of damaged tissues tended to confirm this concept.

It was Paddock’s opinion that the disabilities from which these men were

suffering would persist for years, and that therapy directed at the blood vessels

and nonneural tissues would be ineffective. Observations at Mayo General

Hospital (p. 333) and other vascular centers in the Zone of Interior confirmed

this impression.

The European Theater

The end of the fighting in Europe in May 1945 accounts for the fact that

most of the residua of cold injury sustained in that theater were observed in

hospitals in the United States rather than overseas. As early as April, however, the chief consultant in medicine in the European theater noted that cold

Paddock, F. K.: Chronic Disability in Mild Cases of Trench Foot. New England J. Med. 234: 433-437, 28 Mar. 1946.
CLINICAL PICTURE AND DIAGNOSIS 291

injury promised to constitute continuing problem because of the increased

susceptibility of the feet to trichophytosis after it. In Essential Technical

Medical Data for the month ending 30 April 1945, the same observation was

made. It was also noted that number of men with neglected cold injuries

were now presenting themselves for treatment. They had resisted evacuation

when they sustained their injuries during the hard fighting in December and January of the previous winter, but now they were appearing with extreme vascular changes, usually in the form of cold, clammy, blue feet, frequently

associated with edema.

OBSERVATIONS IN THE ZONE OE INTERIOR

The observations made on the 656 patients with trenchfoot treated at

Mayo General Hospital in 1944 and 1945 may be taken as typical of the late clinical picture of cold injury of moderate to serious degree.

Exposure to Cold (Wet Cold)

Five hundred and eighty-six of these six hundred and fifty-six patients

sustained their cold injuries after single exposure in combat, the duration

varying from to 54 days and averaging 14 days. The injuries occurred

between November 1943 and March 1944, at Cassino or on the Anzio beachhead, and between October 1944 and January 1945 in France, Germany, Luxembourg,

Holland, and Belgium. In practically all instances, the environmental temperature had been in the neighborhood of freezing or only slightly higher, and rain

had been almost continuous for long periods. For the most part, the men had

lived in mud and water and had seldom been able to change their shoes and

socks.

Sixty of the six hundred and fifty-six patients had suffered two attacks of

cold injury. The first exposure, which lasted from to 60 days and averaged

15 days, occurred between November 1943 and March 1944 at Cassino, Venafro,

or the Anzio beachhead. The men were hospitalized for an average of weeks

each, then were sent to convalescent or reconditioning centers before they were

returned to duty. The second exposure occurred between August 1944 and

February 1945 in France, Holland, or Germany. All the patients had been

hospitalized overseas for second time before being evacuated.

Ten men had suffered three exposures each, the first at Cassino, the second

at the Anzio beachhead, and the third in France, Germany, or Holland. They

were returned to duty after the first and second attacks, after varying periods

of hospitalization, and all reached the Zone of Interior about months after

the third exposure.

Some men who had suffered single exposures had remained on patient

status until they were received in general hospitals in the United States.

Others had been returned to full duty after varying periods of hospitalization
292 COLD INJURY, GROUND TYPE

but had been unable to perform their duties. Some men who had sustained

their injuries in Italy in the winter of 1943-44 had had the first evidence of

recurrent trouble during the march on Rome in July 1944 (p. 287). They

complained of their feet almost at once, and pain, swelling, and blister formation eventually made them unable to keep up with their comrades in any kind

of physical endeavor.

The patients with trenchfoot observed at Mayo General Hospital and

other vascular centers in the United States were seen between and 13 months

after exposure. The average timelag was months.

No correlation could be demonstrated between the duration of exposure

and the degree of resulting damage to the tissues in 633 patients with cold

injury treated at Mayo General Hospital (table 8). There was also nothing

in the histories to suggest that men who had suffered previously from trenchfoot or frostbite were any more likely to suffer from gangrene than were men

who had been exposed only once, though they were, obviously, more susceptible

to cold injury.

Table 8. Tissue damage in relation to duration of exposure in 633 patients with trenchfoot, Mayo General Hospital

Classification

Signs and symptoms of the later stages of trenchfoot observed in vascular

centers in the Zone of Interior fell into three general categories:

Predominance of excessive sympathetic activity.—One hundred and fortyfive (22.1 percent) of the six hundred and fifty-six patients observed at Mayo

General Hospital presented symptoms and signs which seemed primarily the result of excessive sympathetic activity. The skin temperature of the toes was low, frequently lower than the environmental temperature. Hyperhidrosis

was invariably present. It ranged from slightly more than the usual amount

of perspiration to an almost continuous flow of sweat which rolled off the foot

Lesion Number of patients

Proportion

(percent)

Average period

of exposure

(days)

No loss of tissue 548 86. 14

Superficial gangrene, slight 15 2.

Superficial gangrene, severe 33 5.

Partial loss of one or more toes or heel 23 3.

Total unilateral loss of one or more toes 1. 12

Unilateral loss of toes, partial loss of heel

Total bilateral loss of one or more toes

Bilateral loss of toes, partial loss of foot..

Total loss of one or both feet 12

10 percent of the patients who lost part of or more toes or part of the heel and 7.7 percent of the patients who

experienced no loss of tissue had previous history of frostbite.
CLINICAL PICTURE AND DIAGNOSIS

in perceptible quantities. The amount was definitely increased by emotional

disturbances. The cooling effect produced by the evaporation of perspiration

was one explanation of why the skin temperature was often lower than the

environmental temperature.

Cyanosis, particularly when the feet were dependent, was another prominent observation. Changes of color and temperature were often observed.

blue, cold foot would become red and hot after exposure in warm room or

after the man had walked short distance in shoes. At other times, for no

apparent reason, blue, cold foot would become red and hot, and then would

revert to its original status. Mottling was fairly common, sometimes as

transient phenomenon and sometimes for longer periods. It assumed varying

patterns, sometimes in the same individual. For the most part, it took the form of sharply demarcated areas of rubor interspersed with numerous areas

of pallor on background of cyanosis.

Palpation of the large peripheral arteries in patients with signs of excessive sympathetic activity and without gangrene revealed absence of the

dorsalis pedis pulsation on one side or both in about percent of all cases

(table 9). The significance of this observation, if there was any, could not

be determined, since comparable observations were not made in normal subjects. There was no evidence of arteriosclerosis in any patient in this group.

Impairment of the blood supply to the muscles of the leg seemed extremely

unusual, history of intermittent claudication being very seldom obtained.

Table 9.—Residual manifestations of trenchfoot to 13 months after exposure in 619 patients

without gangrene, Mayo General Hospital

[Frequency Is expressed as percentage of the total group]

Tests of the efficiency of the circulation substantiated the view that the

s} mptoms and signs in this group of cases were caused primarily by excessive

sympathetic activity and not by organic involvement of the vascular supply

of the lower extremities. Oscillometric readings were carried out on the first

40 patients admitted but were discontinued when they revealed no significant

departures from normal. Indirect vasodilatation, accomplished by applying

hot-water bags to the abdomen and chest and covering the patient with several

Symptoms Frequency Signs Frequency

Hypesthesia__ 41. Cyanosis 59.

Burning and tingling 21. Sweating 50.

Numbness 16. Abnormalties of gait 34.

Neuritic pains 14. Coldness 27.

Tenderness in sole of foot 14. Edema 17.

Aching 3. Muscular atrophy 14.

Stiffness of toes 10.

Absence of pulsations in large

arteries 6.
294 COLD INJURY, GROUND TYPE

wool blankets, was carried out in 25 cases. In all instances, the skin temperature of the feet, which was lower than normal at the beginning of the test,

rose to level considered normal under the circumstances.

The reactive hyperemia test was performed on 10 patients with marked

cyanosis. In all instances, the flush, which appeared within 10 seconds, faded

out in to minutes. This type of reaction, which was interpreted as

normal response to period of anoxia of the cutaneous arterioles and small

vessels (capillaries and subpapillary venous plexuses), helped to rule out

occlusive disease of the blood vessels. Paravertebral lumbar sympathetic

block with procaine was carried out in 11 cases. In all instances, normal

skin temperature response was obtained, while, at the same time, was

replaced by pink coloration of the feet. Hyperhidrosis also disappeared

transiently.

Predominance ofperipheral-nerve involvement.—Sixty-three (9.6 percent)

of the six hundred and fifty-six patients with trenchfoot observed at the Mayo

General Hospital Vascular Center presented symptoms and signs indicative

of some type of peripheral-nerve involvement. Few objective abnormalities

were noted in this group of cases, except that the feet, at rest, appeared pale.

The chief complaint was tenderness in the sole of the foot, at times so severe

that even the slightest pressure on the part could not be tolerated. Some men

could not walk at all, or could walk only by putting the weight on the heel or

along the lateral aspect of the foot.

Anesthesia was infrequent. Many patients had areas of hyperesthesia to

cotton wool and pinpricks, corresponding closely to the sites sensitive to deep

pressure. These areas also included the dorsal surfaces of the toes and the

dorsum of the foot. There were frequent complaints of various types of

paresthesias, such as burning and stinging sensations, shooting pains, sensations

of numbness in the toes, and feeling of pins and needles in the toes.

Combined sympathetic activity and peripheral-nerve involvements—Four

hundred and forty-eight (68.3 percent) of the six hundred and fifty-six patients

observed at Mayo General Hospital presented symptoms or signs of both

excessive sympathetic activity and some type of peripheral-nerve involvement.

Many in this category (as well as in the other categories) entered the hospital

still showing considerable desquamation of thick epidermis on the plantar

surfaces of the feet (fig. 77). As the process of desquamation was completed,

thin, new skin was revealed. Twenty-eight patients had prominent swelling

of the toes and somewhat less marked swelling of the feet (fig. 78). This

swelling did not disappear with rest in bed and elevation of the extremities but

sometimes responded to treatment with typhoid vaccine (p. 337).

Most of the men presented varying degrees of atrophy of the small muscles.

As result, the arches of the feet seemed abnormally high (figs. 79 and 80).

This phenomenon was particularly conspicuous in 11 cases. It was not possible

to determine whether it was nonspecific response to disuse or was part of the

pathologic change in the syndrome of trenchfoot. The latter theory seems
CLINICAL PICTURE AND DIAGNOSIS 295

AFIP (Mayo OH) C32-1

Figure 77.—Typical hyperkeratosis of skin observed in late trenchfoot. Note

wrinkling, Assuring, and maceration, similar to findings observed after long immersion of

feet in water. Note also dry gangrene at tips of toes. There was marked cyanosis on

dependency. The patient complained of severe, throbbing pain in the right foot. Examination showed normal pulsations in the peripheral arteries on both sides.

This infantryman sustained his cold injury in Luxembourg, in November 1944, after

days’ exposure to very cold, wet weather, with snow. In the battalion aid station, he

complained of considerable burning and pain. Both feet were swollen. Multiple blisters,

filled with blood, appeared on both feet after hours’ exposure to hot stove.

more reasonable in the light of the histologic alterations in the muscles and

nerves described by Friedman (p. 250) as part of the initial pathologic change

in trenchfoot. Whether or not this atrophy is reversible can be determined

only by long-term followup studies. Some patients at Mayo General Hospital

showed no beneficial effects from the intensive and prolonged program of

exercises designed to utilize the small muscles of the foot and still presented

considerable atrophy at the time of disposition.

Other Observations

At the time they were admitted to Mayo General Hospital, an average

of months after injury had been sustained, occasional patients still presented

vesicle formation. Frequently, one or more toenails had fallen off, leaving

the nail bed exposed (fig. 81). In other instances, the nails were distorted,
296 COLD INJURY, GROUND TYPE

AFIP (Mayo OH) 680-2, 680-5

Figure 78.—Persistent swelling of feet in late trenchfoot. A. Appearance of feet

months after injury, showing granulating wounds of both great toes, with infection and

osteomyelitis. Note persistent swelling of toes and dorsum of foot. B. Appearance of

feet after revision of amputation stumps.

This infantryman sustained his cold injury in Germany, in November 1944, after days’

exposure to cold, wet weather, with snow. The first note on the record mentions bilateral

swelling of the feet, with deep gangrene of the tips of all the toes. Treatment consisted of

bilateral lumbar sympathectomy, amputation of toes, and the application of split-thickness

skin grafts to both great toes. The grafts did not take, and revision of the stumps was

necessary.

and there was considerable debris beneath them. Dermatophytosis was

common finding.

In 34 cases, there was great stiffness of the toes, and the skin was shiny

and seemed firmly attached to the underlying tissues. Sometimes the great

toe was widely separated from the others and was either flexed (fig. 79) or was

hyperextended in the form of pseudo-Babinski sign. This phenomenon could

probably be explained by disuse. There was no correlation between the degree

of stiffness present and the severity of the original injury.

Osteoporosis was fairly common observation in the more severe cases.

It sometimes disappeared after or months of physical activity, but as

rule there was not much difference between the roentgenograms taken on

admission and the final roentgenograms taken before disposition. The bone

changes, like muscle atrophy, could be explained either as the response to

long period of inactivity or as an integral part of the trenchfoot syndrome.

As with atrophy, whether or not osteoporosis represents an irreversible change

in cold injury can be determined only by long-term followup studies.

Superficial and Deep Gangrene

study of the early records of patients admitted to the trenchfoot centers

suggested that by the time man with trenchfoot had reached fixed installation it could usually be determined whether or not he would eventually lose
CLINICAL PICTURE AND DIAGNOSIS 297

AFIP (Mayo OH) 1226-1

Figure 79.—Atrophy of small muscles of feet, characteristic separation of great toe

from others (pseudo-Babinski sign), and moderate heel walking, months after injury.

This patient sustained his cold injury in France, in October 1944, after days’ exposure

to cold, wet weather, but not to freezing temperatures. The clinical course was characterized

by excessive coldness of the feet, cyanosis, hyperhidrosis, stiffness and numbness of the toes,

and pain in both feet. Cyanosis and hyperhidrosis were still present months after injury

but ability to flex the toes on the right foot had returned.

any significant amount of tissue. Fifty-three of the patients admitted to Mayo

General Hospital still presented small areas of superficial gangrene, usually on

the medial aspect of the foot (fig. 81) or the tips of the toes. The heels were

affected much less often. For the most part, these gangrenous tissues separated

spontaneously, revealing normal tissues beneath (fig. 81C and D). In number

of cases, the original lesions suggested the presence of much more severe type

of involvement than subsequent events proved to exist. These observations

supported the general opinion that conservatism should be practiced in the

early management of trenchfoot complicated by gangrene.

Observations from other vascular centers and from Camp Carson (p. 193)

were to the same effect. At Camp Carson, 400 patients, about percent of

the total number admitted, had gangrenous areas of some degree when they

arrived. It was regarded as significant, however, and the data were utilized

in outlining the plan of management in these cases, that about half of the

other patients received also had had areas of gangrene, which had healed

spontaneously, earlier in the course of the injury. In 50 of the 400 patients
COLD INJURY, GROUND TYPI 298

AFIP (Mayo OH) 697-1

Figure 80.—Atrophy of small muscles of feet and peripheral neuritis in late trenchfoot.

Note marked atrophy of small muscles of both feet months after injury.

This infantryman sustained his cold injury in Italy, in December 1943, after days’

exposure to cold, wet weather but not to freezing temperatures. The clinical course was

characterized by bilateral swelling of the feet, cyanosis, and elevated cutaneous temperatures.

Gangrene did not develop. The patient complained of aching, painful sensations, and numbness. He was returned to duty months after exposure but had to be rehospitalized after

months of duty because of aggravation of all symptoms. At this time, he complained of

tingling and burning sensations and great tenderness on the plantar surfaces of the feet;

all symptoms were increased by extremes of temperature. Areas of hypesthesia and anesthesia

were present on both feet.

who arrived with gangrene, healing progressed so satisfactorily that spontaneous

separation of the non viable tissues occurred, and plastic revision of the scars

was not necessary. Gangrene of degree requiring amputation above the

ankle was encountered in only three patients, all of whom were transferred

to amputation centers. The remaining 347 patients required only amputation

of localized gangrenous parts or some type of surgical revision of the scar left

after spontaneous separation of the gangrenous areas.

The 37 patients with deep gangrene and subsequent extensive loss of

tissue, observed at Mayo General Hospital, may be considered as being typical

of all patients in this category. They had suffered only single exposure,

ranging from to 34 days and averaging days, either inItaly, between November 1943 and March 1944, or on the Western Front, between October 1944 and

January 1945. In some instances, according to the records, gangrene had

been present when the patients reached the battalion aid station. More often,

it appeared after to 10 days of hospitalization. Sometimes ulceration and

infection had also occurred before the men received any medical aid. The

development of gangrene had sometimes been preceded by the appearance of

large hemorrhagic blisters, after which the involved areas quickly became

black and mummified.
CLINICAL PICTURE AND DIAGNOSIS

AFIP (Mayo OH) 584-1, 584-2, 584-3

Figure 81.—Superficial gangrene in late trenchfoot. A. Appearance of feet months

after injury, when areas of superficial gangrene on the medial aspect of the right foot were

becoming demarcated from normal tissue. At this time, the patient complained of stiffness

of the toes and tenderness in the sole on the application of pressure. Cyanosis was conspicuous. Pulsations in the peripheral arteries of both feet were normal. B. Plantar view

of feet months after injury. Note gangrene of plantar surface of tips of toes of both feet

and scaly appearance of skin before desquamation. C. Appearance of feet months later.

The superficial areas of gangrene on the medial aspect of the right foot are completely healed,

and only areas of pigmentation indicate their sites. number of nails have been lost. The

feet were now less cyanotic, and the toes, less stiff. D. Plantar view of feet at same time

as view C. The areas of superficial gangrene on the tips of the toes are completely healed,

and the dead epidermis has separated, leaving normal skin.

This patient sustained his injury in France, in October 1944, after days’ exposure to

cold, wet weather but not to freezing temperatures.

All of the patients with deep gangrene seem to have presented the same

general clinical picture in the first stages of their injury as did the men who did

not develop gangrene, the only difference being that all their symptoms and

signs had apparently been severe. Swelling, cyanosis or pallor, blister formation, severe pain, and numbness of the feet were invariably observed.

Although the gangrene which was present in some cases of cold injury

resembled the gangrene present in other vascular disorders, gangrene associated

with trenchfoot presented certain features peculiar to the original injury. It
300 COLD INJURY, GROUND TYPE

varied widely in extent. Pain was not associated either with the gangrenous

process itself or with the resulting ulceration. Intense vasospasm was

frequent observation. Extensive arterial obliteration proximal to the gangrenous areas was not observed. Finally, the incidence of infection was

extremely high.

In the 37 cases of deep gangrene observed at Mayo General Hospital, as

in other, similar cases, the process differed from the gangrene observed in

thromboangiitis obliterans, arteriosclerosis, and other obliterative vascular

diseases, chiefly because the reduction in the circulation of the foot regularly

present in those diseases as the result of obliterative vascular changes was

generally absent in trenchfoot. Relatively normal circulation was observed

in trenchfoot when vasoconstrictor impulses were eliminated, which is contrary to the usual course of events in the obliterative disorders. When the

gangrenous process had extended into the dorsum of the foot, the dorsalis

pedis pulsation was not palpable, and the pulsation of the posterior tibial

artery was likely to be absent also.

Rest pain, which is characteristic of the obliterative diseases, seldom

occurred in the late stages of trenchfoot, even when ulceration was present.

Initially, rest pain might be very distressing in patients with trenchfoot (p. 271),

regardless of whether or not gangrene had developed, but after an interval of

weeks or months it usually disappeared completely or almost completely.

Infection does not usually complicate gangrene in the obliterative diseases,

but it was frequently in trenchfoot associated with deep gangrene. Skin

defects can only occasionally be repaired by grafts in the obliterative vascular

diseases, but they could often be successfully covered by this method in cases

of deep gangrene following cold injury.

The deep gangrene observed in trenchfoot also differed from that seen

in Raynaud’s disease and similar disorders, in which the process, even when

associated with ulceration, is generally superficial and limited. All of these

disorders are alike in that obliterative arterial changes are usually limited to

the actual gangrenous areas or, perhaps, to the areas immediately proximal.

Patients with Raynaud-like disorders and with frostbite tend to have few

symptoms connected with gangrene other than cold sensitivity and hyperhidrosis, which are the rule in the former group of diseases and are very common in frostbite also. In trenchfoot and immersion foot, on the other hand,

the most distressing symptoms observed were the result of damage to nerves

and muscles in the foot proximal to the area of gangrene. Areas of hypesthesia

or hyperesthesia, muscle atrophies, and contractures were relatively common

in gangrene associated with trenchfoot. Almost all patients had pain on weight

bearing. However, these symptoms, as well as hyperhidrosis, coldness and

cyanosis, were also prevalent in patients without gangrene and therefore could

not be attributed to postural difficulties resulting from ischemic loss of tissue.

The infection associated with superficial gangrene in cold injury was

usually minimal. In deep gangrene, it was usually extensive and therefore
CLINICAL PICTURE AND DIAGNOSIS 301

was serious problem. Though infection was not part of the primary

pathologic process, the circumstances under which cold injury occurred

naturally favored its development. The hygiene of the feet was often necessarily neglected under conditions of combat. At the time of exposure, the

shoes and socks were often wet and sometimes had not been changed for days

or even weeks. Bleb formation, maceration and desquamation of the skin, and loss of the nails were favored by the constant wetness of the feet and the

ischemia which resulted from exposure. These lesions, though minor in

themselves, served as portals of entry for pathogenic organisms.

When patients with deep gangrene were first seen in Zone of Interior

hospitals, the gangrenous parts were often partially separated by line of

demarcation bathed in foul-smelling purulent exudate. Blebs were often

present. Sometimes there was evidence of extensive bleb formation throughout

all the gangrenous area. The infection was invariably mixed, with penicillinresistant and sulfonamide-resistant Bacillus proteus and Bacillus pyocyaneus

present in addition to other organisms.

Often, when the gangrene appeared to be of the dry type, removal of the

gangrenous tissue at the line of demarcation would reveal underlying pools of

purulent exudate (fig. 82). Osteomyelitis was frequently present in this type

AFIP (Mayo GH) 595-1

Figure 82.—Deep gangrene of toes of both feet in late stage of trenchfoot. A. Appearance of feet months after injury, when areas of dry gangrene were becoming demarcated

from normal tissue. The line of demarcation was bathed in foul-smelling, purulent discharge. At this time, the patient complained of burning, tingling, and numbness of the toes

and excessive sweating. There were areas of hypesthesia on the dorsal and medial surfaces

of the right foot. Both feet were extremely cyanotic on dependency. Oscillometric readings and pulsations in the peripheral arteries were normal on both sides. B. Appearance

of feet months after injury, after bilateral lumbar sympathectomy, amputation of gangrenous toes, and pedicle graft to left foot. The patient was walking well when he was discharged month later.

This infantryman sustained his injury in Aachen, Germany, in November 1944, after

days’ exposure to cold, wet weather, with snow.

438404 —58 21
302 COLD INJURY, GROUND TYRE

of case, as welJ as in cases of wet gangrene, and showed tendency to proximal

spread, in contrast to soft tissue infection, which showed little tendency to

invade adjacent intact soft tissues.

DIAGNOSIS OVERSEAS

Accurate diagnosis in the battalion aid station and other forward installations is of the greatest importance in cold injury. If the soldier is really

suffering from cold trauma, unless it is of the mildest and most superficial t}pe,

he must be evacuated to general hospital for definitive treatment, which is

usually prolonged. If he is suffering merely from cold feet, fungous infection,

trauma from improperly fitted footgear or some such cause, poor pedal hygiene,

or an orthopedic condition, he can usually be treated in the division clearing

station or the evacuation hospital, depending upon the evacuation policy in

force at the time, and can be promptly returned to his unit. The details of

triage are discussed elsewhere (p. 307).

The diagnosis of trenchfoot, when once the possibility of the condition

was realized, seldom offered much difficulty in World War II, especially when

objective findings were present. It was sometimes serious problem in cases

seen late, in which objective findings had been minimal throughout or in which

they had completely disappeared. Patients in the latter group complained of

aches and pains in their feet, often to the point of incapacitation, and admitted

no relief from any kind of treatment. No satisfactory objective tests were

available to aid in diagnosis, and even neuropyschiatric consultation frequently failed to solve the problem. The question of possible malingering

was, of course, always factor in such cases.

Useful points in the diagnosis of cold injury in forward installations

included the following considerations:

1. The history.—A casualty who had been exposed to cold and wet for

prolonged period of time and who complained of pain or loss of sensation in the

feet presumably was suffering from trenchfoot. On the other hand, there was

no definite correlation between the length and severity of the exposure and the

severity, or even the existence, of cold injury. Seventy-two hours was the

average period of incubation, but some men suffered their injuries after an

exposure of 12 hours or even less, and some did not begin to complain for many

days.

2. The branch of service.—Trenchfoot is so predominately disease of

frontline combat infantrymen that many medical officers in World War II

thought the diagnosis questionable when it was made in noncombat troops and

would not accept it without corroboration of the circumstances of injury.

3. Symptoms.—The most constant symptom of cold injury was pain,

worse at night. Areas of hypesthesia or true anesthesia were also corroborative. An important differential point, in the absence of objective findings,

was that patients suffering from cold injury almost universally stated that they

were most comfortable when they were cool and when their feet were exposed
CLINICAL PICTURE AND DIAGNOSIS 303

to the air at room temperature. Men whose feet were merely cold, or whose

complaints were entirely imaginary, were always eager to warm their feet.

4. Signs.—In the forward installations, the appearance of the feet varied,

the findings depending upon the timelag between the injury and the first

examination by medical officer. The feet might be red and extremely tender

or blanched. Swelling might or might not be present. Blebs might be present

or absent. Gangrene and ulceration might already have set in. One point to be borne in mind in forward installations was the possibility

of the occurrence of cold injuries in association with other injuries. It was

pointed out at the Paris Conference on Trench Foot in January 1945 (p. 179)

that, if casualty was brought into field hospital with wounds in the chest or

abdomen, it might be long time before his boots were removed and it was

discovered that he was also suffering from trenchfoot. This was particularly unfortunate error. It was often observed that men with other injuries,

particularly abdominal injuries, tolerated cold poorly, and serious damage to

the feet might occur while all the attention was concentrated on the battle

wound. Ariev 10 pointed out that the cold injury in such cases might be

sustained after the other injury, while the man was still lying in the field, or in

the course of his transportation to hospital.

It was also found to be important to examine the feet for possible cold

injury before an injury of the extremity was splinted. It was pointed out at

the Paris conference that much damage could be done to man suffering from

cold injury as well as from compound fracture of the femur if traction strap

were put over the instep before the shoe had been removed and the foot

examined. The risk of damage of this origin could be avoided by the use in

the field of skin traction with adhesive instead of traction strap.

Differential diagnosis.—The differential diagnosis of trenchfoot and frostbite was not very important. The all-inclusive diagnosis of cold injury would

have been better from every standpoint. The differentiation in World War II

rested upon the arbitrary distinction that the former occurred when the temperature was above freezing and the latter when the temperature was 32° F.

(0° C.) or lower. This distinction was readily made early in the winter, when

the temperatures were generally mild, and later in the winter, when they were

generally severe. When temperatures were borderline, particularly when

they were above freezing during the day and were freezing or lower during the

night, there was often considerable confusion. Clinically, the feet looked much

the same in both conditions, and about the only subjective distinction possible

was that the patient was frequently aware of the precise time that he had been

frostbitten, whereas the onset of trenchfoot was always insidious. High- altitude frostbite, for obvious reasons, was not consideration in forward

installations of the Armv.

The difficulties of the differential diagnosis of trenchfoot and frostbite

and the associated problems which arose in the award of the Purple Heart

10 Ariev, T. V.; Fundamental Outlines of Present Day Knowledge on Frostbite. Medgiz, Moscow, 1943.
304 COLD INJURY, GROUND TYPE

came down, in the end, to purely administrative considerations. They are

discussed in detail elsewhere (p. 191).

Special Pests

The development of clinical criteria and of simple objective tests which

could be applied under military conditions would be of inestimable value for

purposes of triage at various levels of medical care and for determining when

the soldier who had been hospitalized with cold injury could be returned to

Table 10. Classification and disposition of trenchfoot cases used at the 108th General Hospital,

European theater

Classification Trenchfoot—mild (first degree) Trenchfoot—moderate (seconddegree) Trenchfoot—severe (third degree)

History

Physical findings and

appearance;

Only mild swelling

during hyperemic

stage. Could always walk in shoes

without much

pain.

Could replace shoes

and walk with difficulty during hyperemic stage.

Edema subsides

within week.

Unable to replace

shoes or walk in

hyperemic stage.

Edema persists for

more than week.

Hyperemic stage Very few or no objective findings.

Walking without

pain or disability.

Edema less marked.

May have small

localized areas of

ecchymosis.

Marked edema and

hyperemia. Usually large areas of

intracutaneous ecchymosis with occasional blisters

and gangrene

rarely.

Posthype re mic

stage.

_do Color of foot slightly changed on dependency. No edema.

May be only characteristic red flush

of foot with edema

and accentuation

of color on dependency.

Motor function of Walking without Motor function of Marked to complete

foot. pain or disability. toes is fair to

good. Walking

possible within 10

to 15 days of cessation of edema

and with only

mild discomfort.

loss of active toe

motion. Walking

impossible or very

difficult up to over

30 days.

Disposition __

__Hold in ComZ

units (ambulatory)

for return to duty

under 30 days.

U. K. (ambulatory

or litter).

ZI (litter).
CLINICAL PICTURE AND DIAGNOSIS 305

full or limited duty. No such criteria or tests were developed during World

War II. The classification scheme devised during the special study of trenchfoot at the 108th General Hospital in the European theater (table 10) remained

about as useful as any.

The special tests employed overseas in World War II did not prove useful.

Boland and his associates, who made skin temperature studies in patients seen

to weeks after injury, concluded that this method might be of value in

determining the severity of injury early in the course of trenchfoot but that it

was of little help in later cases associated with cold sensitivity. The ischemicpain test devised at the 15th General Hospital 11 as diagnostic and prognostic

aid had rather extensive testing, but it proved too variable to be of any value in

determining progress of the condition. It also had the basic disadvantage

that the results were essentially an interpretation by the patient of his own

complaints, which made it priori of questionable usefulness. Furthermore,

as Paddock noted in his studies with it, complaints were likely to become

intensified as hospitalization continued. It was found, in fact, that only

soldiers of “undeviating character and morale” could resist the temptation,

when furnished the opportunity, to enlarge upon their foot troubles. This

test did not prove reliable when it was employed in Zone of Interior vascular

centers.

Note.—The clinical details of high-altitude frostbite are reported elsewhere (p. 13). The tropical type of cold injury experienced on Leyte is also

reported elsewhere (p. 211), since it was unique and limited experience.

Finally, as matter of convenience, all details of recurrent trenchfoot are

discussed under the heading of epidemiology (p. 381).

11 Schecter, A. E., and Ragan, C. A.: Trench Foot: The Diagnostic Value of“Ischemic Pain.” Bull. U. S. Army M.

Dept. No. 89, pp. 98-100, June 1945.

307

CHAPTER XI

Therapy and Disposition Overseas

The treatment of trenchfoot has never been really satisfactory. No

specific and definitive methods of management were devised in World War

II, nor have any been developed since. As was pointed out in the preceding

chapter, recovery from cold injury is slow. Rehabilitation is difficult of accomplishment, often psychically as well as physically. Sequelae are frequent and

are often permanent.

The final effect of trenchfoot in United States soldiers who fought in

World War II has not yet been fully assessed. The residua are now the responsibility of the Veterans’ Administration. They are also often encountered

by physicians in private practice, whose evaluation of them may be hampered

by their unfamiliarity with condition which has no precise counterpart in

civilian life.

In the last year of World War II, the treatment of cold injury was more

or less standardized according to the principles set forth in War Department

Technical Bulletin (TB MED 81) (appendix A) published August 1944.

These principles, which had been formulated chiefly on the basis of the experience in Italy in the winter of 1943-44 were modified as was required by expediency, theater practices, local tactical conditions, and the needs of the

special patient. As the experience with trenchfoot increased, numerous methods of management reached the literature or were summarized in official

reports. Some of these methods were entirely illogical or even bizarre. Those

which were of any value revolved around certain general principles.

EVACUATION AND TRIAGE

In an overseas theater of operations, evacuation and triage are component parts of therapy. Triage, which is the classification of patients according

to the type of medical care which their injuries require, is also determined

by the point in the chain of evacuation at which medical care, for tactical

and other reasons, can be carried out.

The policy eventually developed in World War II, which proved fairly

satisfactory, was as follows: When the man with cold injury reached the battalion aid station or clearing station, either by litter carry, by ambulance, or

on foot, it was the duty of the first medical officer who saw him to determine

Report, Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, subject; Trenchfoot in the Italian

Campaign 1943-45.
308 COLD INJURY, GROUND TYPE

that his injuries had been caused by cold. If they were, it was the officer’s

further duty to determine whether they were of such degree as to require

evacuation farther to the rear. It was necessary to separate casualties who

required definitive care from those who, with little rest and encouragement,

cup of coffee or other stimulant, cigarette, change of socks, and similar

simple measures, could promptly return to duty. Similar triage was carried

out at each subsequent medical installation, so that, at least theoretically,

only men who really required definitive treatment were evacuated to the rear

as far as an evacuation hospital or general hospital in the communications

zone.

Triage obviously required careful clinical judgment and practical assessment of the need for, and the possibilities of, treatment. It was usually conducted on the simple plan that all men with objective signs (swelling, edema,

blisters, discoloration of the feet) were evacuated farther to the rear, eventually to general hospital. Men without objective signs were frequently

sent to designated medical facility, where they were kept under close observation for 48 hours or little longer. In the Third U. S. Army, for instance,

one or more medical companies of medical gas-treatment battalion were

utilized for this purpose, in addition to an evacuation hospital. If objective

changes were going to occur, they occurred, as rule, within 24 to 48 hours

and were unlikely to occur after this time.

Men who presented objective changes within this period were evacuated

to general hospitals. Those who did not were retained in the holding unit,

under 10-day holding policy, after which, if their condition was satisfactory,

they were returned to their units. considerable number of men were thus

salvaged who might otherwise have been lost to combat units. On the other

hand, it was far better to evacuate man who might later prove to be suffering

merely from cold feet than to return soldier with an overlooked cold injury

to the line, oidy to have his lesion progress to such stage that it caused months

of disability.

The system of evacuation and triage used in the European Theater of

Operations in World War II (chart 5) provided number of ways in which the

individual casualty with trenchfoot who had reached an evacuation or general

hospital couldbe returned to duty or otherwise disposed ofafter hospitalization.

His disposition, naturally, was related to the severity of his injury.

man with mild injuries might be sent from an evacuation hospital to

convalescent hospital or specially designated medical holding unit, such as

medical gas-treatment battalion. If his status after release from the convalescent hospital was still indeterminate, he might be sent to holding unit

for further observation. From this unit, he could either be returned to duty

or sent to general hospital for additional treatment. After treatment at

The medical gas-treatment battalion was an organization set up for the special treatment of gas casualties in the

event that chemical warfare should be employed by the enemy. Since it was well located and was equipped for convalescent and holding medical functions and since it was not needed for the purpose for which it was established, one

or more companies were converted to the management of casualties whose cold injuries were minimal and who, it was

hoped, could bo promptly returned to duty.
THERAPY AND DISPOSITION OVERSEAS 300

Chart 5.—Flow of cold injury casualties through medical channels, European theater

Duty Mild, return in 48 hours or less Battalion aid station

Collecting station

Clearing station Division area

Holding unit

(medical gas

treatment battalion)

Field hospital

or

Evacuation hospital

Army area Convalescent

hospital

(Army)

Mild

(ambulatory)

General hospital (Continent) Communications

zone

Moderate

(ambulatory)

Severe

(litter) Convalescent or rehabilitation hospital, camp,

or replacement center

General hospital (United Kingdom) Study Group

108th General Hospital

Zone of Inferior

general hospital he might be transferred to rehabilitation hospital or to

camp whence he would be sent directly to duty after reconditioning.

man with moderately severe injuries might be sent to convalescent

hospital from general hospital, for further observation. From the convalescent hospital, he might be sent to rehabilitation hospital or to camp

whence he would eventually be assigned to duty. If, however, his injuries

were likely to require relatively long treatment, he would be sent from the general hospital on the Continent to general hospital in the United Kingdom

Base. There his disposition would depend upon the outcome of treatment.

man with severe injuries, who obviously could not be returned to duty,

would be evacuated directly from general hospital on the Continent to

hospital in the Zone of Interior as soon as he was able to travel.

Effective triage in such condition as cold injury is necessarily based

on some general system of classification. In some areas, the original policy

was to send man with any edema, however slight, to general hospital but

to send man whose feet were merely white and cold to the medical companies

438404'—58 22
310 COLD INJURY, GROUND TYPE

of medical gas-treatment battalion. These and similar systems of differentiation were eventually replaced by the classification of injuries into mild,

moderate, and severe types (p. 280), according to the criteria devised at the

108th General Hospital in Paris, which served as special research center.

The limitations of this classification, like those of other classifications, were

clearly recognized, and it was advised for use with the understanding that it

was to serve merely as guide and was to be interpreted broadly.

THE ALEUTIANS

There was no uniformity of treatment of the cold injuries sustained in the

Aleutians campaign either initially or in Zone of Interior hospitals.

Initial Treatment

For all practical purposes, when the soldier on Attn sustained cold

injury, he did whatever seemed to him best for it. Some men simply rested

as best they could, using no active measures. Some massaged the feet, sometimes with oil. They had been warned before the invasion not to rub their

feet with snow if they became frostbitten, and medical officers had also been

cautioned against vigorous massage. Nearly all the men kept their feet elevated

when this was possible. Some found greatest relief by keeping the thighs and

legs flexed.

Large numbers of casualties, as noted elsewhere (p. 88), were obliged to

evacuate themselves by crawling if they could not walk, since litter carries

were often impossible.

Immediate treatment on the hospital ships consisted of general warming

measures, warm food and drink, morphine for the control of pain, and plasma

infusions when they were indicated. All patients were given sulfanilamide

by mouth, and sulfanilamide was applied locally, in the form of cream or

repeated sprays. The feet were then wrapped in sterile dressings.

In the Aleutians, as in all other theaters, tetanus toxoid was given routinely

to all casualties from cold injury, on the ground that it was impossible to

predict the cases in which tetanus might he risk.

Subsequent Treatment

No standardized plan of treatment was in effect in the various hospitals

to which these casualties were admitted, and treatment therefore varied in some respects from one institution to another.

183d Station Hospital.—At the 183d Station Hospital at Fort Richardson,

Alaska, which received the first casualties, the objective of treatment was the

(1) Annual Report, Surgeon, 183d Station Hospital, 1943. (2) Lesser, A.: Report onImmersion Foot Casualties From

the Battle of Attu. Ann. Surg. 121:257-271, March 1944. (3) Patterson, R. H.: Effect of Prolonged Wet and Cold on the

Extremities. Bull. U. S. Army M. Dept. No. 75, April 1944,
THERAPY AND DISPOSITION OVERSEAS 311

control of swelling and transudation and the relief of local heat. This was

accomplished by cleansing and elevation of the parts, sterile dressings, and

cooling by exposure to temperatures lower than room temperature. Electric

fans and icepacks were used in selected cases for the first several days. Lanolin,

cocoa butter, or some bland oil was used three times day to prevent cracking

of the skin and subsequent secondary infection. Active and passive exercises

were instituted promptly, and walking was resumed as soon as possible. McCaw General Hospital.—At McCaw General Hospital, Walla Walla, Wash., the patients fell into two groups, 25 who were received soon after

injury and 27 who were received later, by transfer from the Northwest Pacific

Area.

The 25 patients received soon after injury included 10 men who went to

Attu by submarine (p. 93). All 25 had been among the advance scouts of the

invasion. Nine were evacuated primarily for battle wounds but also had cold

injuries.

These patients were evacuated by ship to Barnes General Hospital and

then, after stay of about days, were transferred to McCaw General Hospital.

All of them were physically exhausted and almost all had lowered red blood

cell counts, lowered hemoglobin levels, and moderate to high leukocytosis.

Six patients were transfused. All were placed on iron-vitamin therapy

and were given high-caloric diets.

Suppurative and gangrenous areas on 30 of the 50 feet had to be treated

by immediate debridement and drainage, the debridement in some instances

including removal of affected bone. The great toes were most frequently

involved in the gangrenous processes. Local therapy after debridement consisted of dressings of Azochloramid in triacetin, activated zinc peroxide emulsions, or physiologic salt solution. Intact skin in the region of the wounds

was covered with protective coating of compound tincture of benzoin, over

which mixture of zinc oxide ointment and castor oil was applied, to prevent

irritation from drainage and from the antiseptic agents used on the wounds.

Large, massive, loose dressings were then applied.

Subsequent revision of the wounds, with closure, was carried out in all

the cases in which debridement had been performed. Amputation was necessary in 23 of these 30 feet, as follows: Amputation of the first (great) toes

alone just proximal or distal to the first metatarsophalangeal joint, in Scases;

minor partial amputations of the other toes, sometimes alone and sometimes in

addition to amputation of the great toes, in cases; amputation and revision

through the distal metatarsal area, in cases; tarsometatarsal disarticulation

in case. Plastic procedures were also necessary in number of these cases, and in one instance pedicle flap from the opposite thigh had to be used to

obtain full-thickness skin covering. In two instances, surgery was necessary

to straighten rigid, flexed toes, and in another case revision of all the distal

phalanges was done for rigid-flexion deformities. Lumbar sympathectomy

See footnote (2), p. 310.
312 COLD INJURY, GROUND TYPE

was performed in two cases just before final plastic revision and closure, because

of evidence of severe vasomotor disturbances.

When the patients who had been operated on became ambulatory, those

who had suffered the loss of distal portions of the feet involving any part of

metatarsals were able to walk surprisingly well with the help of prostheses

adapted to their special needs. spring-steel longitudinal strip incorporated

in the sole of the shoe, back of the metatarsal heads, proved very satisfactory

substitute for the transverse-arch support usually placed inside the shoe.

Pressure points were sought for, and the shoes were modified as necessary to

protect them.

All through the period of hospitalization, vascular exercises were conducted

three times daily, in organized class fashion. As soon as local conditions

permitted, physical therapy was employed, in the form of whirlpool baths,

massage, and muscle stimulation.

Soon after they became ambulatory, many of these patients developed

dermatophytoses. The condition responded promptly to treatment with

potassium permanganate foot soaks and the application of boric salicylic acid

foot powder. Socks and shoes were provided for all the men on the ward.

Two patients had to be separated from service because of their inability

to continue infantry duty and their lack of any other training or qualifications

for other work. In the other 23 cases in this group, the immediate results

were surprisingly good.

The 27 patients received at McCaw General Hospital at intervals of

months or more after exposure at Attu had experienced somewhat less severe

environmental and battle conditions than the 25 patients admitted soon after

injury. Their chief complaints were aching, burning pain in the toes and

varying degrees of sweating and clamminess of the feet. Both warmth and

cold increased the discomfort. Lumbar sympathetic blocks were performed in

all cases, with improvement of the temperature of the feet in all, but with only

variable degrees of subjective relief of discomfort.

Fifteen of the twenty-seven patients, whose discomfort was not excessive,

could be returned to some form of limited duty, not involving excessive standing

or walking, in temperate climates. In three cases, in which lumbar sympathetic block had produced marked relief of symptoms, lumbar sympathectomy

was performed. Immediate results were good, but with increasing physical

activity, aching of the toes again was experienced, though the feet continued

warm and dry. Seven patients were still under observation when the report

from McCaw General Hospital was made, and their ultimate disposition is not

known.

McCloskey General Hospitals—At McCloskey General Hospital, Temple,

Tex., the patients, who were all received late, were divided into three groups

for treatment as follows:

1. Patients whose feet were swollen, congested, warm, and painful were

treated by bed rest, elevation of the foot of the bed, cleansing, gentle rubbing with cocoa butter to hasten desquamation, and exposure of the feet to room
THERAPY AND DISPOSITION OVERSEAS 313

temperature, with no covering at all, high-protein, high-vitamin diet was

given, with supplemental vitamin therapy. The 28 patients in this group

became ambulatory on an average of weeks after admission.

2. Patients whose feet showed moderate blanching on elevation, congestion

on dependency, slight edema, reduced temperature, and residual hypesthesia

or anesthesia, were treated by essentially the same measures just described, supplemented, in 14 of the 36 cases in the group, by paravertebral block with

Metycaine Hydrochloride. In two cases the block was repeated. Two or

three of the fourteen men who were treated in this manner felt that there had

been some improvement in their condition, but, as whole, the patients treated

by block recovered no more rapidly than those who were treated by general

measures only. It was the conclusion of the staff that lumbar sympathetic

block is likely to be useful in cold injury only when edema is present and only

if it can be performed during the initial stage, requirement which can scarcely

be met in combat conditions. All the patients in the second group of cases

became ambulatory in to 10 days.

3. The remaining 47 patients, wtio were well on the way to recovery when

they were admitted, were treated conservatively, were promptly allowed out of

bed for graduated periods, and were given systematic exercises.

The experience at McCloskey General Hospital indicated that the essence

of treatment in these cases was the rehabilitation of the patients by conservative medical measures, including gradually increasing, carefully supervised

muscular activity. It had been originally planned at this hospital to use pavex

machines in cold injury, with the objective of preventing gangrene, but the plan was discarded, because of the length of time which had elapsed since the

original injury, on the advice of the Surgical Consultants Division, Office of

the Surgeon General, after consultation with the inventor of the pavex machine,

Louis Herrman, M. D.

Letterman General Hospital.—At Letterman General Hospital, San

Francisco, Calif., treatment was also based upon the classification of the patient according to the degree of his injury, as follows:

1. Patients with first-degree injuries were not hospitalized.

2. Patients with second-degree injuries were kept at bed rest, with the feet slightly elevated, under unheated, hooded, wooden cradles. Lanolin or

petrolatum was applied once daily, with light massage. As soon as practical,

tepid whirlpool baths and foot exercises, without weight bearing, were instituted. Patients who presented vascular spasm and whose feet were cold and

sweaty received one or more lumbar sympathetic blocks with procaine. That

these blocks hastened convalescence is doubtful, but they were usually followed

by transient improvement, in the form of increased pulsations in the regional

arteries, moderate reduction of perspiration, and lessened tendency toward

edema.

3. The patients in this group were eventually given woolen socks and

soft shoes and were permitted to be ambulatory while exercises and physical

See footnote (3), p. 310.
314 COLD INJURY, GROUND TYPE

therapy were continued. In numerous instances the results of treatment were

not satisfactory. As long as months after injury, some of the patients were

still complaining of superficial burning and aching and of pains deep within

the foot, which were worse on walking.

Patients with third- and fourth degree injuries were dressed in the operating room, under aseptic precautions, on the day of admission to the hospital.

Superficial necrotic tissue was removed to establish free drainage; anesthesia

was not required. At the same time, material for aerobic and anaerobic cultures was obtained from moist or infected areas, especially at the line of demarcation. Sulfathiazole powder was sprinkled over all raw areas, which

were then covered with petrolatum-impregnated gauze and dry sterile dressings.

When trichophytosis was present, as it was in about 80 percent of both these

groups, tincture of Merthiolate was applied to the webs of the toes. Padded

plaster or Cabot’s splints were used to maintain the feet in neutral position.

The feet were kept slightly elevated, at room temperature, under hooded

wooden cradles. Dressings were changed as infrequently as possible.

Lumbar sympathetic block was carried out in 13 patients who complained

of pain, hyperhidrosis, and cold feet. In 10 of the 13 cases, the dorsalis pedis

pulsations were diminished or absent. The posterior tibial pulsations were

diminished in two cases and absent in one. When the pulsations were present,

they varied widely from day to day. Sometimes they were fairly strong,

sometimes they were weak, and sometimes they were totally absent. In all

cases in which sympathetic block was done, the pulses were thought to improve more rapidly than in the cases in which it was omitted. In one case in which both dorsalis pedis pulses were absent, there was permanent bilateral

return of good pulsations after the third block.

Five patients who complained of severe pain were treated by unilateral

sympathetic blocks. All stated that pain was less afterward on the treated

than on the untreated (control) side. Numbness was also decreased in all

five cases. The improvement, however, persisted oidy for the duration of the

block. Four patients with severe hyperhidrosis were transiently benefited by

bilateral block, but no permanent results were observed.

Twenty-one patients at Letterman General Hospital were treated by

mechanical respiration, produced by alternating in positive-negative respirator. Oxygen was administered simultaneously, in further effort to

relieve local tissue anoxia. In lumber of cases, the coloration of the feet

was improved and congestion and edema were reduced, but it was concluded

that, by the time patients with trenchfoot were received in general hospital,

the optimum time for measures of this kind had already passed. Improved

venous drainage and better oxygenation of tissues might, it was thought, have

reduced tissue necrosis appreciably if these objectives could have been accomplished immediately after trauma.

Prophylactic X-ray therapy was used locally in all cases in which it was

feared that gas bacillus infection might occur. That this treatment played
THERAPY AND DISPOSITION OVERSEAS 315

any part in the absence of this complication seems unlikely. The infection

did not occur in other theaters, in none of which X-ray therapy was used.

Amputation was required in 23 cases at Letterman General Hospital, as

follows: Both feet, through the lower third of the tibia, in cases; foot, in

cases, through the upper and the lower third of the tibia, respectively; half of

foot, in case; all the toes of both feet, in cases; to toes, in 13 cases.

In none of these cases did gangrene terminate in mummification and circumscribed line of demarcation. Instead, an edematous and inflammatory zone

persisted in the affected area. At the same time, there was tendency toward

slow extension of infection, especially along fascial planes and into neighboring

small joints.

All the amputations were performed within to weeks after injury, as

soon as fairly definite zone of demarcation was demonstrable. They could

well have been performed even earlier. When the whole foot was involved,

and useful member obviously could not be preserved, much time was saved

by performing guillotine amputation well above the infected demarcating

zone. The stump was left open, and compression bandages and skin traction

were applied.

Reamputation or plastic revision was carried out later in these cases.

Skin grafting was sometimes resorted to, in an attempt to cover exposed areas

as promptly as possible. Penicillin solution and Dakin’s solution were both

tested, but it was eventually found that dressings saturated with physiologic

salt solution and changed every or hours provided the simplest and promptest

way of preparing granulating areas for skin grafting.

MEDITERRANEAN THEATER OF OPERATIONS

It would serve no useful purpose to describe the various methods of

treatment used in the Mediterranean theater during the early months of the

trenchfoot experience. As in the experience in the Aleutians, therapy was not

standardized. Most of the methods employed were tentative, and many of

them were illogical and sometimes actually harmful. Eventually, routine of

treatment, dependent upon the stage at which the casualty was seen, was

adopted in all Fifth Army hospitals, the experience in which, as already noted,

formed the basis for the official policies on treatment set forth little later in

TB MED 81 (appendix A).

Three considerations of therapy were fundamental:

1. Great care was taken to avoid further trauma and to guard against

secondary infection, particularly in the early stages of the injury.

2. Heat was never applied to the feet.

3. The strong psychogenic factor in trenchfoot was recognized early and

was dealt with promptly. All patients, with the exception of the few casualties

whose injuries were severe enough to suggest that amputation would eventually
316 COLD INJURY, GROUND TYPE

be necessary, were impressed from the beginning of treatment with the fact

that they were suffering from curable condition which would permit their

return to full duty and that treatment of their injuries was being carried out

with this objective in view. Even when it became evident, as it soon did,

that only relatively small number of casualties from trenchfoot could be

returned to full duty, this point of view continued to be stressed.

Preinflammatory Stage

In the preinflammatory or ischemic stage of trenchfoot, the patient was

transported by litter unless this was absolutely impractical. Special care was

taken not to set him down near stove at any of the halts in the chain of

evacuation, though blankets were used under and over the body to keep him

comfortably warm. The feet were dried gently and then were kept exposed

to cool air, preferably about 65° F. (18.3° C.). They were never rubbed or

massaged. Treatment was usually limited to these simple measures until the

patient reached an evacuation hospital.

In 13 cases of severe trenchfoot observed by Simeone in clearing station

in Italy, one foot was powdered, the toes were separated by cotton, and uniform

pressure dressings were applied (figs. 83 and 84). The untreated feet served

as controls. These patients, without exception, stated that discomfort and pain

were promptly relieved in the treated feet. Unfortunately, exigencies of evacuation did not permit continued personal direction oftreatment and it was learned

AFIP CA-44-149

Figure 83.—Management of early inflammatory stage of trenchfoot by application of

powder and pressure bandages. A. Trenchfoot observed in clearing station in early inflammatory stage. The feet were warm and dry, but edema had begun to develop. B. Pressure

bandage applied to left foot and leg.
THERAPY AND DISPOSITION OVERSEAS 317

AFIP CA—14-150

Figure 84. —Application of powder and pressure bandage in early

inflammatory stage of trenchfoot.

that the bandages which had been applied were removed as soon as the patients

reached the evacuation hospital. The immediate results, however, suggested

that this simple method is worthy of further trial, which it does not seem to

have received during World War II.

While there was general agreement, from the beginning of the Mediterranean experience with cold injury, that the direct application of heat to the

affected feet was absolutely contraindicated, there was originally some difference of opinion about how rapidly the feet should be allowed to become warm.

In the fall of 1944, there were two distinct schools of thought in the Mediterranean theater.

The observers who believed that thawing should be so gradual that the

feet never actually became hyperemic were in the minority, and their concept

was never generally applied. Their reasoning was as follows: Edema occurs

because abnormal metabolic products are liberated after cold injury in very

large quantities. The liberation of these substances is thought to proceed at

maximal rate when the temperature is about 59° F. (15° C.). It is therefore

desirable that this level be passed as rapidly as possible during the process of

thawing, though, as practical matter, this is possible only on tissue cultures.

Any kind of cold applied to the surface of an extremity produces, at best,

gradient of temperature if there is any circulation at all in the part. The temperature in the depth of the part may be 98.6° F. (37° C.) when the surface

temperature is 59° F. (15° C.). In the light of these facts, even granting that

edema and inflammatory products are injurious to tissues, it still seemed illogical

to many observers to keep limb without circulation, or with minimal circulation, when the duration of ischemia was believed to be an etiologic factor in

trenchfoot (p. 266).
318 COLD INJURY, GROUND TYPE

Other observers regarded it as more reasonable to permit limb to warm

itself as long as the warming was accomplished by the return of the circulation

to the part, which then would not become excessively warm in proportion to

the efficiency of its blood supply. Simeone’s experience inclined him to the

opinion that, if the circulation did not return spontaneously within hours,

efforts should be made to induce vasodilatation, either refiexly or by the use of

vasodilator.

Reflex vasodilatation could be induced by warming the body with blankets

or hot water bottles, leaving the feet exposed. In many hospitals, the beds in

trenchfoot wards were made up so that blankets and sheets could be rolled back,

leaving the distal third of the lower extremities continuously exposed to room

air. In addition, the position of the beds was often reversed, in order to keep

the feet as far as possible from the stoves in the wards. These practices were

in accord with the desires of the patients. Most of them complained of hot

feet and wanted no covering at all over them. It was exceptional, in fact, to

find man who did not say that he was more comfrotable when his feet were

exposed to cool air.

Whisky was the most generally useful vasodilating agent, but, whatever

the agent used, the best results were accomplished if, in the presence of maximal

circulation, the tissues were cooled to point at which vasoconstriction did not

occur. It was then certain that the circulation was ample to dispose of products

of metabolism and that tissue repair could begin and proceed.

Inflammatory Stage

As rule, patients were kept at complete bed rest during the inflammatory

stage. Those with mild injuries were occasionally permitted mess and latrine

privileges shortly after hospitalization, but this was exceptional.

During this stage, as during the previous ischemic stage, the chief objectives of treatment were to prevent trauma and infection and to avoid local

heating of the affected part. To achieve the first objectives, strict surgical

cleanliness was maintained. The feet were washed daily with warm, soapy

water, at 70° F. (21.1° C.), then dried gently and carefully. The toes were

kept separated by bits of cotton. Blisters were left undisturbed unless they

were sufficiently tense to bo painful. Then they were evacuated through

small bore needle. If blisters were already ruptured when the patient was

admitted, dead tissue was removed and the area cleansed, after which the foot

was wrapped loosely in sterile towel. The practice of dusting sulfanilamide

powder over the lesion was discontinued in the spring of 1944. Feet with

gangrenous areas were kept loosely wrapped in sterile towels. Ointments

Inan experimentalstudy conducted during the course of the trenchfoot experience, two groupsofanimals which had

been exposed to cold injury by immersion in cold water under identical conditions were treated, respectively, by rapid

thawing and by slow thawing. Someanimals in the group treated by rapid thawing developed gangrene, but only in the

toes, while some in the group treatedby slow thawing suffered total loss of tissue up to the level at which the extremities

had been Immersed. In terms of tissue salvage, the advantage appeared to liewith treatment by rapid thawing. In this

group, however, massive fibrosis and induration ultimately occurred.
THERAPY AND DISPOSITION OVERSEAS 319

were avoided unless the skin was excessively dry and wrinkled. Then cottonseed oil or lanolin was applied, but only once daily and always lightly.

The most desirable temperature to which the feet were exposed was thought

to be between 60° and 65° F. (15.6° to 18.3° C.). If it proved impossible to

maintain this temperature in the ward, or if this environmental temperature

was not low enough to keep the feet cool, icecaps were applied. Sterile pledgets

of cotton were placed between the toes, and the feet were wrapped in sterile

cotton batting and covered with sterile towels before the icecaps were applied.

Care was taken not to cool the feet too much and to keep them dry. Equal

care was taken to keep the ice bags dry. Wet cold was thought to be actually

injurious.

If ice was not available, transient relief was sometimes secured by spraying

rubbing alcohol on the feet several times daily. The fan and spray method

described by Webster, Woolhouse, and Johnston proved simple and effective.

In some hospitals, it was thought that some benefits were accomplished by

soaks in cool water and whirlpool baths at 70° F. (21.1° C.) for 20 to 30 minutes

daily. Not all patients could tolerate such methods, nor was it thought that

they expedited recovery. They were used merely because some patients with

hot, swollen, painful feet were temporarily relieved by them and were able to

sleep without sedatives and analgesics after one or more of these methods had

been employed.

Relief of pain was accomplished by medication only when no other measures

were effective. Whatever drug was used was discontinued as promptly as

possible. number of other methods were employed to relieve pain, with

variable results or none at all. Polyvitamin therapy, thiamine chloride alone

or in combination with other measures, nicotinic acid, pilocarpine, and carbarnylcholine chloride gave no better results than were accomplished in

cases in which only general measures, which were also employed when these

agents were administered, were used exclusively.

Edwards, Shapiro, and Ruffin tested the use of daily intravenous injections of physiologic salt solution, in amounts of 150 to 300 cc. and had variable

results. Nineteen patients who had previously had no relief from aspirin or

codeine were promptly relieved of pain by the injections but two others, who

were bedridden with painful, swollen feet, had no relief at all. No reduction

of edema was observed in some cases, but in others it was thought that the

swelling disappeared more promptly than usual. Intravenous injections of

hypertonic salt solution relieved pains and aches present when the patients were

at rest, but relief was transient; the difficulties recurred when the patients became ambulatory. Combined injections of physiologic salt solution and 50-

percent glucose in 50-cc. doses were ineffective.

In five cases of severe bilateral cold injury treated at the 23d General

Hospital, snug plaster cast was applied to one foot while the other was left

Webster, D. R., Woolhouse, F. M., and Johnston, J. L.: Immersion Foot. J. Bone <fe Joint Surg. 24:785-794, October 1942.

Edwards, J. C., Shapiro, M. S., and Ruffin, J. B.: Trenchfoot: Report of 351 Cases. Bull. U. S. Army M. Dept.

No. 83, December 1944.
320 COLD INJURY, GROUND TYPE

exposed, according to the usual practice. Every patient was convinced that

the foot in the cast was less painful than the other, and of the requested

that the cast be reapplied when it was removed. Objectively, it was not possible to detect any differences between the treated and control feet. During this

period, almost any change in the environment of the foot or in the method of

management was likely to produce transient relief, and too much influence

therefore could not be attributed to any special therapeutic measure.

The patients were usually most comfortable with the feet level. In few

instances, relief was obtained by elevating them 10 to 12 inches above heart

level, but most of the men found this position uncomfortable. If there was

considerable edema, the feet were kept elevated most of the time. This position was not practiced in patients with signs of circulatory inefficiency.

As soon as acute pain was relieved, passive vascular exercises were begun.

The routine was simple. The feet were elevated at an angle of 45° on board

or chair, at first for minutes and later for minutes. Then, after the patient

had lain with the legs horizontal for minutes, he sat on the edge of the bed,

with his feet dangling, at first for minutes and later for minutes. These

exercises, which were carried out or times daily, were supplemented by

calisthenics in bed, which were conducted each morning by the ward master.

Areas of gangrene were kept under close observation, but in the absence

of infection amputation could be safely delayed for 10 to 12 weeks; by this time,

the necessity for the operation and the extent of resection required had become

absolutely clear cut.

Postinflammatory Stage

The number of therapeutic procedures advised for the management of the

postinflammatory stage of trenchfoot was, as always, an index of the lack of

effectiveness of any of them. As in the inflammatory stage, any new method

of treatment, however irrational it might be, was likely to produce transient

relief.

During this stage, management was chiefly symptomatic, the principal

objective being to prevent disabling atrophy of the feet. After men had been

confined to bed for to weeks or longer, atrophy of the intrinsic muscles of

the foot was often evident, and the ligamentous supports of the arches were

weakened. Exercise was the best remedy, though it was extremely difficult

to make the patients employ it when movement of the feet caused pain and discomfort. Arch supports, while theoretically advisable, were seldom tolerated

in the cases in which they were tested. Plaster casts gave unsatisfactory results. Physiotherapy, which was contraindicated during the inflammatory

stage, was frequently useful in the postinflammatory stage, but the results

were uneven and were usually less good than those the patient accomplished

by his own efforts.

The first exercises consisted of gentle passive motion, followed by active

motion in the toes and ankles. Walking was begun as soon as possible and was

gradually increased until hikes and marches could be attempted. At one re-
THERAPY AND DISPOSITION OVERSEAS 321

conditioning and training unit, an attempt was made to toughen the thin, delicate skin of the feet by having the men exercise barefoot ou beach, but

the results were not notable.

Most patients recovering from treuchfoot had aches and pains in the

muscles and metatarsophalangeal joints for several weeks after objective signs

of damage had disappeared. When ordinary walking had ceased to be uncomfortable, minor aches were common after hikes, but if they were ignored and

regular exercise was continued, they usually disappeared.

The morale of men with treuchfoot who required prolonged hospitaliza- tion was serious problem. Opinion was divided concerning the wisdom of

segregating groups of patients in the postinflammatory stage. They could be

handled more easily, and group exercises could be conducted more efficiently,

when they were kept together. On the other hand, symptoms seemed almost

contagious, and new complaint by one patient often meant its prompt appearance in many other men in the same ward. The best solution of the problem was the segregation of patients whose progress was satisfactory and the

dispersion of those who presented problems requiring individual attention or

who, for one reason or another, made en masse treatment difficult.

The time of bed patients could be occupied by systematic planning, involvingreading, writing letters, occupational therapy, supervised exercises, and

games and other entertainment. Ambulatory patients required equally careful

supervision, but it was less of problem because outdoor games and exercises

were possible.

The establishment of reconditioning and rehabilita ion section in hospital

which treated patients with treuchfoot was always helpful because it took the

men out of the ward atmosphere. After medical treatment had been concluded,

this atmosphere was highly undesirable. In one hospital in which such

section was established, the men were required to attend formation each

morning and retreat each evening. Also, according to their ability, they worked

as ward attendants; helped in the post office, Red Cross, and message center;

and acted as clerks, telephone operators, and mechanics. In addition, they

participated in planned exercises and games and attended lectures on orientation, combat problems, and current events.

Sympathetic Block and Sympathectomy

The value of sympathetic block and sympathectomy was debatable matter in the Mediterranean theater. There was rather general agreement that

very early block, shortly after vasoconstriction had occurred and before

ischemia had been present for considerable length of time, might be useful,

but its employment at this time was an obvious impossibility under battle

conditions. When the operation was performed later, the results were widely

variable. Some observers explained the generally unsatisfactory results by

the fact that sympathetic block is delicate procedure and that many of those

who were employing it were not trained in its technique. It is doubtful that
322 COLD INJURY, GROUND TYPE

this explanation covers the situation. Dubious or poor results were achieved

by many surgeons who had had large experience in this field.

Simeone reported the results in several series of cases in which sympathetic

block was employed:

Early in the winter of 1943-44, this method was used, with the idea of

relieving the subjective complaint of pain, on 11 patients seen within 14 days

after injury and on 40 others seen in the postinflammatory stage. Immediate

effects were good, but no results were permanent.

In another group of 65 patients, seen within 14 days of the injury, it was

thought that the blocks performed increased the chances of favorable results

when skin grafting was necessary, and possibly shortened the convalescence

after the acute or hyperemic stage had passed. There was, however, no

significant difference in total hospitalization time for patients treated by this

method and those who were treated only by general measures.

Paravertebral block with Novocain relieved the pain of of 17 patients in

still another series, but the results were questionable, since comparable relief

was experienced in 50 percent of the control group when the needle as merely

introduced and no Novocain at all was injected.

Simeone reported only slight relief from the performance of unilateral

sympathectomy on 13 patients who had disabling pain; the operation was done

at periods varying from the late inflammatory to the late postinflammatory

stage. On the other hand, edema disappeared more rapidly than usual in some

of these cases, and, in at least one instance of gangrene of the toes, more tissue

was salvaged than had originally been thought possible (fig. 85).

Simeone also reported another series of 23 sympathectomies performed in

17 patients who were suffering from such late sequelae of cold injury as vasospasm, hyperhidrosis, bromidrosis, and maceration of the skin. In the only

case in which there was no improvement at all, it was found that the operation

had been incomplete. Edwards and his associates found unilateral sympathectomy of value in patients with hyperhidrosis; the treated foot improved

remarkably in comparison with the untreated foot. Telford’s results in five

British soldiers were generally good.

The total experience with interruption of the sympathetic-nerve supply

in the management of cold injury in the Mediterranean Theater of Operations

was uneven and, on the whole, disappointing. As has been pointed out, it was

thought that the operation might be of value in cases of obvious circulatory

insufficiency (fig. 86), if it could be carried out soon after injury. This would

usually be impractical. The procedure seemed of some value late in the course

of the injury, for the relief of chronic vasospasm, hyperhidrosis, and the complications of these conditions. It did not seem, however, to have any effect upon

subjective complaints of persistent pain in any stage of the condition, nor did

it seem to modify the clinical course in any material way.

Telford, E. D.: Sympathectomy in Treatment of the Cryopathies. Brit. M. J. 2:360, 18 Sept. 1943.
THERAPY AND DISPOSITION OVERSEAS 323

AFIP A-44-354 A,

Figure 85.—Effect of sympathectomy in severe trenchfoot. A. Appearance of feet

after months of hospitalization and months after right lumbar ganglionectomy. The

circulation in the right foot improved considerably after the operation, and more tissue was

salvaged than had originally been thought possible. B. Plantar aspect of feet shown in

view A.

AFIP A-44-96

Figure 86.—Inflammatory stage of trenchfoot after 14 days of hospitalization. In this case, the skin cleared distal to the serpentine line

at the base of the right great toe after alcohol block of the lumbar

sympathetic trunk.
324 COLD INJURY, GROUND TYPE

Amputation

Amputation was always delayed as long as possible, being employed early

only for advancing and intractable infection. In such cases, particular care

had to be taken to distinguish between an infectious inflammation and the

nonbacterial reaction characteristic of the inflammatory stage of trenchfoot.

The practice of delaying amputation as long as possible proved well worthwhile. Circulatory channels were frequently reestablished, and unexpectedly

large amounts of tissue were saved. In some of these cases, it was thought that

lumbar sympathetic block had increased the salvage. It was repeatedly

observed that gangrene, which had seemed deep, was only superficial and that

healthy epithelization was present beneath the eschar when it separated spontaneously (p. 296).

EUROPEAN THEATER

In the European Theater of Operations, methods of treatment of cold

injury were essentially the same as those finally standardized in the Mediterranean theater. When the European experience occurred, the official policy of

management, based on the Mediterranean experience, had already been published in TB MED 81, though its circulation in the theater was later than it

should have been to achieve the greatest possible usefulness (p. 164).

General measures.-—As the first step, the patient was required to get off

his feet. He was transported by litter, and, after his wet clothing had been

changed for warm, dry garments, he was kept recumbent. The feet were

covered loosely and were protected from further trauma and from infection.

No active treatment was undertaken until the evacuation hospital was reached.

Here, the patient was placed at complete bed rest, with the feet on level

with the heart. Care was taken to protect pressure points and to guard against

infection. Massage was not practiced, and the feet were handled as little as

possible after they had been cleansed when the patient was admitted. The

body was kept well covered, but the feet were left exposed, preferably at room

temperature of 65° to 70° F. (18.3° to 21.1° C.). Heat was not applied in any

form. Artificial cooling was sometimes accomplished by electric fans. If the

feet were covered, the covering was elevated by wooden cradle. The maintenance of minimal tissue metabolism was the objective during the hyperemic

stage.

Measures to prevent infection were limited to the use of careful aseptic

technique when the feet had to be handled. The sulfonamides and penicillin

were used only when established infection was present. Surgical measures were

conservative. Blisters were left intact, and ulcers were treated by simple

aseptic methods.

nutritious diet, high in proteins and vitamins, was provided. The

occasional use of vitamin and nicotinic acid therapy was no more successful in

European theater hospitals than it had been in the Mediterranean theater.
THERAPY AND DISPOSITION OVERSEAS 325

At the 114th General Hospital, in England, it was noted that patients with

streptococcic sore throat, who had had fever of 102°F. (38.9° C.) for 24 hours or

more, showed much more rapid improvement than 26 other patients who were

admitted at the same time and who had apparently the same degree of cold

injury. The possible significance of this observation is not clear.

Vasodilator agents.—Vasodilator drugs were tested in some hospitals, with

equivocal results. Whisky was occasionally used but was not generally recommended. It was mentioned at the Paris conference on trenchfoot in January

1945 (p. 179) that the Stars and Stripes had described trenchfoot as the way to

get “this nice treatment.” The rather enthusiastic early reports from one

general hospital on the use of special negative-pressure respirator were not

substantiated when further trials with this method were made.

Sympathetic block and sympathectomy.—The consensus in the European

theater was that sympathetic block and sympathectomy did not promote recovery in cold injury. At the Paris conference just mentioned, several observers stated that, while relief of pain was sometimes accomplished and earlier movement of the feet was thus made possible, these results were too infrequent to

justify the routine use of this method. Another observer stated that the results

were always transient and that some of them were shared by the man in the

next bed. An occasional officer thought that sympathetic block or sympathectomy was justified when edema was intractable. In the late stages of

cold injury, relief of chronic vasospasm and hyperhidrosis was sometimes

secured by these methods.

Amputation.—Superficial gangrene was not uncommon in the European

theater, but the necessity for surgical intervention and amputation seldom

arose. The only indication regarded as valid for early amputation was intractable advancing infection. Gangrene frequently proved to be only superficial. When the eschar separated, healthy epithelization was present, and

rapid regeneration of the tissues was likely to follow. If it did not, skin

grafting was performed later.

Orthopedic appliances.—In late stages of cold injury orthopedic appliances

or specially fitted or constructed shoes were sometimes used to make walking more comfortable. At the 216th General Hospital, walking was

expedited in or cases by injecting the posterior tibial nerve with Novocain

and Pontocaine Hydrochloride. Weight bearing was then possible for some

hours without pain. This method does not seem to have had any other trial.

Physiotherapy was of value in the correction of deformities arising from

fibrosis, muscular atrophy, and chronic edema.

Rehabilitation. —On the whole, the best results were accomplished when

active muscular exercise was instituted promptly and carried out energetically.

This policy was strongly emphasized at the Paris conference on trenchfoot.

One particularly aggressive surgeon, it was reported there, supplied his patients

with marbles, which they had to transfer from one box to another with their

toes. One group of men who were treated by this method were walking and

10 miles within month after their injuries. It was stressed that medical
COLD INJURY, GROUND TYPE

officers with “defeatist attitude,” who let their patients merely lie on their

backs, “with toes pointed heavenward,” had very poor results, including

deformities of the toes and feet caused by too prolonged bed rest.

As general rule, it was the policy to segregate patients with trenchfoot

of the same average severity in the same ward. This made it possible to set up

sound program of muscular rehabilitation under the direction of good noncommissioned officer, or an officer patient, who would see to it that the program

was carried out energetically several times day. As soon as possible, the

men were fitted with shoes, in larger sizes than they had previously worn, and

were required to be ambulatory.

All patients who could be returned to duty were sent to the rehabilitation

service for at least weeks before reassignment to replacement (reinforcement)

depot. During this time, hikes of minimum of to miles were used to gage

their progress. This program was applicable, of course, only in patients with

mild to moderate injuries, but even patients with severe injuries, when they

became ambulatory, could undertake modified program of this kind and were

improved by it. At the 110th Station Hospital, for instance, it was instituted

in 25 cases of trenchfoot of more than average severity, in some instances associated with superficial gangrene. At the end of weeks, 12 of the 25 accomplished route march of miles. Eleven of the others were ambulatory, and

all twenty-three had duties about the ward.

All reconditioning and rehabilitation programs, even if they did not return

men to full or limited duty, were successful in the sense that most patients

became ambulatory reasonably early and that many were spared neuropsychiatric complications. In addition, hospital beds were conserved, as were the

time and effort of medical personnel.

Heparin therapy.—In December 1944, joint effort was made by the

Medical and Surgical Consultants Divisions, Office of the Surgeon General, to

set up an investigation of the effect of heparin in the treatment of cold injury,

as had been proposed by Lange and Boyd. 10 The rationale of this method of

therapy was explained as follows: The primary pathologic process in trenchfoot

is tissue injury caused by cold and anoxia. At low temperatures, the tissues

release substance which initiates sterile inflammation. Small blood vessels

are injured in this inflammatory process, and transudation of plasma occurs

through their thin walls. Because of combination of factors resulting from

arteriolar constriction and diffuse inflammation, clotting of the blood tends to

occur in these vessels and is apparently responsible for the most serious damage

to the tissues, which in some instances may include gangrene. Whether the

associated nerve injury is caused by exudation and anoxia is not yet known.

The proposed therapy was the use of an anticoagulant, based on the assumption

that thrombosis would thus be halted in its progression if not prevented

entirely.

Heparin suspended in Pitkin menstruum was selected for the trial, in

10 Lange, K., and Boyd, L. J.: The FunctionalPathology ofExperimental Frostbiteand the Prevention of Subsequent

Gangrene. Surg., Gynec. Obst. 80: 346-350, April 1945.
THERAPY AND DISPOSITION OVERSEAS 327

preference to Dicumarol, because of the immediate effectiveness of the former

and the lag of 48 to 72 hours before the anticoagulant effect of the latter becomes

manifest. Heparin was also better adapted for military use for another reason.

When it is used, sufficient control can be maintained by determination of the

clotting time by the Lee-White method, which is relatively simple test. When

Dicumarol is used, the prothrombin time must be determined repeatedly by

decidedly more complicated method.

Plans for controlled experimental testing of the technique were carefully

worked out and supply of heparin was sent to the European theater. By the

time it arrived and could be distributed, the trenchfoot experience was practically over, 11 and controlled experiment therefore could not be continued. 12

RESULTS OF THERAPY-DISPOSITION

As has already been pointed out, the evacuation of casualties within and

from theater of operations is conditioned on the one hand by the continuous

necessity of maintaining open beds in forward areas for the reception of battle

casualties, and on the other hand by the advisability of keeping as near the

frontline as possible all men who might be expected to return to the front within

the permitted holding period in this area. Experience in World War II showed

that this plan favored the return to duty of the maximum number of nonwounded men within the shortest possible time.

Trenchfoot was managed according to this general plan (p. 307), but the

results, from the standpoint ofreturning men to duty, were far from satisfactory.

Crisler stated at the Paris conference on trenchfoot in January 1945 (p. 179) that

about 25 percent of all casualties with suspected trenchfoot were sent to the

medical gas-treatment battalion centers for trenchfoot. The figure sounds promising, but, when it is broken down into its components, it is found that only

one-fifth of these men were ambulatory and able to return to frontline duty at

the end of the permitted holding period. The other four-fifths had to be evacuated to general hospitals for definitive treatment. Furthermore, as other

observers brought out at this conference, many of those sent back to frontline

duty continued to complain of pain in their feet, exactly as many other men in

the Zone of Interior had constantly complained of low-back pain.

The disposition of patients with trenchfoot was always major problem.

The disability was of long duration. The results of therapy were discouraging.

11 Toone, E. C., and William, J. P.; Trenchfoot; Prognosis and Disposition. Bull. U. S. Army M. Dept. 5: 198-210,

February 1946. 12 Heparinseems to have given goodresults when it wasused inKorea. Lt. Col. Kenneth D. Orr, MC, who observed

approximately 1,500cases of cold injury in December 1950, wrote as follows on 14 March 1956; “No agent or procedure was

clearly demonstrated to prevent gangrene in 4th degreefrostbite. However,in those cases treated with heparin in which

treatmentwas begun less than 36 hours after rewarming, the eventual tissue loss was less than predicted when the patient was first seen. Fifty percent of cases of 4th degree frostbiteextending proximal to the web of the toes who received

only general supportive measures developed soft, wet, infected gangrene. This same result occurred among patients

receiving vasodilators and sympathetic ganglion blocks. Those cases of severe 4th degree frostbite extending proximal

to the web of the toes who received heparin all dried and mummified. Theseheparin-treated cases had asymptomatic,

afebrile courses and were transportable after 14 days to the Zone of Interior for definitive surgery.”
328 COLD INJURY, GROUND TYPE

Only small numbers of men could be returned to full duty, from either forward or rear areas, and additional problems were introduced by the inability

of even men returned to limited duty to hold up under any sort of strain.

It was essential for medical officers accustomed to civilian practices to

bear in mind that soldiers who were returned to duty, whether full or limited,

had to be able to perform all the duties for which they were classified. No

arrangements could be made for intermittent or partial performance of assigned

tasks. Moreover, the return to duty of soldiers who promptly had to be evacuated again entailed great waste of valuable time, effort, material, and transportation facilities. strict disposition policy therefore proved, in the end,

to be far wiser than liberal policy, but, in both the Mediterranean and the

European theaters, this had to be learned by experience.

Mediterranean Theater

The experience in the Mediterranean theater, which from the standpoint

of disposition was much longer than the experience in the European theater,

may be accepted as typical. In general, the criteria of return to full duty

were as follows:

1. There must be complete subsidence of swelling and erythema.

2. Vasomotor stability must have been reestablished.

3. Paresthesia and pain must have disappeared entirely unless there was

clear evidence that their presence could be explained on psychogenic grounds.

4. There must be no evidence of mechanical strain or arthritic processes.

5. The soldier must have demonstrated, in actual practice, his ability to

hike, march, and otherwise stand up under the physical strain of military life.

Criteria for evacuation to the Zone of Interior were as follows: (1) Extensive edema or blister formation; (2) hyperhidrosis or signs of generalized vasomotor instability in either upper or lower extremities; (3) persistence of symptoms after months of adequate treatment; (4) disabling amputations; and

(5) associated arthritis, fallen arches, bunions, exostosis, or similar abnormalities.

Of the 50 patients with trenchfoot who formed the material for the first

investigation of cold injury in the Mediterranean theater, were returned to

duty at the end of month and more at the end of weeks. At the end

of weeks, however, 16 had already been evacuated to hospitals in the Communications Zone, and the remainder were still under treatment in the army

area. The duration of edema had proved the best index of the severity of

the injury. None of the 11 patients returned to duty within the 6-week

period had had edema for more than days.

Although it was not realized at the time, the experience with these 50

patients was to be typical of the whole experience in both the Mediterranean

and the European theaters. The duration of treatment was to prove prolonged, and the number of men returned to duty was to be small. Furthermore^—as these figures do not show—many of the men returned to duty as
THERAPY AND DISPOSITION OVERSEAS 329

cured were to prove unable to carry out their duties satisfactorily. The following experience, reported by Toone and Williams from an evacuation hospital in Italy, shows very clearly that liberal disposition policy did not pay.

In all, 1,057 patients with cold injury were disposed of in this hospital

between 24 December 1943 and May 1945. During the first month of the

survey, the holding period could not exceed 30 days, and 95 percent of the

318 patients with trenchfoot admitted during this time were transferred, as

promptly as evacuation facilities permitted, to hospitals in North Africa.

Only patients with very mild injuries were retained, because the need for

hospital beds in the area was extremely acute.

During the second month of the survey, the holding period was increased

to 90 days, and only patients with severe trenchfoot (grades and 4) had to

be evacuated. This policy, however, did not prove practical; it resulted in

serious shortage of beds, since the rate of admission for cold injury far outstripped the rate of discharge. It was therefore necessary to transfer some

patients to convalescent hospitals in the vicinity and others to other hospitals

in the Peninsular Base Section. The establishment of reconditioning section in each general hospital which received trenchfoot casualties finally solved

this special problem.

Between January and June 1944, 249 casualties with trenchfoot were

disposed of. Of these, 125 (50.2 percent) were classified for full duty or provisional duty. Seventy-four were reclassified for limited duty and fifty as

unfit for duty. At this time, it was thought that the greater number of the

men classified for provisional duty could be returned to combat duty after

another month of hard reconditioning. It was also thought that many of the

men classified for limited assignment could eventually be reclassified for full

duty. The 50 patients classified as unfit for any duty were returned to the

Zone of Interior. Ml had had severe initial lesions or, even though their

initial lesions had not been severe, had had persistent edema or incapacitating

pain.

Between June and 15 October 1944, this evacuation hospital readmitted

99 patients with chronic, persistent, or recurrent trenchfoot, as well as 10 others

who had attempted to sweat it out without hospitalization during their primary

attacks of trenchfoot. Although only of these 99 patients had originally

been treated in this particular hospital, the medical staff was fully aware that

their own errors of prognosis were undoubtedly being corrected in other

hospitals. The staff also realized that, while they had originally considered

their proportion of disposition to duty as too low, actually, because of inexperience with trenchfoot, the proportion had been too high and had proved wasteful

rather than conservative. As result, when these 109 patients were disposed

of, only was returned to full duty. Thirty-two were returned to limited

duty, and seventy-six were sent to the Zone of Interior.

An analysis of 60 of the 99 patients rehospitalized for trenchfoot made it

clear that the new policy was the only sound and practical one. The combined

time these 60 patients had been hospitalized and had spent in rehabilitation far
330 COLD INJURY, GROUND TYPE

exceeded the time in which they had been able to do any kind of duty after

disposition. Furthermore, 46 of these men had spent from to weeks of the

duty period in training, and their effective combat time had been at the most,

weeks; in some instances, it had not exceeded weeks. The prolonged

hospitalization time and the rehabilitation effort expended on them were thus

almost entirely wasted. They had had to be withdrawn from combat during

very active campaign and be replaced by men who, for the most part, had

not had the benefit of the intensive training which had been wasted on the

trenchfoot casualties.

Toone and Williams told in some detail the dismal story of 25 men who

had been discharged from various hospitals to full duty. They had been

unable to meet duty requirements either in training programs or actual combat

They had to fall out on hikes and marches. They caught rides as best they

could on trucks, jeeps, or tanks. If they were fortunate, they finally found

assignments as clerks or cooks at headquarters or with rear echelon group.

They were totally unfit for combat. Their disability was hardship to themselves, it increased administrative difficulties, and itreduced the combat effectiveness of their organizations, which would have been better off if this group

of men had never been assigned to them.

The symptoms from which these men suffered all suggested that none of

them had recovered completely from the damage resulting from their original

exposure to cold, wet weather. All had history of persistence of one or more

of the symptoms of the posthyperemic phase of their original injuries. These

symptoms had gradually increased in severity during their brief periods of duty and had been acutely exacerbated by excessive walking or by marching for

even short distances. Most of the men also told stories of mild recurrences

of the hyperemic phase of the cold injury after minor exposure. In fact, chronic trenchfoot with exacerbation seemed more appropriate diagnosis in

these cases than recurrent trenchfoot.

As result of this experience, the disposition policies of this particular

evacuation hospital were radically altered. Of the 315 men with trenchfoot

disposed of between September 1944 and May 1945, only (2.2 percent)

were classified for full duty, in sharp contrast to the 50 percent thus classified

during the preceding winter. One hundred and twenty-nine (41.0 percent)

were reclassified for limited duty, and one hundred seventy-nine (56.8 percent)

were returned to the United States. fairly large number of men with

relatively mild trenchfoot were discharged from the hospital when the winter

was at its height, and perhaps, had weather conditions been more favorable,

10 to 15 percent of them might have been given trial at full duty. Even if

this had been possible and the trial had been successful, the total number of

men returned to full duty would still have been under 10 percent.

It was the conclusion of the staff of this hospital, as it was eventually the

conclusion of the staffs of most other hospitals which received trenchfoot

casualties, that less than 10 percent of soldiers who suffer attacks of cold injury

can be restored to duty as combat infantrymen. It was also their opinion
THERAPY AND DISPOSITION OVERSEAS 331

that prolonged and futile attempts to rehabilitate the other 90 percent should

be abandoned as wasteful and impractical. When the men in this group had

only moderate injuries, the best plan was to train them for such combat duties

as they could perform in tank companies, antiaircraft or field-artillery batteries,

or motor-transport units. Men with the most severe injuries should be assigned

at once to duties in the rear echelons of combat units or in the more protected

environment of the base areas. The rationale of this policy of classification

was that, from the standpoint of manpower necessities and losses, hospitalization and rehabilitation in excess of months could accomplish nothing that

could not be accomplished better by prompt assignment to duty status

which was likely to be maintained.

The duration of hospitalization, which furnished an index of the severity

of the cold injury, was useful aid in disposition. 13 About 140 patients with

trenchfoot were still hospitalized when study of dispositions was made in the

spring of 1945, as part of the continuing theater investigation of this condition.

Between 16 September 1944 and April 1945, 1,617 men hospitalized for the

ground type of cold injury had already appeared before hospital disposition

boards, with the following results:

Six hundred and seventy-one (41 percent of the total number) were

discharged to full duty. The average period of hospitalization was known in

618 cases and averaged 26.1 days.

Six hundred and seventy-three (42 percent of the total number) were

discharged to limited duty. The average period of hospitalization was known

in 504 cases and averaged 56.3 days.

Two hundred and seventy-three (17 percent of the total number) were

evacuated to the United States. The average period of hospitalization was

known in 210 cases and averaged 63 days.

The average period of hospitalization for the whole group in which these

data were known was 43.4 days. Seventeen percent were lost from an active

theater of operations after they had occupied hospital beds on an average of

months each, and only 42 percent, less than half, were returned to full duty.

If allowance is made for the undoubted recurrences in the group returned to

full duty, the picture is even more discouraging.

Over the period in which these 1,607 patients were disposed of, patients

with cold injury of the hand appeared before disposition boards in the

Mediterranean theater. One man was returned to full duty after 15 days of

hospitalization and the other to limited duty after 31 days.

13 See footnote 1, p, 307.

438404 —58 23 333

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, 111., 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

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

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 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.

PREVIOUS (OVERSEAS) TREATMENT

From 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 heated environment was usually avoided. Eleven patients at Mayo General Hospital furnished

striking exception; all had been treated by the application of moderate heat

The reports and analyses upon which most of the material in this chapter is based were prepared by Lt. Col. Harris

B. Shumaeker, Jr., MC, formerly Chief of Surgery, Mayo General Hospital.
334 COLD INJURY, GROUND TYPE

to the feet. In another instance, in which bilateral gangrene subsequently

developed, the feet had been exposed to 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 to months. In 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 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 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.

THERAPY (MEDICAL PHASE)

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 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

preparation of mineral oil and dilute solution of alcohol, which was rubbed
THERAPY AND DISPOSITION, ZONE OF INTERIOR 335

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 weeks (the range being from 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 shoidd 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 prominent symptom, the shoes

were perforated in numerous sites.

Almost 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 thick piece of leather

or 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
COLD INJURY, GROUND TYPE

AFIP (Mayo GH) 458-2

Figure 87.—Typical heelwalker, who shifts pressure to heel

to remove weight from sensitive sole of foot in later stages of

trenchfoot.

AFIP (Mayo GH) 458-4, 458-3

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 vicious circle was

broken which, if it had been permitted to continue unchecked, would have led

eventually to invalidism.

Lumbar sympathetic block.— number of patients in the vascular centers

were treated by paravertebral lumbar sympathetic block, partly to establish
THERAPY AND DISPOSITION, ZONE OF INTERIOR

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 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 single injection was followed by

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

as that some patients showed considerable reduction in edema. Thereafter,

the use of this method as limited to patients whose chief complaint was edema.

In 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 weeks of complete bed rest,

ere 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 or injections.

Control of hyperhidrosis. —Hyperhidrosis was 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 powffiers. Frehs method of applying formalin by means of electrophoresis as 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 galvanic current.

This method was never employed until the patients had been tested for

sensitivity. The precaution proved essential, as well over 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 bakelite container filled with 1-percent formalin

solution in sufficient quantity to reach above the ankles. course of treat-
COLD INJURY, GROUND TYPE

mont 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 fair response, and

the others had no benefit at all. At the end of 4-week followup period, the

therapeutic effect was still excellent in 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

wore good in cases, fair in 8, and poor in 4. At the end of 2-month period

of observation, liyperhidrosis 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 definite, if transient, beneficial effect in the late stages of

trenchfoot. Patients with liyperhidrosis treated by sympathectomy had, of

course, complete and lasting relief (p. 342).

Other measures.— 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 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

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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 339

THERAPY (SURGICAL PHASE)

Sympathectomy.—Since vasoconstriction is 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 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 months earlier. From

to 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.

AFIP (Mayo GII) 578-1, 578-2

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.

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 sympathectomy, but there is some evidence, as
340 COLD INJURY, GROUND TYPE

AFIP (Mayo GH) 595-7, 595-1

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.

APIP (Mayo GH) 687-1, 687-2, 687-9, 687-10

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.

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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 341

case indicates, that the increase in circulation following the operation had

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 months, small, deep grafts were applied, with poor results; the grafts did not take and

little or no epithelization followed. Sympathectomy was then performed because the foot

was cold, wet, and cyanotic. Complete healing occurred within 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 healthy color, and sweating was no longer problem. If the

skin was excessively dry, lanolin was applied daily.

When small split-thickness grafts were attempted after sympathectomy, it was not always possible to secure takes (figs. 92 and 93), but tube grafts

were transferred as readily as to normal limbs.

AFIP (Mayo OH) 700-1, 700-4

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.

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 tibia!

pulsations were generally present and full, and there was nothing to suggest

any extensive obliterative change in the arteries of the feet, although there

438404 —58 24
342 COLD INJURY, GROUND TYPE

AFIP (Mayo OH) 680-2, 680-5

Figure 93.—-Gangrene of both feet in late stage of trenchfoot. A. Appearance of

feet after excision of gangrenous parts and bilateral sympathectomy. 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 patients. Four

patients in this group suffered from sweating to such degree that their socks

were almost constantly wet. In two cases, maceration of the skin had occurred,

followed by secondary infection. These patients, as well as the other 5,

whose chief symptom was cold sensitivity, all complained of pain on exposure,

with distressing sense of numbness. In 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 hearing. —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

prominent symptom, particularly when maceration of the skin, local infection,

and cold sensitivity are associated; and (3) is of questionable value in the
THERAPY AND DISPOSITION, ZONE OF INTERIOR

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 veryrecent 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 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 welldemarcated, 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 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 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 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-
344 COLD INJURY, GROUND TYPE

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 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 painful,

unstable and entirely unsatisfactory stump. He was transferred to an amputation center for Syme’s operation

AFIP (Mayo OH) 596-1, 596-2

Figure 94.—Extensive gangrene in late stage of trenchfoot, for which amputation through

leg was eventually necessary. A. Dorsal view. B. Plantar view.

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 few instances, the contracture was

so severe and disabling that amputation seemed wiser than continued attempts

to 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), themajority 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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR

AFIP (Mayo OH) 1222-1, 1222-2

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 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.

Iii 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

split-thickness graft as temporary procedure even if full-thickness graft later had to be used. In some cases, split-thickness grafts were satisfactory
346 COLD INJURY, GROUND TYPE

AFIP (Mayo GH) 583-2

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.

AFIP (Mayo OH) 581-2, 581-1

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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 347

(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 weight-bearing surface.

AFIP (Mayo OH) 585-1, 585-2, 598-2, 598-3

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 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 after unilateral sympathectomy and coverage of ulcerated area over

right metatarsal ends with split-thickness skin grafts.
348 COLD INJURY, GROUND TYRE

AFIP (Mayo GH) 630-1, 630-3, 677-1, 677-5

Figure 99—Continued. E. Appearance of feet before operation. F. Appearance of

feet shown in view 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 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, double pedicle

graft was elevated from the opposite leg, 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 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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 349

AFIP (Mayo GH) 682-1, 682-

Figurb 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 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 tube (fig. 103). Between the second and third weeks after operation,

the circulation in the tubewas tested by the application of 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 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 of the 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, 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 small sequestrum from the
350 COLD INJURY, GROUND TYPE

APIP (Mayo GH) 595-1, 595-7, 595-8

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 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 portion of toe and revision of the stump

was necessary because of osteomyelitis or because the skin was thin and

adherent, the sacrifice of 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 rule, more comfortable and more

useful foot was obtained when the metatarsal heads were left in situ and were

covered by skin graft.

Prostheses.—The majority of patients with deep gangrene following

trenchfoot had useful feet when they were discharged, though in some instances
THERAPY AND DISPOSITION, ZONE OF INTERIOR 351

AFIP (Mayo OH) 580-2, 580-8

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 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.

AFIP (Mayo GH) 682-1
352 COLD INJURY, GROUND TYPE

AFIP (Mayo OH) 595-2, 595-3

Figure 104. and B. Technique of plaster immobilization after tube transfer graft.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 353

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 satisfactory stump, better

result would probably have been obtained if

tube transfer graft had been used instead of

reamputation operation.

APIP (Mayo OH) 543-2

prostheses were necessary. When all the toes had been amputated, spongerubber 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, 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 metatarsal bar or of second heel in front of the regular heel of the

shoe (p. 335).

RECONDITIONING

Although reconditioning of men with trenchfoot was 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 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 rule, reconditioning had been on voluntary basis since their arrival in the

Zone of Interior, and most of them had not participated. Their 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
354 COLD INJURY, GROUND TYPE

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 weeks, the exercises, although

they were carried out in the gymnasium, were of such character that only

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

weeks, 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 to 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 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 matter of fact, 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, dermatitis appeared, perhaps because of
THERAPY AND DISPOSITION, ZONE OF INTERIOR 355

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 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 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 weeks of the reconditioning

program, with hiking and bicycle riding occupying most of the time allotted

for them. Group walking at leisurely pace was continued all during the

program, the short distances at first attempted being gradually increased to

or miles. 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
356 COLD INJURY, GROUND TYPE

marching cadence was required only at Retreat, which was conducted three

times 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

ofreconditioning, most of the patients could ride to miles without difficult3 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 thereconditioning program

at Mayo General Hospital was 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 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 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 he 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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 357

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 close. Many of them were no longer interested, and the

spirit of cooperation which had played so vital 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 secondary objective.

DISPOSITION

When it was thought that 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 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

summary of the case history, the examination of the patient by members of

the board, including survey of his gait without shoes, and discussion of the

findings. All information obtained during board proceeding was placed on

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 result of gangrene, (7) the tendency to blister formation ad

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

“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 Certificate of Disability Discharge. In about two-thirds of the

cases, there was no difficulty at all in arriving at decision. The patients

clearly fell into one category or another. In the remaining third, there was

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.
358 COLD INJURY, GROUND TYPE

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 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.

T1iree hundred and ninety-four enlisted men (37.8 percent of the total

number) were discharged from the hospital to civilian life. About 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 psychoneurosis.

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 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 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 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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR

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 letter and questionnaire

sent, 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

little over month after discharge, and well over half of these held their original

jobs. Six percent were enrolled in technical schools and colleges. About

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 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 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. few complained of blister formation and trichophytosis. Less than half could walk

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.

Officers

Disposition of officers with trenchfoot, as exemplified by the 17 observed

at Mayo General Hospital, differed in number of respects from the disposition

of enlisted men. Only one of these officers was brought before retirement

board. He had had 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.
360 COLD INJURY, GROUND TYPE

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 months, to determine whether they could

then be returned to full duty. At the end of 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 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, months after his transfer to 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 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 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

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 or 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 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.
THERAPY AND DISPOSITION, ZONE OF INTERIOR 361

PREDICTIVE TESTS

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, 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 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 bad suffered from

trenchfoot, was carefully controlled, the controls including both normal subjects

and psychoneurotic subjects without organic disease of an}' kind. All observations were made in 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 toe at the end of 15 minutes’ stay in constanttemperature 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 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 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° (3° C.),

the chances ofabnormality are about 75 percent. In fact, with fall of 3.6° F.

(2° C.) during occlusion and rise on the same order during release, the chances

of abnormality are more than 50 percent.

Burch, Q. H.. Myers, H. L., Porter, R. R., and Schaffer, N.; Objective Studies of Some Physiologic Responses

in Mild Chronic Trench Foot. Bull. Johns HopkinsHosp. 80: 1-70, January 1947.
362 COLD INJURY, GROUND TYPE

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 oidy 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 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 total, or almost total, absence of objective findings.

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. inan articleentitled “Chronic Trench Foot. —A Problem in the Care ofWorld

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 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 chroniccold injury were continuing to seek medical care from the Veterans’ Administration

late in 1946, almost years after the last cold injuries had been sustained in combat.

Information personally secured from the Veterans’ Administrationshowed 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 diagnosisof cold injury. Those figures give no indication of the numberof patients with cold injury stillunder

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 were still underthe care of the Administration. Five such patients were discharged in 1946, and four more

were observed in 1949.

followup study of men with previous cold injuryhas been under way as research project in the Veterans’ Adminstrationsince 1950. Theinformation securedwill make it possible to determinethe permanent residua (or lack of residua)

in men discharged to civilianlife after their injuries.

Anotherfollowup study of 100cold injury patients, made years after occurrence of the injuryin Korea waspublished

by Blair, Schatzi, and Orr in the Journal of the American Medical Association, April 1957.
363

CHAPTER XIII

The Epidemiology of Cold Injury

GENERAL CONSIDERATIONS

Studies made in ETOUSA (European Theater of Operation, United States

Army) during the winter of 1944-45 clearly showed that cold injury is component of mass trauma and that is behaves in accordance with epidemiologic

laws. It was thus demonstrated again that the biologic principles that govern

disease as community problem bold equally well for trauma, including trauma

caused by cold.

Before cold injury is discussed from this point of view, certain general facts

concerning epidemiology must be stated, as follows:

Epidemiology, according to Gordon, may be defined as medical ecology

and may be interpreted as the influence of the total environment upon the reactions of living things. By this concept, health is the equilibrium of all the

factors which come into play to influence disease or injury in man. Agent, host, and environmental factors make up the total epidemiologic potential, and their

equilibrium, or their lack of equilibrium, determines the presence or absence of

disease or trauma in any given community.

The agent is the specific cause of trauma or disease. The host, man, has

many inherent qualities which predispose him to, or which protect him against,

injury or disease. The environment in all its aspects, physical, biologic, and

socioeconomic, constitutes the medium through which agent and host are

brought together to cause injury or disease. Man’s equilibrium in health may

become lack, or absence, of equilibrium in trauma or disease through (1)

actions of the agent, (2) reactions of the host, (3) functions of the environment,

or (4) the interactions of any two, or of all three, of these epidemiologic

potentials.

With the acceptance of this concept, the causation of disease or injury is

not limited to any specific micro-organism, or to any single agent, such as cold.

Multiple factors are always involved. Epidemiology embraces both multiple

causation and the multiple mechanisms through which multiple causative

factors interact. An understanding of the effect of the interactions of causative

factors is essential to comprehension of the whole epidemiologic problem.

Epidemiologic analysis of total cause and effect is the only sound basis from

Gordon, J. E.: The Strategic and Tactical Influenceof Diseasein WorldWar II (Preventive Medicine and Epidemiology). Am. J. M. Sc. 215: 311-326, March 1948.
364 COLD INJURY, GROUND TYPE

which clear picture of the total situation can be derived; it is also the only

sound basis upon which an effective program of prevention and control can be

built.

Application of Epidemiologic Principles to Cold Injury

All of these generalizations are applicable to cold injury. The specific

causative agent is cold, or cold inassociation with wet. number of host factors

determine the susceptibility of the soldier to these agents. The interplay of

agent and host factors is governed by number of environmental factors.

The total causation of cold injury is complex. This is not so much because

any single factor involved is complex but because of the interrelation of the

multiple factors which come into play to make up the mechanism of cold injury

under variable circumstances. It is not at all difficult to classify these several

factors according to agent, host, or environment. What is difficult, in the

analysis of the over-all problem, is to determine the relative weight which

should be assigned to each single factor.

Interpretation of World War II experience of cold injury.—The interpretation of the cold injury experience of World War 11 may be approached in

several ways, as follows:

1. The first approach is an endeavor to interpret this experience from the

point of view of broad causality. It has been established historically, both by

experiment and experience, that cold and wet, singly or associated, are the

preeminent causal factors in cold injury. They are the conditions which must

be present if it is to occur. Historically, mass cold injury has occurred only in

time of war, only then in the cold or wet-cold season, and only then under

circumstances of military stress that bring about unusual exposure of the

soldier. Exposure has two components, degree and duration. Time, or duration, thus becomes an additional component of broad causation.

With these fundamental concepts established, it is possible to investigate

how the several modifying factors of agent, host, and environment impinge upon

the core of causation. The chronicle of cold injury in World War and the

field investigations of cold injury carried out in World War II were along these

lines and pointed toward the determination of the factors which made up total

causation.

2. In view of the constancy of the basic causative factors of cold injury,

that is, cold and wet, second approach toward the problem is logically directed

toward the study of modifying factors. This particular study is limited to individual factors or to circumscribed groups of the several causative components of

cold injury. The effect of cold injury is readily measured in terms of numbers of

cases and time lost as result. It is difficult to count and measure the modifying

factors which may chiefly determine the prevalence of the injury. Many of

them are intangible host factors, such as fatigue, nutritional status, or the effect

of previous cold injury. Environmental factors such as command leadership,

discipline, and training are even more difficult to measure precisely.
EPIDEMIOLOGY OF COLD INJURY 365

It would have been fairly simple to measure the agent factors of cold and

wet in World War II if detailed records of temperature fluctuations and precipitation had been made part of the record of each division. They were not.

Average weather data were recorded by army areas, but in no theater do

records exist of the detailed day-by-day fluctuations within division areas.

3. theoretical method of approach is to assign relative values to each of

the factors implicated in cold injury and to study the trenchfoot record in each

division in the light of these values. This method permits composite evaluation of the circumstances which are favorable and unfavorable to trenchfoot.

As practical matter, when this method was used, low ratings generally were

associated with good division records for cold injury, but the distinctions were

not drawn finely enough to establish reliable quantitative multiple-factor

relationships.

Twenty-one infantry divisions in the European theater were rated by

this method for the months of November and December 1944 according to

type of combat action, clothing supply, rotation, training and experience,

shelter, and terrain, in addition to the basic factors of cold and wet. Details

of this study are recorded elsewhere (p. 366). In general, it may be said that

the selection of qualitatively significant factors by multiple correlation techniques was restricted by lack of precise measurements for factors presumed

to be important on the basis of previous experience. Significant correlation

could be established between the cold injury experience and the degree of

combat as well as cold injury and shelter. Significant correlation could also

be established, though to lesser extent, for rotation as well as terrain. Had

more precise data been available, multiple regression studies of these factors

might have made possible the assessment of relative factor weights.

However, in spite of its limitations, this study bore out, in general, the

ratings already established for the various divisions in relation to their cold

injury records. It also confirmed the feasibility of evaluating the modifying

factors in cold injury for which precise quantitative measurements are not

available.

4. In the absence of data ample enough and precise enough to permit

statistical measurement of the influence of such factors of concern to the

individual soldier as leadership, training, clothing, fatigue, or foot discipline,

some other method had to be found to assess the role of these and other factors

involved in cold injury in World War II. None presented itself except the

epidemiologic approach of studying organizations ranging in size from battalions

to divisions by the selection of periods of time and situations in which only one

factor seemed to vary in comparison with other organizations of similar size

operating under identical or almost identical conditions. This method, which

is applicable to agent, host, and environmental factors alike, has been utilized

in this chapter to study the modifying agents of cold injury. All possible factors

All data concerning the variousdivisionsand other organizations used for unit case historiesand other studies in this

chapter were obtained from the appropriate records on filein the Office of the Surgeon General of the Army.

25
COLD INJURY, GROUND TYPE

have been evaluated by tliis method. In addition, the influence of certain of

them lias been assessed in part by the rating method and statistical procedures

already mentioned.

ANALYSIS OF SELECTED DIVISIONS BY

CORRELATION STUDIES

The experiences of 21 divisions on the Western Front in November and

December 1944 were studied, by the technique already described in the

light of six factors of environment, in an attempt to weigh the impact of

these factors on the incidence of trenchfoot. These factors, namely, combat

action, rotation policies, weather, shelter, terrain, and troop experience, constitute the independent variables among which interaction may take place.

The dependent variable is the incidence of trenchfoot.

Since none of these factors are susceptible of quantitative grading,

subjective scoring of their intensity was set up (see footnote 1, table 11),

ranging from (1) least predisposing to (4) most predisposing. Each division

was then rated separately for November and December, and the data were

recorded, together with the actual numbers of cases of cold injury each had

experienced (tables 11 and 12).

Data concerning temperature and precipitation could not be weighed

in relation to other factors because, as already noted, they arc available only

as means for whole army areas and thus do not fluctuate by division. Similarly, criteria for measuring training and experience are gross and thus do not vary

significantly between the divisions or between the months covered by the

analysis.

Clothing supply was theater problem. All divisions were affected to

some extent. No division was without supplies, but no division was fully

equipped. Variations between divisions in this respect were not great, and

the moderate improvement which occurred in December affected them all.

The influence of this factor can therefore be judged only by isolated circumstances, such as were created, for instance, when overshoes were left behind

by order.

Before statistical analysis of these data was undertaken, it was necessary to find linear function of the incidence which was roughly related to the

independent variables. The logarithm of the incidence was found to fulfill

this requirement. Next, the usual procedure of computing correlation coefficients was applied for each of the six independent variables and the dependent

variable (table 13). The coefficients of combat action and shelter were found

highly significant. Those of terrain and rotation were of borderline significance. The paradoxical finding that the coefficient of weather, which is

basic factor, was entirely insignificant could be explained only by the nature of the data. As pointed out earlier in this chapter, these data were general

and incomplete. During the period chosen for the study, the weather seems
EPIDEMIOLOGY OF COLD INJURY 3f>7

Table

11.

—Scores

of

21

infantry

divisions,

European theater,

by

cold

Injury

modifying

factor,

November 1944

Combat

action

Scor- ing

criScorCold

and

wet

Scoringcriteria

Shelter

ScorInfantry divisions

Cases(num- ber)

Duration by

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight- ed

aver- age

of

scores

teriaforcloth- ing

sup- ply

ing

cri- teria for

ro- tation

Duration by

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores for

train- ing

and combat experi-ence

Duration by

scor- ing

cri-teria(days)

Scor- ing

cri-teria

Weight- ed

aver- age

of

scores

ing

cri- teriafor

ter- rain

Sum

of

weighted scores

st

267

2.

22

3.3

10

30

16.

13

20

2d

37

3.

22

3.3

3. 4. 2.

18. 19. 17.

3d

498

4.

4.

5th

857

20

3.

3.

19

10 20

8th

109

31

3.

2.

16.

th

118

18

2.

22

3,3

15

2.

17.

12

26th

1,

679

4.

3.3

23

3.

25.

29th

97

15

22

3.3

2. 1. 3.4

17. 15. 21.

30th

16

15 15

!•

2.

i!

35th

504

15

3.4

3.

11

19

15

19

36th

380

3.

3.4

2.

17.

13

See

footnotes

on

p.

369.
368 COLD INJURY, GROUND TYPE

Table 11.

—Scores

of

21

infantry

divisions,

European

theater,

by

cold

injury

modifying

factor,

November 1944 —Continued

Combat

action

Scor- ing

criScorCold

and

wet

Scoring criteria

Shelter

ScorSum

of

weighted scores

Infantry divisions

Cases(num- ber)

Duration by

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores

teriafor cloth-ing

sup-ply

ing

cri- teria forro- tation

Duration by

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores for

train- ing

and combat experi- ence

Duration by

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores

ing

cri- teriafor

ter-rain

44th

310

2.

17

3.

4.

20.

12

13

13 17

45th

113

4.

3.

2.

18.

80th

928

4.

17

3.

4.

22.

83d

2.

13 22

3.

1.

15.

84th

450

10

3.

22

3.

10 20

3.

20.

20

90th

307

19

an

17 13

3.

26

3.

21.

95th.

229

20

3.

17 13

3.

10

2.

19.

io

12

99th

496

22

3.

3.

19.

22

102d

78

27

2.

22

3.

4.

19.

104th

350

23

2.

22

3.

23

2.

18.
EPIDEMIOLOGY OF COLD INJURY

Scoring

criteria

for

modifying

factors

in

cold

injury,

based

on

favorability

to

cold

injury

(from

1,

least

predisposing, to

4,

most

predisposing):

Combat

action;

Rotation:

Clothing

supply:

1.

Movement

unopposed; reserve;

rest.

1.

Excellent;

rotation by

units

and

within

units

at

1.

Completely

supplied,

overshoes or

shoepacs.

2.

Static

defense,

patrolling;

static

defense,

regular

intervals; rest

and

bathing

facilities.

2.

Shortage

of

overshoes or

shoepacs;

socks

and

line

holding.

2.

Good; rotation by

unit

and

within

units

when

clothing

completely

supplied.

3.

Active

defense,

minor

fighting.

situation

permits;

limitation

on

numbers of

men

3.

Shortage of

overshoes

and

socks;

socks

with

ration

4.

Active

offense,

major

fighting;

active

rotated;

limited

facilities.

poor.

defense,

with

attack.

3.

Fair;

no

definite

division rotation

policy;

small

4.

Shortage

of

overshoes or

shoepacs,

socks,

and

Shelter:

unit

rotation when

opportunity

exists.

clothing.

1.

Buildings.

4.

Poor; no

specified

policy or

facilities.

2.

Tents,

dugouts, bunkers.

3.

Foxholes,

improved.

4.

Foxholes,

unimproved,

wet.

Training

and

combat

experience;

Cold

and

wet:

Terrain:

1.

MTO,

ETO,

active

campaigning.

1.

Above

50°

F.

(10°

C.),

with

or

without

rain.

1.

Dry,

hilly,

or

mountainous;

frozen

snow

2.

ETO

throughout,

battlewise, no

trenchfoot

2.

Below

32°

F.

(0°

C.),

with

or

without

precipitaunderfoot.

experience.

tion.

2.

Hilly

or

mountainous,

forested;

moderate

3.

Entered

ETO

September or

October 1944

without

3.

40°

F.-50°

F.

(4.5°

C.-IO

C.),

with

rain.

mud.

battle or

trenchfoot

experience.

4.

32°

F.-40

F.

(0°

C.-4.5°

C.),

with

rain.

3.

Flat

to

rolling,

muddy,

wet.

4.

New

division,

no

experience;

began

combat

in

4.

Marshy,

flooded,

streams.

cold

weather

November or

December 1944.

The

duration

of

scoiing

criterion was

20

days

and

for

scoring

criterion was

10

days;

the

average

weighted score

was 2.7.

The

duration of

scoring

criteria

and

was

15

days

each;

the

average

weighted score

was 2.5.

Overshoes

left

behind

by

order.
370 COLD INJURY, GROUND TYPI

Table 12.

—Scores

of

21

infantry

divisions,

European

theater,

by

cold

injury

modifying

factor,

December19^4

Infantry divisions

Cases(num- ber)

Combat

action

Scor- ing

cri- teria forcloth- ing

sup-ply

Scor- ing

cri- teriafor

ro- tation

Cold

and

wet

Scoring criteria for

train- ing

andcombat experi- ence

Shelter

Scor- ing

cri- teriaforter-rain

Sum

of

weighted scores

Duration of

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight- ed

aver- age

of

scores

Duration of

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores

Duration of

scor- ing

cri- teria(days)

Scor- ing

cri- teria

Weight-ed

aver- age

of

scores

io

1st

126

2.5

2.

16

2.

13.

11

i9

12

2d

204

10

3.

2.

3.1

18.

15

3d

222

4.

4.

1.

16.

21

21

20

5th

154

3.

3.

f:

2.

16.

io

16

ii

8th

339

25

3.

3.

2.

17.

9th

143

2.

15

3.

3.1

16.

16

16

12

i3

24

26th

333

3.

10

3.

2.

21.

1.

ii

15

29th

57

15

3.

3.

15

2.

17.

16

16

12

ii

30

th

112

3.

11

3.

18

2.

17.

13

14
EPIDEMIOLOGY OF COLD INJURY 371

35th

115

23

2.

11

2.

2C

2.

16.

11

36

th

200

3.

14

3.

2.

17.

2J

44

th

320

3.

3.

4.

20.

300

4.

13 1-

3.

4.

19.

i6

13 19

80th

236

3.

2.

2.

17.

11

2j

83d

291

24

3.

19

2.

3.

18.

2J

84th

210

20

2.

‘5

2.

20 io

3.

17.

10

2)

90th

369

24

3.

•!

2.

4.

20.

95th

72

12

2.

*:

2.

2.

17.

19 12

19

15 16

99th

733

16

3.

2.

3.

19.

102d

203

2.

14 10

:i

3.

28

1-3

15.

28

19

2J

104th

92

2.

2.

1.

15.

See

footnotes

on

p.

372.
372 COLD INJURY, GROUND TYPE

Scoring

criteria

for

modifying

factors

in

cold

injury,

based on

favorability to

cold

injury

(from

1,

least

predisposing, to

4,

most

predisposing):

Combat

action:

Rotation:

Clothing

supply;

Movement l.

unopposed; reserve;

rest.

1.

Excellent;

rotation by

units

and

within

units

at

1.

Completely

supplied,

overshoes or

shoepacs.

2.

Static

defense,

patrolling; static

defense,

regular

intervals;

rest

and

bathing

facilities.

2.

Shortage

of

overshoes or

shoepacs;

socks

and

clothline

holding.

3.

Active

defense,

minor

fighting.

2.

Good;

rotation by

unit

and

within

units

when

situation

permits;

limitation

on

numbers

of

ing

completely

supplied.

3.

Shortage

of

overshoes

and

socks;

socks

with

ration

4.

Active

offense,

major

fighting;

active

men rotated;

limited

facilities.

poor.

defense,

with

attack.

3.

Fair;

no

definite

division rotation

policy;

small

4.

Shortage

of

overshoes or

shoepacs,

socks,

and

Shelter:

unit

rotation when

opportunity

exists.

clothing.

1.

Buildings.

4.

Poor; no

specified

policy

or

facilities.

2.

Tents,

dugouts, bunkers.

3.

Foxholes,

improved.

4.

Foxholes,

unimproved,

wet.

Training

and

combat

experience:

Cold

and

wet:

Terrain:

1.

MTO,

ETO,

active

campaigning.

1.

Above

50°

F.

(10°

C.),

with

or

without

rain.

1.

Dry,

hilly,

or

mountainous;

frozen

2.

ETO

throughout,

battlewise, no

trenchfoot ex2.

Below

32°

F.

(0°

C.),

with

or

without

precipitasnow

underfoot.

perience.

tion.

2.

Hilly

or

mountainous,

forested;

moder3.

Entered

ETO

September or

October 1944

without

3.

40°

F.-50° F.

(4.5°

C.-10°

C.),

with

rain.

ate

mud.

battle or

trenchfoot

experience.

4.

32°

F.-40°

F.

(0°

C.-4.5°

C.),

with

rain.

3.

Flat

to

rolling,

muddy,

wet.

4.

New

division,

no

experience; began

combat

in

4.

Marshy,

flooded,

streams.

cold

weather

November or

December 1944.

The

duration

of

scoring

criterion was

days,

for

scoring

ciiterion was

and

16

days,

respectively: the

average

weighted score

was

2.2.

The

duration of

scoring

criterion was

10

days

and

for

scoring

criterion was

11

days;

the

average

weighted score

was 2.5.

The

duration of

scoring

criterion was 18

days

and

for

scoring

criterion was

13

days;

the

average

weighted score

was

2.6.

The

duration of

scoring

criterion was 20

days

and

for

scoring

criterion was

11

days;

the

average

weighted score

was

2.6.

he

duration

of

scoring

criteria

and

was

15

days

each;

the

average

weighted score

was

1.5.

The

duration

of

scoring

criterion was

26

days

and

for

scoring

criterion was

days;

the

average

weighted score

was

1.8.

The

duration of

scoring

criterion was 20

days

and

for

scoring

criterion was

10

days;

the

average

weighted score

was

2.3.
EPIDEMIOLOGY OF COLD INJURY 373

to have held fairly constant, so that it could not greatly influence variations

in the trenchfoot incidence. The correlation coefficient for training and

experience versus incidence can be disregarded, since it was rather low.

Table 13.—Cases of trenchfoot in 21 infantry divisions, European theater, November and

December 1944, in relation to ratings of several predisposing factors

[Relationship between variables expressed by coefficient of correlation; logarithms of incidence of cold injury were used in computing the coefficients]

Of the four apparently significant factors left after those just discussed

are eliminated, shelter and terrain appear to be of the same nature, both

being determined by the topography of the area. It is therefore feasible to

combine them in one score by simply averaging the individual scores. With

the combined score, significant correlation is found with trenchfoot. The

weighting of each of the three factors, rotation, combat action, and shelterterrain, is possible, by means of multiple regression analysis. However, this

complicated procedure would scarcely be profitable, since it would reflect only

the relative weight within this particular situation, while other relative weights

might be applicable to other situations, in another area of combat, for instance,

or in another season. The relative importance of the three factors cannot be

evaluated, but some interrelation can be found by the first order of correlation coefficients between their independent variables. There is certain interaction between combat action and rotation (table 13) but no correlation

between rotation and shelter. third significant correlation between combat

action and shelter adds further uncertainty to their evaluation.

The result of this analysis can therefore be summarized as follows: In

an area with relatively bad weather, factors of the military environment were

of more importance than weather in determining trenchfoot. Among these,

combat action and shelter seemed to be of highest importance. Rotation

policy was less influential. No relation between trenchfoot and troop training and experience could be found. Thus, within the broad causation of

trenchfoot, certain factors of environment were found to influence incidence

26

Independent variables Dependent

variable

Interacting independent variables

Combat

action

Shelter Rotation

Combat action 0. 419

271

547

262

021

120

532

Rotation. 0. 283

268

234

0)

0)

350

0. 017

Shelter.

Terrain

Weather. ...

322

0)

0)

0. 172

0)

0)

029

Training and experience. ...

Shelter-terrain

Data not computed. Mean score.

Note.—The figures in italic are significant correlation coefficients. Those above0.304 are significant at the 5-percent

level; those above 0.393 are significant at the 1-percent level.
374 COLD INJURY, GROUND TYPE

when the weather was highly favorable for the occurrence of this special type

of cold injury.

This analysis of cold injury in 21 divisions on the Western Front in

November and December 1944 does not entirely bear out the epidemiologic

findings of detailed unit surveys presented later in this chapter, especially in

regard to such factors as the influence of weather, training and experience,

clothing supplies, and rotation. The discrepancy, in itself, emphasizes the

need for much more detailed data by units if, in the future, valid statistical

analysis is to clarify the roles of the several modifying factors in the causation

of cold injury.

Interaction of combat action and season.—The statistical analysis just

recorded was limited to short period of the winter in Europe which was highly

conducive to the occurrence of trenchfoot. Data on the incidence of trenchfoot

among United States and British troops in Italy from October 1944 through

March 1945 throw different light upon certain factors. Trenchfoot was

more frequent among United States troops, as is shown by the rate by months

(chart 6, table 14). Combat action, however, varied for the two forces, as

shown by battle-casualty rates. It is possible to correct the trenchfoot incidence for combat action by relating the rate of trenchfoot to that of battle

casualties. When the rates thus obtained are plotted against the months of

occurrence, two facts emerge. The first is that there is distinct seasonal effect,

with the peak in January and February. The second is that the apparent

difference between British and United States troops seems to be without significance (chart 7, table 14). The interesting point in these data is that the seasonal

Chart 6. Trenchfoot incidence rates United States and British forces in Italy, October 1944 through March 1945

[Rate expressed as number per annum per 1,000 average strength]
EPIDEMIOLOGY OF COLD INJURY 375

Chart 7.—Comparison of ratios of trenchfoot to battle casualties in United States and British

forces in Italy, October 1944 through March 1945

[Ratio of trenchfoot to battle casualties expressed as percentage]

Table 14.—Comparative incidence rates for trenchfoot cases and battle casualties, United States and British forces in Italy, October 1944 through March 1945

[Rate expressed as numberper annum per 1,000 average strength]

U. S. Army British forces

Month and year Trenchfoot (rate)Battle

casualties (rate)

Ratio of trenchfoot

to battle casualties

Trenchfoot (rate)

Battle

casualties (rate)

Ratio of trenchfoot

to battle casualties

1944 October 28 647 4. 32:100 236 2. 54:100

November 21 153 13. 72:100 75 12. 00:100

December 20 85 23. 52:100 10 80 12. 50:100

1945 January. 23 47 48. 93:100 14 22 63. 63:100

February 24 154 15. 58:100 17 37 45. 94:100

March 113 6. 19:100
376 COLD INJURY, GROUND TYPE

factor was originally hidden by interaction with the military operation. The

severest combat action took place during the months when the temperature

was highest, but the trenchfoot incidence was apparently the same throughout

the whole period. When the interaction of combat action and season was

dissolved, however, the relatively higher incidence of trenchfoot in the colder

months became evident, and it was then possible to explain the differences in

the incidence of trenchfoot in the two forces by differences in their exposure.

EPIDEMIOLOGIC ANALYSIS OF AGENT, HOST, AND

ENVIRONMENTAL FACTORS

Agent Factors

Cold.—Cold is the predominant agent in the production of cold injury, just

as it is also the immediate exciting cause of tissue damage, irrespective of the

influence of extraneous modifying factors. If the effect of cold is described as

loss of body heat, the role of wetness as one of the modifjung factors in cold

injury is more easily comprehended. Experimental studies, the experience of

armies in previous wars, and the experience of Arctic explorers and of the inhabitants of cold countries leave no doubt of the part cold plays in the production of cold injury.

The role of cold and the mechanism of the production of cold injury have

been described in detail elsewhere (pp. 404 and 235).

Man is tropical animal and is therefore highly susceptible to the effects

of cold. The temperature of the human body and, to lesser extent, that of

the feet is kept independent of the temperature of the environment by two

mechanisms. The first is natural means, such as metabolism and the circulation. Metabolic heat is distributed to the periphery by way of the circulation,

upon which the hands and feet are particularly dependent for the maintenance

of temperature independent of that of the environment. Any factor that

tends to impede the circulation (p. 390) would therefore be expected to render

the hands and feet more susceptible to the action of cold.

The second means by which the temperature of the body is kept independent of that of the environment is artificial, the use of clothing. When man is

reasonably well clothed, he is not greatly affected by dry cold above the freezing

point. This was clearly established by the experience of British troops in

World War I. Losses from trenchfoot were promptly and markedly reduced

by the simple expedients of using trenchboards and wearing gum boots, which

allowed the men to reach the trenches dry-shod. After these measures had

been adopted, exposure to moderate degrees of cold (from above freezing to

50° F. (10° C.)) did not cause significant cold injury.

The evaluation of cold as an agent factor in the production of cold injury

would be simple if the effects were in direct proportion to temperature. Then

simple relation between temperature and duration of exposure could easily
EPIDEMIOLOGY OF COLD INJURY 377

be expressed. The situation is not so simple. The effect of cold as an agent

in cold injury is, as already indicated, best described as loss of body heat,

concept which serves to explain the role of wetness as modifying factor.

Since loss of body heat is the important consideration, the relation of cold and of

several other factors becomes complex. Heat loss may be much greater at

temperatures above freezing than it is at temperatures below this level if

wetness or other factors expedite the process. The loss may be much less at

temperatures below freezing if the soldier is properly insulated with clothing

and can keep dry. Under these circumstances, it is both expedient and advisable to regard cold as an agent in cold injury which acts in the same manner

in which bacterium acts as the agent in an infectious disease. Similarly, it is well to view the modifying factors that determine the extent and seriousness

of cold injury in the same way in which various circumstances may influence

the invasiveness of micro-organisms.

Wet. —In the causation of cold injuries that occur in the range of temperatures above freezing, the synergistic relation that wet bears to cold may again

be compared to the synergistic relations of certain micro-organisms to each

other in the causation of infectious disease. Because of the physical properties

of water, wetness enhances the effect of cold. Body heat is readily conducted

to the outside atmosphere from the feet and other parts of the body through

wet stocks, shoes, gloves, and other articles of clothing. Evaporation of water

in wet clothing occurs with substantial additional cooling effects, even when the

outside atmosphere is cold and humid.

Wetness has other undesirable effects. It causes clothing to cling closely

to the skin and thus eliminates the insulating layer of air ordinarily present

between the skin and the clothing. Air spaces between layers of clothing and

air in the interstices of the clothing are also lost when the clothing is wet. Dry,

intact skin, because of its horny layer, has inherent insulating properties that

are destroyed by wetness. Finally, water or wet clothing in contact with the

skin for long periods may cause maceration, which in turn increases the likelihood of trauma and infection.

The synergistic effect of wetness is highly important because many military

operations conducted in winter take place at temperatures at which wetness

combines with cold to produce cold injury. Since cold, as temperature, and

wetness, as precipitation, are components of weather, and in this capacity are

also environmental factors, both will be discussed in greater detail under the

latter heading (p. 404).

Host Factors

The host factors responsible for cold injury are inextricably interwoven

with the same human attributes that cause soldiers to perform well or poorly

in battle, that build up high morale or result in indifference, and that motivate

men to fight to the bitter end on one hand and to desert on the other. These

are human attitudes, traits, and resources. They are, at one and the same time,

physical, mental, and emotional. No precise standards of measurement are
378 COLD INJURY, GROUND TYPE

available for them, but full understanding of them is the essence of leadership

and command function.

Leadership and personnel have been accorded vast amount of study in the

past, and extensive research on human action, attitude, and motivation are

currently under way. In some of these studies, great emphasis has been placed

upon the psychology of war and on leadership, while in others the chief attention has been given to physical attributes. There is considerable doubt, however, whether all of these studies, and the knowledge derived from them, have

been utilized to the best advantage. It has been proposed that the Armed

Forces might, with full justification, establish and support research to study

man as whole and to evaluate influences of all kinds, physical, mental, emotional, environmental, and all others that combine to cause men to react and

perform as the} do. Until this or some similar approach to the measurement

of human host factors can be accomplished, it will be impossible to evaluate

thoroughly the factors that influence cold injury, combat trauma, neuropsychiatric conditions, and disease.

Because of the absence of satisfactory methods ofmeasurement, the evaluation of host factors is necessarily imperfect. It is based on observations made

in wartime, opinions, and such crude measurements as are possible. Nonetheless, by these methods, the important role of host factors is made clear, as

is the need for greater understanding of them and for precise methods of measuring them. In spite of these lacks, the crude methods necessarily used in World

War II made clear the important role of host factors. The questionnaire

submitted to 1,018 trenchfoot casualties and to an adequate control group

toward the end of the war (p. 400) furnished material that, together with unit

observations, demonstrated both host and environmental influences.

Age —No conclusive evidence exists that age, per se, influences individual

susceptibility to cold injury in the age range of military combat soldiers; that

is, 18 to 35 years (table 15). Observations on shipwrecked mariners and passengers suggest that persons below the age of 17 and above the age of 40 years

may be more susceptible than those in the years between. These phenomena

can be explained by the instability of the cardiovascular system, its inability to

adjust to stress in the younger group, and the generally lowered adaptability

of the circulatory system in those in middle age and older.

In 1,018 trenchfoot casualties surveyed in Zone of Interior hospitals in

1945 (p. 400), age distribution bore no relationship at all to cold injury (table 15).

These were chiefly combat troops, and the age range was narrow. Age seemed

similarly without influence in the 114 patients with trenchfoot who were surveyed by Berson and Angelucci in hospitals in Italy and who were compared

with 877 soldiers hospitalized for other reasons.

In one sense, age does play role in the susceptibility to trenchfoot.

Observations made at the 1st Arctic Aeromedical Laboratory and reported by

Berson, R. C., and Angelucci, R. J.: Trench Foot. Bull. IT. S. Army M. Dept. No. 77, pp. 91-99, June 1944.
EPIDEMIOLOGY OF COLD INJURY 379

Miller emphasize the importance of physical fitness in withstanding the

stress of cold. Since physical fitness is, as rule, likely to be less in older age

groups, an increased individual susceptibility probably could be shown in

them. In combat units, however, this would not hold, since the physically

unfit are screened out by intent at the time of induction and by the exigencies

of battle experience if they have passed the initial screening.

Table 15. Age at last birthday of 1,018 'patients with trenchfoot hospitalized in Zone of Interior

Sex.—No data came out of World War II to justify the consideration of sex

as host factor in susceptibility to cold injury. This might be expected because of the military circumstances. Members of the Women’s Army Corps

were not exposed to conditions conducive to cold injury. They were utilized

in the larger headquarters and in hospitals and, in both locations, had shelter,

food, and ample clothing. Nurses were assigned as far forward as evacuation

or field hospitals in army areas, but the installations were always under canvas

or in other sheltered locations. The hospital sites, it is true, often became

quagmires, but exposure was not great, and adequate clothing, including

galoshes, was provided. Furthermore, the nature of their work kept the

nurses, for the most part, in heated shelters.

Race and geographic origin.—Therole ofrace and geographic origin as host

factors in cold injury is not well clarified by data recorded for either of the

World ars.

Gilcreest recorded the unusual prevalence of trenchfoot among American

Negroes in World War with great deal of humor, but his comments concerning cold injury among men of this race in combat are neither convincing

nor informative. In World War II, observations in training areas in the

United States, as well as in Italy and on the Western Front, furnished no indications that United States Negroes or other soldiers native to Southern States

Miller, A. J.; Physical Fitness for Strenuous Work in Relation to the Survival Situation in Cold Environment.

Report of Project XIV, 1st Artie Aeromedical Laboratory, Ladd Air Force Base, Alaska, 1948.

Brownrigg, E. M.: Frostbite in Shipwrecked Mariners. Am. J. Surg. 59: 232-247, February 1943. [Includes discussion by Edgar L. Gilcreest, pp. 245-246.]

Age Cases (number) Percent

18 and 19 122 12

20 to 24 234 23

25 to 29 448 44

30 to 34 143 14

35 and over 41

Unknown 30

Total 1, 018 100
380 COLD INJURY, GROUND TYPE

were any more or any less susceptible to cold injuries than were other troops.

Combat comparisons are not valid because large proportion of Negro troops

were assigned to service organizations and did not suffer much exposure.

Such combat records as do exist, however, suggest possible racial susceptibility to cold. The 92d Infantry Division, Negro combat unit, was

exposed to cold in Italy, in the winter of 1944-45, when protection was far

better understood and clothing far more adequate than in the previous winter.

Although the total incidence of trenchfoot in the Mediterranean theater was

greatly reduced for these reasons, this particular division supplied one out of

every three cold casualties reported. possible explanation is that the unit

was new to combat and lacked the battle training and experience with cold

which other Fifth U. S. Army divisions possessed in the second winter of

lighting in Italy.

It was also observed that trenchfoot was relatively more frequent in

Japanese-American soldiers than in other United States troops. The rate

was high in the 100th Infantry Battalion (Separate), composed of JapaneseAmerican soldiers, although it was attached to regiment (the 133d Infantry)

in which the rate was low because foot discipline was excellent. The explanation offered by the commanding officer of the regiment was that JapaneseAmerican soldiers were peculiarly susceptible to cold injury because of the

delicate construction of their feet. The regimental surgeon was of the same

opinion.

Not great deal of information exists about other troops. In World War

I, the French used Senegalese troops on the Western Front in 1917 and had

high incidence of “frozen feet” in the middle of April, when cold injury was

negligible among other French forces. Brazilian and Hawaiian troops fighting

in Italy in the winter of 1944-45 had high incidence of trenchfoot. The

original injuries were thought to be more severe than in North American

troops, and recurrences were unusually frequent. Inexperience and newness to

combat probably accounted for part of this record, as in the Negro division

just mentioned, but racial susceptibility cannot be entirely discounted.

Later studies confirm the Mediterranean experience concerning cold injuryin the Negro. In the winter of 1951-52.

special cold injuryresearch team, commandedby Lt. Col. KennethD. Orr, MC, made an extendedstudy of theetiologic,

pathologic, epidemiologic, clinical, and therapeutic aspects of these injuries. The report of the work of this team was

published on April 1953 (Summary of Activities, Cold Injury Research Team Korea, 1951-52, Report No. 113, Army

Medical Research Laboratory, Fort Knox, Ky.). This report (p. 418) stated that Negro soldiers proved to be significantly greater risk forattack by frostbite (6 times) than other soldiers when all environmental conditions were equalized.

At the regimental level, the Negro rate was 35.9 per 1,000, compared to 5.8 per 1,000 for white soldiers. Negroes also

showed more severe injuries than white soldiers. Differences in tissue susceptibility wereneither proved nor disproved.

Additional confirmation of the apparently greater Negro susceptibilityto cold injuryis also foundin report by Maj.

Gen. Alvin L. Oorby, in Essential Technical Medical Data for January-March 1956, United States Army, Europe.

During February 1956, the numberof reported cases of cold injury exceeded the totalreported for the cold injury season of

1954-55. While cold Injury was the outstanding morbidity problem during this month, it was consideredremarkable that

the incidencewas not higherand the severity not greater, since the winter of 1955-56was the most severe in Europe in the past century. On the other hand, while the incidence of cold injury was not inordinately high, large proportion of the

cases occurred in Negro troops, which indicates, as previous studies have indicated, that race is predisposing factor in this condition.

Annual Report, Surgeon, VI Corps, Seventh U. S. Army, 1944.

Toone, E. C., and Williams, J. P.: Trench Foot; Prognosis and Disposition. Bull. U. S. ArmyM. Dept. 5:198-210,

February 1946.
EPIDEMIOLOGY OF COLD INJURY 381

The evidence of racial susceptibility to cold is thus fragmentary. It is

certainly not sufficiently convincing to prevent the employment of presumably susceptible races in winter operations, such as those in Europe in World ar II, although better knowledge of this host factor might strengthen the

decision to use certain racial groups in service echelons or in light holding defense operations pending long period of acclimatization. As matter of

fact, acclimatization and adaptation to climatic environment are difficult to

separate from purely inherent racial susceptibility or lack of susceptibility.

All races can acclimatize to cold, to some extent, at least, and can learn to do

the things necessary for survival in the cold.

The Eskimos furnish the outstanding illustration of this ability. The

white man can acclimatize to the arctic cold, but he never develops inherent protective mechanisms equal to those of the Eskimos, who, as the result of

long development, undoubtedly possess racial tolerance to cold. Eskimo

babies wear no clothes. They are carried in pouches on their mothers’ backs, in skin-to-skin contact, and they are removed stark naked, in weather far

below zero, for excretion, feeding, and other care, without apparent harm.

The Eskimos, furthermore, know the value ofprotective clothing and of special

care of the feet. All their clothing is layered and loosely fitted. The inner

layer, of caribou skin, is worn with the fur to the wearer’s skin; second,

outer skin is worn with the fur outside. For footgear, Eskimos wear sealskin

mukluks, which are loosely fitted, changed frequently, and discarded when

it is no longer possible to chew them into pliability.

Previous cold injury experience.—There seems no doubt that previous

cold injury predisposes the soldier who has experienced it to further trauma

from cold. The degree of predisposition varies in proportion to the severity

of the original injury, recurrence being most frequent when the previous

injury has been moderate to severe.

It was thought that some of the cases of cold injury which occurred on

Kiska were early recurrences of the injuries which had been sustained on

Attn, though the possibility of recrudescence rather than recurrence could not,

of course, be completely dismissed (p. 99). In Italy and in Europe, however,

there was no doubt of the seriousness of recurrent cold injury.

Lt. Col. (later Col.) Fiorindo A. Simeone, who made special investigation

of trenchfoot in the Mediterranean theater in the winter of 1943-44 and in the

following winter (p. 101), estimated that 15 percent of all casualties from this

cause who were returned to duty might be expected to have recurrences. He

also expressed the opinion that man who had suffered cold injury would

be particularly susceptible to the effects of cold if he were exposed again within

few weeks or few months. The course of events substantiated his opinion.

Although only percent of the personnel of all divisions of the Fifth U. S. Army

suffered from trenchfoot, 18 percent of all patients hospitalized for this cause

had previously been hospitalized for it. Twenty-two percent of the cases

observed in December 1944 were instances of recurrence (8 percent from the

winter of 1944-45 and 14 percent from the previous winter), and, in January
382 COLD INJURY, GROUND TYPE

1945, 23 percent of the cases were recurrent (18 percent from the winter of

1944-45 and percent from the previous winter). The conclusion of Berson

and Angelucci, that previous exposure is not an important factor in susceptibility to cold injury, is not in accord with the conclusions of others. The

explanation probably is that their studies were made before the factor of

previous exposure had begun to exert its heaviest influence.

Recurrent trenchfoot in the European theater was first encountered in

the Seventh U. S. Army, many of whose components had fought in Italy the

previous winter. On 30 November 1944, an officer from the Preventive

Medicine Division, Office of the Chief Surgeon, ETOUSA, noted in memorandum on trenchfoot in the Third and Seventh U. S. Armies that, between

October and 18 November, 1,441 cases had been reported in the Seventh

U. S. Army and that about 50 percent of these were instances of recurrence.

The experienced divisions from which most of these recurrences came had few

new cases except among Japanese-American troops. These troops had suffered

heavily from this cause in Italy and had the same experience in France. Other

estimates of recurrent trenchfoot in soldiers who had sustained cold injury in

Italy the previous winter ranged from 30 to 35 percent.

When investigators from the Office of the Chief Surgeon, ETOUSA,

questioned the surgeons from various combat divisions concerning recurrent

cases of trenchfoot and their opinion of the susceptibility to subsequent cold

injury of those who had previously experienced it, it was the consensus that

men with prior injuries were more susceptible to subsequent injury. The

following endorsement forwarded by the Surgeon, 45th Infantry Division, to

the Surgeon, Seventh U. S. Army, was based on the opinions of all surgeons in

the division and was representative of the opinion in the whole theater:

a. Trench foot in Italy, especially if of such degree as to be classified as moderate, did

render the men susceptible to vascular disturbances in the feet between the period of landing

in Southern France and the onset of weather cold enough to actually precipitate trench foot.

b. Persons who have had trench foot will not tolerate well intensive marching, even

though the weather is warm.

Incidentally, the surgeon of the 2d Infantry Division recorded that men

who had suffered from frozen feet in Michigan during winter maneuvers

earlier were the first to succumb to cold trauma in the 1944-45 campaign

on the Western Front.

The situation with respect to recurrence is excellently summed up in

report from the 23d General Hospital covering data from November to

December 1944 and included in Essential Technical Medical Data, ETOUSA, for November 1944:

Of 122 so-called recurrent cases, 58 patients had received previous hospital care for cold

injury. They had spent total of 3,788 days (10.3 years) in hospitals, and 749 additional

days in reconditioning. Many of them had been returned to (full) duty, and had remained

on full duty for several weeks, but closer analysis showed their activities to have been of

limited nature. These men were really burden to their commands because of frequent

sick calls, the periods they spent in quarters, their constant complaints of foot pain on

walking and in wet, cold weather, and the necessity of transporting them in vehicles when
EPIDEMIOLOGY OF COLD INJURY

the troops advanced. Return to combat conditions frequently caused prompt relapses,

especially in men who had sustained their first cold injuries in France. Patients with

recurrent cold injury did not have more severe grade of injury than those primarily affected,

but their tolerance to wet and cold was definitely less.

Medical officers responsible for the management of trenchfoot did not at

first comprehend the ready susceptibility to subsequent cold injury of men

who had previously sustained such injuries. They soon learned the lesson.

In the winter of 1943-44, for instance, 50 percent of all men with trenchfoot

treated at the 45tb General Hospital in Italy were returned to full duty. In the second winter, when the risk of retraumatization by cold had become more

clearly understood, only 2.1 percent were returned to full duty.

Experiences in the European theater also showed that the usefulness to

the Army of man who had sustained cold injury was likely to be limited.

On December 1944, the Commanding General, Third U. S. Army, wrote to the Theater Chief Surgeon that serious consideration must be given to the

rapid replacement of able-bodied soldiers in the rear by men who had suffered from trenchfoot and who could do duty as military police or truck drivers or

who could work in other posts in which they would not again be exposed to wet and cold.

During the week ending 24 February 1945, the Office of the Surgeon,

United Kingdom Base, surveyed one general hospital chosen at random from

each of six hospital centers in respect to the trenchfoot situation. The disposition of the patients indicated that the lesson of recurrent cold injury had been

learned. There had been 1,828 dispositions in total of 3,769 admissions for

cold injury in these six hospitals up to and including 21 February 1945. Of this

number, 192 men had been returned to general duty (11 percent); 672 had

been returned to limited duty (37 percent); 443 had been sent to convalescent

hospitals (24 percent); and 520 had been evacuated to the Zone of Interior

(28 percent). In short, and assuming that the men returned to full duty had

been able to stand up under it, which is highly unlikely assumption, 89 percent

of 1,828 combat troops bad been lost from combat duty because of cold injury.

The results were somewhat better in the hospitals which had stressed early,

active exercise and had conducted special classes in rehabilitation.

These dispositions were far from the optimistic predictions advanced early

in the winter. In the 1944 report of the 108th General Hospital in Paris, in

which 150 beds had been set aside for the investigation of cold injury, the

estimate was that only 10 percent of the casualties from this cause would have

severe enough injuries to require evacuation to the Zone of Interior and that

37 percent would have injuries mild enough to permit their return to duty

within 60 to 90 days. As matter of fact, about third ofall patients admitted

with cold injury as the primary diagnosis had to be evacuated to the Zone

of Interior and 18 percent received Certificate of Disability discharges.

One reason why it was thought that recurrence would not be factor

of major importance in field forces on the Western Front was that the evacuation

See footnote 8, p. 380.
384 COLD INJURY, GROUND TYPE

policy encouraged the removal to rear echelon medical installations of men

with even mild injuries if their symptoms lasted more than or days. 10

With triage and evacuation policy of such strictness, opinions were expressed

as late as January 1945 that recurrent trenchfoot would not be great in combat

soldiers. Recurrence did take place, however, when many casualties originally

evacuated with apparently mild injuries were returned to combat duty; the

importance of previous cold injury as host factor in the causation of this

type of trauma thus was proved again.

When the weather became warmer, many hospitals began to send larger

proportions of their patients with cold injury back to full duty, or to limited

duty, on the ground that they would not be exposed again to extreme cold or

wet cold. This policy was also not successful. Men returned to even limited

assignments did not usually hold up well under their duties, and many of them

eventually had to be evacuated to the Zone of Interior.

The evidence collected in Italy and in the European theater thus left no

doubt that the wisest plan of disposition was to return all casualties with

cold injuries, unless they were very mild (first degree), to the Zone of Interior for

possible assignment to theater where the climate was more moderate and

their services could be better utilized. The loss of time was enormous when

they were returned to fidl or even limited duty in cold climate. It would

have been wiser to retain in the theater in which they had sustained their

injuries only those who had some special talent for the war effort. Even when

this plan is followed, the residua of cold injury (p. 284) will often make these

soldiers burden rather than an asset to their organizations.

Because so many men with recurrent cold injuries lacked any objective

evidence of the disease, their management was particularly difficult. When

there was obvious tissue damage, the decision was simple, but no test was

available by which physiologic disturbances could be demonstrated, and, in

the absence of sound proof to the contrary, complaints had to be accepted at

their face value. At that, malingering was suspected in surprisingly small

number of cases. 11

Inherent constitutional factors.-—Lewis, in his discussion of chilblains and

in his reports on cold in general (p. 235), has shown that the individual response

to cold varies greatly from person to person. This fact is generally accepted,

though the inherent constitutional reasons for the variability are not readily

apparent. The Raynaud and Buerger syndromes are well known and easily

recognizable clinically, but the abnormal physiologic processes upon which

they are based have not been satisfactorily explained. It is not at all clear

why moderate cold should act as trigger mechanism in one person, setting off

the typical response to cold, including blanching and even blue coloration

Minutes, Trenchfoot Conference, Office of the Chief Surgeon, ETOUSA, Paris, 24 Jan. 1945. 11 Another Interesting feature of the report of the research team which studied cold injury in Korea during the winter

of 1951-52 (p. 330) was its confirmation of the experiences in the Mediterranean and European theaters concerning the

effects of previous cold injury. previous injurywas shown incontrovertibly to predispose to secondattack (p. 417).

The attack rate among soldiers who had had no previous injuries was 2.6 per thousand, compared to 5.0 per thousand for

menwho had previously sustained cold injuries.
EPIDEMIOLOGY OF COLD INJURY 385

of the skin, while in other persons under the same conditions of exposure

sensitivity is very much less marked.

Lange and his associates, 12 who accept the thesis that sensitivity to cold

varies widely from person to person, take the position that susceptibility is

rather constant in the same subject They subjected volunteers to spot-freezing,

applying to an area cm. in diameter metal capsule at 3.6° F. (—15.8° C.) for

30 minutes. Exposures that consistently produced extensive gangrene in the

total exposed area in some volunteers did not cause tissue breakdown in others,

in spite of repeated tests. Lange and his group believe that by means of

standard test procedures to be developed from investigations such as these it

may be possible, eventually, to screen persons with an unusually high sensitivity

to cold.

German students of cold injury have repeatedly emphasized the importance

of individual susceptibility to cold. Block, 13 for instance, concluded that the

vasomotor constitution of the particular soldier is the determining consideration and that asthenic types are most susceptible. Stucke 14 found that men who

had followed indoor occupations were more susceptible to cold than those who

followed outdoor occupations and that persons whom he described as vagotonics

suffered most severely of all.

Gohrbandt, 15 who studied this phase of cold injury thoroughly, divided

persons who suffer from cold into two groups, (1) those who show no overt

residual signs after injury and (2) those who continue to show signs and symptoms, such as impaired circulation in the skin, low temperatures in the extremities, sensory disturbances, hyperhidrosis, and inadequate muscular

response to exercise. Men in the latter group he regarded as constitutionally

susceptible to cold and fit for military duty only in warmer climates. In his

opinion, an army medical service should include vascular center, one of the

functions of which would be the differentiation of personnel who are susceptible

to cold and those who are not. He did not consider that it would be practical

for the unit medical officer to undertake this task.

Gohrbandt regarded the vagotonic or bradycardic individual as extremely

susceptible to cold. In this group, he placed all those with pulse rates of less

than 68 per minute and those with any proneness to allergic spasms, dermatographia, and early fatigue. He regarded sticky sweating of the hands and

feet as commonly associated symptom. He also quoted Koch’s dictum to the

effect that cardiac vagotonics are potentially circulatory sympatheticotonics

and suggested that men who answer this description should not be assigned to

service in cold climates. This is sound principle. Its development and

12 Lange, K., Weiner, D., and Boyd, L. J.; Frostbite; Physiology, Pathology and Therapy. New England J. Med

237:383-389, 11 Sept. 1947. 13 Block, W.: Die Bedeutung des Vegetativen Nervensystems heim Zustandekommen Ortlicher Erfrierungen. [The

Significance of the Autonomic Nervous System in Frostbite.] Arch. klin. Chir. 204 64-83, 20 Dec. 1942. Abstract in

Bull. War Med. 4; 268, January 1944. 14 Stucke, K.: Kalteschaden und Erfrierungen In Felde. [Cold Injuries on Active Service.] Beltr. Klin. Chir. 174;

1-10, 30 Nov. 1942. Abstract in Bull. War Med. 4; 507, May 1944. 13 Gohrbandt, E.: Wiedereinsatz Frostgeschadigter. [The Return to Service of Soldiers who have Suffered from

Frostbite.] Zbl. Chir. 70; 1584-1586, 30 Oct. 1943. Abstract in Bull. War Med. 5; 552, May 1945.
386 COLD INJURY, GROUND TYPE

practical application, however, await better understanding of the physiologic

abnormalities involved in susceptibility to cold and the development of simple

specific tests along the lines of those proposed by Lange and his associates.

Ian Aird, who abstracted Gohrbandt’s article which has just been summarized, commented editorially on the more specific type of susceptibility to

the local effects of cold (that is, hereditary cold fingers, chilblains, Raynaud’s

syndrome, and the conditions which give rise to them) and criticized him for

not including them in his discussion. In Aird’s own opinion, cold susceptibility

can be detected on moderately cold winter morning merely by inspecting the

hands of the men who are drawn up on parade. This kind of testing is an

obvious improvisation. It is no more capable of weeding out the persons who

are less than grossty susceptible to cold than sick call inspection can identify

man with rheumatic heart disease who presents no gross physical signs.

The captured German medical officers and noncommissioned medical

officers who were interviewed in January 1945 in the European theater (p.

204) consistently mentioned the constitutional makeup (that is, the state of the

sympathetic and parasympathetic nervous systems) as factor in cold injury.

They also commonly expressed the opinion that age, previous cold injury, and

the use of tobacco influenced individual susceptibility to cold injury. 16

The theory has been advanced that persons who present cold agglutinins

in the blood may be more susceptible to exposure to cold, and may present

higher percentages of intravascular agglutination and ischemia as result, than those in whom this finding is absent. 17 On the basis of this theory,

Loewenthal studied 24 patients with trenchfoot and obtained data which he

interpreted as indicating that cold agglutinins were found more often in their

blood and tissue fluids than in the blood and tissue fluids of the normal soldiers

used as controls. Boland, Claiborne, and Parker, 18 who also found higher

incidence of cold agglutinins inpatients with trenchfoot than in normal controls, stated that these agglutinins were invariably present in the patients with

gangrene who were included in their series. The significance of these observations remains to be elucidated.

In survey of 158 patients with trenchfoot on the surgical service at the

United States Army General Hospital, Camp Butner, N. C., then serving as

trenchfoot center, it was observed that over 95 percent fell into the group of

cases described by Gage 19 as vascular variants. These men had previous

histories of hyperhidrosis, cold feet, nervousness, which sometimes seemed

16 Observations of the research team which studied cold injuryin Korea during the winterof 1951-52indicated negative correlation between the use of tobacco and frostbite. There was highly significantdifference in the use of tobacco

among frostbite victims and their bunkermate controls, with the men with frostbite consuming far less tobacco than the

nonfrostbitten controls. Possible psychiatric factors may explain this finding.

The report of the team bore out to some extent Gohrbandt’s theory that the bradycardie individual is particularly

susceptible to frostbite. The mean pulse rate of cold injury casualties was 75.3 per minute compared to 86.8 per minute for controls.

17 Report, Lt. Col. Fiorindo A. Simeone, MC, to the Surgeon, Fifth U. S. Army, subject: Trenchfoot in the Italian

Campaign 1943-45. 18 Boland, F. K., Claiborne,T. S., and Parker, F. P.: Trench Foot. Surgery 17: 564-571, April 1945. 19 Letter, Col. I. M. Gage, MC, Headquarters, Fourth Service Command, to Brig. Gen. Fred W. Rankin, Chief

Consultant in Surgery, Office of the Surgeon General, 23 Mar. 1945.
EPIDEMIOLOGY OF COLD INJURY 387

hereditary, and other evidence of sympathetic imbalance. They stated that

they had developed cold injury under circumstances in which large numbers

of their associates had not. number of them presented marked dermatographia, with wide hyperemic flares along the pencil marks.

Preexisting Pedal Deformities, Infections, and

Circulatory Abnormalities

In this same connection, Col. Charles B. Odom, MC, Consultant in Surgery, Office of the Surgeon, Headquarters, Third U. S. Army, noted that

the number of deformities such as claw foot, hammertoes, and other pedal

deformities was extremely high in patients with trenchfoot as compared to the

rest of the hospital population. 20 He wondered how some of these men had

ever been accepted in the infantry, and he had no doubt that when they sustained cold injury they were far worse off than men with normal feet. Other

observers commented that men with circulatory deficiencies, flat feet, and other

foot troubles were foot conscious, reported on sick call promptly, and therefore

tended to have milder forms of cold injury. If, however, they could not obtain

care, or if they were treated improperly, they presented severer form of injury, after less exposure, than men without previous foot disabilities.

In both the Mediterranean and the European theaters, there was large

amount of fungous infection of the feet. It caused good deal of concern,

particularly in the European theater, because of the potential loss of manpower

to which it might lead. Investigation showed that the incidence was related

to number of factors, including poor foot hygiene, the type of duty assignment, the use of shoes with rubber soles, the use of extremely heavy Britishissue socks in warm weather, variations in the care of showers, failure to use

preliminary foot baths, and the use of previously worn hospital slippers which

had not been sterilized. The control of these factors invariably reduced the

incidence of fungous infection. There was no apparent connection, however,

between previous fungous infection of the feet and the development of cold injury.

An attempt to determine the possible relation of previous injury or disease

to the occurrence of trenchfoot was undertaken in the Mediterranean theater

but was not conclusive. 21 review of the histories of 144 patients with trenchfoot who were admitted to hospital in North Africa in the first winter of the

Italian fighting showed no higher incidence of previous disease or injury than

was found in control series of 877 patients admitted to the same hospital for

other causes. The distribution of possible etiologic factors, indeed, was strikingly similar in both series.

Fifty patients with trenchfoot who were studied intensively in Italy in

November 1943, soon after the epidemic nature of the condition was realized,

were investigated from the standpoint of dorsalis pedis pulsations. These

20 See footnote 10, p. 384. 21 See footnote 17, p. 386.
388 COLD INJURY, GROUND TYPE

pulsations were not palpable in 11 men after week of hospitalization, which

is very close to the proportion (25 percent) found absent in 125 casualties with

trenchfoot studied later in another general hospital in Italy. The over-all

frequency with which these pulsations cannot be palpated in men of this age

group, while it is not known, is almost certainly not as high as 25 percent. In

neither of these studies was it possible to distinguish cause from effect, and conclusions concerning the etiologic significance of these observations are not

justified.

postwar study, by Silverman, 22 of the dorsalis pedis and posterior tibial

pulsations in 1,014 infantrymen revealed that one or both were absent in 13

percent, although absence of both pulsations on the same side occurred only

five times in the entire series, and both pulsations were absent in both feet in

only one case. The posterior tibial pulsation was more frequently absent in

Negro subjects, and the dorsalis pedis in white subjects. Both arteries were

found to show wide anatomic variations, and Silverman emphasized that

these variations should always be taken into account before pulsations were

reported to be absent. The material in this survey, the conditions of which

were carefully controlled, seems comparable to that studied in the Mediterranean

theater.

In the Pacific, Col. I. Ridgeway Trimble, MC, consultant in surgery,

felt strongly that men with circulatory anomalies of the lower limbs would be

particularly susceptible to trenchfoot. He therefore made serious, though

unsuccessful, effort to have screening from this point of view made part of the

preliminary physical examination (p. 222).

Physiologic processes.—While it is not within the scope of this volume to

discuss the general physiologic processes involved in heat production in the

body, or to describe the mechanisms of human-heat regulation, these functions

cannot be entirely ignored. They are intimately related to the nutritional

status of the host (p. 394), and lowering of efficiency or other alterations may

account, in part, for the influence of recent infectious disease (p. 390) on cold

susceptibility. When there is an excessive loss of body heat because of low

environmental temperatures, the metabolic rate rises in an effort to maintain

balance between heat loss and heat production. The principal sources of the

compensatory heat are the liver and the muscular tissues, especially those of

the extremities. The mechanism involves increased tone of the skeletal

muscles, involuntary muscle reactions, such as shivering, and the contraction

of the smooth muscles of the skin which results in gooseflesh. All of these

reactions consume energy and eventually produce fatigue. Some hemoconcentration also occurs, and there is probably an increase in therate of circulation

of the blood.

Numerous observations have been made on the basal metabolic rate in

relation to environment, though none of the studies is conclusive. It is generally believed that thyroid function is increased in cold climates, and there is

22 Silverman, J. J.: The Incidence of Palpable Dorsalis Pedis and Posterior TibialPulsations in Soldiers. An Analysis of Over 1,000 Infantry Soldiers. Am. Heart.1. 32: 82-87, July 1946.
EPIDEMIOLOGY OF COLD INJURY 389

some evidence that oriental races and white men living under the same climatic

conditions have different basal metabolic rates. 23 White persons living in

tropical climates appear to have reduced metabolic rates. By comparison,

rates for Eskimos are higher.

Experiments have been carried out under the auspices of the Medical

Research and Development Board, Office of the Surgeon General of the Army,

to determine changes in thyroid activity in hypothermia by the use of tracer

radioactive iodine. Lange, Gold, Weiner, and Kramer 24 conducted experiments on rabbits to observe the possible protective effect of thyroid adminis- tration against cold injury. Animals given thyroid in amounts sufficient to

raise their basal metabolic rates between 30 and 50 percent had reduced rate of loss of body heat and decided prolongation of survival time, which could he

increased by as much as 54 percent when the optimal dosage of thyroid was

administered. Conversely, there was an increase in the rate of loss of body

heat and reduction of survival time, in comparison with normal controls, when

thyroid function was suppressed by the administration of thiouracil. The

protection afforded by thyroid administration was not immediate. There was

timelag of or days after the drug was given before any protection against

cold was discernible. These studies suggest that the level of the basal metabolic rate may serve as an index of susceptibility to cold, and also suggest that

personnel with depressed or borderline rates may be unsuited for military

service in cold climates.

Selye, 25 who studied the protective physiologic mechanisms which come

into play as result of long-continued stress of various kinds, concluded, in

general, that mild stress reactions may be beneficial but that reactions which

are excessive or of long duration may give rise to diseases of adaptation. Cold

is an agent of stress.

The general adaptation syndrome may be subdivided into (1) the alarm

reaction, which may be followed by shock phenomena, including hypothermia,

hypotension, hemoconcentration, increased capillary permeability, and depression of the central nervous system; (2) the stage of resistance, which follows

upon continued stress and the development of adaptation, characterized by

enlargement of the adrenal cortex and increased secretion of cortical hormones;

and (3) the stage of exhaustion, which occurs when the degree or duration of

stress is such that adaptation fails and defenses are lost.

The defense mechanism, Selye has pointed out, is intimately related to

the activities of the hypophysis and the adrenal glands, the hormones of

which play an important role in metabolism. In McFarland’s studies (p. 393),

which include the stress factor of fatigue, information is summarized on the

relationship between fatigue and the excretion of the 17-ketosteroids. In

23 Best, C. H., and Taylor, N. B.: The Physiological Basis of GeneralPractice. 2d ed. Baltimore: Williams and

Wilkins Co., 1950. 24 Lange, K., Gold, M. A., Weiner, D., and Kramer, M.: Factors Influencing Resistance to Cold Environments.

Bull. U. S. Army M. Dept. 8; 849-859, November 1948. 25 Selye, H.; The General Adaptation Syndrome and the Diseases of Adaptation. Practitioner 163:393-405, November

1949.
390 COLD INJURY, GROUND TYPE

extreme cases, this observer believes, there is significant positive correlation.

He also believes thatfurther study of neuroendocrine changes would be valuable,

since, if these reactions are part of adaptation to all stresses, accurate and

useful indexes of fatigue and other stresses might thus be determined. If

McFarland’s theory is correct, promising avenue of approach to the cold

problem would seem to be opened.

The Medical Department Field Research Laboratory, as part of its investigation of the physiologic effects of cold, endeavored to determine the

factors which control the secretion of the various endocrine organs under

conditions of stress, including cold. It was found that hyperglycemia produced in experimental animals by orally administered glucose caused an increase in adrenal cholesterol and that an insulin-produced hypoglycemia caused

decrease. The results thus indicate, respectively, an inhibition and stimulation of the adrenal cortex. Loss of cholesterol from the adrenal gland, which

was observed in experimental animals exposed to low temperatures, was

interpreted as evidence of decreased resistance. When aqueous adrenal

cortical extract was administered to animals exposed to cold, it prevented the

lowering of the adrenal cholesterol to the levels observed in control animals.

The understanding of these various inherent constitutional factors is, at

best, imperfect at this time, and further investigation along these lines is

essential if military management of personnel under stress, including the

stress of cold, is to reach an optimum level of effectiveness.

Recent infectious disease. —Russian authorities, especially Ariev (p. 240),

laid great stress upon recent infectious disease, in addition to wounding and

other trauma, as factor predisposing to cold injury. Their principal concern,

however, was with severe frostbite, not trenchfoot. Neither the World War

nor the World War II experience with cold injury affords basis for this

point of view or for any other authoritative opinion concerning the influence

of infectious disease on susceptibility to cold trauma. On the other hand, it

is reasonable assumption that the physical stress of an infectious disease

would increase susceptibility to cold by lowering the efficiency of the circulatory

system, reducing the local skin resistance to trauma, increasing fatigue, and,

in general, decreasing physical fitness.

Posture and dependency.-—The position of the host has decided influence

on the incidence and severity of cold injury of the lower extremities. When

Lange and his associates restricted the movements of rabbits during exposure

to cold, they observed decided decrease in survival time in the restricted

animals as compared with that in animals exposed to the same conditions but

left free to move about.

Attention has already been called to so-called sbelterleg, type of injury

similar to trenchfoot, which occurred in persons sleeping in deck chairs or on

benches or boxes, with the lower extremities dependent, in the cool, damp

air-raid shelters in London (p. 9). Dependency was also shown to be an

important factor in immersion foot in surviving shipwrecked sailors, who had

been compelled to sit or stand for several days in lifeboats or on rafts, with
EPIDEMIOLOGY OF COLD INJURY 391

little opportunity for movement and with their feet wet or in water. The records of frontline units afford many examples of the high incidence of cold

injury among men pinned down by enemy fire and forced to remain sitting

or squatting in wet, cold foxholes for long periods of time. There were also

numerous excellent individual and small unit illustrations of men similarly

pinned down who had moved their feet and legs sufficiently to ward off cold

injury. In one instance, cold injury developed among all the men in one frontline unit except those who left the position daily to go after the rations. Fatigue.—The role offatigue in the development of trenchfoot is difficult to

isolate as an entity. Fatigue develops in proportion to the duration and intensity of stress. Similarly, the development of cold injury is related to the period

of exposure. Time is factor in both fatigue and cold injury, and periods of

stress and exposure are likely to coincide. Fatigue is also inherent in exposure

to cold, especially when loss of body heat and shivering are taken into

consideration.

For these various reasons, difficulties arise in the evaluation of the host

factor of fatigue. Crude measurements can be made in terms of old and new

troops, and by the comparison of the incidence of trenchfoot in troops in the

line or in combat for few days with the incidence in troops in line or in combat

for many days. Wartime data do not provide good examples of any specific

studies made to determine the influence of fatigue in the production of cold

injury, and the general data available by units are not specific enough to permit

correlation studies to demonstrate its effects. As in the matter of individual

training, it is necessary to make assumptions and draw broad conclusions from

circumstantial evidence alone.

Fatigue is interpreted as meaning exhaustion of strength because of toil

and weariness. It is mental and emotional as well as physical. It is important

as host factor in cold injury, if for no other reason than that soldiers, when

they are fatigued, are less willing as well as less able to carry out such simple

preventive measures as removing their shoes, putting on dry socks, massaging

their feet, and exercising to restore the efficiency of the circulation in the lower

extremities. Under circumstances of fatigue, discipline generally deteriorates,

the deterioration including one of the key points in control of trenchfoot;

namely, discipline of the individual soldier in carrying out measures for his

own protection.

Soldiers in the trenchfoot opinion survey to be described (p. 400) were

questioned about the number of days they had been without rest (table 16).

Seventy percent of those with trenchfoot had been in combat days or more

before the onset of cold injury, and almost half (44 percent) of those who

contracted it had fought for 15 days or more without rest. Details concerning

the type of combat, periods of intense exposure, and other modifying factors

are not available, but, if it can be assumed that they balanced out, it seems

reasonable to infer from the data that fatigue, as expressed in days of actual

combat, does influence the incidence of cold injury. The soldiers who did not

contract cold injuries showed an almost identical distribution of combat days,
COLD INJURY, GROUND TYPE

Table 16.—Combat days without rest before onset of trenchfoot in 1,018 patients hospitalized

in Zone of Interior

but in this instance these men cannot serve as controls because fatigue may

also predispose to injuries other than cold trauma.

Fatigue is also an element in the differential between units that had good

rotation of individuals and total units, as opposed to those that had no rotation

policy and that required units and individuals to stay in the line for reasons of

tactical expediency. This point is discussed in more detail elsewhere (p. 446),

but it may be said here that soldiers in combat are chronically fatigued and that

their fatigue is resolved only when they are brought out of the line and provided with facilities for rest. The difference between the incidence of cold injury

in units in combat and in units in reserve is striking, as would be expected;

but the presence or absence of other modifying factors, such as exposure, wet

clothing, lack of shelter, inadequate food, and perhaps other considerations precludes more than generalized inferences concerning the host factor of fatigue.

It all comes down to the fact, already pointed out, that under combat conditions

fatigue was not evaluated and could not be evaluated in relation to cold injuries or to battle casualties in general. For that matter, the influence of

fatigue upon nonbattle injuries, especially accidents, is not more than hinted

at in the available records.

Nonetheless, the influence of fatigue upon the incidence of cold injury can

be roughly demonstrated by the following experience of three regiments of the

83d Infantry Division between December and 27 December 1944.

Unit case history No. 1.—This division left the United States in the spring

of 1944, entered active combat in Normandy soon after D-day, and by early fall

had fought across France into Luxembourg. During November, the division

had light static defensive assignment. On December, the 330th Infantry

Regiment was thrown into hard fighting in an active offense in the Hurtgen

Forest. Four days later, on December, the 331st Infantry Regiment entered

upon the same type of combat. The 329th Infantry Regiment was not committed until 11 December. All three regiments fought in thickly wooded, hilly,

muddy terrain. The weather was continuously cold and rainy, and the troops

lived in foxholes, with little rotation possible because of the tactical situation.

Days without rest Trenchfoot cases Days without rest Trenchfoot cases

Number Percent umber Percent

20 72

to 14 265 26

10 15 to 30 295 29

20 31 and over 153 15

20 Unknown 61

61

41 Total 1, 018 100
EPIDEMIOLOGY OF COLD INJURY 393

In other words, there was no fundamental difference in the mission of any of these regiments, and all three experienced the same tactical and environmental

conditions. The only differential of importance was the period of combat.

The order of magnitude of trenchfoot experience in the three regiments was in

rough proportion to the period of time each spent in combat. The highest

incidence was in the 330th Infantry Regiment, which had the longest period of

combat, and the lowest in the 329th, which had the shortest. In this respect,

the 331st Infantry Regiment was intermediate (chart 8, table 17).

good deal of attention has been devoted to the effects of fatigue upon Air

Force personnel and airline pilots and other operational personnel. McFarland’s

book on human factors in air-transport operations contains review and critical

analysis of the whole subject, as well as summary of the general concepts of the nature of fatigue. Fatigue is discussed in relation to the operation of motor vehicles, and there is special discussion of the temporary proneness to accidents

observed among drivers of cross-country trucks after long hours at the wheel.

Physical, mental, and emotional fatigue is defined, methods of measuring each

of them are described, and acute fatigue and chronic fatigue are differentiated.

Special stress is laid upon the fact that chronic fatigue is not relieved by short

periods of rest and is therefore cumulative.

Much of McFarland’s work, as is clear from this brief resume, is directly

applicable to many aspects of fatigue in combat ground forces. He did not,

however, discuss the relation of fatigue to trauma, except trauma resulting from

accidents, and further investigations and research in this field would be highly

Chart 8.—Cold injury in regiments of the 83d Infantry Division, European theater, for weeks

ending 10 November 1944 through January 1945
394 COLD INJURY, GROUND TYPE

Table 17. Cold injury in regiments of the 83d Infantry Division, European theater, for weeks ending 10 November 1944 through January 1945

profitable. He emphasized the need for further research on neuroendocrine

mechanisms as part of the fatigue process and as part of emotional fatigue.

Physiologic changes resulting from fatigue, particularly as they affect nervous

tissue, blood vessels, and the susceptibility of tissue in general to trauma also

require great deal more study.

Nutritional status.—Just as with fatigue, it is difficult to measure and

assess the nutritional status of the individual soldier under combat conditions.

Poor nutrition is undoubtedly factor in the development of physical fatigue,

and it may also influence the man’s psychic responses in his reaction to the

requirements for self-preservation. The nutritional status has direct physiologic bearing upon the efficiency of the circulatory system and also upon the

ability of local tissue to resist trauma and infection. Miller, 26 after studying

groups of men living for periods of up to 10 days in extreme cold, with daily

caloric intakes varying from no calories to 4,000 calories, noted directrelationship between physical fitness and ability to rise to situations of stress. Men

on low caloric intakes were inactive and responded with less serious effort to

situations in which their survival was at stake. Failure to exercise in an

effort to improve the circulation is part of the causation of cold injury, and

failure to expend the necessary energy to change the shoes and socks and massage

the feet is also cause. In this study, both causes could be related to poor

nutritional status combined with fatigue.

It is not always simple matter to provide troops in active combat with

adequate rations. Inadequacies are often associated with the stress of hard

fighting, and sometimes with long periods of inactivity. During rapid motorized advances, or when forces are pinned down in static positions and are largely

26 See footnote 4, p. 379.

Week ending— 329th

Infantry 330thInfantry 331st Infantry Total

19

November 10

17 10

24

December

12 12

15 10 63 42 115

22 25 52 24 101

29 13

1945 January

Total 46 146 69 261
EPIDEMIOLOGY OF COLD INJURY 395

cut off by tiie enemy, sufficient rations often cannot reach the frontline. Then

men must subsist on emergency rations for periods well in excess of those for

which these rations were intended. In these situations, it is conceivable that

mild degrees of dehydration, as well as subclinical vitamin and protein deficiencies, will occur and may be sufficient to affect the general host susceptibility

to cold injury.

No specific studies on these points were carried out during World War II,

and survey of unit histories does not reveal any circumstances in which

nutrition appeared to be the only variable in the factors productive of cold

trauma. number of tactical situations were recorded, however, in which

troops of battalion or regimental size were cut off by enemy action for periods

varying from few days to few weeks, in circumstances in which poor nutrition

undoubtedly was an important consideration in the causation of cold injury.

At the same time, cold and wet, and number of modifying factors such as

exposure, lack of shelter, immobility, intense combat, fatigue, and emotional

stress also came into play. It is therefore not possible to evaluate the factor

of nutritional status accuratelv by the method of unit study.

It is nonetheless interesting in this connection, despite the limitation of

many variables, to analyze the cold injury experience of the 8th Infantry

Division, which was virtually isolated for period of weeks (chart 9, table 18).

Unit case history No. 2.—This division arrived in Ireland from the United

States in December 1943. It crossed to the Continent early in July 1944, and

by late October had fought across France to Luxembourg. By this time it

Chart 9.—Cold injury in regiments of the 8th Infantry Division European theater for
396 COLD INJURY, GROUND TYPE

Table 18. Cold injury in regiments of the 8th Infantry Division, European theater, for weeks ending 17 November 1944 through February 1945

had become an experienced combat division. From November to 20 November inclusive, it fought defensive action in Luxembourg on 30-mile front,

over terrain which was hilly and rugged but which was relatively dry except

for the muddy lowlands. During this period, the weather was moderately

cold and there was considerable rainfall, but the troops had fairly satisfactory

shelter. Rotation was good, and each man had two hot meals daily. Trenchfoot incidence did not exceed 25 cases per week.

On 21 November, the troops were moved to the Hurtgen Forest. Here,

between 23 November and December inclusive, they fought an active offensive

action. The terrain was wooded and flat. The weather was moderate, but

there was considerable rainfall, and the ground, which was poorly drained,

became extremely muddy. An upsurge of cold injuries occurred late in

November and in the first few days of December (chart 9, table 18), predominantly in the 121st Infantry Regiment. The incidence was not exorbitant

and could be accounted for by heavy offensive action.

The type of combat action changed on December, and from that time

until 25 December the division made limited attacks in the same area to clean

out towns. It also conducted sporadic, intermittent offensive actions. On

December, the 28th Infantry Regiment was almost completely cut off in the

Hurtgen Forest and could not be relieved until 23 December. During this

period, the men were isolated and were almost continuously pinned down by

enemy fire. Supplies had to be delivered through long, narrow corridor and

could be brought forward only at night. The type of ration provided is not

Week ending— 13th Infantry 28th Infantry 121st Infantry Total

19

November 17

24 20 24

December 14 24 59 97

13 19 31 63

15 12 86 18 116

22 89 14 no 29 15 23

1945 January 13

12 10 12 27

19 19 28

26 13 28 50 February 12 25

12

Total 76 288 224 588
EPIDEMIOLOGY OF COLD INJURY 397

stated in the regimental and divisional records, but circumstances such as these

usually meant that K-rations had to be used. Hot food and facilities for

heating food could not have been made available.

Before the period of isolation, this regiment had bad less than 25 cases of

cold injury week. With isolation, there was an immediate and dramatic

rise in incidence, there being 86 cases the first week of isolation and 89 cases

the second. Almost as soon as the regiment had been relieved, the incidence

fell to 15 cases per week, or fewer, and did not rise above this level for the next

weeks. Thereafter, except for 25 cases recorded for the week ending on

March 1945, cases per week did not exceed during the time that cold injury

was prevalent.

This was not simple situation. Many variables were involved. The

combat action was severe. Rotation was impossible. Shelter was limited to

wet, muddy foxholes. All of these circumstances are conducive to cold injury.

On the other hand, this was an experienced, battlewise unit. It had acquitted

itself well in other engagements of equal intensity, in which it had had no

undue incidence of cold injury. The principal difference in the situation

described was isolation, which always greatly complicates the problem of

providing adequate food for troops, while at the same time it increases exposure

and decreases the effectiveness of triage and medical care. It can fairly be

said, therefore, that inadequate nutrition was apparently factor in bringing

about an increased incidence of cold injury in this experienced unit during period of isolation.

Psychosocial factors.-—At the beginning of World War 11, the status of

knowledge of psychosocial factors and of the possibilities of influencing them

through preventive psychiatry was not such as to permit an attack upon them

with any confidence. These are crucial elements in the effectiveness of combat

personnel. They encompass the total range of physical, mental, and emotional

stress; battle casualties; nonbattle injuries; combat exhaustion; and neuropsychiatric disability in addition to cold injury. Their efficient analysis would

require the combined efforts of qualified psychiatrists, psychologists, and

sociologists, as well as of competent military leaders.

It is necessary, in spite of these lacks and requirements, to fill in the general

background of the psychic effects of stress in order to appreciate bow the

addition of further stress, in the form of wet and cold, could intensify the

situation. The data collected in World War II provide no means of measuring

accurately the psychosocial host factor. It can be thought of only as part

of the over-all host factor of stress and as component in the total causation

of cold injury.

The cost of neuropsychiatric casualties, together with the concept that

men wear out in combat, just as truck wears out under continuous use, was

not fully appreciated in the early phases ofWorld War IIby any medical officers,

including psychiatrists. Later, both in Italy and on the Western Front, the

value of psychiatric advice and consultation as preventive measure was much

more widely appreciated, and psychiatrists were assigned as far forward as

438404 —58 27
398 COLD INJURY, GROUND TYRE

divisions. There were many times, however, when the tactical situation made

the application of optimum psychiatric procedures impossible, and the effectiveness of these measures also showed unit variations. As result, rates for

psychiatric casualties remained high throughout the war, especially during

periods when combat action was severe and protracted.

Of all combat branches, the infantry is exposed to the greatest danger of

trauma. An analysis of attrition and replacement in the Fifth U. S. Army

during its operations in North Africa 27 revealed that, by the time regiment

had been in combat 120 days, 50 percent of the original strength of its rifle

battalions had been killed, wounded, or captured or was missing in action.

The percentage would have been higher except for the removal of men from

combat for illness or noncombat trauma. Neuropsychiatric rates of 1,200 and

1,500 per 1,000 per year were recorded in many rifle battalions, in comparison

with rates of 30 or less in units of similar size in other branches of service.

Fifteen to twenty percent of the total nonfatal combat losses sustained

during severe combat in World War II were usually found to be neuropsychiatric, the proportion depending upon the intensity and duration of continued

combat. Limits of endurance for the average soldier were found to range

between 200 and 240 regimental combat days. Soldiers who received psychiatric care at the end of 200 combat days or earlier could usually be returned

to combat duty. Men treated later were, as rule, permanently lost as combat

personnel. The British in Italy expected to obtain service of approximately

400 combat days per rifleman, but their policy was to relieve frontline riflemen

after period of 12 days or less, for rest periods of days. American troops

in the same theater, in contrast, were often in combat up to 40 days without

relief, and sometimes fought as long as 80 days. Another point to be noted is

that the men who were kept in combat for the longest periods were the indispensable, competent, well-tried, frontline soldiers, such as company or platoon

officers, noncommissioned officers, squad leaders, and key enlisted men. When

these men did break from stress, they were likely to be irretrievably lost to

the combat forces, and they were always difficult to replace.

Although motivation is basic consideration, it is difficult to say precisely

what role it plays in the production of trenchfoot. In the Mediterranean

theater, for instance, when cold injury first appeared in the winter of 1943-44,

the willingness of troops to endure conflict was on the decline. They had

begun to feel that they were being kept in the line for too long periods, without

provision for sufficient rest, and this feeling may well have influenced them in

their lack of effort to protect themselves or, more correctly, influenced those

of them who, at this time, had the means and knowledge to protect themselves.

An analysis of motivation in the second winter in Italy is still more difficult

Favoring deterioration were two factors, continued and very heavy combat,

especially during the capture of Rome and the piercing of the Gothic Line, and

the mere passage of time. There were, however, other factors operating to

27 Letter, Brig. Gen. R. B. Lovett, Adjutant General, ETOUSA, to Commanding Generals of Major Commands,

Oct. 1944, subject: Prevention of Loss of Manpower from Psychiatric Disorders, enclosure thereto.
EPIDEMIOLOGY OF COLD INJURY 399

sustain morale. Although fighting was sometimes heavy, there was relative

tactical inactivity dining large part of the winter. Many preventive and protective practices had been instituted, including the rotation of troops through rest areas, correction of many of the former discriminations against

combat troops, especially when they were on leave in base areas, and the belated

attempt to glorify the role of the combat soldier by such means as extra pay

and the award of the Combat Infantryman’s Badge. It is not possible to say,

however, whether the decrease in trenchfoot during the second Italian winter was in any way influenced by greater desire on the part of the men to protect

themselves against cold injury than they had displayed during the first winter. It is curious fact that in the European theater, when trenchfoot rates

were high, rates for neuropsychiatric disorders were reduced. The immediate explanation would seem to be that potential neuropsychiatric casualties found

medical evaluation for mild cold injury an honorable as well as convenient

way to avoid combat, and that their number was large enough to affect the

rates for these conditions. Such course was undoubtedly taken by some

soldiers. There were, however, other considerations. The soldier was often

faced with an actual choice between severe injury or death on the one hand and

acquiring trenchfoot by remaining immobile in his foxhole, on the other. He

usually remained immobile. The fact that large numbers of men with bona

fide trenchfoot were evacuated from combat units before they might be expected

to become neuropsychiatric casualties would seem, automatically, to establish

the relation noted between trenchfoot and neuropsychiatric disorders.

Intelligence and morale are both components of the group of psychosocial

factors. Intelligence enters into the host complex, in that the intelligent

soldier is more easily trained and more readily understands the necessity for

the maintenance of fitness. Morale is an intangible state of mind and emotion

that is difficult to elucidate. Moreover, the morale of the individual soldier, which is host factor, cannot be disassociated from unit morale, which is

complex of leadership, motivation, confidence, and the state of discipline and

training. Units in which the morale of the individual soldier was high always

had less cold injury for the same reasons that they had lower rates for venereal

disease, fewer courts-martial, and minimum of accidents.

Psychiatrists and military leaders alike came to consider motivation in

the individual soldier important in his ability to withstand stress of all kinds.

It could be shown that an incentive beyond the urge for self-preservation and

the desire to maintain self-respect was necessary for the soldier. The psychiatrists believed that rewards should be given for achievement. They also

advocated tactical and strategic orientation of troops, individually and by

groups, as broad as was consonant with security. The wisdom of this concept

was amply demonstrated by the performance of such outstanding combat units

as the 3d Infantry Division, whose combat missions were arduous and difficult

over period of more than years. Considering the type of combat in which

this division was engaged, it could have been expected that its rates for cold

injury would sometimes be high; the over-all record, however, was excellent.
400 COLD INJURY, GROUND TYPE

About all that can be said in summarizing the influence of psychosocial

host factors is that many of them are intangibles not susceptible of precise

measurement and that the war experience provided unfortunately little data

concerning their true importance. No apparent sharp line separates the

effects of physical stress, emotional stress, and mental stress. There is considerable reason to believe that there may be an organic approach to many of

these psychiatric problems. It may be that the same neuroendocrine influences

that now seem to condition fatigue are also components of the associated

emotional reactions to stress. Be this as it may, the situation further indicates

the need for additional study and research and for the evaluation of men as

whole rather than the mere collection of data dealing with individual facets of

the behavior and physical responses of the individual. Much, in short, remains

to be learned concerning the prevention of the cumulative effects of stress upon

the individual host.

Training.—The effectiveness of unit in combat depends upon training.

The life of the individual soldier also depends upon it. In the military sense,

training is term of broad significance. It includes education, indoctrination,

and motivation of the individual soldier, and the teaching of combat techniques

to military units. The incidence of cold injuries varies greatly between experienced, well-trained units and inexperienced organizations not so well

versed in the art and techniques of combat.

Training must therefore logically be considered both as an environmental

and as host factor. As host factor, it concerns the hardening of the individual soldier. In this sense, it might also be interpreted broadly to include

acclimatization and the necessary physiologic adjustments required to develop

good combat soldier in excellent physical condition.

At the same time, training involves series of intangible human factors

such as self-discipline, morale, intelligence, character, and habits of self-preservation. Training, in the present discussion and also later, when it is discussed

as social-environmental factor (p. 442), must be interpreted as including experience, because it is impossible to differentiate successful!} between the

influence of training as an educational process and the influence of experience

as teacher in the hard school of combat.

Opinion survey.—In the spring of 1945, the Preventive Medicine Service,

Office of the Surgeon General, in conjunction with the Information and Education Division, Army Service Forces, undertook survey of soldiers returned

from overseas with trenchfoot. 28 The survey was designed to evaluate many

factors, including host factors, to study men’s attitudes and behavior, and to

determine, as far as could be determined, why they had contracted cold injury.

The investigation covered 1,018 enlisted men who had become casualties

from cold injury. The 234 controls, who were selected from total of 600 men

hospitalized at the same time for causes other than trenchfoot, were chosen

because the conditions of their combat service were comparable to those sus28 Report No. C-114, Information and Education Division, Army Service Forces, June 1945, subject; Trenchfoot

Survey.
EPIDEMIOLOGY OF COLD INJURY 401

tained by the men who had acquired trenchfoot. Both groups represented

many units. Some had fought in Italy and others in the European theater

during the winter season. Certain inferences can be drawn from the responses

of both groups about the amount of instruction they had received concerning

cold injury and about their knowledge of, and concern in, its prevention.

The report, made 21 June 1945, showed that only 55 percent of the men

who contracted trenchfoot had heard about it before going into combat, whereas

79 percent of those who did not contract it had knowledge of it. Only 37 percent of the men with trenchfoot said that their officers or noncommissioned

officers had told them how to prevent it; 71 percent of the men who did not

contract it had had this type of training. Only 26 percent of the men with

trenchfoot had given some thought to their chances of acquiring cold injury

under winter combat conditions, while nearly twice as many (49 percent) of the

men who did not contract it had considered the possibility. Queries concerning the opinion of the two groups about the amount of training they had received on certain items before they went into combat elicited variable replies

(table 19).

No definitive conclusions can be drawn from these data. On the other

hand, after the merits and fallacies of opinion surveys in general have been

taken into consideration, the inference is permissible that the training the

soldiers had received varied from individual to individual, and that those who

had had the least training in cold injury prevention, and who had been the least

interested in it. were chiefly the men who acquired the injury.

Table 19.—Opinion on training in trenchfoot prevention of 1,018 patients with trenchfoot and

234 patients with other injuries hospitalized in Zone of Interior

further example of the role of individual training in the causation of

trenchfoot is illustrated by the experience of replacements (reinforcements) in

combat units as compared with the experience of older, better trained, more

battlewise soldiers. The official records of trenchfoot incidence do not differentiate between replacement or veteran status, but unit records and sanitary and

other reports of unit sick contain numerous comments concerning the inadequate

training status of replacements. The investigators from the Office of the Chief

Surgeon, ETOUSA, who studied trenchfoot in several armies, division by division, consistently recorded similar observations. Some replacement troops

acquired trenchfoot en route to frontline units from replacement centers.

Trenchfoot occurred in one unit, the 89th Infantry Division, while it was still

Estimate of precombat training Too much About right Toolittle None No answer Total

Trenchfoot group

Control group

Percent Percent

15

41

Percent

23

26

Percent

52

21

Percent Percent

100

100

The 234 patients who served as controls underwent the same conditions of exposure as the patients with trenchfoot.
402 COLD INJURY, GROUND TYPE

in replacement center. It was universally recognized that the incidence of

cold injury among replacements was much higher in their first weeks of combat

than it was for experienced soldiers.

It is only fair to add that this situation cannot be attributed entirely to

defects in training. Many times, soldiers who had been properly trained failed

to appreciate the importance of the training they had had and consequently

failed to apply what they had been taught, or were unable, because of the combat

situation, to apply their knowledge.

The reverse of this situation is demonstrated by the experiences of old and

tried units in whichall the factors relating to trenchfoot or cold injury, including

the individual training of the soldier, were good.

Unit case history No. 3.—The 95th Infantry Division 29 is an excellent example of what has just been said (chart 10, table 20). This division was on the

offense during November and part of December. It made at least three river

crossings, and it assisted in the reduction of the Metz fortresses. Yet at no

time during this whole period was its incidence of trenchfoot high. The maximum number of cases on single day never exceeded 35, and on only one other

day did the number reach 30. It is interesting that during this period replacements for casualties of all types were slow in being brought forward, which

means that the men at risk were for the most part well trained and experienced.

The excellent record of this division of course involves many other factors, but there can be little doubt that the good status of training of the individual

soldier was one important reason for the low incidence of cold injury. In this

Chart 10.—Cold injury in regiments of the 95th Infantry Division European theater,

November through 21 December 1944

29 Further details of the experience of this division are presented on p. 426 (unit case history No. 10).
EPIDEMIOLOGY OF COLD INJURY 403

Table 20.—Cold injury in regiments of the 93th Infantry Division, European theater,

November through 21 December 1944

Date 377th In- fantry

378th In- fantry 379th In- fantry Total

1944 November

__ ________

10

11 ______

12 -__

13

14

15 _-

16

17 __

18 _____

15 30

19 _____

30 35

20 _____

10 12

21 _____

22

23 __

24 11

25 ______ __

10

26 _______

12

27 ______

12

28 ______

16

29

30 22

December 14 16

__

_____

10 ___

11

12 ___

13 _____

___

14 __

16 __

17 __

18

19 ___

20

21 ______

91 67 115 273
404 COLD INJURY, GROUND TYPE

division, as in others, though the evidence in favor of training as positive modifying factor in cold injury is largely circumstantial and corroborative, it is

nevertheless indicative of the significance of this special factor, which deserves

more careful evaluation in the future.

Environmental Factors

Environment is the medium through which agent and host are brought

into contact and interact to produce cold injury. Elements providing the

mechanism through which cold injury takes place are chiefly environmental.

Physical environmental factors include temperature, altitude, precipitation,

wind, thawing, terrain, and shelter. Socioeconomic environmental factors include leadership, medical care, type of combat action, rotation policies and

practices, and certain elements of training and discipline.

The biologic environment, which is so important in many mass diseases, has little or no relation to cold trauma. Cold, or cold and wet in combination,

are the specific cause of cold injury in the same sense that species of Streptococcus is the specific cause of puerperal fever or that Bacillus typhi is the specific

cause of typhoid fever. The mechanisms through which the agent may act

upon the host (man) are widely various. The typhoid baccillus may affect

the host through the accidental drinking of contaminated water, the family

use of milk containing typhoid bacilli, or the consumption at church or other large supper of food made dangerous by the typhoid carrier who prepared it.

The mechanisms which produce cold injury are much more varied and encompass greater range of environmental variables. They may extend from

low, muddy terrain, coupled with severe combat, at one extreme, to lack of

individual leadership during simple static defense on the other.

Physical Environmental Factors

eather.—Climate may be defined as the average weather of given place

or region. Weather is interpreted to mean the interaction of meteorologic

components, including temperature, moisture, precipitation, wind, and similar

factors, at given time. Each of the more important of these factors must

be analyzed separately if the total influence of weather as an environmental

factor in the production of cold injury is to be fully understood.

Temperature.—Cold has been incriminated as the primary causative agent

of cold injury, and basically this is fact, but temperature, as it fluctuates by

time periods and as it is associated with other modifying factors, chiefly determines the incidence and severity of this type of injury. This has been true

in all recorded wars. It was true in the Mediterranean theater in World War

II. It was equally true in the European theater (charts 11, 12, 13, and 14,

and tables 21 and 22).
EPIDEMIOLOGY OF COLD INJURY 405

Chart 11.—Cold injury cases, mean temperature, and precipitation, First U. S. Army, European

theater, November and December 1944

From November through 20 December 1944, the mean daily temperature on the Western Front was about 40° F. (4.4° C.). Only infrequently

during this period did minimal temperatures fall below freezing. Then, just before Christmas, cold wave covered the whole area of the front, and daily

mean temperatures were below or only slightly above freezing until the end of

January.

It is not always possible to demonstrate that temperature per se has

directly influenced the incidence of trenchfoot. Examination of the records of

several divisions shows periods of high incidence of trenchfoot at times during

the winter of 1944-45 when the mean daily temperature was relatively constant

in the range from little below to little above 40° F. (4.4° C.). One explanation is that trenchfoot does not manifest itself immediately upon exposure.

There is definite incubation or lag period, of days or more on the average,

between the beginning of exposure and the appearance of the injury. As long

as the temperature is below 50° F. (10° C.), trenchfoot is likely to occur, its

development depending upon the presence or absence of other influencing

factors, especially the synergistic factor of wet. To state it more simply, the

appearance of trenchfoot depends chiefly upon factors that enhance loss of

body heat rather than upon low temperature per se. In fact, as the brief

28
406 COLD INJURY, GROUND TYPE

Chart 12.—Cold injury cases, mean temperature, and precipitation, First U. S. Army, European

theater, January and February 19^5

Pacific experience showed (p. 211), form of cold injury can occur, if modifying

factors are favorable, when temperatures are high. On the other hand, frostbite is closely related to temperature. It manifests itself almost immediately

when the temperature falls below freezing. The incubation period, although

dependent upon the duration of exposure, may be only few minutes if the

temperature is very low, and not more than few hours if it is just below the

freezing point.

The first major outbreak of trenchfoot on the Western Front in World

War II reached its peak during the week ending on 17 November 1944 and

continued into the first days of December. During this period, in which no

frostbite was observed, temperatures varied from just below 40° F. (4.4° C.)

to just above 50° F. (10° C.). Precipitation was unseasonably heavy at this

time, and violent offensive fighting was in progress. Therefore, except for the

fact that the average temperatures were within the accepted trenchfoot range,

temperature as an environmental factor does not seem to have had great deal

to do with this epidemic of cold injury.

On the other hand, the epidemic which began the first days of January

1945 and reached its peak during the week ending on 19 January 1945 consisted of relatively high proportion of frostbite cases. The incidence, which
EPIDEMIOLOGY OF COLD INJURY 407

Chart 13.—Cold injury cases, mean temperature, and precipitation, Third U. S. Army

European theater, November and December 1944

continued high all through January, apparently was directly contingent upon

the temperature, which during this entire period was seldom above the freezing

point.

Early in February 1945, frostbite practically disappeared. Then thaw

occurred, and the element of wet again became prominent. As result, the

cold injury curve, which had included relatively large proportion of frostbite

cases during the preceding weeks, leveled off from its downswing during the

week ending on February 1945, principally as the result of an increase in

trenchfoot at this time (chart 15, table 23).

The combat experience of the 30th Infantry Division clearly illustrates the

relation between cold and trenchfoot on the one hand and cold and frostbite on

the other.

Unit case history No. J.—Between November and 15 November 1944, the

30th Infantry Division was in holding action and on active defense near

Aachen, in Germany. From 16 November through 12 December, it was

engaged in an attack toward the Roer River. On 17 December it moved to

Belgium, and from that date until 12 January 1945 it was in defense near

Malmedy. The defense was active, with occasional local offensive action in

favorable terrain, though little shelter was available. During all this time the

cold injury record of the division was good (chart 16, table 24).
408 COLD INJURY, GROUND TYPE

Chart 14.—Cold injury cases, mean temperature, and precipitation, Third U. S. Army, European theater, January and February 19^5

On 13 January 1945, the division was committed to an offensive action

the Malm&iy-Saint-Vith area, in deep snow. Exposure to cold was severe

because of lack of shelter. For the week ending on 19 January (that is, during

the first days of the offensive), the total cold injuries for all three regiments

took sudden and dramatic upswing and reached peak for the whole winter. By far the largest component of this outbreak was frostbite, as can be

determined when the regimental curves for trenchfoot alone during the 2-week

period are followed. During the week ending on 26 January, the outbreak

became less intense, presumably because exposure was less, and, after 29

January, the curve leveled off as all units within the division were moved to

an assembly area, where they were housed in villages.

The increase in the tenor of combat action undoubtedly played considerable part in the upsurge of cold injuries during the 2-week period just

described. Intense combat alone, however, was not responsible. This unit

had been in active combat before this time and had suffered no undue increase

in cold trauma. During the earlier period of combat, the temperatures had

been milder. The principal differentiating factor in the later period was

exposure to low temperatures under conditions in which shelter was not available and which did not offer sufficient opportunity to rotate individual soldiers

or small units to rest or warming areas.
EPIDEMIOLOGY OF COLD INJURY 409

Table 21 —Mean temperature, precipitation, and cold injury cases in the First U. S. Army, European theater, November 1944 through 28 February 1945

It has been pointed out already that cold injury has been known to occur

at temperatures as high as 60° to 70° F. (15.6° to 21.1° C.) when there is long

and constant exposure to wetness (p. 211). At the other extreme are frostbite, which occurs with relatively short periods of exposure at freezing temperatures and just below, and sudden freezing of the tissues, which occurs with

exposure to even lower temperatures. These facts suggest that cold injury

must be acquired with progressively less exposure at progressively lower

temperatures. To demonstrate this principle, carefully controlled experiments

would be necessary within the range of temperatures in which military operations have been carried out in winter. Experiments of this kind have not

yet been conducted.

That low temperature is an extremely important factor in cold injury is

borne out by the fact that in all divisions, young and old, experienced and

November 1944 December 1944 January 1945 February 1945

Day of month Mean Prccip- Mean Precip- Mean Precip- Mean Precip- temper- itation Cases temper- itation Cases temper- itation Cases temper- itation Cases ature ature ature ature

F. Mm. Number F. Mm. Number F. Mm. Number F. Mm. Number

45.5 1.0 47. 79 27.5 79 44.0 0.5 238 41.5 41.0 3.0 51 28.5 2.5 72 46.0 2.0 347

41.5 4.0 45.0 6.0 57 36.0 5.0 87 45.0 2.0 484

47.5 3.0 44.0 3.0 57 34.0 2.5 92 38.0 3.0 343

51.5 1.0 14 40.0 .5 62 31.5 158 44.5 5.0 250

47.0 6.0 15 41.0 4.0 93 29.0 188 44.0 5.0 165

46.5 5.0 42.5 7.0 127 32.5 9,0 132 44.5 4.0 154

46.5 3.0 34 40.0 2.0 77 30.0 8.0 168 42.5 7.0 101

9- 42.5 5.0 no 36.0 3.0 129 29.0 1.0 241 42.0 5.0 125

10 37.5 4.0 135 36.0 7.0 87 27.5 333 42.0 2.0 103

11 38.0 1.0 118 40.0 6.0 144 14.0 5.0 216 37.5 10.0 59

12 39,0 1.0 132 39.0 7.0 161 27.5 209 38.5 7.0 81

13 37.0 7.0 203 38.0 158 28.0 190 51.5 1.0 67

14 39.0 6.0 324 35.0 265 24.0 228 49.5 72 15 35.5 1.0 247 33.5 507 16.5 1.0 282 39.5 66 16 34.5 146 35.0 3.0 146 29.5 1.0 377 42.0 34

17 36.0 7.0 154 47.0 3.0 240 30.0 309 43.5 3.0 16

18 50.0 .5 138 48.0 4.0 146 34.5 5.0 175 44.0 3.0 11

19 53.0 .5 137 40.0 212 35.5 6.0 103 49.5 16

20 54.5 11.0 133 40.0 225 30.0 6.0 228 45.0 2.0 14 21 44.5 2.0 138 38.5 199 27.5 214 41.5 20

22 46.0 6.0 171 41.0 2.0 154 24.5 208 37.0 18

23 55.0 10.0 164 33.5 146 24.0 3.0 272 42.0 22

24 63.0 6.0 171 25.5 232 23.0 163 41.0

25 46.0 6.0 139 24.0 300 16.5 121 40.0 38

26 41.0 4.5 108 24.0 285 18.0 1.0 85 44.5 2.0 35

27 40.0 2.0 71 26.0 133 27.5 1.0 43 47.5 23

28.. 38.0 8.0 61 28.5 80 27.0 .5 53 46.0 34

29 46.5 3.0 76 29.5 113 20.0 48 30 43.0 64 29.0 1.0 51 19.0 3.0 118

31 34.0 66 36.0 3.0 126

3,234 4,782 5,318 2,945
410 COLD INJURY, GROUND TYPE

Table 22.—Mean temperature, precipitation, and cold injury cases in the Third U. S. Army,

European theater, November 1944 through 28 February 1945

inexperienced, and with good control policies and procedures as well as less

satisfactory ones, the cold injury incidence rose on the Western Front during

the periods of extreme cold between the last week of December 1944 and the

first day of February 1945. Modifying factors generally balance out and leave

low temperature as the dominant explanation for what happened.

Precipitation.-—Wetness, which has its source in precipitation, is part of

the agent complex in cold injury. When it is associated with cold, wetness

greatly increases the incidence of cold injury. Precipitation is an environmental factor; that is, it is component of many of the mechanisms which

result in cold injury. The environmental role of terrain is extremely important from the standpoint of precipitation. It may be of such nature as to

cause rapid runoff of precipitation, which is then less conducive to cold

injury. If drainage is poor, on the other hand, the water table is high, mud

or flooding results, and precipitation is then more conducive to cold injury.

November 1944 December 1944 January 1945 February 1945

Day of month Mean Preclp- Mean Preclp- Mean Preclp- Mean Preciptemper- itation Cases temper- Itation Cases temper- itation Cases temper- itation Cases

ature ature ature ature

F. Mm. Number F. Mm. Number F. Mm. Number F. Mm. Number

38.9 42.0 135 26.5 65 37.5 1.0 27

37.0 6.0 37.0 3.0 95 19.0 57 38.6 3.0 37

31.0 42.5 8.0 76 29.0 58 38.5 .5 27

44.0 5.0 45.0 11.0 56 33.5 3.0 37 35.5 5.0 36

48.0 40.0 1.0 83 28.5 1.0 73 38.0 6.0 28

48.0 5.0 42.5 6.0 127 21.0 57 44.5 4.0 29

7_ 46.0 11.0 41.5 9.0 101 25.5 2.0 60 41.5 3.0 67

42.5 10.0 11 41.0 3.0 71 24.0 8.0 102 41.0 4.0 49

40.5 2.0 21 37.0 3.0 87 28.0 1.0 143 43.0 6.0 91

10 37.0 3.0 129 35.5 1.5 43 23.0 128 38.0 6.0 99

11 41.5 1.0 387 38.5 12.0 79 15.0 192 38.5 16.0 102

12 36.5 2.0 501 41.5 4.0 146 19.5 242 46.0 3.0 147

13 35.5 5.0 432 40.0 201 20.0 205 50.5 1.0 189

14 37.5 15.0 424 35.5 103 30.0 150 47.5 77

15 36.0 6.0 719 34.0 142 18.0 217 38.0 64

16 36.5 543 33.0 .5 292 27.5 121 39.5 37

17 33.5 350 41.5 117 16.5 187 39.5 24

18 48.0 228 47.5 6.0 100 30.0 3.0 128 44.0 2.0 32

19 50.0 163 44.0 71 36.0 3.0 234 45.0 30

20 52.0 8.0 102 38.5 143 30.5 7.0 133 37.5 5.0 26

21 42.0 3.0 82 36.0 133 27.0 3.0 172 41.5 28

22 40.0 10.0 103 34.5 2.0 77 26.5 145 36.5 34

23 53.0 3.0 157 26.5 176 22.5 7.6 120 36.5 1.0 65

24 53.0 11.0 192 25.0 177 28.5 2.0 133 36.5 47

25 46 3.0 135 25.0 212 15.0 2.0 144 40.0 1.0 40 26 34.0 1.0 125 26.5 127 24.0 169 42.0 1.0 38

27 35.0 138 22.5 129 24.5 119 45.5 56

28 31.0 3.0 120 20.0 102 23.5 185 43.0 53

29 ... 40.0 5.0 119 24.0 137 18.5 102

30 37.0 131 23.0 79 15.0 47

31 29.0 75 33.0 50

Total 5,312 3,692 3,975 1,579
EPIDEMIOLOGY OF COLD INJURY 411

Table 23.—Cold injury admissions and rates for the First, Third, Seventh, Ninth, and Fifteenth U. S. Armies, European theater, for weeks ending November 1944 through 27 April 1945

[Rate expressed as number per annum per 1,000 average strength]

Baron Larrey was the first to observe the association between precipita- tion and temperatures above the freezing point in the production of cold

injury (p. 31), but the full significance of this factor was not appreciated

until the British experience in World War I. In 1915, Smith, Ritchie, and Dawson (p.241) first demonstrated the role of wet, and thus of precipitation,

by animal experiments in which one group of rabbits had dry footing and the

other was kept in cages with muddy bottoms. The incidence of cold injury

in the second group was significantly higher than in the animals which had

been subjected only to cold.

Precipitation sets the stage for cold injury because it forms mud, floods

valleys, raises streams, and causes the ground water table to rise to such

point that foxholes and trenches become damp, muddy, or partly filled with

Week ending—

First U. S. Army Third U. S. Army Seventh U. S. Army Ninth U. S. Army Fifteenth U. S. Army Total

Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate

19U

17 3.1 184 51. 0. 202 12.3

10..- 322 55. 161 32. 286 75. 45 14. 814 46.4

17... 1,324 184.1 3,356 591.7 585 152.0 98 25.0 5, 363 260.0

24... 1,052 172. 1,027 214.8 365 94.9 478 135. 2,922 160.2

December 598 98.5 903 186.3 465 116.8 461 124.6 2, 427 130.5

524 85.3 609 127.5 262 67.8 313 83.8 1, 708 92.

15 1,451 223. 801 168. 521 127.7 141 39. 2, 914 154.0

22.... 1,322 192.3 933 190. 434 100.6 40 12. 2, 729 142.0

29.... 1,289 214.1 1,060 174. 554 116.1 238 69.3 3,141 154.

1945

605 96.1 444 66. 556 112.8 77 23. 1,682 79.6

12 1,487 238.0 924 141.9 815 166.7 64 19.1 94 233.0 3,384 158.2

19 1, 664 270. 1,242 184. 667 130.9 79 23.5 3, 652 170.9

26 1,291 213. 1,016 149.3 974 165.0 32 9.5 3, 313 149.3

February 973 168.8 567 86.1 1,188 192. 73 19.6 3.7 2,802 124.4

1,622 299.5 327 53. 795 126.1 107 22.4 2,851 123.9

16.— 482 88.0 715 119.6 262 42. 28 5.6 46 136.0 1,533 66.5

23 117 21.5 239 40.9 178 31.3 16 2.9 550 24.

March 216 35.6 320 52.4 83 15.3 81 13.7 1.4 701 29.0

309 50.8 410 66. 95 17.7 42 7.0 1.8 858 34.6

16 168 27. 293 49. 102 16.1 1.3 571 22.0

23 27 4. 68 10. 239 36.4 .2 335 12.

30 14 2.3 1.0 73 11.0 1.0 95 3.5

April 26 4.3 23 3. 52 1.

13 35 5.9 .5 23 3.9 61 2.3

20 .9 24 4. 33 1.1

27 12 1.9 1.3 14 2.3 35 1.2

Total 16,953 106.8 15, 439 99.8 9,767 72.2 2. 423 20.2 146 14.2 44, 728 76.1
412 COLD INJURY, GROUND TYPE

Chart 15. Total cold injury incidence rates for the First, Third, Seventh, Ninth, and Fifteenth U. S. Armies, European theater, for weeks ending November 1944 through 27 April 1945

Chart 16.—Cold injury in regiments of the 30th Infantry Division, European theater, for weeks ending November 1944 through 16 February 1945
EPIDEMIOLOGY OF COLD INJURY 413

Table 24. Cold injury in regiments of the 30th Infantry Division, European theater for weeks ending November 1944 through 16 February 1945

water. Precipitation in the form of snow or sleet may encourage the development of frostbite, and melting snow acts to produce trenchfoot in the same

manner as water from any other source.

In 1944, the unusually heavy precipitation during the autumn and early

winter was chiefly responsible for the first epidemic of cold injury (trenchfoot)

on the Western Front. This epidemic reached its height in mid-November.

Heavier rainfall in that army area was the chief reason why this epidemic

assumed greater proportions in the Third U. S. Army than in the First. In

the Third U. S. Army, trenchfoot took the form of sudden, far-reaching

point epidemic. In the First U. S. Army, the buildup was slower and the

peak was lower. Terrain was also an important consideration in the Third

U. S. Army incidence; its predominant features were streams, and

low-lying land.

Thawing.—Thawing of snow, sleet, ice, and frozen ground brings about wet

and mud. Wet and mud, in combination with the temperatures at which

thawing occurs, provide conditions ideal for the development of trenchfoot.

Thawing is thus an environmental factor favoring trenchfoot in combination

with both temperature and wet. If it occurs during the day, when temperatures are maximal, and is combined with freezing during the night, when they

Week ending— 117th Infantry 119th Infantry 120th Infantry Total

19

November

10

17

24

December 12 16

11

15 10 13

22 16

29 19 20 16 55

1945 January 23 21 49

12 17 12 26 55

19 109 105 99 313

26 11 24 February 19 36

14 24

16

Total 198 199 228 625
414 COLD INJURY, GROUND TYPE

are minimal, it may give rise to both trenchfoot and frostbite in troops subjected to these environmental conditions.

Data for the Western Front support these observations. general thaw

began on 31 January 1945 and extended along the whole length of the front.

The last of the big theaterwide epidemics of cold injury had begun on January (chart 15) and was to continue until 23 February. The epidemic reached

its peak during the week ending on 19 January and then began rather precipitous downswing. With the onset of the thaw which began on 31 January,

the curve abruptly leveled off for the week ending on February and did

not resume its precipitous downward trend until the following week. During

the week ending on February, the predominant cold injury was frostbite.

During the week ending on February, trenchfoot was theaterwide, because

of the wet and mud produced by the thaw which began on 31 January.

The experience of the 9th Infantry Division during this period was typical.

Unit case history No. 5.—This division after previous operations in Africa

and Sicily had been in combat action continuously on the Continent from

days after the initial Allied landings in Normandy. It was thus battletried division, of great experience, with good record for both combat and

cold injury. At no time before the last few days of January 1945 (chart 17,

table 25) had cold injury been very important cause of loss of personnel,

although the division had seen heavy combat under conditions favoring trenchfoot and had had only short alternating periods of defense or reserve.

Chart 17.—Trenchfoot and frostbite in regiments of the 9th Infantry Division, European

theater, for weeks ending November 1944 through 16 March 1945
EPIDEMIOLOGY OF COLD INJURY 415

Table 25. Cold injury in regiments of the 9th Infantry Division, European theater, for weeks

ending November 1944 through 16 March 1945

In the period immediately preceding the 31 January thaw, operations

were in the Monschau area. This is high, rolling, and forested country. The

weather was moderately cold to cold. The ground was frozen and was covered

by 12 to 18 inches of snow. The action was static defense. On 29 January,

the division jumped off in an attack in deep snow. The weather was still cold, but there was alternating freezing by night and thawing by day. On the first

day of the attack, the snow was dry, and frostbite as the predominant cold

injury. By February, the thaw bad become general. By 10 February, the

snow had, for the most part, melted, so that streams were swollen, and fields,

forests, and roads were deep in mud. Chart 17 shows the trenchfoot and frostbite experience of the three regiments of the 9th Infantry Division and demonstrates the effect of alternate freezing and thawing in the production of both

forms of cold injury, as well as the high incidence of trenchfoot during period

when precipitation was absent or light.

The ratio of trenchfoot to frostbite in the 60th Infantry Regiment was

diametrically opposite to that in the 47th (chart 17). The 60th Infantry was

operating in the worst terrain of the Monschau woods during the week ending

Week ending— 39th Infantry 47th Infantry 60th Infantry Total

November

19

10

17 44 53

24 35 14 51

December 14

16 14 38

15 12 23 17 52

22 17

29 11 24

January

1945 19 25 45

12 14

19 11 13

26

February 27 27 64 118

31 122 38 191

16 15

23

March

17 34

16 16 14 34

Total 158 295 279 732
416 COLD INJURY, GROUND TYPE

February; alternate thawing and freezing had exposed this regiment to considerable wet in comparison with the other two regiments in the division,

fact which partly explains the higher trenchfoot incidence in the 60th. In

addition, this regiment made three successive marches in low terrain in which

exposure was great and during which there was limited time for the individual

care of the feet. The 47th Infantry, on the other hand, made long march in the snow in higher terrain, immediately following which it was thrown into

repeated attacks before the objective could be reached. Men were fatigued

and had little opportunity to care for their feet. Again, alternate thawing and

freezing is the explanation, with trenchfoot by day and frostbite by night in

tired soldiers who, because of the tactical situation, were unduly exposed to

cold at night and were unable to obtain rest. Immediately after this experience, the division went on to the Roer River, which was crossed about March.

The Erft Canal was crossed shortly afterward. As result, wet feet produced

another rise in the trenchfoot incidence.

Thus, thawing, by introducing the element of wetness, is an important

environmental factor in the production of cold injury. At the same time,

conditions are ideal for frostbite if soldiers who are subjected to thawing during

the day must operate by night or are exposed by night to minimal, belowfreezing temperatures, without adequate shelter.

Wind.-—Though it is an established fact that exposure to wind hastens loss

of body heat, efforts to measure the degree to which the loss is brought about

by winds of various velocities have been chiefly carried out in extreme temperatures in the Arctics. Siple (cited by Court 30), in 1939, was the first to use the

excellent descriptive term “wind chill” to imply the combined cooling effect

of moving air and low temperature. On the basis of observations made in

the Antarctic in 1940, he developed formula to describe wind chill and its

fluctuations according to temperature and wind velocity. From this formula, the meteorologists in the Quartermaster Corps developed table of wind-chill

values, as well as graphic charts which depicted the relative comfort range for

various combinations of wind speed and temperature.

Wind-chill maps were also developed for North America and certain other

areas, but they were in expectation of military operations in the Arctics and

were not of specific practical value for winter tactics in temperate climates

because they took no account of the element of wetness in combination with

moderate temperatures. They are mentioned in this chapter only because

they demonstrate that it is practical to measure wind chilling.

Measurements of wind chill were not made either in the Mediterranean

or European theater in World War II. Even if they had been made, they

would have been of no practical value unless they had been based upon carefully controlled observations involving correlation between wind, temperature,

and wetness.

Although wind was undoubtedly factor in the production of both trenchfoot and frostbite on the Western Front in the winter of 1944-45, it is not

30 Court, A.: Wind Chill. Bull. Am. Meteorol. Soc. 29:487-493, December 1948.
EPIDEMIOLOGY OF COLD INJURY 417

feasible to study its effect by the comparative experiences of units of any size.

Apparently, it was progressively more important as temperatures became

progressively lower. This is another aspect of cold injury in which lack of

data and of observations during actual combat indicates the need for further study and research for the benefit of both medical officers and commanders.

Without these data, it is obviously impossible to discuss the effect of wind

as an environmental factor except in general terms. Loss of body heat through

wind chill, which is heat exchange through convection, is only one of the

ways in which the body loses heat. The degree of convective heat loss is

always governed by the amount and type of clothing worn. Under no circumstances, according to Court, can convective heat loss account for more than

80 percent of the total body-heat dissipation.

To reduce the facts to the simplest possible terms, the body generates

heat, while clothing holds warm air in and keeps cold air out. Air in itself is

an excellent insulator, and clothing is most effective in holding warm air in (1)

when it fits loosely enough to allow for layer of air next to the skin, (2) when

the inner layers of the cloth of which it is composed are woven loosely enough

to allow air pockets between the fibers, and (3) when the garments are worn in

layers, so that there are air pockets and air layers between the layers of clothing.

Still air is an insulator, and in it warmth is approximately equivalent to insulation. All movement, even winds of miles per hour or less, reduces the effectiveness of the insulating properties of still warm air. The more porous the

insulating clothing, the easier it is for the wind to penetrate and destroy the

insulating properties of trapped and layered air. Wind accelerates the dissipation of body heat when the insulating properties of clothing are modified by

sweating, evaporation, and the conduction of heat through it when it is wet.

Wind chill, as Court pointed out, is only one of number of problems

which must be studied in physiologic laboratories before the loss of body

heat by all means can be accurately computed. Among them are (1) the

relation of breathing rates to the activity level, (2) the temperature and moist

content of exhaled air, (3) the insensible perspiration rate at low temperatures, and (4) the surface temperature and radiative efficiency of the completely clad body. Court further pointed out that even when these problems

are clarified, certain other considerations are likely to make measurements of

wind chill and similar factors subordinate to subjective feelings of comfort or

discomfort in the individual. These considerations include host differences

in individuals, such as race, sex, age, body build, acclimatization, physical

fitness, nutritional adequacy, sufficiency of clothing, and, in particular, mental

attitudes.

Terrain.'—Terrain is an environmental factor which not only has direct

bearing on the incidence of trenchfoot but which also determines whether

injuries caused by cold shall be predominantly trenchfoot, predominantly

frostbite, or combination of both. The weight of terrain as modifying

factor in cold injury has already been discussed in some detail in the section
418 COLD INJURY, GROUND TYPE

on multiple correlation studies of 21 divisions (p. 373). It is also discussed

briefly in connection with altitude, precipitation, and thawing.

Generally speaking, exposure in open, hilly, or mountainous terrain,

usually covered by snow that does not melt in cold weather, is likely to produce frostbite. Trenchfoot is the more probable cold injury when temperatures are high enough to cause thawing, and when slush, mud, and water are

underfoot. More often than not, combat activities are carried out in valleys,

along streams, and in flat terrain subject to flooding and characterized by

highwater tables. In flat terrain, the water table is often high, and it is also

impossible to dig foxholes deep enough to avoid eventual flooding. In valleys and in low, flat terrain, troops in attack must cross muddy or flooded

fields and swamps. During these crossings, they get wet, regardless of the

clothing or type of footgear with which they are supplied.

Kiver crossings are among the most difficult military operations. They

involve service support personnel, especially Engineer and Signal Corps personnel, as well as combat personnel, who usually bear the brunt of cold injury.

Under these circumstances, it is virtually impossible to avoid wet feet and

wet clothing over the lower extremities. If the temperature is within the

trenchfoot range and if exposure is sufficiently long, the cold injury incidence

will almost inevitably be high, and soldiers other than infantrymen will share

the infantryman’s liability to cold injury.

Terrain may modify the incidence of cold injury in other ways. It may

be of such character as to offer shelter from the enemy and provide opportunities for adequate care of the feet. Conversely, it may provide concealment for the enemy and give him command of open country, with deadly

crossfire and unlimited observation. Then, defending troops would be forced

to remain in cramped positions in foxholes, with little opportunity for movement

or for the employment of preventive measures against cold injury.

The experiences of number of units on the Western Front during World

War II show the importance of terrain as modifying factor in cold injury.

Unit case history No. 6.—The 104th Infantry Division arrived in France

early in September 1944. Its first combat experience was gained with the

First Canadian Army, in active offense on the Maas Kiver. The fighting

was in agricultural country, which was low and flat and was traversed by

many ditches and small canals. Foxholes promptly filled with water from

water table only or inches below the surface. After week in these

surroundings, the division was moved to sector between Aachen and Eschweiler, where the terrain was rolling, fairly high, forested, and well drained.

Combat action was sporadic offense, and there was some opportunity for shelter. The first peak of cold injury (chart 18, table 26) could be almost entirely

explained as the result of operations of new division, in terrain highly favorable to trenchfoot. The second peak, early in December, was the result of

different factor, namely, combat action, which took place in terrain not in

itself conducive to trenchfoot.
EPIDEMIOLOGY OF COLD INJURY 419

Chart 18.—Cold injury in regiments of the 104th Infantry Division, European theater, for weeks ending November 1944 through January 1945

Table 26.—Cold injury in regiments of the 104th Infantry Division, European theater, for weeks ending November 1944 through January 1945

Week ending— 413th

Infantry

414th

Infantry

415th

Infantry

Total

19U

November 19 21

10 35 11 49

17 59 12 18 89

24 77 46 14 137

December 24 26 56

108 15 12 135

15 16 20

22

29

1945

January 5_

Total 312 138 74 524
420 COLD INJURY, GROUND TYPE

The strikingly higher incidence of cold injury in one regiment, the 413th

Infantry Regiment, is also easily explained. It operated in worse terrain

than either the 414th or 415th Infantry Regiments, and at the same time

encountered strong opposition, while the other two regiments were less strongly

opposed.

Unit case history No. 7.—The 26th Infantry Division, assigned to the

Third U. S. Army, began combat operations in the November offensive in the

area east of Nancy, where the terrain was low and marshy and rain fell daily.

In forced crossing of the Seille River, two companies of the 101st Infantry

Regiment had to wade across in water more than waist deep. Within day or

two, cases of trenchfoot were being reported from all three companies. In

the beginning, these companies had the highest trenchfoot rates of any units

within the division.

When the 338th Infantry Regiment from the same division was put into

action, in right flanking position, in open, flat, wet, muddy terrain, it was

pinned down, within short time, by enemy fire from Dieuze. It was days

before its relief was accomplished, and there was large outbreak of trenchfoot

as the result of the experience. The number of cases was greatly reduced as

the division progressed to the upper Saar Valley, where combat action was

chiefly in the towns; but second, though much smaller, peak occurred in late

November, when the troops had to fight through the open, muddy area of

the Maginot Line (chart 19). Incidence of cold injury in the division is shown

in the following tabulation:

Cases

November 1944:

19

10 67

11 130

12 115

13 90

14 144

15 361

16 279

17 91

18 32

19 25

20 17

21 14

22 22

23 59

Cases

November 1944—Continued

24 71

25 24

26 18

27 34

28 15

29 14

30

December 1944:

12

22

16

43

29

30

10 16

11 21

12

13

14

15
EPIDEMIOLOGY OF COLD INJURY 421

Chart 19.—Cold injury, 26th Infantry Division, European theater, November through

15 December 1944

Unit case history No. 8.—The 29th Infantry Division, which landed in

France on D-day, had become well-trained, well-led, experienced, and battlewise division by the time it had fought across France and into Belgium. In

the 2-week period 18 November through December 1944, it was in an active

offense toward the Roer River, in open, flat country, with poor drainage. The

weather was only moderately cold, but there was much rain, and mud was deep.

The 116th Infantry Regiment, which operated over open ground, often in

water over the tops of the men’s overshoes, had 72 cases of trenchfoot during

this period (chart 20, table 27). The terrain over which the 175th and 115th

Infantry Regiments fought was higher and drier and offered more protection.

The numbers of cases in these regiments were 26 and 6, respectively.

Unit case history No. 9.—The 78th Infantry Division did not arrive on the

Continent until 22 November 1944. It was therefore without combat experience

when, during the week ending on 15 December, it moved into the frontlines near

Rotgen, Germany, and was immediately thrown into active offensive action.

The terrain was hilly and partly forested, with many streams in the valley

and much deep mud. Much of the time, the men were in exposed foxholes.

When the 309th Infantry Regiment advanced, it was obliged to make several

waist-deep stream crossings. When the 310th Infantry Regiment advanced,

similar crossings were not necessary. The 311th Infantry Regiment was kept

in reserve for most of the period. The 309th Infantry Regiment had 304 cases
422 COLD INJURY, GROUND TYPE

Chart 20.—Cold injury in regiments of the 29th Infantry Division, European theater, for weeks ending 17 November through 29 December 1944

Table 27.—Cold injury in regiments of the 29th Infantry Division, European theater, for weeks ending 17 November through 29 December 1944

of trenchfoot (chart 21, table 28), the 310th had 197, and the 311th had

18 during the period December through 22 December.

The experience of the 9th Infantry Division (unit case history No. 5, p.414)

with respect to the influence of thawing lias already been related. Its unit

history also furnishes an excellent example of the modifying influence of terrain.

Between December and 17 December, company of this division advanced to

occupy trenches from which the Germans had been driven. The trenches were

located in an open field and were filled with about 18 inches of water. Because

of the intensity of enemy fire, the unit was pinned down in them for about

days. Twenty-nine of the one hundred and twenty men in the company conWeek ending— 115th Infantry 116th Infantry 175th Infantry Total

1944 November 17

24 11 24

December 63 15 80

16 10 26

15 13

22

29

Total 96 46 151
EPIDEMIOLOGY OF COLD INJURY 428

Chart 21. —Cold injury in regiments of the 78th Infantry Division, European theater, for weeks ending December 1944 through 26 January 1945

Table 28.—Cold injury in regiments of the 78th Infantry Division, European theater, for weeks ending December 1944 through 26 January 1945.

tracted trenchfoot. unit of similar size which eventually was able to get

forward to relieve this unit brought with it straw and boards, to be used like

the board tracks laid down in the trenches in World War I. As result, the

men kept themselves relatively dry and did not sustain single case of

trenchfoot.

Altitude.—Altitude enters into the possible occurrence of cold injury for

several reasons. It predisposes to the intensity of cold. Because of the cold, it further determines, to some extent, whether precipitation shall be in the

form of snow or rain. In general, the type of terrain at higher altitudes is such

Week ending— 309th

Infantry 310th Infantry 311th Infantry Total

1944 December 19

15 169 83 255

22 135 114 15 264

29 17 28

1945 January 13 19

12 15 24

19 40 49

26 17 22

Total 398 217 65 680
424 COLD INJURY, GROUND TYPE

as to discourage the formation of mud, marshy areas, large flooded areas, and

broad streams. On the other hand, military operations in rough terrain are

likely to be carried out in valleys, where the nature of the ground intensifies

wetness. Exposure is usually greater when difficult operations are carried out

in mountainous terrain. It is unlikely, however, that at altitudes at which

ground forces usually fight, physiologic host changes caused by heights would

be important enough to influence cold injury to any material degree.

Temperatures likely to induce cold injury are reached earlier in the season

in mountainous terrain, and daily fluctuations from low minimums at night

to high maximums at midday appear to be greater in the mountains than on

level ground. Combinations of frostbite and trenchfoot are prone to appear

at the beginning and end of the cold injury season. Altitude thus introduces

number of environmental considerations, though in all of them the basic

factor is the intensification of cold at progressively greater heights.

American ground forces experienced combat in mountainous terrain both

in Italy and in Western Europe during World War II, but data concerning

the effect of altitude on the incidence of cold injury are not readily available.

Socioeconomic Environment

The social environment has significant influence on the incidence of cold

injury. As has been pointed out several times already, this form of trauma is

an occupational disease of the infantryman, especially of the frontline rifleman.

Infantrymen experience more trenchfoot than support or service troops in the

same way, and for many of the same reasons, that outdoor laborers contract

pneumonia more often than office workers.

The susceptibility of infantrymen is well proved by examination of the

incidence of cold injury in armored divisions. In four armored divisions which

saw heavy service on the Western Front in the winter of 1944-45, 72 percent

of 1,837 cases of trenchfoot were concentrated in the infantry battalions (table

29). Similarly, 87 percent of the 1,018 patients with trenchfoot interviewed

in Zone ofInterior hospitals (p. 400) were infantrymen (table 30).

Table 29.—Cold injury cases in armored artillery, and infantry personnel of armored divisions, European theater, 28 October 1944 through 16 March 1945

Armored division Number of cases by component Total Occurrence

in infantry Armored

(tank) Artillery Infantry

2d 240

138

41

81

511

241

255

321

751

379

301

406

Percent

68

64

85

79

3d

th

7th ..

Total 500 1, 328 1, 837 72
EPIDEMIOLOGY OF COLD INJURY 425

Table 30.—Trenchfoot by arm or service in 1,018 patients hospitalized

in Zone of Interior

Combat action.—The most important single modifying factor in the causation of cold injury is the type of combat action. It is true that its influence

cannot he entirely isolated from the concomitant influence of terrain, shelter,

training, and experience. It is also true that combat action is, in turn, modified

by leadership, the status of supplies of clothing and food, and the foot discipline

of the individual soldier. Nonetheless, the intensity and type of combat determine the stress under which fighting men operate, with the result that fatigue,

nutritional status, and psychosocial factors are also materially influenced by

these considerations. These interrelated and interwoven considerations can

best be summed up in the statement that combat action largely determines

the degree of exposure and partly determines the susceptibility of the host

and the opportunity which the individual soldier and his unit will have to

carry out protective measures against cold injury.

The incidence of cold injury varies according to the mission of the troops.

Units in reserve or in rest areas have little. Units in the line on holding

missions, or operating in static defense of various degrees, are subjected to

greater exposure, and there is likely to be moderate increase in the incidence

of cold injury. Difficult defensive operations, which require irregular attacks

to strengthen lines and maintain positions, are associated with almost the same

high peaks of incidence that occur during trying offensive operations. Under

some circumstances, in fact, this type of operation may be responsible for even

larger numbers of cases.

study initiated by the Preventive Medicine Division, Office of the Chief

Surgeon, ETOUSA, bore out these facts. When divisions were in reserve in

rest areas, or were on the move, without combat duties, trenchfoot averaged

2.4 cases per day. When they were in static defense or engaged in holding

operations, the daily average rose to 3.5 cases per day. When they were on

active defense, repelling enemy attacks, the average rose to 14 cases per day.

Several of the unit case histories already related, particularly those

recorded to demonstrate the influence of terrain, show equally well the part

played by the type of combat action in the causation of cold injury. The

specific situations summarized in the following histories also illustrate this point.

Armor service Cases Percent

Infantry.. __ 886 87

Field artillery- 40

Engineers. .. 31

Tanks and tank destroyers 31

Medical Department- 10

Others 20

Total 1, 018 100
426 COLD INJURY, GROUND TYPE

Unit case history No. 10.—The story of the 95tli Infantry Division has

already been told in part (p. 402), to illustrate the effect of training and

experience. By November 1944, it had experienced great deal of combat

and was tried, reliable, and effective organization, with good discipline. Its

total record of cold injury for the whole winter was among the best for any

combat division, but review of the records shows that even this staunch and

battlewise unit had peaks of cold injury incidence when the going was hard

(table 20, chart 10).

This division operated in the Moselle Valley in the envelopment of the

Metz fortresses. Crossings of the Moselle River were required, and the whole

operation was difficult, especially during the 12-day period before the fall of

Metz on 18 November. The peak of the cold injury incidence was reached

on 19 November (chart 10), date which, allowing suitable timelag for the

development of the injury, precisely fits the combat pattern. After Metz fell,

the division moved eastward to Saarlautern in rapid advance, but fighting

was easier, and there was reduction in the number of cases of trenchfoot.

As the city was approached, however, fighting again became harder, and the

Nied River had to be crossed. This was accomplished on December. The

difficult combat situation was again accompanied by rise in the incidence of

trenchfoot.

Unit case history No. 11.—The 2d Infantry Division landed in France on

D-day plus 1, and by the middle of October had fought across France and

Belgium to Saint-Vith. It remained in this area, in static defense operation

with active patrolling, until the first days of December. During November

and the first week of December, the incidence of trenchfoot was negligible

(chart 22, table 31). There was an immediate divisionwide increase in the

number of cases, however, when the division went into an active attack against

pillboxes near Elsenborn during the week ending on 15 December. The German

Chart 22.—Cold injury in regiments of the 2d Infantry Division, European theater, for weeks ending November 1944- through 16 February 1945
EPIDEMIOLOGY OF COLD INJURY 427

counterattack on 16 December resulted in active defensive fighting for the

following week, accompanied by still greater increase in the trenchfoot

incidence. During the week ending on 29 December, which was the second

week after the German counteroffensive, combat action was again defensive,

with active patrolling. The number of cases of trenchfoot fell precipitously,

and there was no increase during the next several days, when combat took the

form of static defense.

The 23d Infantry of the 2d Infantry Division was attached to the 1st

Infantry Division on the 15th of January 1945, and was in an active offense

until the 22d, period for which there was marked increase in the incidence

of cold injury for this unit. The remainder of the division was on defense and

line holding. The 23d Infantry also had returned during the week ending

26 January. On the 29th of January 1945, the division jumped off in an offense

toward the Roer River. During the first few days, the snow was deep and

the weather cold, but with the onset of the February thaw the terrain became

wet and very muddy. Troops were in foxholes in heavily wooded hills in

which there were many villages. Almost immediately after the onset of this

operation, there was drastic rise in the incidence of cold injury whichreached

peak of 179 cases for the week ending February 1945. The division assumed

Table 31. Cold injury in regiments of the 2d Infantry Division, European theater, for weeks ending November 1944 through 16 February 1945

Week ending— 9th

Infantry 23dInfantry 38thInfantry Total

1944 November

10

17 13

24 13

December

15 42 46

22 42 42 23 107

29 11 13 27

1945 January 24 31

12 19 25

19 45 52

26 19

February 20 12 16 48

73 94 12 179

16 14 20

Total. ...

219 253 126 598
428 COLD INJURY, GROUND TYPE

static defense on the west bank of the Roer on February, in which circumstances it remained until 28 February. During the first or days of this

action the principal component of cold injury in the division was frostbite. The

thaw began about February, and immediately trenchfoot and frostbite were

almost equally apparent in the division (table 31). The last case of frostbite

occurred on February, but on and 10 February there were 13 and 14 cases

of trenchfoot, respectively (table 32),

Table 32.—Daily incidence of trenchfool and frostbite, 2d Infantry Division European

theater 29 January through 11 February 19f

Unit case history No. 12.—The experience of the 5th Infantry Division in

the fighting before Metz represents differenct element of combat action.

This division had been stationed in Ireland for 18 months, and foot discipline

and the prevention of cold injury had been an important part of its training.

The division landed in France shortly after D-day and, by early November

1944, had fought forward to the Metz area. In the November offensive, it

jumped off toward Metz near Pont-a-Mousson, in the flat, rain-drenched

Moselle Valley. Enemy resistance was heavy, and almost immediately cold

injury began to occur in all three regiments (chart 23, table 33) though, for

some inexplicable reason, it was at first disproportionately high in the 10th

Infantry Regiment.

Otherwise, the total experience by regiments throughout the difficult

fighting preceding the reduction of Metz on 18 November demonstrates the

effect on cold injury of movement versus holding offense in severe combat.

The division attack was on broad, swinging front. The 11th Infantry Regiment maintained holding and slow moving attack position on the left

Date Trenehfoot Frostbite Total cold injury

19^5 January 29

30

31

February 11 10 21

10

22 32 54

35 30 65

14 15 29

10 12

13 13

10 14 14

11

otal... 121 120 241
EPIDEMIOLOGY OF COLD INJURY 429

Chart 23.—Cold injury in regiments of the 5th Infantry Division. European theater

11-24 November 1944

Table 33. —Cold injury in regiments of the 5th Infantry Division, European theater

11-24 November 194

Date 2d Infantry 10th Infantry nth

Infantry Total

19U November 11 15 16 15 46

12 18 68 14 100

13 31 29 67

14 11 25 44

15 15 28 46

16 24 56 88

17 29 21 73 123

18 35 23 49 107

19 20 35 20 10 27

21

22 12

23

24 16

Total. 198 209 318 725

438404'—58 29
430 COLD INJURY, GROUND TYPE

flank, before Metz. The 2d and 10th Infantry Regiments moved rapidly in an

enveloping maneuver in the center and on the right flank. Except for movement, all elements of the combat situation were essentially the same. Yet

between 11 November and 21 November inclusive, the 11th Infantry Regiment

had 302 casualties from cold injury, against 195 cases each in the 10th and 2d

Infantry Regiments.

Clothing supply.—Keeping warm and dry is fundamental in the prevention

of overexposure to the elements. The kind and the adequacy of the clothing

and footgear worn by combat soldiers therefore directly influence their susceptibility to cold trauma. The mere statement of that fact does not, however,

cover the situation. There are number of considerations implicit in it as

follows;

1. Clothing must be developed scientifically, to take advantage of air

insulation and the layering principle. This means the provision of lightweight

wind-resistant, water-repellent outer garments, to be worn over layers of

loosely woven inner garments. In World War II, the Quartermaster General

approached this problem on the basis of so-called clothing assemblies. Research on clothing in relation to man’s physiologic needs in extremes of climate

and the development of fabrics with known protective qualities led to the

establishment of types and designs for various articles of clothing which, when

worn together, gave maximum protection against cold. The total uniform for

this purpose was designated clothing assembly. great deal of effort and

research went into the development of these assemblies to meet specific conditions, and, on the whole, both principles and designs were good.

2. Clothing must be designed from the standpoint of practical possibilities.

It is probably not possible to design combat clothing that will adequately

protect fighting personnel under extreme conditions of intense combat activity

in cold and wet weather. In these circumstances, long exposure under great

stress can scarcely be avoided. The most practical plan, therefore, in designing

clothing for military operations in the winter, is to take into account only

average conditions of exposure to weather in the coldest months of the year and

to attempt to protect the combat soldier within range of 10° F. above and

below these averages.

3. Clothing and footgear must be designed so that there will be no interference with circulation in any part of the body.

4. Clothing must be worn so as to take advantage of the principle of insulation; that is, air must be present between the skin and first layer, as well as

between all succeeding layers.

5. Clothing must be in proper supply. Adequate supplies must be

brought to the division area. They must also be distributed to the smallest

units farthest forward in such way that individual soldiers will be able to

change into warm, dry clothing as the need arises. The supply of all necessary

items to tons of thousands of men scattered in combat units along several

hundred miles of long fighting front is major problem in logistics.
EPIDEMIOLOGY OF COLD INJURY 431

6. Even granting that clothing is properly designed and that supplies and

distribution of clothing assemblies are sufficient, it is still necessary, for the

greatest protection to be obtained from clothing, that both the commander

and the individual soldier understand the principles involved and the methods

of utilizing the garments provided. The importance of this consideration was

not always realized in World War II, but failure to assemble the uniform for

wear as intended can greatly decrease its ability to protect the wearer against

cold. Since trenchfoot is caused not only by exposure of the feet but also by loss

of body heat, insufficient protection of the torso by failure to include the

sweater or the jacket or some other garment in the assembly can be responsible

for the development of cold injury.

The chief responsibility for the development and production of all types of

clothing rests with the Quartermaster General of the Army. Before the entrance of the United States into World War II, the Office of the Surgeon General

had had little to do with the development of winter clothing, and the Attn

operation was over before there was active medical participation in this phase

of operations.

In June 1942, the National Research Council set up subcommittee on

clothing, whose personnel included, among others, representatives from the

Office of the Surgeon General of the Army and of the Navy, the Office of the Air

Surgeon, the Medical Research Laboratory at Fort Knox, the Rochester

Desert Laboratory, the Harvard Fatigue Laboratory, and the Textile Foundation; liaison personnel from the Royal Air Force also were included. The original function of this committee was to develop lightweight, functional flying

uniform for aviators, but this function was soon expanded to cover clothing

problems of naval and ground forces. The observations made have been brought

together by Newburgh, 31 who served as chairman of the subcommittee. The

text includes data on acclimatization, methods for determining heat exchange,

physiologic adjustments to heat and cold, and studies of the protective properties of clothing. This resume of what is known of host reactions and responses

to heat and cold simply emphasizes the need for continued research if man’s

ability to cope with cold trauma in war is to be fully understood.

The work of this subcommittee was complemented by the work carried out

at the Armored Medical Research Laboratory, which had been established at

Fort Knox in September 1942, with the specific mission of conducting research

on physiologic problems of practical significance to this branch of the service.

Special attention was directed to the study of the soldier in relation to his

duties. Later studies included tests of the adequacy and range of winter

combat clothing.

The problems of the choice, supply, and utilization of clothing in the

Aleutians and in the Mediterranean and European theaters have been presented

in detail under the appropriate headings (pp. 90 and 111). Of interest in this

connection is the report by Maj. Paul Siple, the representative of the Quarter3] Newburgh, Louis H.; Physiology of Heat Regulation and the Science of Clothing. Philadelphia: W. B. Saunders

Co., 1949.
432 COLD INJURY, GROUND TYPE

master General, who arrived in the European theater in February 1945, with

the mission of observing the adequacy of the supply and distribution of winter

clothing. In essence, he reported as follows:

While the complete clothing assembly designed for frontline troops was

in itself adequate, it was provided in insufficient quantities. In many instances,

too, it was provided so late in the winter that it was not available during the

coldest weather, when it was most needed. The campaign was therefore fought

by most combat personnel in uniforms deficient in proper protection because

of inadequate insulation, poor balance of insulation, lack of windproofness,

lack of water repcllency, and faulty closure.

The clothing initially provided for winter combat in the European theater,

the report continued, did not provide ample enough insulation because it was

poorly balanced, it lacked sufficient thickness, it was worn inefficiently, and it

did not provide satisfactory means of preventing movement of air from

destroying insulation through the garments or at the points of closure. As an

example, the legs were covered by only two layers of clothing, wool drawers, and

wool serge trousers. When the soldier was standing, even when he was not exposed to wind, this covering provided only about half an inch of insulation and

oidy about two-thirds of the protection needed under average conditions. When

the absence of windproofness in the wool trousers was taken into consideration,

the warmth-retaining value of protection for the legs was lowered by about

50 percent. When the man was seated, with underwear and trousers tight

over the seat, thighs, and knees, the protection was even less. It was easy to

understand why soldiers frequently complained of cold hands and cold feet.

Loss of body heat, as result of the defects in clothing just described, and

additional losses through openings of the garments at the neck, the wrists, and

the ankles reduced the body temperature to the point at which the most

exposed parts of the body, that is, the hands and feet, gave the first evidence

of the imminence of possible cold injury.

There were other reasons why the clothing situation was often unsatisfactory. One was that, because of lack of training in the use of clothing in cold

weather, items of the uniform assembly were often misassembled. In other

instances, the items could not be assembled properly because of piecemeal issue.

Special types of winter clothing were in short supply in the Army in

Europe throughout most of the winter season; but standard items, such as

underwear, wool shirts and trousers, overcoats, field jackets, and gloves, were

always in adequate supply in the theater. Even standard items, however, were

not always available to the troops. Because of the urgent tactical necessity for

mobility of the individual soldier in combat, commanders sometimes allowed

their men to discard clothing which was not needed during strenuous activity.

Afterward, resupply or redistribution was not always possible.

Footgear.—The United States combat boot, as pointed out earlier (p. 150),

was not well designed. It tended to shrink after it had become wet, and the

uppers were so scantily cut that, however tightly they were laced, they could not

be brought together. In addition, and also as previously noted, the United
EPIDEMIOLOGY OF COLD INJURY 433

States soldier had been accustomed to tight-fitting clothes and snug-fitting

shoes in civilian life, and he carried those habits with him into the Army.

For these and other reasons, there were numerous errors in the fitting of army

shoes. In many instances, no allowance was made for the fact that feet tend

to enlarge under marching and other strenuous activities. Nor was sufficient,

if any, allowance made for the fact that heavy woolen socks, or two pairs

of socks, would be worn during the winter instead of the thin cotton socks

worn during the summer. The soldiers, it must be granted, sometimes created

their own difficulties. When they had been properly fitted originally, they

would trade shoes among themselves until they found the snug-fitting kind

to which they had been accustomed in civilian life.

Similarly, when galoshes were provided, they were not always worn.

Sometimes the men were directed to leave them behind. Sometimes they

simply discarded them of their own initiative because they were cumbersome

to wear into combat.

Socks in the lighter weights were in generous supply at all times in the

various theaters of operations. Heavy wool ski socks were scarce throughout

the winter combat period in the first winter in Italy, as well during the period

of heavy fighting and cold, wet weather on the Western Front.

It is easy to speculate on the effects of these and other deficiencies in

clothing and footgear, and on bad practices in their use, but it is less easy

to prove exactly how they influenced the incidence of cold injury. The effect

of clothing and footgear per se cannot be isolated from other factors and

measured alone. The combat situation and the idiosyncrasies of supply must

always be taken into account. So must human factors. Footgear, for instance,

cannot be designed that will force the soldier to wear itinto combat, or to change

his socks at stated intervals, or to remove his shoes at night, when he knows

full well that he may have to leave the scant protection of his foxhole at

moment’s notice.

Even when allowance is made for these considerations, the incidence of

cold injury in both the Mediterranean theater and the European theater seems

clearly related to the completeness of provision of clothing and footgear.

study by the Preventive Medicine Division, Office of the Chief Surgeon,

ETOUSA, showed unmistakably that the total cold injury rate during the

period of combat was 4.3 per 1,000 for divisions fully equipped in November

1944, 10.5 per 1,000 for those not fully equipped until December, and 11.7 per

1,000 for those not fully equipped until January 1945. The study also revealed

that, when only trenchfoot was related to the degree of completeness of equipment, the rates were, respectively, 2.5 for November, 6.0 for December, and

8.5 for January. These proportions might have been expected, since footgear

is not the only item of clothing related to the production and prevention of

cold injury.

The whole experience in Italy and western Europe in World War II serves

to emphasize the need for simpler and more efficient types of clothing and

footgear to reduce exposure during winter operations. The Theater Quarter-
434 COLD INJURY, GROUND TYPE

master was emphatic on this point. In March 1945, at the Paris conference

(p. 184), he pointed out that the uniform must be made simple and basic, if only

because transportation is limited in wartime and allowances for the movement

of supplies would therefore always be limited; food, gasoline, and ammunition

have priority in tonnage moving forward. Similarly, the production of clothing in the Zone of Interior would be expedited if all items were kept simple and

uniform; there were limits to what could be produced when an army was growing rapidly and straining production of wide variety of items. The quality

of the raw materials and the workmanship in British uniforms, the Theater

Quartermaster concluded, might not meet United States standards, but British

clothing was simple, and it had been kept uniform, with the result that supplies

were adequate all during the fighting in Europe.

The experience in Italy and in western Europe also showed that supply

procedures and practices must be simplified and that command and all other

personnel must be thoroughly trained in the most efficient use of the clothing

and footgear provided.

As the war progressed, special items of clothing were reduced to minimum.

Observers from the Quartermaster Corps not only studied the use of the various

items under as many conditions as possible but also went to great lengths to

sample soldier opinion about them. The results of these surveys sometimes

appeared to have more influence on changes of policy and clothing directives

than they merited, fact which emphasizes the need for better training of the

soldier in the efficient use of clothing and what could be expected from it.

Shelter.-—Shelter is an important consideration in the incidence of cold

injury because it is means to shorten periods of exposure to the elements, as

well as periods of exposure to enemy observation and fire. Seeking shelter to

avoid exposure to cold and wet in combat is as natural and as sensible as coming

into one’s own home to avoid the rigors of winter day. It is not an easy

matter, however, to provide shelter for troops in combat. Though terrain

enters into the problem, whether or not shelter is practical depends chiefly

upon the tactical situation.

Under many combat situations, it is impossible to provide shelter of any

kind except that offered by natural features of the terrain and the hasty digging

of individual foxholes. What can be provided ranges from none at all, which

means complete exposure in open ground, through quickly improvised, unimproved foxholes, foxholes in which there is time for improvement and greater

protection, tents, dugouts, pillboxes, other improvised shelter and damaged

buildings, to, finally, unscarred buildings suitable for the comfortable housing

of troops. Soldiers able to take shelter in buildings, basements, or dugouts,

or even tents and improved foxholes, are obviously much better able to look

after themselves and to take the measures necessary to prevent cold injury

than are those who must pass their nights in hurriedly dug foxholes.

As the war progressed on the Western Front in the winter of 1944-45, the

men developed many expedients to improve their lot, even in the crudest of

shelters. Often they obtained and utilized some form of heat, even in far
EPIDEMIOLOGY OF COLD INJURY 435

forward positions, such as charcoal braziers or hexyl methylamine tablets,

which provide fairly intense heat. At other times, when observation by the

enemy did not forbid it, exposed soldiers poured gasoline on the ground or into

containers filled with loose earth or sand or constructed some other similar

device and then set fire to the fuel to provide the warmth they needed for

protection from the cold. Many hundreds of gallons of priceless motor fuel

were thus consumed. This wastage pointedly indicates the need for developing practical means and methods for providing shelter and heat under adverse

conditions, as well as the need for the provision of more satisfactory types of

clothing and footgear. Incidentally, the use of heat in this manner may sometimes have added to the seriousness of the cold injuries sustained instead of

decreasing their incidence (p. 317).

Some of the unit histories already related illustrate the influence of the

element of shelter as well as of terrain and combat. Other illustrations follow:

Unit case history No. 13.—The 90th Infantry Division was engaged in

operations in the Saar Basin during the first half of December 1944. Two

regiments crossed the Saar River at Dillingen on December. As the fighting

developed, the 357th Infantry Regiment was pinned down in foxholes in the

open, while the 358th and 359th Infantry Regiments, although operating

against equally resolute resistance, fought in the town of Dillingen where some

shelter was available as well as some protection from exposure. By 12 December (chart 24, table 34), the 357th Infantry Regiment had experienced sharp

Chart 24.—Cold injury in regiments of the 90th Infantry Division, European theater, 14 November through 21 December 1944
436 COLD INJURY, GROUND TYPE

Table 34.—Cold injury in regiments of the 90th Infantry Division European theater, 13

November through 21 December 1944

Date 357th Infantry 358th Infantry 359th Infantry Total

1944 November 13

14 17 26

15_ 10 20 40 70

1G 17

17 12

18

19_ 15 21

20_ 11

21

22

23 10

24 10 12

25 13 22

26 16 25

27 10 29 41

28 16 33

29 10

30 10 16

December 13 25

22 31

10

11 12

12_ 45 52

13 82 92

14 33 40

15 12

16

17

18

19

20

21

TotaL __

348 158 163 669
EPIDEMIOLOGY OF COLD INJURY 437

rise in trenchfoot cases; between that date and 14 December, inclusive, it

reported 160 cases, while little increase in incidence was noted in the 3581 and

359th Infantry Regiments. The principal difference in conditions was that the latter regiments had some shelter.

Unit case history No. 14-—A still better illustration of the importance of

shelter is furnished by the experience of the 102d Infantry Division. This

division did not arrive in France until late in September 1944 and therefore

was new to combat. On November, the 406th Infantry Regiment was

detached and the other troops were placed in an inactive defense position where

they remained until 27 November. On 28 November, the 406th Infantry

Regiment was returned to divisional control. From that date until December, an offensive action toward the Roer River was conducted in the Ubach area.

For the weeks ending on December and on December, there was sharp

increase in cold injury (chart 25, table 35).

Chart 25.—Cold injury in regiments of the 103d Infantry Division, European theater, 24 November 1944 through February 1945

Between December 1944 and February 1945, the division remained in

the same sector, in quiet defensive position. The men of the 405th and 407th

Infantry Regiments were for the most part in buildings and basements and

therefore had relatively adequate shelter. The 406th Infantry Regiment, on

the other hand, because of the sector it had to defend, had to seek shelter in

foxholes. The strikingly higher incidence of trenchfoot in this regiment after

the initial offense and during the static defensive weeks, can be accounted for

by one principal differential, the absence of adequate shelter.

438404'— 58 30
438 COLD INJURY, GROUND TYPE

Table 35.—Cold injury in regiments of the 103d Infantry Division, European theater, for weeks ending 24 November 1944 through February 1945

Command leadership and attitude.—Leadership is an intangible quality

which is difficult to define or measure precisely. It is not the intention to

attempt to do either here, but some general statements may nonetheless be

made concerning it.

Leadership is socioenvironmental factor. The standard of leadership

materially influences the unit liability to cold injury. Lack of leadership predisposes to high incidence. When leadership is good, the discipline and

esprit de corps are such that the tedious and sometimes tactically disadvantageous measures which are required to prevent cold injury are willingly

carried out for the good of the command. Good leadership can modify or

control many of the host and environmental factors responsible for cold

injury. Good planning, astute decisions, and firm example can determine the

outcome of combat action. Good leadership is always concerned with the

welfare of the individual soldier. The necessary steps are therefore taken to

insure appropriate supplies of food and clothing, adequate medical facilities, and rest and rotation schedules that will reduce fatigue and increase fighting

efficiency.

good commander understands and accepts his responsibility for the

prevention and control of mass diseases and injuries that may affect his unit.

In so doing, he makes full use of the special knowledge and skills of his technical advisors. He cannot, because of tactical and other circumstances, always

accept the advice given him, at least in all details, but he is very certain of

the consequences when he rejects the advice. He does not wait until large

number of casualties from cold injury has lowered the effectiveness of his

Week ending— 405th

Infantry 406th Infantry 407thInfantry Total

19U November 24

December 32 11 12 55

27 36 69

15 43 51

22 10 13

29 31 39

1945 January 19 24

12

19

26

February

Total 48 150 76 274
EPIDEMIOLOGY OF COLD INJURY 439

unit. Instead, he institutes education, training, and indoctrination programs well in advance of the possible occurrence of cold injury. It is by

no means the least important manifestation of good leadership that good

commander establishes such liaison and understanding with the men under

him that they appreciate the role of the unit in the general conflict. They know what they are fighting for, and they understand the reasons for the

policies and procedures they are called upon to carry out. United States soldiers will always respond willingly when they understand the rationale of

such measures and the benefits to be derived from them for themselves and

their units. It is almost impossible to force them to carry out measures whose rationale they do not understand.

This is not theoretical reasoning. It was repeatedly observed in both the

Mediterranean and the European theaters that well-led units always had the

best average records for cold injury. Numerous divisional records prove this

point. The story of the 29th Infantry Division has already been related (unit

case history No. 8, p. 421). This battle-tried unit, in spite of hard fighting, had only 164 cases of cold injury during the entire winter of 1944-45 on the

Western Front. Similarly, the record of the 95th Infantry Division (unit case

history No. 3, p. 402), which had even harder combat missions than the 29th

Infantry Division during this winter, illustrates the effects of excellent leadership. During the hard fighting between November 1944 and 15 January

1945, it had only 325 cases of cold injury of all types.

The following record of the 87th Infantry Division represents both good and bad leadership:

Unit case history No. 15.—This unit was assigned to the Third U. S. Army

early in December 1944. It had had no previous combat experience. On 11

December, it was committed in drive toward Saareguemines, directly east of

Metz. The weather was moderately cold, and there was daily rainfall. The

terrain consisted largely ofridges and valleys and was not forested, so that the

ground was very muddy.

The story is now best continued by regiments:

The 346th Infantry Regiment was the first to gain contact with the enemy.

Its casualties were heavy at first and the attack bogged down on gently

sloping hillside because of the intensity of enemy fire. On its second day of

combat, casualties were again high, and 12 cases of trenchfoot made their

appearance. At the same time, combat exhaustion cases accounted for 15

percent of total casualties. Battle casualties dropped to on the fourth day.

On the following day, which was the 15th of December, the number of trenchfoot cases far exceeded battle casualties and for the most part came from the

1st Battalion. On the 6th day of combat, this battalion alone had 206 trenchfoot casualties. By the end of week of fighting, the 346th Infantry Regiment

had experienced over 400 cases of trenchfoot in men fully equipped with overshoes and winter clothing (chart 26, table 36; chart 27, table 37).
440 COLD INJURY, GROUND TYPE

Chart 26.—Cold injury in regiments of the 87th Infantry Division, European theater

11-22 December 1944

The record of the other regiments was quite different. The 345th Infantry

Regiment was not committed until 30 December and was in intensive combat

only for matter of days. It experienced only few cases of frostbite. The

347th Infantry Regiment was committed to the support of the 346th the

fourth day of the battle (14 December). It began to suffer casualties from

trenchfoot almost immediately, but at no time in the period under consideration

did the daily number of cases exceed 42, and the total for the whole period was

only 178.

The records of the 346th Infantry Regiment show that the regimental

commander and the commanding officer of the 1st Battalion were chiefly at

fault in the poor record of this regiment, and especially of this battalion, with

respect to cold injury. Lack of progress in the attack, with demoralizing

enemy fire, resulted in considerable break in morale. complete breakdown

in foot discipline was the direct result. Poor attention to the welfare of the

riflemen in the regiment also played part in the high incidence of trenchfoot.
EPIDEMIOLOGY OF COLD INJURY 441

Table 36.—Cold injury in regiments of the 87th Infantry Division, European theater,

11-22 December 1944

Chart 27.—Cold injury in battalions of the 346th Infantry, 87th Infantry Division, European

theater, 11-22 December 1944

Date 345th In- fantry 346th In- fantry 347th In- fantry Total

Deeenriher 11

1944

12 12 12

13 11 12

14 11 11

15 81 13 94

16 255 42 301

17 12 20 38 70

18 40 39 85

19 32 34

20_ 12

21. ... ... 11

22

Total 30 441 178 649
442 COLD INJURY, GROUND TYPE

Table 37. Cold injury in battalions of the 346th Infantry, 28th Infantry Division, European theater, 11-22 December 1944

Because training was not good enough to support the troops in time of trial,

the regiment suffered serious point epidemic of cold injury. It is true that

this was new, untried, and inexperienced unit. It was called upon to spearhead an attack in difficult terrain and in opposition to heavy German forces,

which used tanks in defense, but it is equally true that leadership was the

principal factor responsible for the high incidence of trenchfoot.

The story of these regiments emphasizes vital principle in the prevention

of cold injury; namely, that this type of injury, with its prevention, is problem

of the small units. One regiment of this division (chart 26) was careless. One

battalion in this regiment (chart 27) was at fault. It is interesting to speculate

whether or not the errors could be traced down to poor leadership in certain

companies. It is probable that the same principles held in them.

Training and experience.-—From the standpoint of cold injury, training and

experience are inseparable from individual and unit discipline. Effective

training is based on good discipline, and the development of good discipline

is part of the soldier’s training. When men are well trained and properly

disciplined, they profit from experience and become better able to look after

themselves and save themselves from trauma, whether it be from enemy

weapons or from cold.

The good record of some experienced and battlewise divisions with respect

to the incidence of cold injury has already been mentioned. Among them are

the 104th Infantry Division (chart 18) and the 90th (chart 24). The 99th

Infantry Division furnishes reverse example of the effect of inexperience and

lack of battle training.

Date 1st Bat- talion 2d Bat- talion 3d Bat- talion Total

1944 December 11

12._ 12

13 11

14 11

15.__ 72 81

16 206 12 37 255

17. 14 20

18 35 40

19.

20. ...

21

22

Total. 336 26 79 441
EPIDEMIOLOGY OF COLD INJURY 443

Unit case history No. 16.—The 99th Infantry Division arrived in England in October 1944, landed in France during the first week of November. It was

committed to combat on November, in static defense, with active patrols.

The country was hilly and partly forested. The weather was moderately cold. It rained, and some snow fell. The ground was either muddy or slushy. The division remained in the line under these conditions through 12 December. Cases of cold injury, principally trenchfoot, began to appear almost as soon as it

was committed, and there was peak of 194 cases for the week ending 24 November (chart 28, table 38). Weather conditions were favorable for its

occurrence, it is true, but combat missions were light, and the high incidence could be attributed only to inexperience and to lack of training in the measures

required to prevent cold injury. contributory factor may have been the incomplete provision of galoshes during this period.

second, even larger, outbreak of cold injury occurred between 13 Decem- ber 1944 and January 1945. On 13 and 14 December, the 395th Infantry Regiment and battalion of the 393d Infantry Regiment were in active combat.

The action shifted to heavy defense against the German midwinter counterattack of 16-18 December. Between 19 December and 28 December, retrograde movement was made, and combat action took the form of active defense.

Between 29 December and 28 January, action was also defensive, with active

patrolling. The second outbreak of cold injury was, like the first, largely

attributable to the inexperience of the troops, though intensification of the

combat action also played part.

Chart 28.—Cold injury, 99th Infantry Division, European theater, for weeks ending 10 November 1944 through 16 March 1945
444 COLD INJURY, GROUND TYPE

Table 38.—Cold injury in regiments of the 99th Infantry Division, European theater, for weeks ending 10 November 195Ji. through 16 March 19^5

third peak of cold injury in this division occurred between 26 January

and 16 March 1945. From February onward, operations were in melting

snow, rain and mud, at temperatures between 30° and 40° F. (—1.1° and 4.4°

C.), but the high incidence was also to be explained by heavy combat, sometimes

in extreme cold.

Foot discipline.—Foot discipline in itself cannot, of course, be separated

from discipline in general. It is part of both unit and individual training.

The incidence of cold injury was always low when it was good. Foot discipline,

moreover, was best in those divisions in which the practice of inspection of the

feet was established early, and in which the inspection was not only by commissioned officers but also by noncommissioned officers down to, and including,

the squad level. Even under severe combat conditions, it was repeatedly

observed that when discipline was good sufficient time and safe enough surroundings could usually be found for the use of protective measures. Even if

daily care was not possible, in most situations care of the feet could be resumed

before the end of the mean incubation period for trenehfoot, that is, approximately days, though as temperatures approached the freezing point the

margin of safety became less.

Week ending— 393d Infantry 394th

Infantry 395thInfantry Total

1944 November 10

17 72 76

24 102 62 30 194

December 19 65 17 101

13 14

15 29 41 75

22 146 150 88 384

29 46 83 26 155

1945 January 16 28 46

12 13 37 53

19 25 34

2C 16 38 56

February 109 58 12 179

58 79 45 182

16 14 30

23

March

16

Total 619 693 288 1, 600
EPIDEMIOLOGY OF COLD INJURY 445

study by Colonel Gordon’soffice showed that, during the winter of 1944-

45, six divisions which had not been in combat before November 1944 averaged 15.5 cases of cold injury per day of combat, while 13 units with long combat

experience averaged only 7.6 cases per day. Although several factors undoubtedly helped to explain this difference, the observers attributed it chiefly to better foot discipline in the experienced divisions. The inexperienced divisions had not received adequate training in the individual care of the feet, or,

if they had been trained, they had not come to recognize the importance of the

training and therefore did not apply what they had learned. As result, when

they were first committed to action under conditions favorable to trenchfoot,

many became casualties to cold and mud.

Intense combat activity influenced the incidence of cold injury, at least

indirectly, because it brought about relaxation of foot discipline. It was the

observation of number of division surgeons that when the incidence of cold

injury was rising prompt decline would ensue, regardless of combat activity,

whenever commanding officers took firm stand in insisting upon individual care

of the feet.

specific example of the effect of foot discipline is furnished by the three

regiments of the 45th Infantry Division as follows:

Unit case history No. 17.—All three regiments of the 45th Infantry Division

fought under similar conditions, with roughly similar missions, between 28

October and 29 December 1944. During this period (chart 29, table 39) the

180th Infantry Regiment had 48 cases of cold injury, the 179th, 108 cases,

and the 157th, 209 cases. When the division was surveyed, the only explanation found for these differences was that training was rather poor in the 157th

Infantry Regiment, was satisfactory but no more in the 179th, and was excellent in the 180th.

Chart 29.—Cold injury in regiments of the 45th Infantry Division, European theater, for weeks ending November through 29 December 1944
446 COLD INJURY, GROUND TYPE

Table 39.—Cold injury in regiments of the 45th Infantry Division, European theater, for weeks ending November through 29 December 1944

The story of the 9th Infantry Division has already been used (unit case

history No. 5, chart 17) to illustrate the effects of both thawing (p. 414) and

terrain (p. 422). It also illustrates the effect of foot discipline. Both frostbite

and trenchfoot were kept at low levels. There was one small outbreak of

trenchfoot in the middle of November, before the troops were completely supplied with galoshes, and second, minor elevation in December, coinciding

with period of active defense. When this division was surveyed, it was

concluded that its excellent record could be attributed to number of factors,

including (1) its battle experience, (2) the early date at which it was supplied

with galoshes, (3) the extensive use of drying tents, (4) the unusual ingenuity

shown in obtaining and issuing charcoal braziers for the use of frontline troops,

and (5) the intensive program of instruction, in which the burden of prevention

of cold injury was placed on the individual soldier.

Similar observations could bo multiplied. All of them can be interpreted

as indicating the importance of foot discipline, which includes familiarity with

the measures which the individual soldier can use to prevent cold injury and

the diligent application of these measures.

Rotation.-—Rotation, or the regular relief of troops from frontline positions

in which exposure to the elements is great, materially influences the incidence

of cold injury. The most adverse conditions of weather and terrain can be

tolerated by combat soldiers for short periods if they can be rotated within

units or by units, both large and small, and thus be provided with opportunities

to carry out appropriate control measures.

Week ending— 157th Infantry 179th Infantry 180th Infantry Total

19

November 14 20 II) 47 52

17

24

December 13 24

29 42 79

15 48 27 81

22 23 11 40

29 25 12 20 57

Total ___ 209 108 48 365
EPIDEMIOLOGY OF COLD INJURY 447

The practice is beneficial at any level, from individual frontline riflemen

and squads through progressively larger units by echelon, np to and including

whole divisions. good rotation policy begins with the individual soldier in

the frontline. In forward areas, it need consist of no more than the opportunity to withdraw from his foxhole to crude shelter few hundred yards

to the rear, where, in relative safety, he may change his clothing, exercise

little, and carry out appropriate measures, including massage, for the care of

his feet. In the battalion area, better arrangements can be made for foot care,

and facilities improve progressively in regimental and division areas. Somewhere along the line, bathing and laundry facilities are available, the men can

obtain few hours of rest, and, under ideal circumstances, they are provided

with hot food and the morale-lifting advantages of the Red Cross truck and of

getting mail and writing letters home.

Intervals of rotation should vary according to the size of the units. In

frontline units, the rotation of individuals and small units depends upon weather

and the intensity of combat action. In World War II, it was the consensus

of division surgeons that period of days or more was usually required for

trenchfoot to develop at temperatures above freezing, while, below that level,

frostbite could develop in few hours. In progressively larger units, rotation

should be progressively less frequent but for longer intervals. In addition to

the importance of rotation in the prevention of cold injury, its employment

for this cause bolsters morale in general, lessens fatigue, and decreases losses

from neuropsychiatric causes.

definitive rotation policy was never established by United States armies

in Europe. Instead, divisions determined and executed their own rotation

practices, while, within divisions, the policies were usually left to the discretion

of regimental or battalion commanders. Under these circumstances, policies

and practices naturally varied widely. They were good in some units and poor

in others. In all, they were of necessity greatly influenced by the exigencies of

combat.

During the German counteroffensive in December 1944, the defense

operation in the first few days was so urgent that good rotation practices could

not be executed. The intensity of the fighting during the later United States

counterattack had the same inhibiting effect. The combat situation was

therefore partly responsible for the second Army-wide cold injury epidemic on

the Western Front (chart 15). In situations such as these, the determination

of the extent of rotation must be command decision, but the establishment

of the general principles of rotation by army, or even by army group, and the

insistence that these principles be applied consistently within the limits permitted by the combat situation, would have influenced the cold injury incidence

downward in World War II. It would also have reduced losses from combat

exhaustion and psychoneurosis.
448 COLD INJURY, GROUND TYPE

The effectiveness of rotation in reducing the incidence of trenchfoot is

well illustrated in the following experience of the three regiments of the 35th

Infantry Division:

Unit case history No. 18.—This division landed on the Continent in July

1944 and fought across France in the Third U. S. Army. At the beginning of

the November offensive, it was in the line east of Nancy, in muddy, rolling,

open country near the Seille River. As the offensive opened, division order

was issued directing that galoshes be left behind.

The 320th Infantry Regiment made an all-night march to get into position,

then crossed the river. Three days later, it began to report trenchfoot casualties

(chart 30, table 40). At this time, the 134th and 137th Infantry Regiments

went into action. Rain fell continuously, and the foxholes were usually half

filled with water. During the first days of the operation, the 134th and

320th Infantry Regiments had, respectively, 161 and 163 cases of cold injury.

For the same period, the 137th Infantry Regiment had only 36 cases. Conditions for all three regiments were substantially the same, with one exception:

The 137th Infantry Regiment fought through few small, built-up areas and

had what amounted to daily rotation of small groups, to allow for drying the

clothing and caring for the feet. It was the opinion of those who studied the

cold injury situation in the three regiments that it was principally good rotation

practice in one regiment, as opposed to the lack of rotation in the other two, that accounted for this striking difference in the trenchfoot experience.

Chart 30.—Cold injury in regiments of the 35th Infantry Division, European theater, 8-30

November 1944
EPIDEMIOLOGY OF COLD INJURY 449

Table 40.—Cold injury in regiments of the 35th Infantry Division, European theater, 8-30

November 1944

Interrelationships of Causative Factors

The following records of the 3d and the 36th Infantry Divisions summarize

effectively much of what has been discussed in the earlier pages of this chapter.

Unit case history No. 19.—The 3d Infantry Division, battle-experienced,

hard-hitting unit, which was the mainstay of the Seventh U. S. Army, reduced

the Colmar Pocket, and then fought out into the Colmar Plain toward the

Rhine during January and February 1945. The interrelationships of many of

the modifying factors of cold trauma which have been discussed are apparent

in the graphic record (chart 31). When the incubation period of cold injury

is considered, the influence of weather, type of combat action, wetness from

river crossings, terrain, and adequacy of clothing and equipment is well

demonstrated.

Date 320th

Infantry 134th Infantry 137th Infantry Total

1944 November _.

10 11 16

11 43 58

12 42 13 57

13 39 31 73

14 24 38 67

15 40 46

16 33 43

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Total. 194 167 57 418
450 COLD INJURY, GROUND TYPE

Chart 31.—Cold injury incidence, 3d Infantry Division, European theater, 20 January through

13 February 19jo

Date Combat action Weather Terrain Clothing supply Equipment

ms Training; patrol;

moving into

position.

Cold; snow; sleet. Flat; rolling; cultivated and one

forested; one regiment in mountains.

Jan. 20-21 90 percent of

troops had shoepacs.

85 percent complete; 85 percent

adequate.

Jan. 23 ...

Jan. 24-26 Attack; heavy opposition; conn

terattack;

holding.

Unchanged; snow.

Jan. 27 Slightly warmer..

Jan. 28-29 Holding; consolidating gains.

Jan. 30

Jan. 31-Feh. 2... Attack; consolidating gains;

holding.

Warmer; rain;

thawing February.

Jan. 28-Feb. 2...

Feb. 3-7 Attack; holding...

some articles of

clothing.

equipment.

80 percent complete.

Feb.

Feb. 9-12 Reserve
EPIDEMIOLOGY OF COLD INJURY 451

Unit case history No. 20.—The 36th Infantry Division had considerable

experience with cold injury in Italy during the winter of 1943-44. In the fall

of 1944, it participated in the landings in southern France. During the

succeeding winter, it found itself in almost constant contact with the enemy.

In its progress, it fought on wide front, through difficult, mountainous terrain.

All movement of any consequence had to be on foot. After 15 September, the

weather was cold, and, during November, rain fell almost continuously. Several

streams had to be crossed, and the constant rains kept the troops wet even

when they were on high ground.

The cold injury experience to date and the problems encountered during

1944 were summarized by the surgeon of the 36th Infantry Division in his

December 1944 sanitary report, as follows:

Trench foot has caused serious loss of manpower within the Division during combat

operations in the winter months in Italy and France due to the cold wet climates encountered.

The highest incidences were reported during the months of January with 401 cases, February

with 270 cases, November with 279 new and 97 recurrent cases, and December, with 155 new

and 45 recurrent cases. During the month of November, 77 cases of trench foot were received over four day period from one Regiment of the Division that was attacking during

driving rain. These troops had been issued an extra pair of heavy wool socks and an extra

light wool pair. Although most of them had shoepacs they had four times as much trench

foot as the rest of the division. The other two Regiments of the Division were in holding

position and had total of 19 cases of trench foot. Another observation of two adjoining

companies under the same conditions of exposure as made when one company had 10 cases

of trench foot over six day period while the other company had cases. It was found that

the men of the company having 10 cases had had no exchange of light wool socks while those

of the other company had dry socks exchanged times. This was corrected. The marked

decrease during the month of December is attributed to comparatively dry weather encountered during the month and to the educational program conducted during the months

of October and November on foot hygiene and the prevention of trench foot. Shoepacs

were issued to the troops during the month of November with instructions for their proper

wear and the importance of changing to dry clean socks and dry inner soles daily. Approximately 1,700 men of this division do not have shoepacs or overshoes because of the lack

of proper sizes in Quartermaster stocks. Every effort is being made to issue combat boots

of sufficient size to permit wearing of heavy wool socks and light wool pair. system

has been worked out by which the infantry S-4s [supply] replace the dirty socks with clean

dry socks daily by sending the clean socks forward with the daily ration issue. The high

casualty rate among Commissioned and Non-Commissioned Officers, resulting in frequent

turnover of the command while in combat causes the necessary supervision of foot hygiene

in small units and footgear discipline to be less efficient than is desired, even though constant

attention is given to this matter in Battalion, Regimental and Division Headquarters.

Instructions on prevention of trench foot given at the direction of Seventh Army to personnel

of Replacement Depots and Convalescent Hospitals is believed to be an important aid in the

educational program against this disease. Random comments in the report of the trench

foot survey of the 36th Division emphasize still other causes for the high trench foot incidence:

“Unfortunately, the tactical situation has largely precluded the possibility of rotation

of men. No regiment has been inreserve and riflemen have been in the line for long periods

of time.

“There has been no policy to set up houses or tents to be used specifically as drying

rooms for front line soldiers. It is felt that if houses or dug-outs are available, soldiers, will

go to them to warm themselves and build fires to dry their clothing of their own accord.
452 COLD INJURY, GROUND TYPE

“Shoe pacs were issued during the second week of November. About 2,000 men do

not have them because of wrong sizes.

“This division tried to get socks to front line soldiers each day with rations. It is

believed that sock exchange is fairly satisfactory.

“The division went through the Italian winter campaign and officers and men in that

campaign are well trained in the prevention of trench foot. Replacements are not well

trained in care of the feet. “*

trench foot is disease of riflemen. With the exception of small percentage

of supporting troops, such as company aid men and combat engineers, the disease should not

occur in any except infantry riflemen. Even the heavy weapons companies have very little

trench foot.

“Battle conditions play very important part in the development of trench foot.

The surgeon believes that 24 to 36 hours exposure in wet, cold weather, without supply, ill

be sufficient to produce trench foot.

“The Surgeon believes that control of trench foot is purely command function. If the

command is well trained in the prevention of trench foot and realizes its importance, the rate

of trench foot will be very low in that organization. He also points out that when unit

officers are frequently changed, the trench foot incidence is always higher than in units

which retain their officers for longer periods.”

It was not until late in January 1945 that thoroughgoing, well-rounded

cold injury prevention program was, or could be, instituted in the 36th Infantry

Division. By this time, all replacements were receiving detailed instruction

on the proper care of the feet, both wdien they first were assigned to the division

and upon assignment to regiments. Supplies of shoepacs, light wool socks, and ski socks were now adequate. In its holding operations, the division had

found it feasible to establish good rotation system by the use of houses,

dugouts, or tents immediately behind the frontline, where each man could

spend an hour out of every or hours warming himself, changing his socks,

and massaging his feet.

Even under these improved conditions, report by unit surgeon of this

division for January 1945 noted that “the lack of close supervision of some small

unit commanders has caused the incidence of trenchfoot to rise in these units

during the past weeks.” At this time, each unit surgeon was required to furnish report of these

and other deficiencies to the commanding general of the division, who took the

necessary corrective action. The result w-as notable decrease in the incidence of trenchfoot.

SUMMARY

It is evident, from what has been said in this chapter, that the causation of

cold injury is an intricately woven fabric of agent, host, and environmental

factors, and that no single one of the factor strands can be altered without

influencing, or being influenced by, the other factor strands. The final design

is an interaction and interrelationship of them all. One factor may predominate

in influencing the incidence at one particular time. Then the situation may

change, and another, or others, may gain in influence.
EPIDEMIOLOGY OF COLD INJURY 453

The various modifying factors described in the examples given were predominant for the periods selected, but no single factor could be completely

divorced from all the others. In the absence of more precise data, however,

and of more detailed observations, the examples do serve (1) to emphasize the roles of the various factors involved, and (2) to point up the need for further

study, research, and evaluation of the influence and interrelationship of the

several agent, host, and environmental factors responsible for cold trauma.

The surveys which provided the data for these selected studies brought into

play the principles of simple, sound field investigation.

The data and examples thus secured provide reasonable and convincing

basis for concluding that cold trauma, as component of mass trauma, behaves

in accordance with the biologic principles and laws that govern disease or injury

as community problem. The specific causative agent in cold injury is cold, but number of modifying factors enter into its total causation. These can

best be analyzed if they are divided into agent, host, and environmental factors.

Studies of war records by theaters and units, and the reports of epidemiologic

surveys by division in the European theater, demonstrated that epidemiologic

behavior of cold trauma differs in only minor degrees from that of communicable

disease.

Evaluation of this experience has shown that the agent factors are cold

and wet and that wet may be conceived of as having synergistic relationship

to cold. Host factors include status of individual training, fatigue, nutritional

status, previous cold injury experience, inherent constitutional factors, psychosocial factors, and posture and dependency. Both the physical environment

and the social environment are factors in the causation of cold injury. Physical

environmental factors include weather (that is, temperature, precipitation,

and wind), thawing, terrain, and altitude. Socioeconomic environmental

factors include type of combat action, clothing supply and equipment, shelter,

command leadership and attitude, training and experience, foot discipline, and

rotation. Some of these are individual considerations and some apply to the

unit. All of them entered into the total causation of cold injury in the European

Theater of Operations in World War II, but it was only by assessing their

individual weights by unit, by means of epidemiologic methods, that definitive

preventive and control procedures could be applied.

455

CHAPTER XIV

The Cold Injury Record of the 84th

Infantry Division

Many divisions in the European Theater of Operations had worse cold

injury records than the 84th Infantry Division. Some had better records.

Some were in heavier combat for longer periods of time. The history of the

84th Division, however, has been selected as unit case study in cold injury

for the following three reasons:

1. The experience of this division clearly demonstrates the influence of

several modifying factors in cold injury without, at the same time, making it

necessary to pursue an extremely complicated combat narrative.

2. Its combat engagements were sharply divided into difficult initial

combat period, when trenchfoot was predominant; an intensive combat situation in which terrain and weather combined ideally to give rise to frostbite; and

return to exactly the same weather conditions as those previously experienced,

which favored the development of trenchfoot but in which trenchfoot did not

occur at all and the incidence of frostbite was negligible, chiefly because the

combat situation, while active, coidd be regarded as mild to moderate for

division that had become battlewise and self-sufficient.

3. This division had received good training, in which the prevention and

control of trenchfoot were included.

The 84th Infantry Division, which was made up of the 333d, 334th, and

335th Infantry Regiments, artillery and supporting troops, was re-formed in

August 1942 from World War outfit. It was fully trained in the United

States, where it was activated on 15 October 1944. It assembled in England,

and the first elements arrived on the Continent on November. The division

went at once to the front. It was attached to the XIII Corps but was initially

placed under the operational control of the British 30 Corps, Second Army, for

commitment with British troops.

During November and December, the XIII Corps had the following

missions: (1) To maintain liaison with the British on the left; (2) to maintain

liaison with the U. S. XIX Corps on the right; (3) to protect the left flank of

the Ninth U. S. Army; (4) to capture Geilenkirchen and the high ground northeast of it; (5) to seize the line of the Roer River from Flossdorf to Linnich,

The tactical material in this chapter is based on two books by TheodoreDraper: (1) The 84th InfantryDivision in

the Battle of the Ardennes. Liege: Society dTmpression et d’Edltion Societe Cooperative, April 1945; and (2) The 84th

InfantryDivisionin the Battle of Germany, November 1944-May 1945. New York: The Viking Press, 1946. Theclinical

material is derived from the medical histories of the 84th InfantryDivision for 1944 and 1945.
456 COLD INJURY, GROUND TYPE

inclusive; (6) to seize the Beeck-Wurm-Lindern area; and (7) to prepare for

crossing the Roer River.

The assignment of the 84th Infantry Division in these missions was (1)

to reduce Geilenkirchen, (2) to carry out the Beeck-Wurm-Lindern operation,

and (3) to make plans for crossing the Roer River in December. For unit

which was entering combat totally inexperienced, these were indeed formidable

tasks.

28 NOVEMBER 1944

Since the missions and the cold injury experiences of one regiment of this

division differed considerably from those of the other two regiments, it is convenient to discuss them separately.

335th Infantry Regiment

Tactical situation.-—The 335th Infantry Regiment was detached from the

parent 84th Infantry Division on November and was attached to the 30th

Infantry Division, under the XIX Corps. Until 16 November, the entire

XIX Corps was engaged in defense and regrouping activities. Combat activity was light. The 335th Infantry was placed in the line in the Geilenkirchen area in holding action characterized by occasional active defense.

On 17 November, the corps moved in an attack that met moderate to heavy

resistance, but the 335th, as an inexperienced unit, was not heavily engaged in

these operations.

The weather during this period was cold, but the temperatures remained

above freezing. Heavy rains had fallen, however, and the mud was deep in the

generally flat terrain. Large expanses of open field were broken by small

towns from to miles apart, and coal mines in the area also provided some

shelter.

Cold injury.—During this period, the 335th Infantry Regiment sustained

only few cases of trenchfoot, not quite as many, in fact, as the 334th Infantry,

which had not yet been committed.

333d and 334th Infantry Regiments

Tactical situation. —The first action for the 334th Infantry Regiment came

on 18 November, when it launched an attack designed to capture high ground

to the northeast of Geilenkirchen. The following day, the 333d Infantry went

into its initial combat, with the British 43d Division. Geilenkirchen fell at the

end of that day, and the attack was continued, against heavy resistance, to the

north and northeast. The high ground northeast of Beeck was captured on

23 November, and Beeck itself fell on 30 November. On 24 November, both

regiments reverted to XIII Corps control and resumed defensive action to hold

the ground which had been gained.
COLD INJURY, 84TH INFANTRY DIVISION 457

During the period 18 November through 25 November, as will be pointed

out shortly, rain fell much of the time, and the troops were forced to remain

for long stretches in water-filled foxholes, in which water was sometimes within foot of the top.

Cold injury.—In the days of combat just described, 349 casualties with

trenchfoot were evacuated from the division, 340 of whom came from the 333d

and 334th Infantry Regiments. Assuming that the strength of regiment is

4,000 men, this is rate, for the days, of 37.2 evacuated trenchfoot casualties

per 1,000 strength.

Division Conference on Trenchfoot

By 24 November, the division staff had become greatly concerned over the

increasing incidence of trenchfoot, and certain preventive measures had already

been instituted. At conference called on this date to discuss the situation, attended by the division G-4 (logistics), quartermaster and surgeon

and the regimental surgeons of the two regiments most seriously affected,

report was prepared, approved by the division commander, and forwarded to the commanding general of the XIII Corps. The seriousness of the situation

was pointed out in this report, and the factors underlying the outbreak of cold

injury were outlined.

The incidence of trenchfoot in the 84th Infantry Division, this memorandum

noted, had risen precipitously from cases on 10 November to 133 cases on 23

November. Of the 133 casualties recorded for 23 November, 108 were from the 334th Infantry Regiment, the great majority being from the 2d and 3d

Battalions. Both of these battalions had been pinned down in foxholes for

periods of 12 hours each by heavy artillery and mortar fire. During the week in which the 333d and 334th Infantry Regiments were heavily engaged in combat,

rain fell much of the time and water collected, sometimes up to depth of

feet, in the foxholes in which the soldiers were compelled, for tactical reasons, to

spend all day and part of the night. Enemy artillery fire repeatedly forced

the men in these units to dig in, with the result that they had no opportunity

to care for their feet before they were again committed to combat.

Soldiers from the 334th Infantry who were interviewed in the medical

collecting station all stated that they had received instruction in the prevention

of trenchfoot before they went into the line. They had not, however, been

able to carry out the measures recommended. Some of them had not had their

shoes off for days. While some of them had changed their socks daily, all

of them pointed out that, under the existing climatic conditions, it was impossible to change into dry socks. Most of the men had not removed their shoes as

instructed because they were afraid that if they did they would be unable to

get them back on. Not all of the troops had had overshoes, but many who

It will be noted that these figures are slightly higher than those presented in table 41. The explanation is that these

figures cover all casualties, including those not evacuated from the division, while figures in table 41 cover only the

casualties evacuated.
458 COLD INJURY, GROUND TYPE

possessed them had discarded them, partly because they were useless in already

rain-filled foxholes.

These facts were corroborated in an afteraction report for the month of

November by the surgeon of the XIII Corps, who summed up the reasons for

the high incidence of trenchfoot in the 84th Division, as follows:

An inexperienced division was engaged in combat for days under the

most adverse conditions of weather and terrain. Combat was intense, and some

elements were pinned down by enemy fire for as long as 12 hours at time.

Overshoes were not available in large sizes for several days after the battle

began, and all troops had not been equipped with their full allowance of socks.

The principal causes for these trenchfoot casualties, in addition to extremely

unfavorable weather and terrain and lack of equipment for winter operations,

were listed as (1) failure to relieve troops at frequent intervals, (2) failure to

provide areas for changing and drying wet clothes and footgear, and (3) failure

of some troops to carry out the foot hygiene which they had been taught.

Preventive Measures

Even before the conference on trenchfoot was held, the commanding

general of the 84th Infantry Division had reacted to the dangerous situation

and had been fully supported in his plans by the commander of the XIII Corps.

After 22 November, it became division policy to rotate battalion at time

out of the line, for or days of rest in billets in which hot showers were avail

able. On 23 November, each regiment established center with facilities for

rest and rehabilitation from combat exhaustion. These centers also served as

rotation points for combat soldiers to dry themselves out and to obtain changes

of socks and of other clothing. By 24 November, enough heavy socks and

overshoes were available to equip the entire division. On the same day,

daily sock exchange was instituted. Dry socks were to be brought forward

with the rations, and the sodden socks worn b} combat soldiers were to be

exchanged for them. In practice, this arrangement worked out somewhat less satisfactorily than it sounds, partly because of frequent failures to turn in

worn socks and partly because proper sizes were often not available in the

socks brought up for replacement.

On 29 November, the commanding general of the 84th Division issued

memorandum to all unit commanders in which he specifically put the responsibility for the control of trenchfoot upon commanders of all echelons. It was

made clear that high incidence of trenchfoot in any unit would be regarded

as an indication of command failure in that unit. All officers were instructed

to institute daily foot inspections immediately. Command responsibility was

interpreted to mean that the inspections would be held not only by commissioned officers but also by noncommissioned officers of platoons and squads;

it was desired that these men should realize that the prevention of trenchfoot

was quite as much their responsibility as it was the responsibility of commissioned officers.
COLD INJURY, 84TH INFANTRY DIVISION 459

The memorandum of 29 November also included extracts from pertinent

War Department, theater, and army-group directives dealing with the prevention of trenchfoot. It was directed that all commanders familiarize themselves with the details of these extracts thoroughly and at once.

Analysis of Experience

It is improbable that an outbreak of trenchfoot could have been entirely

avoided in the circumstances in which these inexperienced troops were thrown,

almost abruptly, into intense combat, in flat, waterlogged, muddy terrain,

when the mean temperature ranged between 42.5° and 56.5° F. (5.83° and

13.6° C.) and it rained 60 percent of the time. The result was that over an

8-day period severe point epidemic of cold injury occurred (chart 32, table 41.)

The immediate command response to this experience evidenced good

leadership. This is further shown by statement of the division surgeon in his

sanitary report for December 1944. The marked decrease in the incidence of

trenchfoot, frostbite, and immersion foot which occurred during this period,

the surgeon noted, could be attributed chiefly to (1) frequent inspections by

unit commanders and medical officers and (2) the splendid cooperation of the

men themselves in following the directives with preventive measures.

29 NOVEMBER-20 DECEMBER 1944

Tactical situation.—On 29 November, the 84th Infantry Division participated in the offensive in which the town of Lindern was captured. Thereafter,

the division continued slow-moving offensive toward the low-lying approaches

to the Roer River, and, by 15 December, it had assumed holding defense

facing the river. Terrain and weather conditions were similar to those just

described.

Cold injury.—On 29 November, the day the attack began, cases of trenchfoot were reported by the division, and 24 cases were reported the following

day. After this date, while trenchfoot continued to occur, the rate was greatly

reduced. There were number of reasons for this improvement, as follows:

1. The combat situation was less intense.

2. Individual and unit preventive measures had been put into operation.

3. Supplies of overshoes and socks were now adequate.

4. Rotation was being practiced throughout the division.

The practices just listed had been effective in spite of the continuation of

adverse environmental conditions including continued rain, unfavorable

terrain, and the waterlogged and very muddy ground.

Only few cases of trenchfoot were reported between this date and 20

December 1944, when the course of events abruptly ended the holding action.
460 COLD INJURY, GROUND TYPE

Chart

32.

—Mean

temperature, precipitation,

and

cold

injury

cases

evacuated

from

the

84th

Infantry

Division,

European

theater,

November 1944

through

31

January

1945
COLD INJURY, 84TH INFANTRY DIVISION 4C1

Table 41. Mean temperature, precipitation, and cold injury cases evacuated from the 84th

Infantry Division, European theater, November 1944 through January 1945

[Weather data were prepared by the Air WeatherService Military Climatology Division]

21 DECEMBER 1944-2 JANUARY 1945

Tactical situation.—On 20 and 21 December, the entire 84th Infantry

Division was withdrawn from its position facing the Roer River and moved

southeastward to Marche, Belgium, where it was to enter into an extremely

active defensive operation against the German midwinter counteroffensive and

was also to participate in the American offensive that followed. The suddenness

438404'—58 31

Day of month

November 1944 December 1944 January 1945

Mean

temperature

Precipitation Cases Mean

temperature

Precipitation Cases Mean

tempera- ture

Precipitation Cases

°F. Mm. Number °F. Mm. Number Mm. Number

44. 1. 43. 22 27.

43. 47. 3. 34. 1.

42. 4. 40. 6. 39. 5.

47. 3. 38. 3. 27 34. 1.

49. 1. 34. 1. 33 33. 16

___

49. 6. 38. 4. 14 31.

50. 5. 34. 7. 34. 11.

44. 3. 20. 2. 28. 8. ii

36. 5. 15. 3. 21 31. 1. 57

10 37. 4. 19. 7. 12 30. 48

11 .. 40. 1. 30. 6. 28. 5. 62

12 40. 1. 36. 7. 27. 22

13 36. 7. 38. 21.

14 40. 6. 35. 29.

15_ 30. 1. 36. 18. 1.

16 29. 41. 3. 29. 1.

17 31. 7. 47. 3. 30.

18 48. 48. 4. 34. 5.

19 47. 40. 35. 6.

20 53. 11. 40. 23. 6.

21 45. 2. 37. 22.

22 42. 6. 17 39. 2. 26.

23 56. 10. 118 35. 27. 3.

24 50. 6. 125 27. 27. 13

25 46. 6. 77 29. 28.

26 38. 4. 29 28. 18. 1.

27 43. 2. 23 26. 27. 1. 10

28 41. 8. 29. 26.

29 41. 3. 29. 20.

30 40. 30 29. 1. 19. 3.

31 34. 32. 3.

Total 450 210 310
462 COLD INJURY, GROUND TYPE

of the German attack required the immediate marshaling of all defensive resources, as well as the assignment to individual units of missions that under less

urgent circumstances would have been considered ill-advised military policy.

The perilous situation in the vicinity of Marche, as well as the confidence of the

Germans in the success of their offensive, is illustrated by the following excerpt

from the surrender note which they dropped on Bastogne on 22 December;

“The fortune of war is changing. This timethe USA forces in and near Bastogne

have been encircled by strong German armoured units. More German armoured units have crossed the River Our near Ourtheville, have taken Marche

and reached St. Hubert by passing through Homores-Sibret-Tillet.”

The Germans proved to be somewhat overconfident. Late in the day on

21 December, the 334th Infantry Regiment of the 84th Division arrived in

Marche, which was never taken. By nightfall of the following day, the entire

division was settled inand around the town, under the control of the VII Corps,

First U. S. Army. For the first days, the division operated in military void,

without friendly forces on either flank. In effect, it constituted an island of

defensive resistance against the 2d SS Panzer Division and the 116th Panzer

Division. By 22 December, the 12-mile-long line between Hampteau and

Hogne required the spacing of foxholes 150 yards apart.

The lack of intelligence and the confusion of the situation led the 84th

Division commander to undertake probing reconnaissance operations to the

west and southwest of Marche. The 3d Battalion of the 335th Infantry was

given the former mission, and the 1st Battalion of the 333d Infantry the latter.

Each battalion, in advances in excess of 10 miles each from Marche, ran into

heavy enemy resistance. At this time, the 3d Battalion was all that was in

front of the 2d Panzer Division. The good leadership and aggressive concept

that inspired these probing tactics can be considered responsible for deflecting

the German drive to the south of Marche, at time when armor had not yet

been brought up to the support of the 84th Division, but the German advance,

nonetheless reached to within miles of Dinant on the Meuse River and acutely

threatened the encirclement of Marche.

By 24 December, the 84th Division had dug in on the front at both ends of

the Marche-Hotton road. Its flanks, meantime, had been filled in, on the right

by the 2d Armored Division and on the left by the 3d Armored Division. Great

tank battles raged around Celles, and the 116th Panzer Division tried, without

success, to crack the center of the divisional line. The German attack on the

town of Verdenne and counterattack by the 84th Division to wipe out an

enemy pocket collided head on. The Germans took the town temporarily, but it

was soon retaken by the 84th Division, after seesaw battle.

second attempt, supported by tanks, to reduce the pocketed enemy

forces proved difficult operation, but, by the night of 26 December, the divisional line had been straightened out. strenuous attempt by the Germans to

break through the lines at Menil did not succeed and ended by dark on 27

December. This battle is regarded as the operation that finally broke the

German drive toward the Meuse River.
COLD INJURY, 84TH INFANTRY DIVISION 463

German forces engaged in the Battle of the Bulge were contained by both

British and American forces. The Third U. S. Army struck from the Bastogne

area in the south, the First U. S. Army counterattacked from the north on both

sides of Manhay, and the British Corps operated to the west from Marche.

Logically therefore, British forces took over the position of the 84th Division

at the end of the defensive operation. The division then moved northward on

January 1945, to join the 83d Infantry Division and the 2d and 3d Armored

Divisions under the First U. 8. Army and to take part in difficult counteroffensive in the Ardennes. The changeover was effected by complex, sideslipping movement, over narrow, icy roads, but in spite of these difficulties the

84th Division managed, within approximately 36 hours, to complete its relief

and concentration in new area.

Cold injury.'—Up to 25 December, although the combat was more intense

than the division had ever before experienced, the incidence of trenchfoot

remained low (table 41, chart 32). For this, there were number of reasons:

1. Although the temperature range was favorable for the development of

trenchfoot, very little rain fell.

2. The terrain was rolling and hilly, in contrast to the flat ground over which

the division had fought on the approaches to the Roer River.

3. The many villages in the sector provided more protective shelter than

had been available during the early experience.

4. The division had profited by its cold injury experience in November.

After 24 December, the mean daily temperature was below freezing

(table 41, chart 32), and cold injuries, made up of both trenchfoot and frostbite, increased sharply. Up to this time, the division had not experienced

frostbite, with which it was destined to become intimately acquainted during January.

3-16 JANUARY 1945

Tactical situation.—As part of the First \J. S. Army counteroffensive made from the north in the Battle of the Bulge, the 84th Infantry Division, teamed

with the 2d Armored Division, spearheaded the principal advance. The

attack, which was launched between the Ourthe and the Sahn Rivers, had as

its primary objective to take the ground between the rivers and reach the city

of Houffalize, which was key strategic point. The 84th Division was assigned

the zone between the Ourthe River and the Houffalize road, which split the

sector between the two rivers; this zone was cut by small river, the Aisne.

On the right of the division was the 2d Armored Division and on the left were

the 83d Infantry Division and the 3d Armored Division. The secondary

objective was to cut the vital crossroads at La Roche, which furnished the key

to egress and ingress for German supply transportation. The first attack

was largely an infantry effort, with armor in support. The type of terrain

and the condition of the roads made the full use of tanks impractical. German

opposing forces consisted of the 2d SS Panzer Division on the right, the 560th
464 COLD INJURY, GROUND TYRE

Volksgrenadier Division in the center, and the 12th Volksgrenadier Division

on the left.

The 84th Infantry Division jumped off at 8:30 on the morning of January 1945. For few days, the 335th Infantry was on the right flank, bearing

the brunt of the attack. The 333d Infantry on the left had easier going.

The 334th Infantry was in reserve. Four days of fighting, the most difficult

the men of the 84th Division had ever experienced, saw the capture of the

villages of Beffe and Devantave and the ultimate occupation, on January,

of the commanding Consy Ridge and its village. The severe weather and

the type of terrain continued to make the tanks largely ineffective, and the fighting was chiefly by the infantry.

On 11 January, the La Roche road was cut. On 13 January, the 333d

Infantry captured Les Tallies and jumped off toward Dinez. On the same

day, the 335th Infantry, which by this time had been fighting steadily for

days, captured Samree, on the top of an 1,800-foot hill. By the end of the

day, the same regiment had also captured Berismenil and Nadrin. These

operations had denied the enemy access to the critical crossroads at La Roche.

The morning of 15 January, Houffalize was made untenable by the 1stBattalion

of the 335th, which had taken Hill 430, overlooking the city, and the 2d Armored

Division moved in to occupy it.

From 11 January onward, elements of the 84th Infantry Division had been

in the area in which they might expect to meet patrols from the Third U. S.

Army. On 15 January, 33-man patrol was sent out from the village of

Filly, with the expectation of making rendezvous with similar patrol from

that army. The original rendezvous point had been changed, however, and

it not until the next day, 16 January, that the patrol from the 84th Division sighted United States soldier in the yard of Belgian farmhouse and,

upon challenging him, learned that he as with patrol from the Third U. S.

Army. As one of the histories of the 84th Division recorded, “The second

rendezvous point was the home of farmer with pretty 22 year old daughter.”

After 13 days of difficult and intensive combat, in extreme cold, over an

unfavorable terrain, the 84th Division was given 5-day rest, until 21 January,

in the vicinity of Barvaux, Belgium. This period as also used for reorganization and for the servicing of equipment.

The terrain over which the fighting just described had occurred was

rolling and heavily forested; some of the hills reached height of 1,800 feet

above sea level. There as maze of tiny villages astride the roads and trails,

each of which potential enemy strong point.

On the first day of the attack, snow, sleet, and rain fell. The temperature

dropped, and snow in the hills in some areas as knee deep. Snow continued

to fall during the first week, sometimes lightly but on two occasions with

blizzard intensity. The temperature sometimes fell to 13° F, —10.6° C.).

The roads were icy. The wmods were dense, and the trails became invisible.

At times, the mist was so thick that visibility limited to 30 or 40 yards.
COLD INJURY, &4TH INFANTRY DIVISION 465

The resistance of the enemy was heavy, and both weather and terrain favored their activities. They could fall back from one village to another, and from one prepared hilltop to another, which made attack doubly difficult. The problem of cover was critical during this time. It took hours to dig through the frozen crust of the ground and hours to dig foxhole feet deep. Sleeping was an equally serious problem, because of the danger that exposed

parts of the body would freeze. Water froze in the canteens and rations, and other supplies could be brought up to the front only in halftrack vehicles and by hand carry.

Under these unfavorable circumstances, the infantrymen of the 84th Division fought long and hard. Those who engaged in the reduction of Beffe and Devantave were in combat 96 hours without break. The aggressiveness of United States forces in pushing attacks under such conditions eventually

made Germanreliance on the weather serious mistake. On several occasions, the enemy was taken completely by surprise, and once they were even found

asleep when village was taken by the Americans.

Cold injury.—During these 13 days of hard fighting, the 84th Division suffered no trenchfoot, but frostbite was in evidence in all combat units (chart

32). In the narrative history of the divisional operations for this period, it

was noted that “frostbite was as dangerous as all Krauts and their guns put

together.” Five cases occurred on the first day of the attack (3 January),

and between and 16 cases were reported daily until January. precipitous

rise to 57 cases occurred on this date, and fluctuating point epidemic, with

high incidence of 62 cases on 11 January, was maintained through 12 January.

Nine cases were reported on 13 January, but no more than six on any day

thereafter until 16 January, when this period of fighting ended.

The absence of trenchfoot and the prevalence of frostbite during this

period are readily explained. While the average precipitation reported for

the First U. S. Army area is at variance with the divisional records for this

time, precipitation as such, since it was in the form of snow, did not directly

influence the incidence of frostbite. On the other hand, the deep snow which

covered the already difficult terrain undoubtedly did interfere mechanically

with operations, and, by increasing fatigue and prolonging exposure, it contributed, at least indirectly, to the occurrence of cold injury.

The point epidemic of frostbite which occurred between and 14 January

is chiefly attributable to below-freezing temperatures, the severe type of combat

action, insufficient protective clothing (p. 144), lack of shelter, and the tactical

impossibility of practicing rotation of troops. All divisions on the Western

Front experienced cold injury when they were first exposed to extreme cold.

The 84th Infantry Division was no exception. However, in view of its difficult

mission and the moderate nature of the epidemic offrostbite which it sustained, it must be concluded that by this time this unit had become seasoned and

battlewise fighting force.
466 COLD INJURY. GROUND TYRE

16-31 JANUARY 1945

Tactical situation.—After rest period of days, beginning 16 January,

the 84th Division took the offensive on 22 January, with the specific mission

of reducing the villages of Gouvy and Beho, midway between Houffalize and

Saint-Vith. Two days of bitter fighting ensued, characterized by heavy

resistance and hard enemy counterattacks, before the mission was completed

on the night of 23 January. Mopping-up and defense operations occupied

the troops until 27 January, when the division was moved to the vicinity of

Harze, Belgium. The rest of the month was spent here, in rest, reorganization,

and maintenance of equipment.

At the conclusion of this phase of divisional operation, and upon the

occasion of the detachment of the 84th Infantry Division from the VII Corps,

the commanding general of the division received from Maj. Gen. J. Lawton

Collins, Commanding General, VII Corps, letter of commendation. In this

letter, the general expressed his appreciation of the splendid combat record of

the division and of the vital part which it had played “in closing out the ill

fated attempt of the German Fifth Army to break through the Ardennes.”

Cold injury.—Although the division entered combat after rest period and

although the tactical situation was not as intense as it was earlier in the month,

cold weather and difficult terrain again caused an upsurge in the incidence of

frostbite during this period (table 41, chart 32). Thirteen cases were reported

on 24 January and ten on 27 January. For the remainder of the period of

combat the daily number of cases was five or less.

FEBRUARY-5 MARCH 1945

Tactical situation.—On and February 1945, the 84th Infantry Division

moved to new assembly area in Holland, in the vicinity of Waubach. The

period to February was spent in resting and in reorganization and maintenance of equipment. This was familiar territory, in which the division had

seen its first combat. Its new mission was to prepare for crossing, and then

to cross, the Roer River and to exploit the bridgehead toward the Rhine.

The original plan was to cross the Roer on or 10 February. With this in

mind, rigorous training, with practice crossings of the Wurm River, was

carried out on 6-8 February. On February, the crossing was postponed for

24 hours, and, on 10 February, it had to be postponed indefinitely because

the enemy released the water behind the dams guarding the great reservoirs

fed by the Roer. The result was the artificial flooding of the river in the area

occupied by the 84th Infantry Division. The river rose to an excess of 11 feet

on 10 February and remained at nearly 10 feet for the rest of the month.
COLD INJURY, 84T1I INFANTRY DIVISION 467

During this time, training was intensified, and maneuvers identical to

those involved in the actual Roer crossing were carried out several times by

each unit, both in the forward area on small streams and in the rear on the

Meuse, which in width, depth, and current is similar to the Roer River. Each battalion designated to make the crossing rehearsed for it completely six times. On 19 and 20 February, the final training was received on the Meuse River. The 1st Battalion of the 334th Infantry crossed the Roer early in the

morning of 25 February. By the end of the day, two-regiment front, driving

toward the north, had been established on the far shore, and armor had crossed

and had been brought to bear against the enemy. Resistance was irregular

and was only moderately heavy. Evidently, the Germans had been thrown off balance by the division’s turning to the north when they had expected

straight eastward drive to the Rhine out of the Roer bridgehead. Soon afterward, as the enemy defense deteriorated and became disorganized, the division,

in an aggressive attack, drove steadily northward and then turned east, reaching

the Rhine by March. The bridges in this sector had been blown up while

the division was approaching the river, and therefore, after mopping-up

operations, it entered holding phase on the west bank of the river.

At the conclusion of Operation GRENADE (the crossing of the Roer

River and the advance to the Rhine), Lt. Gen. W. H. Simpson, Commanding

General, Ninth U. S. Army, sent letter of commendation to the commanding

general of the 84th Infantry Division. In this letter, note was taken of the

three phases of combat operation in which the division had participated, beginning with the reduction of Geilenkirchen, going on through the Battle of

the Bulge, and ending with the crossing of the Roer River and the advance to

the Rhine. It was also noted that the 84th was one of the few divisions engaged in the operation which had fought all the way from the Roer River to

the Rhine without ever losing momentum.

While training was in progress near Wauback, temperatures were above

freezing, and the February thaw gave rise to much mud and wet. Though

there was no great exposure after February, cover was not adequate. Many

of the men lived in tents, the dirt floors of which were always wet and muddy.

Cold injury.—Trenchfoot did not occur in the 84th Division during the

training period of Operation GRENADE), although temperatures and environmental conditions were ideal for its development. There were no cold injuries

of any kind during the advance to the Rhine, and only nine cases, all of which

were frostbite cases, during the crossing of the Roer. It may be significant,

as the divisional history notes, that “orientation, sanitation and trenchfoot

prevention rounded out the training phase” of the Roer-Rhine action. Jt is

probably also significant that, during this time, although there was some

resistance which at times was moderately heavy, the stress of combat action

was lacking.
468 COLD INJURY, GROUND TYPE

ANALYSIS OF THE TOTAL EXPERIENCE

From the standpoint of cold injury, the experience of the 84th Infantry

Division falls into three distinct periods.

First period.—During this period, in which the division experienced its first

combat, the high incidence of trenchfoot demonstrates the great susceptibility

of inexperienced troops to this type of cold injury, even when they have had

training before combat in its prevention. This phase of the experience also

shows that the incidence and severity of cold injury are considerably influenced

by the type of combat, the availability or lack of shelter, and terrain. Finally,

it demonstrates conclusively that, even among new troops, trenchfoot can be

brought under control by good leadership, the vigorous application, collectively

and individually, of appropriate preventive methods and procedures, and

adequate supply of the proper clothing, and regular rotation of individuals

and units.

The concern felt in both division and corps over the initial high incidence

of trenchfoot led to prompt investigations to determine the causes of the outbreak. The surgeon of the XIII Corps listed the causes (stated them), as

follows, in his annual report of medical department activities for 1944;

1. The terrain was extremely unfavorable because it was naturally soft

and boggy. Rain fell nearly every day of the operation, and mud was deep

and constantly present.

2. The tactical situation did not permit relief of troops from frontline

duties, even for short periods.

3. The supply of overshoes was inadequate, and those which were available

were often used incorrectly. Many men threw them away. In one regiment,

they were taken away by order.

4. The supply of socks was inadequate. Many units had only one pair of

socks per man.

5. Shoes had not been properly fitted. Many men were wearing sizes

too small for military purposes, in that they would not comfortably accommodate second pair of socks. Also, after the shoes became wet, shrinkage was

sufficient to cause constriction of the circulation.

6. Tactical circumstances made it difficult or impossible for the men to

remove their shoes and socks. Even when this was possible, many were afraid

to take them off, for fear, that in case of an attack, they might not be able to

get them on again quickly enough, if at all. Removal of the footgear, for that

matter, seemed useless, since there were no facilities for drying shoes and socks.

7. Although the great majority of the troops were aware of the signs and

symptoms of trenchfoot, appreciated its dangers, and had been taught how to

prevent it, many of them failed to practice what they had been taught.

Once the responsible factors were fully understood, vigorous campaign

was initiated to reduce the incidence of trenchfoot. It was extremely effective.

Components of the regimen were as follows: (1) Frequent rotation of frontline

troops; (2) provision of drying rooms; (3) provision of overshoes; (4) provision
COLD INJURY, 84TH INFANTRY DIVISION 469

of dry socks daily, or as frequently as possible, by bringing them forward with

tlierations; (5) instruction of unit commanders by medical officers; (6) thorough indoctrination of the troops; (7) daily foot inspections or inspections as often

as the tactical situation permitted; (8) diagnosis of trenchfoot only after

careful history has been taken and an equally careful examination has been

made at the clearing station; (9) use of questionnaires in determining the causes

in each individual case of trenchfoot; and (10) requirement that explanation of

high incidence of trenchfoot in any unit be made by the commander of the unit. Second period.—The second period of combat activity in the 84th Infantry

Division provided additional evidence of the universal susceptibility of both

experienced and inexperienced troops to frostbite (which was then the prevalent

type of cold injury) when combat is intense. The rates, however, were never

as high as those in the epidemic of trenchfoot in the first period. This phase of the experience therefore clearly demonstrates that, even under the most

trying conditions of combat, terrain, and weather, well-led unit, with high

morale and good individual training, can function without unduly high losses

from cold injury.

Third period.—In the third period of the 84th Division’s combat experience,

there were no cases at all of trenchfoot and only nine cases of frostbite. The

circumstances and terrain were ideal for the production of trenchfoot. This

was the period of the February thaw. Precipitation was moderately heavy.

The terrain was low and muddy. The temperature ranged between 40° and

50° F. (4.44° and 10.0° C.). Most elements of the division were living without

adequate shelter. Training was intensive. Many river crossings were necessary. Actual operations required the crossing of the Roer River, the establishment and exploitation of bridgehead on the far shore, and drive to the Rhine.

The complete absence of trenchfoot under circumstances so highly propitious

to the development of the condition seems to demonstrate conclusively the

importance of the type of combat action and the psychological response of

competent troops in aggressive and victorious tactics.

438404'-—58 32

471

CHAPTER XV

The Prevention and Control of Cold Injury

GENERAL CONSIDERATIONS

The fundamental principles of the prophylaxis of cold injury were in large

part developed during World War (p. 45). It is extremely unfortunate that

they were not recollected and promptly put into practice in the United States

Army in World War II. If this had been done, many thousands of casualties

from cold injury would almost certainly have been avoided.

In World War II, the trenchfoot experience in the Aleutians (p. 83) was

brief because the campaign itself was brief as result, no formal program of

prevention and control was instituted. In the Mediterranean Theater of Operations (p. 101),ittook bitter experience in the winter of 1943-44 to demonstrate

the need for the program which was put into effect, with excellentresults, during

the winter of 1944-45. In the European Theater of Operations (p. 127), the

cold injury experience in the winter of 1944-45 was even more disastrous than

the early Mediterranean experience. Eventually, an effective program of prevention and control was put into effect in the European theater, but only when

it was too late to prevent the major losses from cold injury which had already

occurred. Had the war in the Pacific continued into the winter of 1945, there

seems little doubt that losses from this cause could have been kept at an acceptable level. The program of prevention and control which had been set up and

which was in the process of implementation when the war ended was based on

sound principles. It involved the cooperative efforts of the Quartermaster Corps, the Medical Corps, and command, and it incorporated the lessons that

had been learned in the Mediterranean and European Theaters of Operations.

The key to the prevention of undue losses from cold trauma is full appreciation by all personnel, on all levels, of the fundamental fact that weather is

bitter enemy, quite as capable of causing casualties as is human enemy.

Measures of prevention and control must be based on this concept and on the

additional concept that, even if military operations must be undertaken in

winter, it is not inevitable that cold trauma of significant degree occur in association with them.

brief experience in the Pacific showed that certain type of cold injury

may occur even in warm weather (p. 211). The danger of this form of trauma is

therefore not imaginary when war must be prosecuted in theater located in

climate in which winter temperatures fall below 50° F. During certain periods of winter fighting in Italy and in western Europe, as has been pointed out
472 COLD INJURY, GROUND TYPE

elsewhere, cold injury was second only to combat casualties as cause of disability and loss of man days. In some units, under some circumstances,

losses from this cause were even greater than losses from combat injuries. On

the Western Front, the numerical loss from cold injury amounted to about three

divisions In terms of military effectiveness, the loss was nearer 12 divisions, since 90 percent of the casualties occurred in combat infantry riflemen, who

made up about quarter of each division. No fighting forces can afford such

losses over any considerable period of time, particularly since the outlay of

personnel, training effort, and time required for the application of preventive

measures, in comparison with the outlay required to train combat replacements,

is so small and gives such gratifying results.

Of course, not all losses from cold injury can be prevented, and the accomplishment of urgent objectives may sometimes be worth high price in casualties

from cold as well as in the more usual combat losses. It is quite possible, in

fact, that on occasion the calculated risk may be worth the cost. That gamble

was made at least once in World War II (p. 209). But the risk can be assessed,

and the decision concerning it made, only by command thoroughly appreciative of the danger from cold injury and of the possible scale of losses from it.

The responsibility for such decisions clearly furnishes one more reason why

there must be full understanding, by all echelons of command, of the total

implications of cold injury in all winter combat operations.

Attention has been called elsewhere (p. 181) to the vigorous program of

preventive measures instituted by regimental combat commander who happened to see, in the hospital in which he was patient for another cause, precisely how serious trcnchfoot can be. Another commander of an infantry

regiment was wise before the event. An observer for the Army Ground Forces

Board, NATOUSA, quotes him as saying:

wrote monograph at Banning in 1928-29 on the subject of the care of the feet.

thought it was an important subject then, though some other people did not. It is still one

of the most important subjects for an infantry officer to know. Trench foot is one of the major

causes of non-battle casualties and non-battle casualty reduces your combat strength just

as much as does battle casualty *. The remainder of this regiment [he excluded the

Japanese-American component, which for various reasons had high rate] has consistently

had the lowest trench-foot rate among the infantry of the division. This, am sure, is largely

due to the emphasis we have placed on care of the feet. have personally conducted

school on care of the feet for the junior officers of the regiment. We require every man to

go into combat with clean, dry pair of socks inside his shirt and we require platoon leaders

to see that their men change wet socks for dry ones, and massage their feet, whenever it is

at all practicable. If Benning does not already have it in its officer-candidate course, it

should include short course on care of the feet. The instructor should be competent

doughboy who has done lot of marching and knows how to take care of feet in wet, cold

weather. don’t think that anything that Benning can teach its students is of more

importance.

If this sort of down-to-earth concept of cold injury and of methods of preventing it had been common at all levels, casualties from this cause would

Report on Infantry, Army Ground Forces Board, Army Ground Forces Headquarters, NATOUSA, 27 Mar. 1944.
PREVENTION AND CONTROL 473

promptly have been reduced to minimum. Soldiers who contracted trenchfoot might have been ignorant of its dangers and of methods of prevention, but

they were shrewd enough to figure out what they should have been taught, as

the following letter shows. It was written to his ward officer by an enlisted man hospitalized with trenchfoot in hospital in Italy:

Not single person talked to, out of many in the hospital with trench foot, had ever

heard of the ailment until he was told that he had it. Since it is putting so many men out of

action, think it would be well worth an effort on the Army’s part to inform the soldier on the

subject before and not after he has it. Printed matter on the subject is allright but too often

printed matter is discarded, before reading, as nonsense. If not replaced by, printed matter

on the subject should at least be supplemented by talk given to soldiers by medical officer.

Naturally, the talk should emphasize the ill effects of the ailment rather than describe it

as means of getting back to the hospital for rest. Description should be made of its

worst possible effects, such as damage to blood vessels and gangrene setting in making amputations necessary. If possible, show pictures of and describe worst cases, giving length of

time confined (not alking) and possible discomforts of the feet after the war is over. Then

the soldier should be told what he can do to keep from getting trench feet.

Although it would probably be good thing to do, no soldier has much of an urge to take

his socks off while in actual combat. However, he should be supplied with and carry at least

one pair of socks with him and be urged to change them at the first opportunity. If socks to

be carried in the pack could be sealed in cellophane wrapper or canned in something like

ration tin, they would have better chance of being dry when the change as made.

Back in bivouac orrest area sleeping with shoes and socks on should be discouraged.

Shoes and feet should be dried out. During the day, especially if the sun is out, feet should

be aired *. Whenever it is practicable to get shoes off, whether at night or during the

day, feet should be massaged to stimulate circulation. Because of differences in circulatory

systems, some persons are, undoubtedly, more susceptible than others. Nevertheless, much

can be done, as preventative measures, by the individual soldier.

The supply sergeant should make an honest effort to see that the soldier is frequently

given pair of clean, dry socks. During wet seasons, shoes should be waterproofed when

given to the soldier. Even if his shoes are waterproof, the soldier should either change his

socks or air and dry his feet and socks to rid them of dampness due to perspiration.

Officers and Non-coms should be held responsible for seeing that each soldier takes care

of his own feet, both in beneficial practice and in making the best use of what supplies he has.

Company feet inspections would be more effective, as preventative measure, than the

individual reporting on sick book.

The soldier should first be informed, and then guided. Don’t rely too much on the soldier’s own initiative in the matter.

PREVENTIVE PRINCIPLES AND PRACTICES

The approach to the problem of prevention and control should be entirely

realistic. The agent role of cold or wet cold in the production of cold injury is

fairly well understood. The weather cannot be altered. If operations are

planned under winter conditions, the weather must simply be accepted and

compensated for. Similarly, once tactical objectives have been established,

intensity of combat action and the terrain to be fought over must also be

Report, Lt. Col. F. A. Simeone, to Surgeon, Fifth U. S. Army, subject: Trench Foot in the Italian Campaign 1943-45,

1945.
474 COLD INJURY, GROUND TYPE

accepted. Little can be done to ameliorate their adverse effects. Shelter, like

the weather, is largely fortuitous. Not much planned provision can be made

for it.

What are those things about which something can be done? Several cold

injury modifying factors (p. 366j can be influenced deliberately. It has been

shown that the degree of training, the level of unit and individual discipline,

the adequacy of supply and the extent and effectiveness of the rotation practice

are readily amenable to good staff and command practices. The organization

to accomplish these purposes likewise is readily established and easily directed.

Although it has been recognized since World War that the prevention and

control of trenchfoot are command functions, almost everything written on the

subject in World War II appeared in the medical literature, and with few

exceptions the directives, circular letters, and other official documents dealing

with cold injury either originated in the Medical Corps or were inspired by

medical officers. Quite early in the war, medical officers in the Surgeon

General’s Office (p. 57) and in overseas theaters became impressed with the

necessity for adequate prophylaxis against cold trauma, an important reason

for their concern being their realization that there were no rapid and effective

methods of therapy. Summaries of preventive practices began to reach the

literature soon after trenchfoot first appeared in the Mediterranean theater,

and they continued to appear until the end of the war. Most of them, however, quoted or reflected official Army policy. Few represented new contributions.

By the end of World War II, adequate principles and procedures for the

prevention of trenchfoot and other forms of cold injury had been formulated

and published. These presentations, however, were applicable only to individuals and to small military units. There were no similar publications in which

were set forth the organizational, administrative, and technical principles and

practices applicable to the prevention and control of cold trauma in large

military organizations. This need has not yet been met. This chapter, therefore, has two purposes, to outline the general principles of the prevention of

cold injury and, in addition, to propose an organizational setup by which the

mass prophylaxis of cold injury can be accomplished. The principles of prevention and control are, in themselves, simple. On the other hand, the organizational and administrative practices necessary to secure their implementation

and continued application cannot be left to chance.

Elements of prevention and control.—Any discussion of the management

of cold trauma should begin with the unqualified statement that neither prevention nor control can be accomplished without competent, interested command supervision. The success or failure of the effort depends upon this factor.

When command supervision is available, as the experiences of both World

War and World War II make clear, the incidence of cold injury can be kept

at an acceptably low level.

The essential elements of prevention and control include the following;

(1) The provision of ample supplies of clothing and footgear which arc properly

sized, well fitted, correctly worn, and always readily available; (2) the mainte-
PREVENTION AND CONTROL 475

nance of good foot and clothing discipline; and (3) the rotation of the individual

soldier within his unit and the rotation of whole units out of the line.

The maintenance of good foot and clothing discipline implies the training of the individualsoldier in the personal prevention of cold injury. Each man must

carry extra socks with him. He must change them once daily, and preferably

oftener. He must remove his shoes when he goes to sleep. He must massage

his feet at regular intervals. He must so fully understand the necessity for

movement that he will automatically exercise his feet and legs whenever he

can, even if he can do no more than tap his feet or wiggle his toes in his boots. He must also understand the necessity for seeking medical care promptly when

he suspects that he has sustained cold injury. Many of these things are

difficult to do in frontline combat, and they will not be done in the absence of

good discipline and constant command supervision.

The rotation of the individual soldier involves his removal from frontline

position to dugout, tent, the basement of damaged building, or some other

improvised shelter where he can rest for an hour or longer, change his socks,

dry his clothes, and secure hot coffee or some other hot drink. If this sort of

individual rotation can be carried out daily, or at least within the 48- to 72-hour

period regarded as the incubation period for trenchfoot, the soldier will be out

of the line for only brief periods and for only few hundred yards, but the

chances of his developing cold injury will have been considerably reduced.

The second type of rotation implies the rotation of battalion, regiment,

or some other military unit out of the line into reserve position in the division

area or farther back in the corps or army area. This type ofrotation concerns

total military organization, in contrast to individual rotation. Both types

should be practiced on planned and regular basis unless the combat situation

absolutely forbids it.

It is the responsibility of command that the measures just outlined be

planned and implemented. This implies command responsibility for the

provision of clothing, for its ready availability, and for its proper utilization; for the provision of hot food and drink for the individual soldier as often as is

possible; for the enforcement of foot discipline; for the provision of warming

and drying devices and their utilization as often as is feasible; and for insuring that men with complaints referable to their feet, whether or not the symptoms

are regarded as caused by cold trauma, be sent to the rear promptly for medical

advice, as prophylactic measure, or for medical treatment if that should be

necessary.

If the indoctrination of all personnel has been properly carried out and if

the simple measures just described are instituted and employed whenever the

tactical situation does not absolutely prevent them, the incidence of cold injury

in winter combat will be greatly reduced. Furthermore, once such program

is made an integral part of unit training and discipline, minimum of command

supervision will be required above battalion level. If the details are well carried

out, company by company, platoon by platoon, and squad by squad, the
476 COLD INJURY, GROUND TYPE

program will be certain to yield dividends, not the least of which will be the

retention in combat of effective and essential personnel.

Clothing.—Clothing plays so important role in the success of program

of prevention and control that, even at the expense of some repetition, certain

points must be emphasized again:

1. Adequate supplies must, of course, be provided in the army and the

division area, but their provision there is useless uidess they are brought forward and made readily available to meet the needs of the individual soldier

in the most advanced outpost.

2. Clothing includes more than the uniform. Shoes, shoepacs, gloves,

socks, and sleeping bags must also be provided. Footgear fully adequate for

protection may be canceled out by inadequate covering of other parts of the

body, and vice versa. Footgear and clothing completely adequate for operations in cold temperatures and in dry snow offer little or no protection in valleys

where the temperature is higher and where wetness as well as cold may produce

numbers of casualties from trenchfoot.

3. The individual soldier must be taught how to wear the clothing provided

so that it will furnish the most effective possible protection against exposure.

4. The daily sock exchange is an essential phase of the program of prevention. It requires the provision of enough socks, of proper sizes, to permit the

exchange, which is best effected, as the World War II experience showed, b}'

bringing the clean, dry socks forward with the daily rations.

5. Provision must be made not only for the original issue of clothing but

also for the reequipment of men who may have lost or discarded parts of their

uniform in combat. Reissue involves collection and salvage, as well as the

issue of new clothing as necessary, and therefore has economic implications.

The economic aspect, however, must be subordinated to more important consideration, that the period of exposure of the combat soldier must not last any

longer than is absolutely necessary.

Individual instruction.—The soldier should receive individual printed

instructions concerning foot care in addition to the mass instruction in the prevention of cold injury which he receives as part of his training. The Preventive

Medicine Section, Office of the Surgeon, NATOUSA, in its annual report for

1943 set forth the following essential facts concerning the prevention of trenchfoot which the individual soldier should know:

1. Trenchfoot is produced by standing or sitting about over long period

of time with cold, wet feet. Intense cold is not necessary for its development.

It can occur when the temperature is 50° F. (10° C.) or higher. The most

important causes are moisture, cold, and lack of activity. Trenchfoot is frequently associated with constriction of the limbs by boots and tight clothing.

2. In the early stages of trenchfoot, the feet feel heavy, wooden, and numb.

They are insensitive to pain, touch, or temperature, particularly around the

toes. At this time, they are usually cold to touch. Thev are swollen and
PREVENTION AND CONTROL 477

white except for few scattered bluish areas. If they are warmed rapidly

which they should not be—they become first red, then purple, hot, greatly

swollen, and painful. Sometimes blisters appear.

3. Once trenchfoot has been incurred, the patient should be sent promptly

to hospital where he can be treated adequately. In the meantime, he should

not be permitted to walk. His feet should not be warmed. They should not

be massaged. Instead, they should be kept cool and should be elevated above

the level of the trunk. If trenchfoot is not handled according to these directions, serious disability and possible loss of the feet may follow.

4. Since the treatment of trenchfoot is far from satisfactory, it is of the

utmost importance that this condition not be permitted to occur. It can be

prevented by keeping the feet clean, dry, and warm. Under winter combat

conditions, it is not always possible to achieve these objectives, but constant

attention to certain preventive measures will reduce or prevent occurrence.

Seeing that preventive measures are carried out is the responsibility of the commanding officers of units. Observing them is to the best interests of the

individual soldier, as well as of his outfit.

Among preventive measures recommended in the report are the following:

1. Frequently (once or twice daily, at least) remove shoes and socks.

Wash, dry, and massage the feet. Apply foot powder. If possible, put on

clean, dry socks; if this is not possible, wring out the wet soeks until they are as

dry as possible.

2. No matter how cold it is, do not sleep with shoes on, particularly if

shoes and socks arc wet. This practice interferes with the circulation of the

feet and also keeps them wet and cold.

3. If means are not available for drying socks and if fresh socks cannot be

supplied, dry the wet ones by pinning them to the inner side of the overcoat or

field jacket, or place them across the shoulders under the jacket during the day.

At night, keep them in the sleeping bag.

4. Do not stand in cold water or mud unless it is absolutely impossible not

to. Rocks, boards, brushwood, branches, and any similar material that is

available will keep the feet out of the water, at least to some extent.

5. Keep the feet and legs in motion, particularly when they are wet as well

as cold and when dry socks are not available. If troops must remain in one

place, the individual soldier can mark time or can move his legs vigorously and

frequently. If he can do nothing else, he can wiggle his toes inside his shoes.

If he sits down, he can keep the feet higher than the buttocks.

6. Be certain that the shoes are not laced so tightly, and that clothing is

not worn so tightly, as to interfere with the circulation of the feet and legs.

Shoes should be laced loosely. Clothing should be worn loosely. Even moderate constriction of the blood supply, to degree often unnoticed by the

wearer, may reduce the circulation enough to cause trenchfoot. The first

noticeable signs of interference with the circulation usually are numbness and
478 COLD INJURY, GROUND TYPE

tingling sensations in the feet and legs. When these occur, exercise the legs

and feet immediately until they feel normal and warm. Every means must

be used to keep further constriction of the limbs to minimum.

RESEARCH ON COLD TRAUMA

At the end of the war, knowledge of the several host factors which contribute to the production of cold injury (p. 377) was still grossly inadequate.

This was all the more unfortunate because many of these factors are of such

character that they concern not only cold injury but also trauma in general.

Some, in fact, are of sufficient importance to influence the total fighting

effectiveness of combat soldiers.

Much more needed also to be learned about how to cope with the environmental factors of cold injury which can be influenced. The solution of these

problems could no more await mobilization day than can organization and

training for the prevention and control of cold trauma be delayed until troops

have been committed to battle or even until they have been sent to foreign

theaters. Individuals immediately concerned with the problem were of the

opinion that all knowledge at hand at any time should be used to the fullest

possible extent. However, they also believed that the best possible results in

the prevention and control of cold trauma would require additional research

and the development of new equipment to indicate practices and to provide

means for dealing with the intangible host and environmental factors involved

in the problem.

It was the consensus among authorities that full coordination of research

and development required to meet the problems inherent in cold injury, as

well as in other trauma, in any future war might be best directed toward the

study of man as whole in relation to his environment. Only from such an

all-inclusive program can there come the fullest understanding of the factors

involved in cold and other trauma. Whether research program, and the

organization necessary to carry it out, should be set up within the framework

of the Armed Forces or under civilian science foundation is matter for discussion. The important consideration is the realization of the magnitude of

the task and of the necessity for full coordination of research and development

to meet the problem in future combat.

Several investigations toward these ends have already been carried out. Important studies in clothing and equipment made by the Quartermaster General have greatly reduced the exposuresustained by infantrymen. The Air Force

has conducted studies on survival in the Arctic and, within the limits of its research facilities, has supplemented them

with basic studies. The Departmentof the Army has evaluated equipment in relation to environmentat post set up

in cold climate and has also studied special phases of cold trauma, such as hygiene, sanitation, acclimatization, and

nutrition. Investigations of several host factors in cold trauma have been conducted under the auspices of the Medical

Service Research and Development Board. In the winter of 1951-52, research team was sent to Korea to study program of prevention and control which, for the first time in United States Army history, was planned in advance of the

expected cold injuries.
L'KEVENTIOX AND CONTROL 479

COMPREHENSIVE PROGRAM FOR THE

PREVENTION AND CONTROL OF COLD TRAUMA

satisfactory program for the prevention and control of cold trauma

begins in the Zone of Interior and ends with the individual combat soldier in

the foxhole of the winter frontline. Its basic components are organization,

command support, indoctrination, training, discipline, and adequacy of supplies.

Zone of Interior

The foundation for the prevention and control of cold injury is naturally

laid in the Zone of Interior, where potential losses from this cause must be

taken into account in all strategic and tactical planning. In the past, too

little attention has heen paid to these considerations. Lack of appreciation

of the dangerous potentialities of cold and wet cold and of their consequences

was in large part responsible for the high casualty rate from these causes in

World War II. There was also equally little appreciation (1) of the many

factors in addition to weather that make up the total causation of cold injury

and (2) of the possibility of modifying some of them, at least, to the advantage

of an army fighting in winter. Trenchfoot and other forms of cold injury are

not unexpected accidents, suddenly introduced into the course of military

operations. They are so certainly feature of campaigns in wet, cold climates

that they necessarily enter into the total military plan.

The objective of indoctrination in the Zone of Interior is to inculcate upon

command, staff, and service personnel, as well as future combat personnel,

full appreciation (1) of the cost of cold injury in combat troops, (2) of the

responsibility of command echelons for its prevention and control, and (3) of

the responsibility of every officer, noncommissioned officer, and enlisted man,

both as an individual and as member of group, to carry out the simple,

fundamental procedures that will protect individual soldiers and their

organizations against cold trauma.

The strategic and tactical implications of cold trauma must be made

part of the education of every officer in the United States Army. They must

be presented and emphasized in all service and staff schools and at the United

States Military Academy; in general way, this has been done for the last

several years in the series of lectures on medical matters delivered at West

Point. Similarly, the training of Reserve and National Guard officers must

include indoctrination on this subject. If command and staff are to he fully

effective in time of war, their training and indoctrination with respect to cold

injury must be undertaken in time of peace.

The authors of this volume, on the basis of their personal experiences in World War If and after thoroughreview

of both the good and the bad practices in the controlof cold injuries in this war, believe that the preventive principles outlined in the following pages should beadopted.
480 COLD INJURY, GROUND TYPE

Broad policies for the prevention and control of cold trauma are formulated

in the Zone of Interior. They should be embodied in recommendations

and directives which should (1) be suitable for general application, (2) be

based on the opinions that emerge from pooling of staff and technical knowledge, on previous experiences, and on research data produced by agencies

studying cold trauma, and (3) be limited to principles, methods, and procedures

applicable to operations in wide range of winter climates and terrain. These

recommendations and directives should not be concerned with details. It

would be impractical, in fact, to work out detailed programs in the Zone of

Interior, since such programs necessarily vary with the place of operation,

the type of combat mission, the degree of cold, the amount of precipitation,

and the nature of the terrain.

Training aids, training literature, and training directives for general

distribution should originate in the Zone of Interior. They should be provided

in sufficient quantity, and should be kept current, so that they will always

include the latest developments. All of these releases should be simply and

clearly expressed and should be as brief as is consistent with completeness.

Whether or not training in the prevention of cold injury should be part

of the training of the individual soldier in the Zone of Interior during peacetime is matter which training authorities must finally decide. Certainly,

it would seem the part of wisdom that plans for unit training and for the

indoctrination of commissioned and noncommissioned officers should be set

up and kept current. Furthermore, since the enlisted components of the

Army today will make up the small key cadres which will train the combat

soldier of tomorrow, it would seem wise that the men who make them up should

clearly understand their own responsibility in the prevention of cold trauma.

In the light of present knowledge, such training should include the practice

in the field, by individuals and small units, of preventive measures against

cold, including care of the feet and the use and care of clothing assemblies

designed to prevent exposure. As other preventive measures are formulated

in the light of results of research, they should be incorporated in the training program.

Finally, the Zone of Interior has two other missions with respect to cold

injury. One is the conduct of research and development, to improve methods

and practices currently in use. The other is the provision of expert consultants

wherever and whenever they may be needed and requested in overseas theaters.

Overseas Theaters

The difficulties which were connected with the indoctrination and training program for the prevention and control of cold injuries in World War II,

and which were evident in both, the Mediterranean and the European theaters,

should not exist in future wars. In the European theater, while the program

eventually set up was extremely effective, it was established too late, and

it had to be implemented in the course of combat. In the Pacific theater,
PREVENTION AND CONTROL 481

the program set up was established well in advance of the need for it. It

took full account of previous errors and covered all conceivable emergencies

(appendix I; see also appendix H). On the other hand, except for the teams

previously employed in the malaria-control program (p. 487), no administrative

facilities existed for its implementation within the framework of the theater

organization. Command, staff, and technical personnel all had to undergo

comprehensive indoctrination along with enlisted components, and administrative facilities had to be developed before the training program could he

undertaken. Neither the pattern of the program nor its effectiveness was

tested in combat, but it is believed that, if there had been such test, the

results would have been satisfactory.

Cold injury indoctrination in overseas theaters should he simpler in the

future because the groundwork for the full appreciation of the importance of

cold trauma in winter operations will already have been laid in the Zone of Interior. Command will be aware of the necessity for early planning, organization, and training. Officers will have had their basic training. Noncommissioned officers and key enlisted men will have had sufficient training to

make them generally familiar with the subject, and their period of indoctrination can be correspondingly shortened.

The program in an overseas theater has three components: (1) central

organization at theater level, (2) indoctrination teams at the theater level,

and (3) control teams at the army level.

Central organization.—The central organization at the theater level is

simple in constitution and economical of personnel. It consists of board or

commission made up of the assistant chief of staff, G-3 (operations and training), the theater quartermaster, and the theater surgeon, or their immediate

deputies. These are the staff division and service chiefs who are most intimately concerned with the prevention and control of cold trauma and who

must make the decisions and determine the policies which will achieve these

objectives. Subordinates will not serve the purpose. Ideally, the chief

of staff would be member of the board and would serve as its chairman.

If his responsibilities do not permit the assumption of this duty, or even his

inclusion in the membership of the board, then it is essential that deputy

chief of staff serve in this capacity, so that the theater commander may be

kept fully cognizant of its findings, decisions, and recommendations.

cold-trauma board in an overseas theater of operations would necessarily keep fully informed as to (1) the general situation and the specific details

of cold injury in its various phases and manifestations in the theater, including

incidence, (2) the level of clothing supplies and the efficiency of their distribution to field units, (3) the status of training and discipline with respect to cold

injury, and (4) the effect!vness with which the cold injury program is being

carried out by the major theater organizations. Other functions of such

board would be (1) to keep the theater commander advised on the general

situation and its special phases; (2) to determine general theater policies and

plans in advance of winter combat; (3) to advise subordinate commands on
482 COLD INJURY, GROUND TYPE

cold injury policies and preventive measures; (4) to confer with army, base, and

other organizational cold injury teams or expert personnel at such intervals as

the situation might require; (5) to direct and supervise the utilization of joint

indoctrination teams for theaterwide cold injury training before the beginning

of cold weather; and (6) to authorize and direct special investigations of unusual

outbreaks of cold injury. cold-trauma board should also recommend policies

and plans for all theater units, covering (1) the supply of clothing, footgear,

and supplementary equipment; (2) individual and unit practices for the prevention of cold injury; (3) discipline; (4) rotation; (5) medical triage, evacuation, and care; and (6) whatever other measures might be required to improve

the effectiveness of the theater program.

Men with the manifold duties and responsibilities of members of the coldtrauma board naturally could not be expected to do the traveling or to spend

the time necessary to investigate personally the many aspects which cold

injury may present. This difficulty would be overcome by providing the board

with the advice and services of two or more technical consultants, who would

serve as its eyes and ears. If desired, these consultants could be associate

members of the board. One of them should be highly qualified medical

officer, trained in epidemiology and thoroughly familiar with all aspects of cold

injury and with the particular responsibilities of the medical service for it.

The other should be Quartermaster Corps officer who, for his part, fully

understands clothing requirements for combat in cold weather, clothing supply,

and the correct utilization of clothing to minimize exposure.

The consultants to the cold-trauma board, in addition to their general

duties as technical advisers, would have certain special duties. They would

visit subordinate commands, especially army areas and replacement centers,

as frequently as would be necessary to keep themselves fully informed on (1)

all aspects of the cold injury problem, including incidence, (2) the status of

supply, distribution, and utilization of clothing and footgear, and (3) the

effectiveness of control practices. They would (1) advise and consult with

army cold injury teams and officers in liaison capacity; (2) work in close coordination with the parent agencies of the cold injury teams (that is, the office

of the chief surgeon and the office of the quartermaster); (3) maintain liaison

with G-3 and the quartermaster and surgeon of other major headquarters,

such as subtheaters, bases, and army groups; (4) make plans and prepare

directives for the over-all cold injury prevention and control program, for

approval by the board and for publication and distribution through command

channels; (5) advise on and assist in the preparation of technical bulletins and

directives for distribution through technical channels; (6) aid in the planning

and implementation of the theater cold-indoctrination program; (7) report on

the theaterwide incidence of cold injury and maintain records of its occurrence

by units; (8) investigate, for the information of appropriate command, the

occurrence of cold injury in units in which the incidence is unduly high or in

which investigation might be required for other reasons; (9) perform any other
PREVENTION AND CONTROL 483

technical duties which the development of the cold injury program of prevention might make necessary; and (10) assist in the planning and implementation

of health education in cold injury by the use of all effective media, including

newspapers and the radio, in order to reach the greatest possible number of

soldiers.

There would seem to be no need to set up cold-trauma boards in headquarters of communication zones, subtheaters, bases, or army groups. In

these headquarters, it would be better for the responsibility for the prevention

and control of cold injury to rest with an officer of sufficientrank, qualifications,

judgment, and technical competence to advise on special problems as they

arise.

Indoctrination program.—If those responsible for the establishment of an

overseas theater have given sufficient credence to the potential threat of cold

trauma in winter operations, theater planning and organization will provide

qualified personnel and satisfactory methods for its prevention and control.

If planning has been adequate and if the correct organization has been set up

in the first days of the existence of the theater, it is entirely possible that, when

the time for it arrives, complete indoctrination can be executed within the resources of the theater. This will be possible, however, only if the theater

command is interested and alert, if there is complete command support in all

echelons, and if there is full utilization of the advice and assistance which the

cold-trauma board, its consultants, and the cold injury control teams can

supply. Both command and technical personnel have the responsibility for

expediting the training when once it begins. Thereafter, command has the

responsibility for the continuing execution of training doctrines.

Indoctrination teams might find permanent usefulness in any headquarters in which training activities are carried out. Replacement training centers,

for instance, have special need for continuing technical advice and assistance

in the preparation of inexperienced soldiers for combat.

The practical application of the program for prevention of cold injury in

any special theater of operations is determined by the season at which combat

operations are to begin, though, as just pointed out, the organization designed

to carry out the program should be set up the day the theater headquarters

comes into existence. Training and indoctrination for key command and staff

officers should begin promptly thereafter, but, for practical reasons, intensive

training of small units and of individual combat soldiers should precede by

not more than few weeks the time at which the training is to be used. When

the proper time comes, the training program should have top priority. As

rule, this means that training begins in the late summer, just in time to be

completed before autumn rains set in and the temperature falls to the range

within which cold injury is likely to occur.

Key personnel for the indoctrination program are supplied by the chief

quartermaster and the chief surgeon of the theater. The officers selected work

in close coordination with G-3, and with the full support of command, during

the period designated for the completion of the indoctrination program. They
484 COLD INJURY, GROUND TYRE

also work with the technical guidance of the consultants to the cold-trauma

board and with and through lower echelon team and unit resources.

The ultimate objective of cold injury indoctrination program in theater

in which winter combat is being planned or is under way is the training of all

personnel in the theater in the most efficient application of preventive and

control methods and procedures. This includes the fullest possible utilization

of clothing and equipment in order to reduce unit and individual exposure to

unfavorable weather.

Indoctrination must be thorough. It must be based on general principles,

but it must also include detailed instruction in all measures to be carried out

by units and by individuals. It is essential that all elements have complete

understanding of the reasons for all parts of the program. They must also

understand the limitations of clothing, rotation, and other measures to be

applied to, or by, individuals and groups.

Indoctrination must include appropriate training for command, staff, and

technical officer components on all levels. It can be assumed that command and

staff officers of field army will have had sound indoctrination in the Zone of

Interior and will have come to understand, through programs carried out in the

theater, the significance of cold trauma and the necessity for preventive and

control measures. Training at the army level, therefore, would be directed

chiefly to officers and enlisted men in smaller units. Because of their special

exposure to cold injury, combat personnel require the most intensive and most

comprehensive training.

With correct preliminary planning and the appointment of qualified

personnel for indoctrination duties, it should be possible to carry out theaterwide indoctrination program within from to weeks. It should also be

possible to accomplish the total instruction required for any given combat

unit within period of from to days if, during this time, arrangements can

be made for each component of the unit to receive from to hours of training,

including both instruction and demonstration. Indoctrination of support and

service personnel, who are less exposed to cold injury than combat personnel

and who therefore require less intensive training, can be accomplished within

shorter periods of time. If planning lias been careful, it is perfectly possible

to phase the training program for cold injury within an army in such way

that there will be little or no interference either with training in other subjects

or with the planned commitment of units to combat.

Cold injury control teams.—The direct responsibility for guidance in the

prevention and control of cold injury in field army rests with the army trenchfoot-control team. This team is made up of line officer with combat experience and an officer from the Quartermaster Corps. It is not necessary for the

team to include medical officer, though the chief of the preventive medicine

section in the office of the army surgeon should always be associated with the

team in an advisory capacity.

Both officers on the cold injury control team must have thorough knowledge of methods of prevention of cold injury, as well as an understanding of
PREVENTION AND CONTROL 185

tactics and of supply procedures, so that they can form precise judgments of

the cold injury situation in combat units. They must have direct access to

the chief of staff of the field army and must maintain close liaison with G-3, the quartermaster, and the surgeon. They must be provided with satisfactory

transportation. Finally, to the extent that the combat situation and security

considerations permit, they must have authority to enter unit areas down to,

and including, regimental headquarters.

One of the specific duties of an army trenchfoot-control team is to keep

fully informed on the incidence of cold injuries in the army, on the status of

clothing supply, on foot discipline and rotation practices and the effectiveness

of these measures, and on any other matters which might modify the cold

injury situation. Other duties include making frequent, regular visits to corps,

division, and regimental headquarters, in order to study the cold injury situation in these commands; acting in liaison and consultative capacity to

command and technical staffs of these headquarters; and surveying cold injury

within subordinate units as may be necessary.

Trenchfoot-control teams should also perform the following functions:

(1) Develop and maintain, with the support of G-3, continuous indoctrination and training program; (2) carry out training, education, and indoctrination in cold injury prevention and control for selected cold injury control

officers and noncommissioned officers by unit down to and including regiments;

(3) keep the chief of staff of field army, G-3, the quartermaster, and the

surgeon fully informed of the cold injury situation by units; (4) maintain liaison

with the cold injury consultants at theater level and with cold injury officers

or boards at group level or at the level of other intermediate headquarters if

cold-trauma organization has been set up in them; and (5) maintain close

liaison with S-3 (operations and training officer) and S-4 (supply officer), as

well as with the surgeon of each unit.

The army trenchfoot-control team will find its greatest field of usefulness

in the indoctrination and training of (1) officers who lead small combat units

and (2) noncommissioned officers and key enlisted men in companies, platoons,

and squads. Experience in the European theater showed clearly that the

platoon and the squad are the key units through which individual preventive

procedures can best be emphasized and toward which training should be directed

to secure optimum residts.

The trenchfoot-control directive issued in the European theater on 30

January 1945 (appendix G) specified trenchfoot-control teams only at army

levels but did not forbid them in subordinate echelons. After their usefulness

had become apparent, they were authorized in few corps and in several

divisions, and they were occasionally employed at regimental and battalion

levels. Though this is entirely matter for local command decision, it is somewhat doubtful that the mission of these teams justifies their routine use below

the army level. cold injury control officer would seem sufficient for an

organization smaller than an army.
486 COLD INJURY, GROUND TYPE

The effectiveness of cold injury control teams does not depend only upon

their own performance. It rests in large part upon the performance of the

carefully selected officers and noncommissioned officers in small units who act

as receptor points for guidance in cold injury control. Obviously, control

team from an army or corps cannot search out and instruct individual squads.

On the other hand, it is perfectly practical for commanders of units below the

regimental level to designate as trenchfoot-control personnel carefully selected

junior officers and noncommissioned officers and key enlisted men to be sent

to the rear of the regimental area for training in their duty by cold injury teams.

In the European theater, it proved practical for one army cold injury control

team of two officers to carry out successfully the training and instruction of

trenchfoot-control officers and noncommissioned officers by regiments, even

though these duties had to be performed during period of intensely active

combat. With correct advance planning, tins particular situation should not

occur again. Training in the future will be timed in relation to the combat

situation, as it could not be in the European theater in the winter of 1944-45.

In any event, the periods chosen must be satisfactory to regimental commanders.

After their formal training by the army cold injury control team, officers,

noncommissioned officers, and key enlisted men designated as trenchfootcontrol personnel have the responsibility of supervising in detail the protective

measures to be carried out in the small units under their jurisdiction. Detailed

supervision by company and platoon can be made the responsibility of an

officer with special knowledge of cold injury prevention, while an enlisted man

with interest in and knowledge of the subject can be extremely influential in

inducing his squadmates to take the precautions and employ the measures

which will protect them against cold injury.

The effective use of the trcnchfoot control team system, in conjunction

with cold injury control officers, noncommissioned officers, and key enlisted

men, requires fidl acceptance of the prevention and control program by command and full command support in all echelons from the theater downward.

This means, as already emphasized, that officers on the team must be able to

establish prompt and effective liaison with commanding officers and surgeons

in units. It also means that, in the interests of the program, line and medical

officers, on their part, must supply all the information to which they have

access. Officers on the team must not, of course, limit their contacts to designated trenchfoot-control officers, commanding officers, and surgeons. They

must make general contacts with junior officers, noncommissioned officers, and

enlisted men.

In the assessment of the cold injury situation in any unit, the team must

give careful consideration to whatever recommendations the organization

commander and the surgeon may make.
PREVENTION AND CONTROL 487

ALTERNATIVE PLANS

The experience of World War II amply demonstrates that the team method of trenchfoot control is necessary, is well adapted for the critical

problem which it is designed to solve, and is justified by the results. This

might have been expected. Earlier in the war, the team method had provided

the solution for the equally critical problem of malaria in the North African

theater and the Pacific areas. In both malaria and cold injury, the major

emphasis must be placed upon preventive and control practices by individuals

and units. Both conditions are potentially responsible for high casualty rates,

and losses from both were dismayingly high until the institution of the team

system reduced them to acceptable levels.

It must be conceded that the use of the team system means the setting

up of special organization to accomplish what should be accomplished automatically by ordinary staff and command methods. Furthermore, it might be argued that if special setup is necessary for the control of cold injury it is

also necessary for the solution of other problems. If such reasoning were

carried to the ultimate limits, command could be plagued with number of

extraorganizational groups which, eventually, would disrupt routine processes

and impair command control.

Such arguments are specious. Special organizations are not required to

solve every special problem. The organization and operation of the team

system are fundamentally the same whether the problem is cold injury, or

malaria, or some other disease or condition. In the Pacific, plans were made to

utilize the malaria-control teams, which had worked so effectively in the control

of that disease in tropical combat areas, for the wet-cold indoctrination program.

Such plan would simply have required the transfer of abilities from one field

to another. Men with background, training, and experience in malaria control

would have needed only to master the principles of cold injury indoctrination

and training to become immediately effective. Neither reorganization nor the

setting up of new basic functions would have been necessary.

If it seems undesirable to establish specialist teams to cope with isolated

special problems, the establishment of theater epidemiologic units is an alternative which has ample precedence in both the Army and the Navy. Epidemiology, as has been pointed out elsewhere (p. 2), is broad subject which

encompasses the mass characteristics of chronic diseases and trauma as well

as of communicable diseases. Epidemiologic principles and methods of solution

of individual and mass problems are the same for both disease and injury.

They are just as applicable to an outbreak of cold injury as to an epidemic of typhoid fever.

The control of cold injury might therefore be vested in epidemiologic

teams set up at theater levels. British Army Hygiene Units are an example of
488 COLD INJURY, GROUND TYPE

this practice. So is the Special Epidemiologic Unit created hy the United

States Navy in World War II and used with such effectiveness that it was made

part of peacetime naval medical organization. The epidemiologic teams

set up hy the Army in World War II within the framework of general medical

laboratories and field laboratories attached to armies were somewhat less

effective than they should have been because they were not always utilized as

it had been intended that they should be.

An epidemiologic unit would have as its province many epidemiologic

problems. It could serve in the prevention and control of cold injury during

the winter and of malaria during the summer. Venereal disease, gastrointestinal disease, and accidents would be its continuing concern. The flexibility of such an organization, therefore, as well as its expert personnel, would

add to its advantages.

PROPOSED BOARD FOR THE CONTROL OF TRAUMA

The over-all plan outlined, which in general is based on the experience of

World War II and the lessons learned therein, provides practical, comprehensive plan of cold injury prevention and control within the Military Establishment. It does not, however, provide the whole answer to the problem.

Singleness of purpose, avoidance of duplication, and coordinated direction

of effort in the study of cold trauma could best be accomplished under the

auspices of board made up of representatives of command, training, and the

several technical agencies involved. On the other hand, the scope of cold

trauma, in spite of its dangerous potentialities, is too limited to justify the

setting up of board or commission whose sole function would be its prevention

and control. The solution would be to make all trauma the function of the

proposed board. This is reasonable. Cold injury is part of the total field

of trauma, and combat trauma is constant wartime problem. Trauma from

accidents of all kinds is also growing peacetime military problem, which is

greatly enhanced with the onset of war when cold trauma also becomes an

urgent problem. The mission of the proposed hoard would he to determine

needs, establish policies, and advise upon research, training, and general prevention and control measures for all forms of trauma, including cold trauma.

There is nothing revolutionary about such proposal. Both World War

and World War II furnished illustrations of the medicomilitary fact that coordination of effort by several agencies is frequently most efficiently accomplished by the setting up of special boards or commissions whose scope and

terms of reference go beyond the realm of routine staff procedures. Thus, in

World War I, hoard for the control of pneumonia performed valuable

service in mobilizing and applying all the resources then available for the management of pneumonia, which was the principal cause of death during the influenza epidemic of 1918. In World War II, the Army Epidemiological

Board and the United States of America Typhus Commission, which brought
PREVENTION AND CONTROL 489

together the best talent available in these special fields, carried out invaluable

research upon and contributed immeasurably to the practical field control of

the diseases with which they were concerned. Both these boards were primarily medical organizations. The Army Committee on Insect and Rodent

Control, which was an interstaff agency, had an important influence on the

development and direction of research and practices directed toward insect

and rodent control.

If the proposed board for the control of trauma were set up, it could

profitably adopt at least two principles which have been well established.

The first principle is that representatives assigned to the board be so highly

placed that they speak with authority. Appropriate civilian experts might

profitably sit upon the board for the control of trauma or might be assigned to

it in consultative capacity, but Army representatives must be chiefs, or

deputy chiefs, of the agencies concerned, not their subordinates. The second

principle is that similar boards be set up in the headquarters of the major

operating echelons.

It is conceivable that the setting up of board for the prevention and control

of trauma, including cold trauma, might eventually lead to an even broader

concept, the establishment of board of preventive medicine. Such board

would be composed of command, staff, and service and technical experts.

Its function would be to develop the organizations and outline the policies and practices necessary to meet the entire range of epidemiologic problems, such as

acute communicable diseases, chronic diseases, abnormal psychology, and

trauma, including, of course, cold trauma.

491

CHAPTER XVf

The Military Cost of Cold Injury

In every theater of operations in which combat operations were carried

out during the winter in World War II, cold injury was responsible for large

numbers of casualties and caused sufficiently heavy losses in man-days to interfere materially with military tactics. Some loss from cold trauma is inevitable

during any winter fighting, and must be accepted as part of normal attrition.

During World War IT, however, losses from this cause exceeded expectancies

in every theater in which United States forces conducted winter operations.

In order to avoid such losses in future wars, the reasons for this situation

must be found, and the investigation must be comprehensive. Analyses of

failures to cope successfully with cold trauma can be based in part on the study

of cold injury in the individual soldier and in small units, but this is not enough.

There must also be an evaluation of the policies of management which were

laid down centrally and by theaters if full appreciation is to be secured of the

scope of the problem of cold injury in World War II. It is necessary to find

out (1) what was done, (2) why it was done, (3) when it was done, and (4) why

the policies and procedures instituted failed in conception, application, or both.

Without this knowledge, it will not be possible to determine why cold injury

was not kept within reasonable limits in the United States Army during World

War II.

THE FACTS OF COLD INJURY IN THEATERS OF

OPERATIONS

review of the management of cold injury, including measures of prevention, by theaters necessitates some repetition of material presented elsewhere

in this volume in more detail. The repetition is justified, however, since it

affords useful means of visualizing both the scope of the problem and the

approach to its control. The repetition of the data also demonstrates that,

while substantial understanding of how to manage cold injury had been achieved

in Italy by the second winter of conflict and in the European theater by early

1945, the lessons were learned in both theaters chiefly in the hard school of

experience. The losses from cold injury in the Aleutians provided warnings

that could have set the pattern for an effective approach to the problem. As

matter of fact, these losses did initiate the activities in the Surgeon General’s

Office (p. 57). The Aleutian operations, however, were so small and remote
492 COLD INJURY. GROUND TYPE

that they made almost no impression on the training program in the Zone of

Interior, and they were not utilized as guide for winter operations in Italy.

The lessons learned from the 1943-44 winter campaign in Italy pointed the

way to the control of cold injury during the 1944-45 campaign in that theater

but they were not fully appreciated, nor were they utilized in the planning

and training for the invasion of the Continent of Europe.

Army training and planning. -A partial explanation of the failure to learn

these successive lessons can be found in the progressive development of the

general military situation. In December 1939, the number of Army officers

on active duty was 12,000, and Regular Army enlisted men numbered 212,000.

Mobilization required the expansion of this small force to tens of thousands

of officers and several million enlisted men. The mere expansion was in itself

gigantic task.

The first enemy action had focused attention on the Pacific and on the

Tropics, and some time elapsed before the total military strategy was fully

appreciated. Cold injury, therefore, did not immediately emerge as one of the

basic problems.

The training of large, raw military force, no matter where it was to fight,

could not be expected to encompass, at once, all the special problems which

later assumed special importance. It was proper, and to be expected, that the

primary emphasis in training should be upon combat tactics and upon the technical and other military training of the individual soldier. Training authorities

were besieged from all sides with requests that he be specially trained in great

number of subjects and skills. If the United States soldier could have been

given, and could have retained, knowledge of all the subjects in which it was

proposed that he be trained, he would indeed have been the epitome of military

lore and efficiency. This was an obviously impossible ideal. There was not

even sufficient time to train the troops in the prevention and control of such

familiar causes of military casualties as malaria, the diarrheas, and the

dysenteries.

In the light of these facts, it is easy to understand why cold injury, which

had caused only few United States casualties in World War I, in October,

November, and early December 1918, should not have been appreciated as

potential source of heavy casualties in World War II. As result of this lack

of appreciation, planning, training, and the development and provision of clothing for protection against exposure to cold were not initiated early in the war.

As matter of fact, it was not until the potentialities of cold trauma had been

demonstrated in the Aleutians and, more particularly, during the first winter

in Italy, that vigorous attack began to be made upon these problems.

The Aleutians. —While the great problems of mobilization, training, and

general preparation for war were being wrestled with in the Zone of Interior,

the course of events in theaters of operations began to proclaim the place of

trauma from cold in winter warfare (tables 42, 43, 44, and 45). On Attn (p.

84), the experiences of small and uninitiated task force demonstrated therole

of cold and wet as agent factors, and also emphasized the importance of the
MILITARY COST OF COLD INJURY 493

Table 42 .—Admissions for cold injury in the United States Army {including the Army Air

Forces) by specific diagnosis and theater, 19^2-45

[Preliminary data based on sample tabulations of individual medicalrecords]

modifying factors of duration of exposure, intensity of combat action, inexperience, and improperly designed and used clothing and footgear. The protective

role of training was also brought out: One unit which had engaged in maneuvers in the cold and had received instruction in the prevention of cold injury

suffered very little trenchfoot and frostbite during the whole of the Attn

Campaign.

The Mediterranean (formerly North African) theater.—The signpost of

Attu was not heeded in the preparation and management of troops and replacements for operations in Italy during the winter of 1943-44. The initial phase

of the struggle was series of fights for survival in precarious bridgehead

footholds. Under these circumstances, cold injury had to be accepted because

of the intensity of combat, the inadequacy of supplies, and the impossibility

of rotation of troops and of execution of individual and unit control measures.

On the other hand, there was no appreciation on the part of command and

staff of cold injury as potential cause of casualties as the bridgeheads were

exploited, additional territory was conquered, supply lines were cleared, and it

became obvious that winter operations in the Apennines were inevitable.

All of these facts are summarized in the Fifth Army Medical Service history

for 1944, which read in part:

The Winter campaign for 1943-1944 found Fifth Army troops poorly equipped to meet

the dangers of trench foot. Troops were provided only with the standard Army shoe or

combat boot and light wool sock. These shoes and boots became water-soaked and the

light wool sock offered no protection against either wet or cold. The shoe or combat boot

438404'—58——33

Theateror area Total cold

injuries Trenchfoot Frostbite Immersion foot (or hand) Chilblains Other

effects

of cold

All theaters and areas 82, 580 58, 355 18, 249 1, 361 901 3, 714

Continental United States. 5, 133 290 4, 307 36 330 170

Total outside continental

United States 77, 447 58, 065 13, 942 1, 325 571 3, 544

Europe 64, 008 48, 366 11, 974 436 179 3, 053

Mediterranean 10, 397 9, 138 665 312 242 40

Middle East 33 22 11

China-Burma-India. 35 12 15

Southwest Pacific 548 326 10 209

Central and South Pacific 129 26 31 63

North America 2, 205 145 1, 220 295 131 414

Latin America 28 25

Includes 64 admissions on board transports.

Includes North Africa.

Includes Alaska and Iceland.

Source: Medical Statistics Division, Office of the Surgeon General, Department of the Army.
494 COLD INJURY, GROUND TYPE

Table 43.—Incidence of cold injury in the United States Army (including the Army Air

Forces by specific diagnosis and theater, 19j2~j5

[Preliminary data based on sample tabulations of individual medicalrecords]

fit so snugly that heavy wool sock could be worn only by issuing larger size shoe. Supplies

were not adequate for such readjustment, nor were heavy wool socks available for issue

early in the winter. Apart from these deficiencies, neither officers nor enlisted men were

alert to the dangers of trench foot, or adequately indoctrinated in preventive measures.

Trench foot was new experience to Fifth Army troops and the preventive measures urged

by the Surgeon were difficult to put into effect.

There had been some early warnings of the possible hazards of cold injury

(p. 101) but they were issued only short time-—a matter of days—before trenchfoot made its appearance in the theater. In the early winter of 1943-44, number of command directives relating to the prevention and management of

trenchfoot were published and disseminated (appendixes and D), but they

appeared only after the conditionhad become epidemic. Even after preventive

measures had been described and ordered, their importance was apparently not

fully realized. Whatever the reason, the Fifth U. S. Army, operating in the

Mediterranean theater, learned about trenchfoot by experience in winter combat and paid for the experience with high incidence of casualties from trenchfoot (tables 42, 43, 45, and 46).

The lessons learned during this period were summarized in the letter

(p. 122) written in June 1944 to the Commanding General, NATOUSA, by the

Theater or area Total cold injuries Trenchfoot Frostbite Immersion foot (or hand)

Chilblains Other

effects

of cold

All theaters and areas 90, 535

5, 203

85, 332

71, 038

11, 192

33

64, 590 19, 559 1, 451

36

971 3, 964

Continental United States 315 4, 342 335 175

Total outside continental

United States 64, 275 15, 217 J, 415 636 3, 789

3, 283

55

Europe

Mediterranean

Middle East

53, 911

9, 778

22

13, 134

765

11

506

322

204

272

China-Burma-India 35 12 15

Southwest Pacific 578 351 10 214

Central and South Pacific

North America

139

2, 225

26

145

36

1, 230

68

295 141 414

Latin America 28 25

Consists of both admissions for cold injury and cases in which admission was for other conditions but in which cold

injuries appeared as secondary diagnoses. Data on secondary-diagnosis cases are not presently available for 1942 and

1943, and, for these years, only admissions have been included in this table. It should be noted that cold injury admissions in 1942and 1943 constituted but small proportion of the World War II admissions for cold injury. For 1942

and 1943, admissions may be considered an approximation of incidence. During 1944-45, in the total Army the incidence of cold injury exceeded admissions by 11 percent.

Includes 64 cases among admissions on board transports.

Includes North Africa.

IncludesAlaska and Iceland.

Source: Medical Statistics Division, Office of the Surgeon General, Department of the Army.
MILITARY COST OF COLD INJURY 495

Table 44.—Incidence of cold injury in the United States Army (including the Army Air

Forces) by specific diagnosis and theater, 1942

(Preliminary data based on sample tabulations of individual medicalrecords]

Surgeon of the theater, Maj. Gen. Morrison C. Stayer (appendix J). During the second winter in Italy, the application of preventive measures against

cold injury became an integral part of the military operation. The result was

great reduction in the incidence of cold trauma as compared with the previous

winter (tables and 4) and convincing demonstration that cold injury could

indeed be prevented and controlled.

Losses from cold injury in Italy in the winter of 1943-44 increased the

concern over this danger which was already felt in the Surgeon General’s

Office (p. 60). They also became matter of concern to the War Department.

In expectation of further winter operations, both in Italy and in western Europe,

the available knowledge of cold trauma in military operations in the Arctics

was brought together, and guiding command and technical directives were

published (p. 63, and appendix A). These publications, however, appeared

too late, and reached the European theater too late, to influence the epidemics

of cold injury which occurred there during the winter of 1944-45.

The European theater.—Although representatives from the Chief Surgeon’s

Office had visited the Mediterranean theater in the winter of 1943-44, their

observations on trenchfoot had been only incidental to the other purposes of

their visit. An attempt to alert authorities in the European theater to the risks of cold injury had been made in the spring of 1944 (p. 161) but had not

been successful.

Theater or area Total cold injuries Trenchfoot Frostbite Immersion foot (or hand) Chilblains Other

effects

of cold

All theaters and areas 1, 305

913

77 022 154

110

49

30

19

Continental United States 55 717

Total outside continental

United States 392 22 305 44 Europe 30 18 11

Mediterranean

Middle East

China-Burma-India

Southwest Pacific 13 12

Central and South Pacific

North America 323 279 32 10

Latin America.

Sincesecondary-diagnosis data are not available for 1942, admission data have been shown and may be regarded as

an approximation of Incidence in 1942. During 1944-45 in the total Army, the incidence of cold Injury exceeded admissions by 11 percent.

Includes admissionson board transports.

Includes North Africa.

Includes Alaska and Iceland.

Source: Medical Statistics Division, Office of the Surgeon General, Departmentof the Army.
496 COLD INJURY, GROUND TYPE

Table 45.—Incidence of cold injury in the United States Army (including the Army Air

Forces) by specific diagnosis and theater, 19jS

[Preliminary data based on sample tabulations of individual medicalrecords]

Then came the successful landings in France and the rapid advance of

the Allied armies across Europe. Morale was high. Victory was in the air.

Many persons, some in high places, were convinced that the success of Allied

arms would bring the conflict to close late in 1944, before the onset of winter.

Whatever the reasons, the important Italian signposts were lost sight of.

Training during the long wait in England before the invasion of France did not

include any emphasis on cold injury prevention, either by unit or by individual.

Command had not been indoctrinated with the importance of cold injury in

winter operations and did not comprehend its responsibility for prevention

and control of this type of trauma. In the European theater, just as in Italy,

command and technical directives were published, but the first cases of trenchfoot were occurring when they began to appear. In the surge across Europe

toward Germany in the summer and early autumn of 1944, the need for such

directives had not been appreciated (appendixes and G).

As result, United States forces were not prepared by training, nor did

they have the proper equipment, to withstand cold injury at the beginning of

the offensive in November 1944. Those in authority were therefore faced

with the necessity of meeting this extremely serious development by expedients,

and they were required to train and indoctrinate both commanders and troops

during active, heavy combat, when trenchfoot was already epidemic.

Theater or area Total cold injuries Trenchfoot Frostbite Immersion foot (orhand) Chilblains Othereffects

of cold

All theaters and areas 7, 481 2, 224 3, 645 459 317 836

Continental United States 2, 520 60 2, 220 15 135 90

Total outside continental

United States 4, 961 2, 164 1, 425 444 182 746

Europe 900 10 545 21 321

Mediterranean 2, 320 1, 988 95 142 90

Middle East 28 19

China-Burma-India

Southwest Pacific

Central and South Pacific 11

North America 1, 661 142 761 290 69 399

Latin America

Since secondary-diagnosis data are not available for 1943, admission data have been shown and may be regarded as

an approximation of incidence in 1943. During 1944-45 in the total Army, the incidence of cold injury exceeded admissions by 11 percent.

Includes 34 admissions on board transports.

Includes North Africa.

Includes Alaska and Iceland.

Source: Medical Statistics Division, Office of the Surgeon General, Department of the Army.
MILITARY COST OF COLD INJURY 497

Table 46. Incidence of cold injury in the United States Army (including the Army Air

Forces) by specific diagnosis and theater, 1944

[Preliminary data based on sample tabulations ofindividual medicalrecords]

The price paid in casualties in the European theater was far too high to

justify the conclusion that cold injury losses of such magnitude could be accepted entirely as calculated risk (p. 209). The incidence began to be reduced

only after several weeks, and even then it fluctuated with the severity of the

weather and the intensity of combat (table 47). program of prevention

was finally formulated, but only after thorough epidemiologic study of cold

injury had placed the proper emphasis upon its multiple causation and had

stressed the relative weights of these various factors and their roles in the

mechanism which produced this kind of trauma. By the time the program

had become fully effective, the environmental hazards had almost entirely

disappeared.

AN EVALUATION OF THE COSTS OF COLD INJURY

Preliminary data show that the total incidence of battle and nonbattle

cold injuries of all types among United States Army (including Air Forces)

personnel from 1942 to 1945 was 90,535 cases (table 43). These figures cover

only soldiers excused from duty for treatment; patients who required only

outpatient treatment are not included in them.

Theateror area Total cold injuries Trenchfoot Frostbite Immersion foot (or hand) Chilblains Other

effects

of cold

All theaters and areas 40, 197 35, 555 2, 651 743 320 928

Continental United States 1, 210 75 1, 015 15 75 30

Total outside continental

United States 38, 987 35, 480 1, 636 728 245 898

Europe. 30, 525 28, 191 1, 080 350 60 844

Mediterranean 7, 715 6, 962 394 174 144 41

Middle East China-Burma-India

Southwest Pacific 475 287 186

Central and South Pacific 47 18 11 13

North America 195 150 40

Latin America 15 15

Consists ofboth admissions for cold injury and cases in which admission was for other conditions but in which cold

injuries appeared as secondary diagnoses.

Includes cases among admissions on board transports.

Includes North Africa.

Includes Alaska and Iceland.

Source; Medical Statistics Division, Office of the Surgeon General, Department of the Army.
COLD INJURY, GROUND TYPE 498

Table 47.—Incidence of cold injury in the United States Army (including the Army Air

Forces) by specific diagnosis and theater, 19J

[Preliminary data based on sample tabulations of Individual medicalrecords]

Data compiled during the period of combat from the different theaters,

and recognized then as incomplete, showed that cold injury in the various

theaters of operations was responsible for approximately 55,000 casualties.

More complete study of losses from this cause since the war has brought the

number up to more than 90,000. This figure has been arrived at by postwar sampling of individual medical records. Since it would be an impractical

task to revise various detailed data by review of individual medical records,

certain of the discussions in this chapter are based on wartime data. It is

obvious that some inaccuracies exist. It is equally obvious that these inaccuracies in no way invalidate the conclusion that the military cost of uncontrolled

cold injury in World War 11 was enormous.

Since it would also be an impracticable task to revise unit data, or even

data for armies or total ground forces for theater, by review of individual

medical records, the cost of cold injury according to commands and armies

has also been estimated from the wartime data.

Of the total of 90,535 casualties from cold injury (table 43), 82,580 were

admitted to United States military medical facilities with the admission diagnosis of cold injury (table 42). Trenchfoot, with 64,590 cases, was the predominant type of cold injury, followed by frostbite with 19,559 cases. If

only the theaters in which cold injury was serious problem (that is, the

Mediterranean and European theaters) are considered, and if the total cases

Theater or area Total cold Injuries Trenchfoot Frostbite Immersionfoot (or hand) Chilblains Other

effects

of cold

All theaters and areas 41, 552 26, 734 12, 241 246 180 2, 151

Continental United States 560 125 390 15 25

Total outside continental

United States 40, 992 26, 609 11, 851 241 165 2, 126

Europe 39, 583 25, 709 11, 491 153 112 2, 118

Mediterranean 1, 148 827 271 37

Middle East

China-Burma-India 26 11 15

Southwest Pacific 86 51 27

Central and South Pacific 77 24 50

North America 46 40

Latin America 10 10

Consists of both admissions forcold injury and cases in which admission was for other conditions but in which cold

injuries appeared as secondary diagnoses.

Includes 15 cases among admissions on board transports.

Includes North Africa.

Includes Alaska and Iceland.

Source: Medical Statistics Division, Office of the Surgeon General, Department of the Army.
MILITARY COST OF COLD INJURY 499

are limited to admissions with the primary diagnosis of cold injury, the total figure for trenchfoot is 57,504 cases (48,366 in Europe, 9,138 in the Mediterranean theater), and the total figure for frostbite is 12,639 cases (11,974 in

Europe, 665 in the Mediterranean theater).

The mere statement of statistics does not tell the whole story. The

true cost of any given number of cases of disease or trauma can best be calculated from the military standpoint in terms of total noneffectiveness; that

is, in terms of the number of days lost from combat, support, and service duty

because of the condition. The average number of days lost from duty because

of cold injury in military populations in all areas was 83 per case. Provisional estimates made earlier in Italy had set the figure at 60 days.

An average loss of 83 days per case means that there was total of

7.514.000 man-days lost from cold injuries for the total Army during the

1942-45 period: 6,265,000 days lost because of trenchfoot (97 days average

duration), 1,134,000 days lost because of frostbite (58 days per case), and

115.000 days lost because of other cold injuries. This is 20,586 military manyears. If the loss is considered in terms of hypothetical field army of

250.000 men, it represents the noneffectiveness of the entire field army for

about month. If it is considered in terms of 15,000-man division, it

represents the noneffectiveness of the entire division for about 16 months.

These losses, impressive as they are, still do not tell the whole story of

the cost of cold injury in terms of military effectiveness. Cold injury is

malady of the frontline infantryman in direct contact with the enemy. Each

infantryman in active combat at the front requires several other men to support him, keep him fed, clothed, supplied with ammunition, and provided

with other services which he must have if he is to remain effective. The

higher the echelon of the total command, the greater is the number of support

and service troops not directly exposed to cold injury. Cold injury losses

are therefore proportionately greater when they are calculated for small combat units, of battalion or company size. battalion of infantry, for instance,

has little overhead, and almost its whole strength is exposed to cold injury during combat. If each battalion is assumed to average 750 men, and if

each infantry division is made up of regiments of battalions each, the

population at actual risk is significantly smaller than the total population

of the division; and the proportion of losses, based on the population at risk,

is thus revealed in its true light.

Calculated on this more realistic basis, loss of time from cold injury for

the division, instead of being 16 months, would be 37 months, or more than

years. These data require even more careful analysis to estimate the total

tactical cost of cold injury. If, for example, the time factor is disregarded

and the approximately 70,000 cases of cold injury in Europe in 1944-45 are

used as basic data, it can be said that the equivalent of almost divisions of

15.000 men each was lost to combat.

This still, however, does not give true picture of the situation. Approximately 90 percent of all cold injury casualties were riflemen, of whom about
500 COLD INJURY, GROUND TYRE

4,000 wore in each infantry division. The loss of effective fighting strength

from cold injury thus could be interpreted as more nearly 16 divisions than

as divisions. In the light of the facts just cited about the actual military

populations at risk, the enormous impact of cold injury losses upon effective

fighting strength is apparent.

As has already been pointed out, more complete data established by postwar sampling of individual medical records (tables 42 through 47, inclusive)

show that wartime reporting was incomplete. The numbers of cases of cold

injury by theater are significantly higher when data from all sources are consolidated and secondary diagnoses of cold injury are included. The total

number of cold injury cases of all types during World War 11 approximated

91,000. The total time lost is estimated as 7,514,000 man-days, or 20,586 manyears, an average of 83 days per case. This estimate includes the seriously

injured casualties who were returned to the Zone of Interior. These men often

required many months of military care, and many of them could never be

returned to military duty.

Losses according to commands and armies.—A breakdown of cold injury in United States Army forces by major commands and by principal field units in the European theater for the 6-month period ending with April 1945 (tables

48 and 49) showed that the annual rate per 1,000 men for total field forces was

75.9, as compared to the total theater rate of 46.6. The First and Third U. S.

Armies had higher rates, 106.8 and 99.8, respectively. By comparison, the

major field headquarters, the 6th and 12th Army Groups, had an annual rate

per thousand men of 30.6. This rate would have been even lower except that

Table 48.—Cold injury incidence for United States Army Ground Forces, European theater

(Continent only), by month, November 1944 through April 1945

[Rate expressed as number perannum per 1,000 average strength]

Month and year

First U. S. Army Third U. S. Army Seventh U. Army Ninth U. S. Army Fifteenth

U. S. Army XVIII Corps Airborne

Headquarters

andattached troops, 6th and 12th Army

Groups

Total

Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate

19U

November... 2,715 110.9 4,544 224.4 1,420 94.5 622 47.5 (') (i) 27 16.1 9,328 125. December 5.184 104. (I 4, 306 170.0 2, 236 106. 1,193 67.8 (') 0) 105 35.4 13,024 132.

194S

January. 5,047 203.9 3,626 135.9 3,012 144.7 252 18.9 94 187.5 78 108 35.3 12,140 136.0 February 3,194 144. 1,848 75.4 2, 423 99.3 224 11.7 47 49.0 5.5 277 49.8 8,017 83.4

March... .. 734 23.9 1,097 35.9 592 19.5 132 4.3 .7 15 2. 18 6.4 2,593 18.6 April 79 3.2 18 .7 84 3.5 181 1.6

Total 16,953 106.8 15, 439 99.8 9, 767 72.2 2,423 20.2 146 14. 20 2.5 535 30.6 45, 283 75.9

Not in theater.
MILITARY COST OF COLD INJURY 501

Table 49. Cold injury incidence in major commands, United Slates Army, European theater

(Continent only), by month, November 1944 through April 1945

[Rate expressed as number per annum per 1,000 average strength]

division attached to one of these headquarters, for guard, patrol, and similar

duties, had to be thrown into combat during the German counteroffensive and in the succeeding weeks, when every possible resource was being utilized to

bring the war to rapid conclusion.

The Seventh and Ninth U. S. Armies had rates relatively much lower than

those of the First and Third U. S. Armies, one of the explanations being that

they had shorter periods of heavy offensive operations during the cold season.

The explanation of the low rate for the Fifteenth U. S. Army (14.2) is similar:

This army was not effectively in the theater until the end of December 1944,

and its mission, except for short period in the counteroffensive early in 1945,

was to consolidate gains and hold and administer territory already overrun by

the other armies of the 12th Army Group.

When the number of cases and the annual rates by weeks and months for

the period from November 1944 to April 1945 are broken down for the First,

Third, Seventh, and Ninth U. S. Armies (table 48), the high price of cold injury

is further emphasized. Wide fluctuations are apparent in the weekly rates.

At no time during the winter did the annual rate by months drop below 110

for either the First or the Third U. S. Army except for February 1945. Both

of these armies were heavily engaged throughout this period. The Third

U. S. Army experienced sudden point epidemic in November 1944, which then

leveled off somewhat. In the First U. S. Army, the buildup was slower, but

the rate was maintained at higher level for longer period.

Examination of the rates for small individual units showed even higher

rates for some periods than those just cited for larger bodies of troops. The

438404'—58 34

Month and year

Ground Forces Ground Force Reinforcement Command

Communications Zone Air Forces Total

Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate

1944

November 9, 328 125. 0. 10 0. 10 0. 9, 350 75.

December 13, 024 132. 115 17. 57 1. 20 1. 13, 216 80.

1945

January 12, 140 136. 236 33. 122 3. 48 3. 12, 546 85. February 8, 017 83. 176 25. 159 4.3 13 8, 365 53.

March 2, 593 18. 86 8. 12 2, 693 12. April 181 1. 19 1. 22 1. 230 2.

Total 45, 283 75. 634 13. 368 1. 115 1. 46, 400 46.
502 COLD INJURY, GROUND TYRE

combat effectiveness of some of the smaller units, in fact, was reduced by more

than half during some weeks of the November offensive.

Reinforcements. The loss of manpower through cold injury was costly

not only in the prosecution of offensive actions, but also in the increased load

it placed upon reinforcement and hospital facilities. During December 1944

and January and February 1945 (table 49) the Ground Force Reinforcement

Command in the European theater had annual rates for cold injury of 17.0,

33.1, and 25.0, respectively. The annual rate for the November-April period

was 13.2. These rates are an indication of the stress under which replacement facilities were operated to train and send forward men to compensate

for those lost to the combat forces as the result of cold injury. replacement

had to be furnished for every soldier lost to the frontline combat organization,

but, again, mere numerical statements do not tell the whole story. Every

soldier requires from to 15 weeks of basic training before he can be assigned

to combat theater. Then, because he is still raw and inexperienced, he must

undergo several additional weeks of seasoning in battle before he reaches high

combat efficiency. Every week of combat experience which soldier has

short of the point of combat exhaustion—increases his value to the frontline

commander and to the war effort. Unit records repeatedly show that it is

not possible to measure quantitatively, much less qualitatively, the reduction

in combat effectiveness of unit that has experienced high casualties for any

cause and that must operate with large proportion of inexperienced replacements.

There is still another aspect to this problem. Certain intangibles cannot

be discounted, such as morale, loyalty to one’s unit, teamwork, and the comaraderie of men who have served with each other and with special units for

long periods. It is long time before replacements, no matter how well trained

and experienced they may be, can take the place of men tried and trusted and

with long periods of service. These intangible losses must therefore be added

to the total quantitative and qualitative cost of cold injury.

Medical and hospitalization costs.—Cold injury is burden to the medical

services of the army. Medical costs begin at the frontline. Many casualties

from this cause are not ambulatory and must be evacuated by litter carry, jeep,

or ambulance. Later, patients with serious injuries must be evacuated to

general hospitals in the communications zone, and finally, by hospital train, air,

ambulance, or ship, to the Zone of Interior.

Each casualty from cold injury occupies hospital bed for periods varying

from few days to several months. Most often, the period of hospitalization

is long and the effect of new admissions is therefore cumulative (tables 50 and

51). Between 11 November 1944 and 29 June 1945, the average number of

casualties in hospitals in the European theater because of cold trauma at the

end of each week was 14,026. When the incidence of cold injury was high

(from the week beginning on 25 November 1944 through the week ending on

See footnote 49, p. 171.
MILITARY COST OF COLD INJURY 503

April 1945), the average number of patients remaining under hospital care

by weekly periods was 22,454. The maximum number remaining under medical supervision at the end of any single weekly period in the European theater

was 35,424; this was for the week ending February 1945 (table 51). Xot

all of these men, it is true, occupied hospital beds on any given day, but large

proportion of them did, and all of them, whether confined to bed or not, required

medical supervision.

Table 50. Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and

prevalence rates, United States forces, Mediterranean theater, 1943-45

[Prevalence rates expressed as numbers remaining per 1,000strength]

Patientsremaining at Rate at end of period

end of period Period

Trenchfoot Trenchfoot and im- Frostbite and im- Frostbite mersion foot mersion foot

1943 Aug.-29 Oct 30 Oct.-26 Nov

27 Nov.-3I Dec 136 0. 22

1944 Jan.-28 Jan__ 573 92

29 Jan.-25 Feb 1, 697 2. 68

26 Feb—31 Mar 1, 550 2. 31

Apr-28 Apr

29 Apr.-10 Nov

11 Nov.—17 Nov 004

18 Nov.-24 Nov 349 11 70 0. 02

25 Nov.-l Dec 298 16 59 03

Dec.-8 Dec 357 16 71 03

Dec.-15 Dec 398 11 80 02

16 Dec.-22 Dec .. 341 11 68 02

23 Dec.-29 Dec... 359 14 70 03

1945 30 Dec.-5 Jan 435 28 85 05

Jan.-12 Jan 537 22 1. 05 04

13 Jan-19 Jan 583 25 1. 13 05

20 Jan-26 Jan 537 31 1. 03 06

27 Jan.-2 Feb 514 61 99 12

Feb. Feb 538 63 1. 04 12

10 Feb.-16 Feb 506 56 98 11

17 Feb.-23 Feb 567 47 1. 10 09

24 Feb.-2 Mar 539 56 1. 07 11

Mar.-9 Mar 481 39 98 08

10 Mar.-16 Mar 461 30 93 06

17 Mar. 23 Mar 428 22 86 04

24 Mar.-30 Mar 335 14 67 03
504 COLD INJURY, GROUND TYPE

Table 50. Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and

prevalence rates, United States forces, Mediterranean theater, 1943-45—Continued

Most of the general hospitals which received cold injury casualties found

it convenient and practical to set up convalescent sections to carry out the

rehabilitation program necessary to get the men back to duty. These sections

required medical supervision and ancillary medical help. Whole convalescent

hospitals were designated for the care of patients with milder cold injuries, who,

it seemed reasonable to assume, might be returned to active service. Men

with still slighter injuries were placed in such medical units as medical gastreatment battalions (p. 308). Hospital-bed space was thus conserved, but

the patients, nonetheless, needed considerable medical supervision.

In short, the medical cost of cold injuries required several types of medical

facilities, the time of many busy medical officers, the labor of hundreds of

personnel ancillary to the Medical Corps, and the utilization of many units of

medical evacuation transport for millions of miles to bring casualties with cold

trauma to medical installations in which they could receive appropriate

treatment.

Cold injury-battle casualty ratio.—Battle casualties are the chief index

of the cost of military operations. In terms of total cases, they represent the

greatest single cause of loss of manpower to combat units. The ratio of cold

injuries to battle casualties therefore furnishes sound criterion of the military

cost of cold trauma.

Period

Patients remaining at end of period Rate at end of period

Trenchfoot

and im- mersion foot Frostbite Trenchfootand immersion foot Frostbite

ms 31 Mar.-6 Apr 283 11 0. 57 0. 02

Apr.-13 Apr 248 12 50 02

14 Apr-20 Apr 206 11 42 02

21 Apr-27 Apr 154 32 02

28 Apr -4 May 135 28 02

May-11 May 110 23 02

12 May-18 May 72 15 01

19 May-25 May 40 09 01

26 May-1 June 24 06 01

June-8 June 24 06 01

June-15 June 10 03 002

16 June-22 June 02 01

23 June-29 June 02 01

Source; Medical Statistics Division, Office of the Surgeon General, Department of the Army.
MILITARY COST OF COLD INJURY 505

Table 51. Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and prevalence rates, United States forces, European theater, 1943-45

[Prevalence rates expressed as numbers remaining per 1,000 strength]

Period

Patients remaining at end of period Rate at end of period

Trenchfoot

and im- mersion footFrostbite Trenchfoot

and im- mersion foot Frostbite

1943

31 July—31 Dee

1944 Jan.—30 June

Aug.—10 Nov

11 Nov.-17 Nov 428 0. 21

18 Nov.-24 Nov 4, 171 1. 92 0. 001

25 Nov.-l Dec 8, 636 28 3. 82 01

Dec.-8 Dec_ 10, 064 40 4. 26 02

Dec.-15 Dec_ _. 15, 676 78 6. 48 03

16 Dec.-22 Dec 17, 001 67 7. 05 03

23 Dec.-29 Dec 19, 463 232 7. 90 09

1945 30 Dec.-5 Jan ___ 20, 566 460 8. 19 18

Jan.-12 Jan 24, 085 1, 375 9. 50 54

13 Jan.-19 Jan 25, 238 3, 198 9. 77 1. 24

20 Jan .-26 Jan 26, 728 4, 753 10. 07 1. 79

27 Jan.-2 Feb 27, 654 6, 101 10. 43 2. 30

Feb.-9 Feb __

28, 042 7, 382 10. 57 2. 78

10 Feb-16 Feb 26, 338 7, 080 9. 75 2. 62

17 Feb.-23 Feb 23, 939 6, 552 8. 90 2. 44

24 Feb.-2 Mar 21, 517 6, 155 7. 98 2. 28

Mar.-9 Mar 19, 188 5, 526 7. 01 2. 02

10 Mar.—16 Mar_ 16, 397 4, 863 5. 94 1. 76

17 Mar.-23 Mar ..

13, 500 4, 024 4. 81 1. 43

24 Mar.-30 Mar 10, 615 3, 257 3. 74 1. 15

31 Mar.-6 Apr __ 8, 277 2, 541 2. 92 90

Apr.-13 Apr 6, 513 2, 070 2. 27 72

14 Apr.-20 Apr .. 4, 838 1, 559 1. 69 55

21 Apr.-27 Apr 3, 645 1, 252 1. 29 44

28 Apr.-4 May 2, 516 901 88 31

May-11 May_ 1, 828 691 63 24

12 May-18 May 1, 169 404 40 14

19 May-25 May 927 356 33 13

26 May-1 June __ 592 223 21 08

Juno-8 June 536 190 19 07

June-15 June 389 149 14 05

16 June-22 June 354 112 13 04

23 June-29 June. 305 100 12 04

Source; Medical Statistics Division, Office of the Surgeon General, Department of the Army.
506 COLD INJURY, GROUND TYPE

In the 22-day operation on Attn in May and June 1943 (table 52), which

was small operation, the ratio of cold injuries to battle casualties was approximately 1:1. Cold injury in this operation was responsible for 31 percent of the

casualties from all causes, including, in addition to cold injury, both battle

and nonbattle casualties and deaths in action. In the Fifth U. S. Army in

Italy (table 52), for the period from November 1943 to April 1944, inclusive,

the ratio of cold injury to battle casualties was 1:5. For the period from

October 1944 to March 1945, inclusive, this same army, with the previous

year’s experience behind it, had ratio of oidy 1:10. In the European theater

in the winter of 1944-45 (table 52), the ratio of cold injury to battle injury in

the First U. S. Army was 1: 3.2, in the Third U. S. Army 1: 4, and in the First

and Third U.S. Armies combined, 1:3.6.

Table 52. Ratio of cold injuries to battle casualties by United States force or army, Attu

and Mediterranean and European theaters

The cost to military force from cold injury is both tangible and intangible, as has already been pointed out. Some measure of the tangible cost can

be arrived at by tabulation of the number of combat soldiers lost from this

cause, as well as by the annual incidence rates resulting therefrom for the

periods when it is problem. Measurement by ratio of cold injuries to battle

casualties is another effective index of cost. It is evident from the figures,

rates, and estimates which have been cited that cold injury in military forces

operating under winter weather conditions is expensive in trained and experienced combat personnel. That these costs can be reduced is inherent in the

comparison between the ratio of cold injuries to battle casualties in the Fifth

U. S. Armv in Italv for the winter of 1943-44 and the winter of 1944-45.

Force Period Cold

injuries Wounded

in action

Ratio of

cold in- juries to battle

casualties

Attu Task Force 11 May 1943-1 June 1943 1, 200 1, 148 1:1

Mediterranean theater:

Fifth U. S. Army November 1943-April 1944

October 1944-March 1945

5, 752 27, 602

15, 864

1:5

1, 572 1:10

European theater;

First U. S. Army Nov. 1944-16 Mar. 1945 16, 816 53, 611 1:3.

Third U. S. Army do 15,347 61, 905 1:4.

Total, First and Third do 32, 163 115, 516 1:3.

U. S. Armies.
MILITARY COST OF COLD INJURY 507

ADVANCE PLANNING

Details of the program of prevention and control planned for the invasion

of Japan, and planned well in advance of the daet set for it, are described in

detail in the chapter dealing with the Pacific (p.216). The picture there was

indeed very different from the picture in Italy and in the European theater

in the weeks before the launching of the massive assaults in those areas. The

signposts of Attu, the Mediterranean theater, and the European theater had

at last been read and heeded.

The program set up in expectation of the invasion of Japan represented

coordinated effort. Training personnel, Quartermaster Corps personnel,

and medical specialists and organizations united in common effort to meet

the potential problem. In these endeavors, all the services were fully supported

by command. Behind the entire effort as the approval and encouragement

of the War Department. At last it had come to be realized that the combat

soldier is just as noneffective when he is evacuated from the front because of

cold injury as he is when he is sent to the rear with combat wound. It had

also come to be realized that it was just as important to teach the soldier the

proper use of clothing and winter equipment to protect himself from cold

trauma as it as to train him in the use of his rifle to protect himself in comhat.

The end of fighting in the Pacific made the implementation of the planned

program unnecessary. Such training estimates, however, as could be made

before actual combat in winter weather gave promise of significant success and

indicated that the measures which had been adopted would likely have been

extremely effective.

509

APPENDIX

War Department Technical Bulletin (TB Med 81)

TRENCH FOOT

War Department, Washington 25, D. C. August 1944

1. DEFINITION, a. Trench foot is the term applied to the condition resulting from prolonged exposure of the feet to cold and moisture, usually associated with dependency and

immobility of the lower extremities and with constriction of the limbs by shoes or clothing.

The condition is closely related to immersion foot and shelter foot. Prolonged standing or

long hours spent in an upright or crouching position in cold, wet trenches or foxholes, especially if they have previously become mud-soaked by rain and the weather then changes to

frost, and the continual wearing of wet socks and footgear, are the most frequently responsible

circumstances leading to the development of the syndrome. The period of exposure varies

from several hours to several weeks.

b. Factors influencing the occurrence and severity of the condition include degree of

cold, duration of exposure, and footwear which, although affording some protection during

short exposure, causes constriction and is harmful after long exposure. Contributory factors

are dependency and immobility which reduce peripheral circulation; body cooling as from

wind and inadequate, damp, or wet clothing and footwear, resulting in loss of body heat and

production of general vasoconstriction with consequent circulatory stagnation; trauma; and

dehydration and nutritional and vitamin deficiency. Men over 40 and youths under 17

appear to be less resistant to the general effects of cold than those of intermediate ages.

Racial hypersusceptibility to cold has not been definitely established, but it appears that

individuals accustomed to warm environment do not have the same defenses as those who

have been accustomed to colder climates.

2. PATHOGENESIS AND MORBID ANATOMY, a. The essential vascular change during the period of exposure and hypothermia is peripheral vasoconstriction which involves predominantly the arteriolar vessels but may affect even the larger arteries and which results

in decreased blood flow to the part. This is induced both reflexly and as result of the

direct action of cold. The resultant ischemia causes anoxia of the capillaries with consequent

increased permeability, exudation, and edema. Existing arterial disease or compression of

the part by tight shoes or leggings may accentuate this mechanism. Direct thermal injury

to the skin from prolonged exposure to cold may also be factor as well as the traumata

incurred from walking on the damaged feet.

b. Immediately after the part is exposed to warmth, there occurs an intense inflammatory hyperemia with excessive vasodilatation which may be due to several factors, including the release of histamine-like substances resulting from tissue injury by the cold,

actual damage to vessels, and nerve injury causing vasomotor paralysis. This phase of

hyperemia is accompanied by swelling of the tissues and edema. The transudation of fluid

may be due either to mechanical factors or, in most instances, to increased permeability of

the damaged capillary endothelium. vicious circle is thus established, in which transudation contributes further to an already existing oxygen deficiency in the involved part. Involvement of peripheral nerves is suggested by paresthesias, dysthesias, anesthesia, and

sudomotor disturbances. Meager histological studies have revealed mixed degenerative

and regenerative changes in peripheral nerves. The significance of these findings is not
510 COLD INJURY, GROUND TYPE

established but local interference with neurogenic control of peripheral blood vessels is

probable. The tissues appear edematous and contain perivascular collections of lymphocytes, extravasated blood cells, and some polymorphonuclear leucocytes rather similar to

any sterile inflammatory reaction. The exudates are fibrinous and the finer lymphatics may

be blocked. The vessels themselves may show intimal thickening and vacuolization of the

muscle fibers or more complete disorganization with extending thrombosis in the vessels

adjacent to the traumatized area. In the more severe forms, histological studies made during

the late stages of the condition, i. e., several months after exposure, show atrophy and thinning of the epidermis with much fibrosis and deposition of collagen around the nerve endings

and blood vessels in the subcutaneous tissues. Fibrous infiltration of the muscles is also

evident. This is believed to be the explanation for the late pain, rigidity, and weakness of

the feet in this group of patients. The observation that these patients tend to improve

spontaneously after to months, the time at which collagen ceases to contract, supports

this belief.

3. CLINICAL MANIFESTATIONS, a. Classification. The clinical manifestations are

variable. Depending upon the period of exposure and extent of tissue damage, the condition as it appears clinically during the period following admission may be classified according

to degree as mild, moderate, and severe. The mild type is characterized by erythema, slight

sensory changes, and little or no pitting edema. In addition to these manifestations, there

are, in the moderate type, blebs, ecchymotic spots, and definite pitting edema. In the severe

forms, these manifestations are more pronounced with evidence of massive extravasations of

blood and incipient or actual gangrene.

h. Signs and symptoms. (1) During onset and period of exposure, there is first an uncomfortable sensation of coldness of the feet, and this is soon followed by numbness. There

may be temporary tingling, and mild aching or cramping pain about the arches, ankles, and

soles of the feet. In general, discomfort is not pronounced during this period, and the most

prominent manifestations are numbness and heavy wooden sensation of the feet. The

patients complain of ataxia, walking is clumsy, and they feel as if they were “walking on

blocks of wood.” Swelling of the feet may occur after several hours or days but is usually

not pronounced at this time. The skin, which is at first red, later becomes pale,

white,” “sickly yellow,” mottled blue, or purplish. Blisters usually develop at later stage.

(2) At the time of admission and after the shoes are removed, the signs and symptoms

enumerated above are present and may be more pronounced. The feet are cold and may be

anesthetic to pain, touch, and temperature. The peripheral pulses may be absent. The

signs and symptoms during this period are considerably influenced from the standpoint of

onset, duration, and degree by the method of treatment, as well as by the degree of damage

hich resulted before treatment as instituted. However, the condition progresses through

three more or less distinct stages, each with characteristic signs and symptoms:

(a) Prehyperemic or ischemic stage. This may last for several hours or more. The

feet remain cold, somew hat swollen, discolored, and numb. Areas of purplish discoloration

may sometimes be observed particularly in or about the toes. Although in the milder cases

there may be hyperesthesia, most cases are characterized by anesthesia of varying extent.

In the more severe case, there is fairly extensive “sock anesthesia,” and in the less severe

forms, these areas involve the toes and extend around the margins of the foot and over its

plantar aspect. In some cases in which exposure has been sufficiently prolonged, areas of

incipient or even actual gangrene may be already apparent, particularly about the toes.

Some patients experience poorly localized, dull, aching sensation in the feet. The peripheral

pulses may remain absent for some hours. As the feet grow warm, swelling increases rapidly,

and severe burning pain begins, marking the onset of the second stage.

(b) Hyperemic or inflammatory stage. This may last from few days to few weeks.

Swelling increases rapidly, and the feet become red, hyperemic, hot, and dry. The peripheral

pulses are full and bounding. Damage is greatest in the toes, the distal part of the dorsum
APPENDIX 511

of the foot, and the ball of the foot. These parts remain edematous and hot and assume livid cadaveric appearance. Blebs appear, except in the very mild cases, and may be filled

with straw-colored fluid or extravasated blood. Patchy areas of ecchymosis are commonly

found over the medial aspect of the first metatarsophalangeal joint, and of the longitudinal

metatarsal arch, and over the sides of the foot. The rigid swelling, the redness, and the local

warmth of the part indicate an intensive hyperemia. Superimposed damage to the peripheral

vessels is suggested by the ulceration and actual gangrene which sometimes involves the

more vulnerable parts, particularly the toes. The sensory disturbances are quite characteristic and may begin at once or be delayed for several days to week. The initial anesthesia

and hypesthesia are replaced by intense paresthesia. This has been described as an intense

burning pain over the surface of the entire foot which seems to be relieved by cold and

aggravated by heat or even by warmth. It is sometimes followed by intense, intermittent,

stabbing, shooting pains beginning in the ankle joint or in the midtarsus and radiating to

the tips of the toes. generalized tingling sensation is often felt in the skin but is overshadowed by the burning pain. The periphery of the foot is usually anesthetic and this

merges more proximally into areas of hyperesthesia and paresthesia. As these sensations

subside, they gradually recede distally to the toes. The affected parts may ache or throb,

and the pains are made worse by warmth and dependency. Anhydrosis or lack of sweating

is evident and seems to coincide with sensory loss. The degree of edema varies with the

extent of injury and, in the severe cases, may extend as high as the knee. Usually reaching

its height by the fourth to sixth day, it gradually subsides to be followed by fine wrinkling

of the skin. The red color slowly fades and usually within week to 10 days may take on

waxy pallor. In the majority of cases, in which the injury has not been great, the skin

assumes normal color after some exfoliation. In few cases, however, the feet become

cold, blue, and sweaty. The subsidence of edema, heat, and redness marks the end of this

stage.

Complications include localized infection, cellulitis, lymphangitis, and septicemia.

Phlebothrombosis along the course of the veins of the dorsum of the feet and along the

course of the saphenous veins has occurred and may be associated with petechiae in the

nearby skin. Rarely transient hematuria and albuminuria, enlargement of the liver, and

mild febrile reaction have been observed in cases of immersion foot but have not been

reported in trench foot.

(c) Posthyperemic stage. The clinical manifestations during this stage vary and

depend upon the degree of involvement and type of therapy. In the milder cases, the end

results are satisfactory, and there is apparently complete recovery. In the more severe

cases, there may be recurrence of pain, tingling, and swelling especially on walking, prolonged standing, or exposure to cold. In many of these cases, the transition from the

second to the third stage is not sharp but occurs gradually and, during this period, the

manifestations may vary from hour to hour or from day to day from those characteristic

of the third stage to those characteristic of the second. In few cases, deep-seated aching

pain persists and may be associated with tenderness in the joints, usually the first metatarsophalangeal joint, or may be localized deep in the arch of the foot. This is usually

worse at night. In still others, there may be limitation of motion in the joints, muscle weakness and wasting, and difficulty in walking. Some complain of hyperhidrosis of the feet,

and anesthesia and paresthesia in the tips of the toes are not uncommon. The late pains,

the paresthesias, and rigidity of the part may be due to compression of nerve endings and

infiltration of muscle bundles with scar tissue. Hypocalcification or evidence of osteoporosis

has been demonstrated in some of the cases and appears on the roentgenogram as diffuse or

rounded areas affecting the distal part of the metatarsal bones and the proximal part of

the phalanges. Occasionally, the extremities may become excessively sensitive to cold so

that Raynaud’s phenomenon or simple coldness may persist for hours after return to

warm environment. These sequelae have been observed for months or years after exposure.
512 COLD INJURY, GROUND TYPE

4. PROPHYLAXIS. Prophylactic measures are directed toward conserving body heat and

avoiding unnecessarily prolonged exposure of the feet to moisture, coldness, and other

factors that decrease peripheral circulation.

a. Loose-fitting waterproof or water-resistant boots with replaceable thick felt innersoles and heavy woolen socks should be worn to provide good insulation as well as ventilation.

The shoe-pac (rubber foot-piece, leather top type of footgear) is probably best for this

purpose except on rough mountainous terrain. It is important, however, that the shoe-pac

fits properly and does not constrict the toes or foot when the innersole and heavy woolen

socks are used. If shoes are worn, they should be water-resistant, of relatively soft top

construction, and sufficiently large to accommodate heavy woolen socks without constriction.

h. Every effort should be made to keep the feet dry and, if the socks or innersoles become

damp or moist as result of perspiration or prolonged immersion in wet mud or snow, they

should be replaced by dry ones as soon as possible. An extra pair of dry heavy woolen

socks should be carried by each soldier and others made available by an exchange service

when troops are on duty in wet cold regions for periods longer than several days.

c. Standing in water or mud-soaked areas should be avoided as much as possible even

though waterproof boots are worn. If the trench or foxhole contains water, it should be

bailed out, if possible, and stones or branches of tree placed at the bottom on which to

stand.

d. The shoes should be removed at least once daily and the feet cleansed and dried.

Innersoles and socks should be well dried before being replaced.

e. Cramped positions, prolonged immobility, and dependency of the extremities should

be avoided. Frequent exercises and temporary elevation of the feet are desirable. If this

is impractical, exercise of the toes and ankles within the shoes and elevation of the feet

should be done as frequently as possible.

/. The upper part of the body should be kept warm and dry, and exposure to cold

winds reduced to minimum. Gloves should be worn, if possible.

g. Constriction by tight clothing, shoes, socks, garters, and leggings should be avoided.

h. Nutrition should be maintained at as high level as circumstances permit. Whiskey

and other alcoholic beverages should be avoided.

i. Whenever feasible, the feet should be inspected at least once weekly and injuries or

infections properly treated.

j. Whenever circumstances permit, in cold wet weather, troops should be relieved from

front-line action after several days exposure.

k. Unit commanders should be cognizant of the factors concerned in the causation and

prevention of trench foot and of the importance of foot discipline and, in accordance with

section IV, War Department Circular No. 312, 1944, are held responsible for the diligent

application of the protective measures.

5. TREATMENT. The principles of treatment consist essentially of rest, avoidance of

local trauma and infection, elevation of the feet to promote drainage of edema fluid, and

reduction of metabolism in the affected part. The rationale of treatment is to reduce the

metabolic demands of the part until edema subsides, extravasated blood is absorbed, and

vasomotor tone is reestablished. Under these conditions, rapid tissue repair is favored.

During the recovery stage, the reactive hyperemia, if too intense and if induced too rapidly,

can be not only painful but also harmful. Therefore, rapid warming should be avoided.

a. Initial or emergency treatment. (1) As soon as the symptoms of trench foot appear,

the patient should be sent to the hospital. He should be carried and not permitted to walk

on damaged feet.

(2) Wet clothing should be removed and the patient wrapped in warm blankets

leaving the involved extremities exposed to the air in moderately cool room.

(3) The involved extremities should be handled very gently. The limbs should not

be rubbed or massaged. If necessary, the feet may be cleansed carefully with plain white

soap and water, dried, and then allowed to remain exposed, and elevated on pillows. While
APPENDIX 513

it is desirable to warm the patient, the feet should always be kept cool by exposure to the

room air.

(4) Strict asepsis must be maintained to avoid infection which may readily develop

and rapidly spread in the damaged tissue of the feet. Tf sulfonamide drugs are available, they may be administered orally until the danger of spreading infection is past.

(5) Protection against pressure necrosis especially in the region of the heel is desirable

and may be accomplished by frequent turning, by doughnut dressings, or by supporting the

back of the legs down to the ankles on pillow.

(6) During evacuation to the hospital, loose covering of the feet with sterile or, at

least, clean towels or sheet is desirable in order to protect against bacterial contamination.

b. Definitive treatment. The same principles which underlie the initial treatment measures

(that is, conservation of body heat and avoidance of trauma, infection, and heat to the

involved part) are continued in the definitive treatment.

(1) Patients should be kept in bed, with the affected parts on horizontal level with

or elevated on pillows only slightly above heart level, and protected from external pressure

either by complete exposure or by means of cradle. Elevation of the extremities should

be done only if there is evidence of inadequate circulation, that is, incipient gangrene, otherwise they should be maintained on horizontal level. The period of bed rest is determined

by the degree and rate of subsidence of edema.

(2) Massage or rubbing of any sort in the early stages must be avoided, and the

part should be handled as little and as gently as possible. All antiseptics and ointments

should be avoided, and blisters ordinarily should not be disturbed.

(3) Although the feet should remain exposed to the moderately cool room-air (65° F.

to 70° F.), the body should be kept warm by means of blankets. (4) In the early prehyperemic or ischemic stage when vasospasm is still evident

and persists for longer than hours, whiskey in 1-ounce doses may be administered for its

vasodilating effect. Sympathetic block, using percent procaine hydrochloride solution,

may also be done for this purpose. These measures are not indicated after the hyperemic

stage begins and should be discontinued. (5) Maintenance of minimal tissue metabolism in the affected parts is important

especially during the hyperemic type and may be accomplished by strictly avoiding the

application of external heat and, if necessary, by actually cooling the limbs, in those cases

in which persistent pain indicates the need for such treatment. In instances where the room

temperature is not above 70° F., simple exposure of the parts may be sufficient. Cooling

may be enhanced by directing the air from an electric fan against the exposed feet. Still

greater cooling can be accomplished by spraying cold water from an atomizer through the

fan blades. In the more severe cases with intense hyperemia and severe neuritic pains,

these measures may be inadequate and greater cooling is required. This may be achieved

through the application of ice bags or the use of special refrigeration cabinet. If ice bags

are to be used, sterile pledgets of cotton or gauze are placed between the toes and the whole

foot loosely wrapped with sterile cotton batting and covered with sterile sheet or towel.

Carefully dried ice bags are then placed around each foot over the towel and the whole

inclosed in an oiled-silk bag, around which, in turn, is wrapped thick layers of cellu-cotton

or other equivalent insulating material. As an outer covering, rubber pillowcase may be

used, loosely tied about the upper calf. Ordinarily, it is sufficient to change the ice bags

about every hours. At this time, palpation of the toes may be done to make sure that the

part is not too severely chilled. Ordinarily, skin temperature of about 70° F. is optimum

whether ice bags or refrigeration cabinet is used. In cases with extreme hyperemia, more

frequent changing will be necessary, but as hyperemia subsides, fewer ice bags will be needed

to reduce the temperature of the foot to the required degree. It may be necessary to continue

the ice-bag treatment for several days to weeks. Care should be exercised to avoid wetting

and maceration of the skin by the ice bags.
514 COLD INJURY, GROUND TYPE

(6) Measures to prevent secondary infection including tetanus should always be

instituted. Sulfadiazine by mouth should be used in cases with threatening infection. Blisters

ordinarily should not be disturbed but, if opening becomes necessary, this should be done

aseptically using needle. Dressings, except when cooling is done by ice bags, and all local

medication should be avoided. Areas of necrosis and ulceration which may subsequently

develop should be treated conservatively as long as possible. In patients with gangrene,

amputation should be delayed as long as possible and done early only in the presence of

superimposed infection.

(7) generally nutritious high protein, high vitamin diet should be supplied.

(8) After the hyperemia and edema have subsided, graduated vascular exercises

should be instituted. These consist of: elevating the extremities to minutes at an angle

of 80° to 50°; hanging the extremities over the side of the bed for to minutes during which

the patient should flex and extend the toes; and assuming the supine position with the feet

in the horizontal position for to minutes. This cycle is to be repeated for periods of 30

minutes, three to four times daily, for at least week before the patient is allowed out of bed.

Gradually, increasing activity should then be urged.

(9) Physiotherapy, including warm baths, massage, and passive exercises, is of value

in the late stages and should be used, especially when the movement of the toes is limited

by late fibrosis or edema.

(10) In cases wdth intractable edema and pain not controlled by ordinary measures,

sympathetic block, using percent procaine hydrochloride solution, compression dressings

or an elastic bandage may be cautiously employed even though the value of these measures

has not yet been established. Sympathectomy is indicated only in cases in which there is

objective evidence of circulatory insufficiency or in which manifestations resembling Raynaud’s phenomenon develop and persist months or years after the acute phase of the disease

and can be shown to be relieved by "test’' sympathetic blocks.

[A. G. 300.5 (27 Jul 44).]

By order of the Secretary of War:

G. C. MARSHALL, Official: Chief of Staff. J. A. ULIO,

Major General,

The Adjutant General.

Distribution:

Med Corp Off (1).
APPENDIX 515

MED 81 (Change 1) October 1944

TB MED 81, August 1944, is changed as follows

5. TREATMENT.

b. Definitive treatment.

(1) Patients should be kept in bed, with the affected parts on horizontal level with

or elevated on pillows oidy slightly above heart level, and protected from external pressure

either by complete exposure or by means of cradle. Elevation of the extremities should

be done only if there is no evidence of inadequate circulation, that is, incipient gangrene,

otherwise they should be maintained on horizontal level. The period of bed rest is determined by the degree and rate of subsidence of edema for this form of treatment.

[A. G. 300.5 (21 Sep 44).]

By order of the Secretary of War:

Official:

J. A. ULIO,

Major General,

The Adjutant General. Distribution:

Armies (5); Corps (5); SvC (10); Depts

(5); Def (5); (55); ID (60)

(45); IB (35), (10) (2); IR (6)

(5), (40) (30) (20) (15) (10) (5);

IBn (1), (1), (2) (1), (2) (1),

(3) (1), 10 (7) (6) (3), 11 (2) (1),

17 (3) (2) (1), 18 (2) (1), 19 (2) (1),

44 (3) (2); IC 2, (2), (3) (2) (1),

(2), (15) (10) (5) (3) (2), (2)

(1) 10 (2), 18 (2), 20 (2) (1), 55 (3)

(2) Cs of Tech Sv (2); Army Sv

Boards (2); ROTC (2); Gen Sp Sv

Schs (5); of Opn (25); Island

(5); Base (5); Med Tng Ctrs (60);

ASTP Units (1); Indue Stas (10);

SvC Labs (5).

ID (60) T/O 8-550.

ID (45) T/O 8-550S.

IB T/O 5-51OS.

IB (10) T/O 8-650.

IB (2) T/O 8-520.

IR (6) T/O 5-251.

IR (5) T/O 5-21.

IR (40) T/O 8-560; 8-580.

For explanationof symbol, see FM 21-6.

G. C. MARSHALL,

Chief of Staff.

IR (30) T/O 8-581.

IR (20) T/O 8-590.

IR (15) T/O 8-510.

IR (10) T/O 8-750; 8-760.

IR (5) T/O &-572S; &-780; 8-790.

Bn T/O 3-25.

Bn T/O 4-45: 4-145; 4-232.

Ibn (2) T/O 5-535S.

Ibn (1) T/O 5-55; 5-95; 5-275.

Bn (2) T/O 6-45.

IBn (1): T/O 6-35; 6-55; 6-65; 6-75: 6-95; 6-175; 6-325; 6-355; 6-365;

6-395.

Ibn (3) T/O 7-95.

Ibn (1) T/O 7-85.

Ibn 10 (7) T/O 10-95.

Ibn 10 (6) T/O 10-125.

Ibn 10 (3) T/O 10-175.

Ibn 11 (2) T/O 11-15.

Ibn 11 (1) T/O 11-25.

IBn 17 (3) T/O 17-115.

Ibn 17 (2) T/O 17-15.

Ibn 17 (1) T/O 17-55; 17-125.

Ibn 18 (2) T/O 18-35.

APPENDIX

HEADQUARTERS, ARMY GROUND FORCES

Army War College

Washington 25, D.

710/111 (30 Jan 45) GNGBI. 20 January 1945

SUBJECT: Prevention of Trench Foot and Frost Bite.

TO: Commanding Generals,

All Armies,

All Corps,

XXXII Corps Atry,

Airborne Center,

Antiaircraft Command,

AGF Replacement Depots No and No 2,

Replacement and School Command,

All Divisions,

1st Hq Hq Det, Sp Trps, AGF,

All Replacement Training Centers.

Commanding Officers,

All Hq Hq Dets, Sp Trps,

All Regiments,

All Groups,

All Battalions,

All Squadrons,

All Companies,

All Troops,

All Batteries.

1. The attached report is considered an excellent outline of training program used by

an overseas army for instruction in the prevention of trench foot and frostbite and the

principles of wearing special cold weather clothing, sleeping warm and keeping dry.

2. This report is furnished for your information only. Reproduction and distribution

are authorized.

3. Changes in training doctrine as enunciated in War Department publications which

are necessary because of the information contained in observers’ report will be published

by the War Department. Change in training directives of this headquarters which are

necessary because of information in observers’ reports will be promulgated by this

headquarters.

Command of the Commanding General

fsj Holman Hamilton

/t/ Holman Hamilton,

Capt., A. G. D.,

Ass’t Ground Adjutant General.

517
518 COLD INJURY, GROUND TYPE

Inclosure

SEVERE WINTER WEATHER WILL SOON BE HERE

TEACH YOUR MEN THESE PRINCIPLES AND PROTECT

THEM FROM FROSTBITE AND TRENCHFOOT

Principles:

Body heat, not clothing keeps you warm. Clothing retains layer of warm air around

the body and prevents cold outer air from chilling the skin. In still air, warmth is equivalent

to thickness of insulation.

Layers:

You get still air by wearing the windproof suit, which consists of jacket field M-1943,

trousers field cotton OD and hood jacket field with layers of insulation underneath. The

amount of insulation can be varied, for you can wear just wool shirt under the jacket, or

wool shirt and sweater, or wool underwear and wool shirt and sweater, or all these plus

the jacketfield wool. To get warmth you must wear the jacketfield M-1943 on the outside,

for the sweater and other layers of clothing Jose their value when the wind blows through

them.

As far as possible adjust the number of layers you wear to the temperature about you and

your degree of activity. If you are cold, perhaps you should be wearing more layers. If

you are sweating, you should take off one or more of the inner layers at the first opportunity

to avoid making your clothing damp.

Avoid Overheating:

If your clothes become damp from perspiration, some of your body heat, normally used

to keep you warm, will be diverted to dry out the damp clothing. In this way sweating

makes you colder and in sub-freezing weather may help cause frostbite.

Clean Clothing:

Clean clothing is warmer than dirty clothing because grease or dirt helps conduct heat

away from the body.

Loose:

In cold weather never wear anything that has tight fit. Tight clothing or footgear

restrict circulation and invites frostbite or trenchfoot. If boot fits comfortably with one

pair of socks, never wear it with two pair of socks. You may freeze your feet if you do,

because the second pair will cause the boot to fit too tightly and restrict circulation.

Similarly field jacket which fits snugly and looks snappy when worn over wool shirt

alone will be too tight during cold weather when sweater or wool jacket is also needed under

the outer jacket. If your outer jacket already fits tightly, you may make yourself colder

by putting on another layer under it, for you restrict circulation. In the same way, one pair

of loose gloves is warmer than two pairs of tight ones. If you want to keep warm in cold

weather, keep your clothing loose.

Food:

Food gives your body heat and keeps you warm. If you haven’t eaten for several hours,

your heat output is lowered and frequently you become cold. It this happens to you, eat

candy bar or some biscuits saved from your last or ration and you will immediately

feel warmer and more alert. In cold weather always carry few ounces of candy or other

food in pocket of your field jacket or parka. As far as possible, eat little and often.

Sleeping Warm:

Have as much insulation under you as over you. Your waterrepellent (not waterproof)

case is windproof. Inside it you may use the mountain sleeping bag or wool sleeping bags for
APPENDIX 519

insulation. As this insulation is compressed by the weight of your body, however, you need

additional insulation under you. If they are dry, shelter halves, extra blankets, haversacks,

field packs, eb equipment, fiber ammunition or food containers (such as 10 in ration boxes

torn up), packboards, tree branches and bushes, or extra clothing, maj be placed under your

sleeping bag or blankets, for in general, the more insulation of this type you have under you,

the warmer you will sleep. This is particularly noticeable in mountain sleeping bag, whose

down filling easily compresses under the body.

Mamj men make themselves cold by sleeping with too many clothes on

This clothing, as they turn over in their sleep, restricts circulation at the shoulders and

makes them cold. If they wore less clothing, not only would there be no constriction and

they would sleep warmer, but the extra clothing could be used to advantage as insulation

under them.

Brief exercise before entering the sleeping bag stimulates your circulation and causes you

to heat the bag more quickly. small man, however, may find the bag large and slow to

warm. If so, he can fold part of the bag under him, in this way increasing insulation underneath and reducing the amount of air that his body must warm.

Waterproof and Water Repellent:

The raincoat is unpopular because it is waterproof and fits closely to the body. The man

who marches in it sweats, and the sweat, condensing inside his raincoat, often gets him just

as wet at the shoulders and back as if he wore no raincoat at all. For this reason the completely waterproof piece, navy-type suit, called parka and trousers wet weather, is not

issued to men who march, for they would soon be drenched with sweat. As organizational

issue for special duties, however, this suit has many uses.

The jacket field M1943 and trousers field cotton are water repellent hut not waterproof.

Moisture vapor (sw eat) can pass out through the fabric and does not condense inside. This

means that you are more comfortable when marching in moderate rain if you wear the field

jacket and not the raincoat. However, no ater repellent will keep out ater indefinitely

and if you lie in water or stand for long period in heavy rain, you will gradually get wet

even if you are wearing water repellent garments. Truly aterproof garments will not et

through no matter how much it rains, but you can get wet in them if water goes up your

sleeve or runs off your helmet and down your neck.

Dry Feet Prevent Trenchfoot:

In cold w'eather care of the feet is as important as care of the rifle. When man’s feet

are wet, cold and inactive for periods of more than one day circulation is reduced, and if it

disappears, trenchfoot occurs. You can avoid trenchfoot and the amputation it often causes

as follows:

1. Do this:

a. During wet cold weather wear properly fitted shoepacs for these reasons:

(1) The rubber shell and heavily oiled leather top will keep your feet drv.

(2) The shoepac is sized to fit over pairs of heavy ski socks, insulation which you

need for protection against winter cold. (3) The shoepac has high toe so that your toes are not constricted. Even if you

are pinned down and can’t move your body, you can wiggle your toes inside the shoepacs and

in this way stir the circulation. In cold weather the ability to move your toes within your

boots is important.

(4) The shoepac has removable insole which adds insulation below the foot and

absorbs perspiration.

b. Be sure that your shoepacs fit properly with pairs of ski socks

c. Be sure that you wear them for few days before making long marches in them.
520 COLD INJURY, GROUND TYPE

2. Don’t do this:

a. During wet cold weather don’t wear combat boots or service shoes without overshoes, for the following reasons;

(1) Leather boots quickly get wet, and unless they can be dried and fresh dubbing

put on they will stay wet, making your socks wet, and gradually making your whole body

cold.

(2) Combat boots and service shoes fit over one pair of socks wool light or one pair

of socks wool heavy, which is insufficient insulation to keep your feet warm during the cold

winter months. (Never wear them with ski socks, which willrestrict circulation.)

(3) Combat boots and service shoes have low toe which prevents movement of the

toes to restore circulation.

(4) Combat boots and service shoes do not have removable insoles to add insulation

under the foot.

b. Never wear ski socks inside combat boots or service shoes. If you do, you will

restrict circulation and help cause frostbite.

c. Never keep your boots or shoepacs on for periods of several days without taking

them off. Each consecutive day you wear them without taking them off, circulation becomes

worse and frostbite or trenchfoot more likely. Whenever practical during cold weather,

take off your boots or shoepacs for at least minutes every 24 hours and rub your feet before

putting footgear on again.

3. Other information:

a. Dubbing, which is another name for shoe waterproofing, lasts only day under

conditions of continual wet, but is effective under conditions where it rains only occasionally.

Unless leather boots can be dried, which is frequently impossible, dubbing cannot be applied

in satisfactory manner. Therefore, dubbing, which works well under conditions of occasional rain will not keep your feet dry during cold wet winter months in the line.

b. Dry Socks:

If you are wearing wet combat boots that you can’t dry, the issue of dry socks

will be of limited value to you, for almost as soon as you put them on, the wet leather pressing

against your socks will wet them through. By changing your socks you at least dry your

feet and improve the circulation, which helps, but your wet boots will soon return your

feet to their previous condition.

If you are wearing shoepacs, dry socks will help you for this reason: You replace

socks somewhat damp from perspiration with dry socks. Unlike dry socks used in wet combat boots, these socks will not become wet from the outside.

As dry socks are warmer than damp ones, alternate two sets of socks and insoles.

While wearing one set, dry out the other by body heat or any other available means. (One

good method is to let body heat dry them at night in the sleeping bag.)

4. Summary:

a. Wear properly fitted shoepacwith pairs of ski socks.

b. If possible break them in for or days before making long marches.

c. Alternate sets of ski socks and insoles in order to keep feet dry and warm.

DON’T GET TRENCHFOOT THIS WINTER

REPRODUCED BY: K.F.B. HQ FOURTH ARMY (Surgeon)

29 January 1945
521

APPENDIX

HEADQUARTERS FIFTH ARMY

Office of the Surgeon

A. P. 0. #464, U. S. Army

24 November 1943

MEDICAL CIRCULAR

NUMBER

TRENCH FOOT

1. Approximately 200 men have been admitted to army hospitals in tne past five days

suffering from trench foot.

2. Most of those afflicted report having worn wet socks and shoes for to 14 days without change. Some, but not all, have been exposed to near freezing temperatures.

3. The symptoms include first numbness or loss of sensation. Later, some swelling

develops. Some who have removed their shoes have been unable to get them on again.

At first the feet appear white, perhaps slightly wrinkled and furrowed, and quite cold and insensitive. If the feet are rubbed or warmed, more swelling and pain develops. Heat,

walking or any trauma to the feet increases the escape of fluid and blood into the tissues.

Later, vesiculation may develop. Anesthesia is replaced by hyperesthesia and paresthesia.

The patient complains of shooting pains in the ball of the fool or on the dorsum of the foot.

varying degree of arythema appears. The foot is hot and the posterior tibial pulse is full

and bounding. In the more severe cases anesthesia persists in some areas and necrosis of

those parts may occur.

4. Management of this problem is directed primarily toward prophylaxis. However,

proper treatment, once the condition has developed, will do much to lower morbidity and

will return more of these men to duty. The following regime is suggested;

a. Those patients should be hospitalized.

b. The feet should not be exposed to heat, and the men are best kept out of heated

tents or buildings.

c. The shoes should not be removed until the patient is recumbent and the feet

slightly elevated.

d. All and other trauma is to be avoided.

e. The feet are gently washed with cold water and soap, using pledgets of cotton.

They are then carefully dried, small pledgets of dry cotton placed between the toes, and

light dressing of sterile gauze applied.

f. The feet are kept elevated and are not covered with blankets. The patient is kept

in cool room or tent. In very severe cases, and when ice or snow is available heavier

dressing is applied and ice bags are applied. The ice bag covers must be kept dry.

g. Vesicles should not be opened.

h. The cold treatment is kept up for several days to several weeks depending upon the

amount of swelling, vesiculation, and necrosis.

i. Vitamin and Vitamin should be given orally as vitamin deficiency may be an

etiological factor.
522 COLD INJURY, GROUND TYPE

j. Exercises should be started as soon as swelling has disappeared and open lesions have healed. These exercises should be carried out at hourly intervals consisting of toe flexion and anterior tibial setting. The length of the initial period of exercise should be governed by the comfort of the patient, increasing as tolerance permits.

k. Paravertebral novocaine block of the sympathetic trunk should not be done. For the Surgeon:

fsl C. O. BRUCE

1/ C. O. Bruce,

Lt. Col., Medical Corps,

Executive.
523

APPENDIX

HEADQUARTERS NORTH AFRICAN THEATER OF OPERATIONS

UNITED STATES ARMY

21 December 1943

SUBJECT: Trench Foot

To; Commanding General, Fifth Army, APO 464.

Commanding General, Seventh Army, APO 758.

Commanding General, Peninsular Base Section APO 782.

1. Trench Foot, Immersion Foot, or Shelter Foot which was very common disabling

injury of the feet encountered during the winter months of World War I, is beginning to

occur in troops of this theater. This is very serious but preventable condition and all

organization and unit commanders must become familiar with the measures required for

its prevention.

2. When troops are subjected to exposure, frequent inspections will be made to ensure

that they are taking proper care of their feet. Insofar as the situation permits, all deficiencies

found will be the cause for immediate corrective action.

3. Trench foot is produced by standing or sitting about over long period of time with

cold wet feet. Intense cold is not necessary factor, as the condition can develop at temperatures as high as 50 degrees F. The most important factors are moisture, cold, and lack of

activity. Frequently, there is an associated history of constriction of the limbs by boots

and clothing.

4. Individuals experiencing this condition usually first complain that their feet feel

heavy, woody and numb, and are insensitive to pain, touch, or temperature. The insensitive

areas are most marked around the toes. At this stage the feet are usually cold to touch,

swollen and waxy white in color with few scattered bluish areas present in the skin. When

the feet are warmed up they become markedly swollen, red, hot and painful. Blisters may

develop and the feet may turn purple in color.

5. Once trench foot has developed, the feet should not he massaged or warmed up but

should be kept cool and elevated above the level of the rest of the body. The patient should

not be permitted to walk and should be promptly sent to hospital where adequate treatment

can be given. If this type of injury is not handled in this manner it may lead to serious

disability and possible loss of the feet.

6. The prevention of this condition is of great importance and consists primarily in

keeping the feet clean, dry and warm. Under winter combat conditions it is often difficult

to fulfill these requirements but constant attention to the following will minimize or prevent

the occurrence of this condition.

a. The necessity of frequently removing shoes, leggings, and socks in order to wash, dry and massage the feet, apply foot powder and to put on dry socks if possible.

b. Improvised methods of washing and drying socks and shoes. For instance, in

wet weather when nothing else is available, socks can be dried by pinning them to the inner

side of the overcoat or field jacket or placing them over the shoulders under the jacket.

c. The necessity to keep moving when feet are cold and wet and dry socks and shoes

are not available. If troops have to keep in one place they should mark time or make vigorous,

frequent, movements of the legs. When sitting down they should elevate the feet higher

than the buttocks, being careful that nothing is constricting or interferingwith the circulation
524 COLD INJURY, GROUND TYPE

of the legs. (If the circulation is normal the legs will not develop numb or tingling sensa- tion). If these sensations occur, the legs and feet should be exercised until they feel normal

and warm.

d. The fact that regardless of how cold it may be it is important not to sleep with

shoes on if feet are wet. If this is done there will be interference with the circulation, and

the shoes, socks and feet will be prevented from drying.

command of General EISENHOWER:

J. K. Roberts,

2nd Lt., AGD,

Asst Adj Gen.
525

438404 —58—-—33

APPENDIX

Cir 108 26 Oct 1944

HEADQUARTERS

EUROPEAN THEATER OF OPERATIONS

UNITED STATES ARMY

CARE OF THE FEET

1. General. Proper care of the feet is of the greatest importance for the maintenance of an

effective command. great amount of personal discomfort, as well as actual disability

and loss of manpower, can be prevented by the constant attention of unit commanders and

individual soldiers to the application of measures for foot care.

2. Responsibility. It is the responsibility of each unit commander to insure that all men

of his command are equipped with adequate and properly fitting footwear, within availability

of stocks; to inspect the feet and footwear of the members of his command at regular intervals: and to make certain that each individual soldier understands and practices the essentials

of foot care.

3. Footwear, a. Supply: Footwear for field use will be that issued by the Quartermaster.

Adequate well-fitted footwear is of great importance at all times; however, in cold, wet

weather special equipment is needed and particular attention to foot hygiene is required.

For added protection during the cold season there will be available from Quartermaster

stocks: Maximum

Item Unit Allowance

Boots, service, combat per EM

or

leggings, canvas, M-1938 per EM

and

Shoes, service, Type III per EM

Socks, ool, cushion sole per EM

Socks, wool, light, or socks, wool, heavy pr per EM

Overshoes, arctic er

b. Fitting; Shoes must be fitted so that no undue constriction or pressure will occur

at any point when the foot is expanded by the weight of the body and pack. Because of

individual variations in feet, shoes can be properly fitted only by actual personal fitting.

The fitting will always be made over wool socks for the service shoe; or, for combat boots,

over the sock, cushion sole, or sock, wool, heavy, or two pairs of socks, wool, light. Particular attention will be given to the provision of adequate foot room in the fitting of the

footwear referred to in subparagraph a, above. For wear in wet, cold weather, definite

looseness of fit is preferable to "snug” fit. Fitting may be made by the shoe fitting machine

or by hand. In each instance, fitting will be made with the individual bearing full weight.

(1) Shoe Fitting Machine. When available, the shoe fitting machine will be used in

strict accordance with the instructions issued with the machine.

(2) Fitting without Shoe Fitting Machine. The important consideration in shoe

fitting is the provision of adequate length and width. shoe of proper length will allow

thumb width (%") between the end of the great toe and the end of the shoe when the wearer

bears full weight. Proper width may be judged by the wearer by definite feeling of freedom

of the foot in the shoe. In addition, shoe of proper width will allow the fitter to demonstrate

looseness of the leather in front of the instep over the ball of the foot with the shoe laced,
526 COLD INJURY, GROUND TYPE

and, with the shoe unlaced, will allow him to insert one of his index fingers under the lower

part of the tongue and over the base of the toes.

c. Care: (1) The uppers will be kept soft and pliable and the shoes as waterproof as

possible. Both of these conditions may be maintained by the use of dubbin and polish.

Dubbin will be worked into the leather by rubbing and moulding with the fingers. Particular

attention will be given to the application of dubbin at the junction of the sole and the upper.

The authorized allowance for dubbin, oz cans, is 250 cans per 1,000 men per month.

(2) Even under ordinary conditions, shoes will become moist on the inside from sweating of the feet and must be allowed to dry out at least once every 24 hours. When two pairs

are available, they will be worn on alternate days. When shoes become wet from outside

causes such as rain, mud or snow, they will be dried slowly and not exposed to direct heat

such as from open fires. In the field, ways for drying must be improvised. Broken up hay

or straw, thoroughly dried over fire and dumped into the shoe, will hasten drying; pebbles

may be heated in can and shaken about in the shoes for the same purpose. If dry paper is

available, it may be torn into bits and stuffed into the shoes to absorb moisture. Well

heated grain shaken about in the shoes is particularly effective.

d. Sock: Woolen socks, only, will be worn for marching or field duty. In cold, wet

eather, cushion sole socks, or heavy wool socks, or two pairs of light wool socks will be

worn (see Par 3a, above). Darned socks or socks with holes will not be worn on the march

since they will cause abrasions or blisters.

4. Care of the Feet. a. General: The feet will be ashed and thoroughly dried at least

once day. This is especially important on march. As soon as possible after reaching

camp after march, the feet will be washed (not soaked) with soap and water, dusted with

foot powder, and clean socks and spare shoes will be put on. (Unless the feet are well hardened, foot powder will be applied again in the morning before the march.) The dirty socks

will be washed and hung to dry. The shoes worn during the day will be placed where they

will have the best opportunity to dry.

b. Blisters: If blisters appear on the feet, they will be painted with iodine or alcohol

and emptied by pricking at the lower edge with pin, the point of which has been heated in

flame. The skin will not be removed. The blister will then be covered wdth adhesive tape

or Band-Aid until new skin has formed (2-4 days). The application of foot pow-der to the

edge of the adhesive will prevent its sticking to the sock. Small cuts, scratches, and skinned

places will likewise be cleaned with alcohol and covered with adhesive tape or Band-Aid.

Infections, serious cuts, large skinned areas and painful ingrown toe nails will be treated at

the dispensary or aid station.

c. Ingrown: The toenails will be kept short and clean. If they are cut straight

across and not on curve, most of the trouble from ingrown toenails will be avoided.

d. Athlete’s Foot: Athlete’s Foot, fungus infection of the feet, occurs commonly and

if neglected may lead to considerable disability. The best methods of prevention are the

maintenance of clean, dry feet, and frequent use of foot powder. If the infection does occur,

it will be treated at the aid station or dispensary. Socks once contaminated with infecting

agent may be source of reinfection. Laundering in Quartermaster laundries will control

this agent, and if this facility is not available, washing in soap and water and thorough sunning (inside and out) for minimum of an hour each will be quite effective.

e. Trench Foot: (1) This is serious condition resulting from the long exposure of the

feet to moisture and cold. Extreme cold is not necessary factor, and conditions may occur

at temperatures as high as 50° F. The most important factors are moisture, cold and the

lack of activity, such as occurs when standing or sitting for long periods of time. Tight

footwear and leggings also contribute to the development of trench foot. Experience in

other theaters indicates that large number of troops may suffer from this condition during
APPENDIX 527

the winter months unless the proper precautions are taken. In one active theater during

the cold months, almost one half as many casualties resulted from trench foot as from battle

injuries. large percentage of those affected were unable to do combat duty thereafter.

(2) In addition to coldness of the feet, the first symptom of trench foot is often

feeling of numbness. There may also be tingling and aching of the feet, toes and ankles.

Usually the condition does not cause acute discomfort in the early stages, the most common

complaint being that of feeling of “woodeness of the feet” and difficulty in walking. Swelling follows the other symptoms and the skin becomes hite or mottled in appearance.

Blisters may develop later. Unless proper care is sought early, serious damage to the feet

may be the result.

(3) The prevention of trench foot is of great importance and consists, mainly, in

keeping the feet clean, warm and dry. Under bad field conditions in the winter this is hard

to do but the constant attention and effort of each individual to the measures outlined below

can be very effective:

(a) Adequate, properly fitted footwear (see Par 3a above) must be orn

Do not constrict the lower legs, ankles, or feet by the tight lacing of leggin

or shoes.

(c) Avoid standing in cold ater, mud or snow.

(d) Whenever possible, keep moving when feet are cold and wet. If troops are to

be kept in one place, they should mark time at frequent intervals or make frequent vigorous

movements of the legs. Check for numbness of the toes by wiggling them frequently.

(e) Do not sit with feet low'er than the buttocks.

(/) Loosen the shoe laces or buckles at every opportunity and move the feet around

in the shoes as much as possible.

(g) Frequently (once cr twice daily) remove leggings, shoes and socks in order to

wash, dry and massage the feet, applying foot powder, and, if possible, putting on dry socks.

If dry socks are not available, ring out the wet ones thoroughly before replacing.

Make every effort and use all possible means for drying socks and shoes.

(Socks may be dried by wearing them flat under the shirt above the belt when on the march

or while sleeping).

(i) Do not sleep with the shoes on, if the feet are wet. The feet wall warm up

faster out of the shoes (they may be wrapped in piece of cloth or an extra shirt), and the

shoes will dry much more readily off than on.

(4) When trench foot is suspected, the patient will be handled as non-ambulatory

casualty and transported at once to the nearest aid station or dispensary. It is important

to remember that the patient will not be allowed to walk and the feet will not be massaged

or warmed. All constricting footwear and leggings will be removed, and the feet kept cool

and elevated above the rest of the body. Failure to comply with these simple first aid

procedures may lead to serious disability and possible loss of feet.

5. Inspection of Feet and Footw’ear: Each unit commander will inspect the feet and footwear

of each individual in his unit atregular intervals (at least twice monthly) and, if possible, before march which is to be of more than tw’o hours duration. At these inspections, close

attention will be given to the adequacy and condition of the footwear of each individual.

The feet will be examined for the presence of blisters and reddened areas, corns, callouses,

and other evidence of improperly fitted or poorly repaired shoes or socks and for improperly

trimmed or ingrowing toenails. Deficiencies found on inspectionswill be corrected immediately so that each man will, at all times, have his feet in the best possible condition and

adequate footwear in his possession.

6. Instructions: Each unit commander will provide complete detailed instructions in foot

care and hygiene to all enlisted personnel of his command. This instruction must be

continuous and its application by the individual soldier checked at frequent intervals. This
528 COLD INJURY, GROUND TYPE

directive, or pertinent extracts therefrom, will be posted in each unit for the information of the enlisted personnel. Supplementary information and source material for instruction may be found in these publications:

a. AR 40-205; AR 856-125; FM 8-40; FM 21-10; and FM 21-100. b. Sec IV, Cir 312, WD, 22 Jul 1944. (AG 727.3 PubGD) By Command of General EISENHOWER*

R. B. Lord

Brigadier General, GSC, Deputy Chief of Staff. R. B. Lovett

Brigadier General, USA, Adjutant General

Distribution:
529

APPENDIX

HEADQUARTERS

THIRD U. S. ARMY

APO 403

U. S. ARMY

21 November 1944

MEMORANDUM:

TO: Corps and Division Commander

1. The most serious menace confronting us today is not the German Army, which we

have practically destroyed, but the weather which, if we do not exert ourselves, may well

destroy us through the incidence of trench foot.

2. If the prevention of trench foot were impossible, would not mention it, but prevention is perfectly practicable and is function of command.

3. Trench foot is due primarily to two causes, both of which produce reduction in the

blood supply of the foot. The first cause is due to the feet being cold and wet, which naturally shrinks the small blood vessels. The second cause is due to reduced flow of blood to the

foot due to tight socks, and/or tight shoes, and tight leggings.

4. If company officers and non-commissioned officers did their full duty, there would

be no trench foot. The onus of their failure rests on you. You must see to it that the

following points are brought home to all members of your command:

a. First, each man is personally responsible for the health of his feet. He has to

live with them, and if, through carelessness, he becomes victim of trench foot he may well

become cripple for life.

b. Second, company officers and non-commissioned officers must see to it that the

men care for their feet.

5. This care should be exercised along the following lines:

a. Where men have arctics, they should be worn in wet and cold weather

b. Before putting the arctics on, the shoe should be dried and two pair of dry socks

worn inside it. Size of shoe must be large enough to permit this to be done without constriction. Lace shoe as loosely as possible. Same procedure applies when no arctics are

available.

c. The shoe should also be treated with dubbin, particularly where the upper joins

the sole. One treatment of dubbin is not sufficient; it should be repeated daily.

d. Men should carry one extra pair of socks in their helmets. This will not only

keep the top of the head warm but will dry the socks.

e. Whenever opportunity affords—and certainly each night—the galoshes, shoes,

and socks should be removed, and the feet massaged vigorously for at least five minutes

by the watch. The men should then put on pair of dry socks next to the foot and preferably

second pair of dry socks outside the first pair. If only one dry pair is available it should

be worn next the skin.

6. Orders have been issued that all new shoes be treated with dubbin before issue.

Unit supply officers are responsible to check that this is done.

7. When possible pair of dry socks will be issued with the daily ration and the wet pair

turned in for laundering and drying.

8. We are going to have weather conditions from now on until the end of the war

which will be conducive to trench foot. To win the war we must conquer trench foot.

You have conquered every other obstacle—I am sure you can conquer this.

/s/ G. S. Patton, Jr.,

Lieut. General, U. S. Army,

Commanding.

531

APPENDIX

HEADQUARTERS

EUROPEAN THEATER OF OPERATIONS

UNITED STATES ARMY

RBL/PRH/mgc

APO 887

AG 210.453 OpMS 30 January 1945

SUBJECT: Trench Foot Control Officers.

TO: Commanding Generals,

First US Army

Third US Army

Seventh US Army

Ninth US Army

Fifteenth US Army

1. The Allied forces in the Pacific aiea had to lose four divisions from malaria before

an energetic program was instituted to control the disease. In the European Theater of

Operations the US Army has lost more than 2% divisions because of trench foot. The

trend of the disease is downward, but judged by the current incidence, more energetic

program of prevention is necessary.

2. The Supreme Commander has noted with growing concern the high incidence of

trench foot in this theater. Letter, Supreme Headquarters, Allied Expeditionary Force,

file AG 727.3-1 MED-AGM, subject; “Control of Trench Foot,” dated 24 January 1945,

states in part: “It is desired that higher unit commanders impress upon all ranks the necessity

for unremitting attention to this command responsibility”.

3. Trench foot is preventable disease. The methods to be practiced in its control

have been set forth in War Department Circular 312, dated 22 July 1944, Circular 108,

this headquarters, dated 25 October 1944, and Circular Letter No. 126, Office of the Chief

Surgeon, this headquarters, dated 18 October 1944. As evidenced by the continued excessive

loss of manpower from this cause, the results thus far attained have not been satisfactory.

4. In order to carry out more effectively the provisions of the directives cited above, it

is desired that these measures be instituted without delay and that they be continued until

15 April 1945:

a. Each army will provide team of two officers; one officer from the line and one from

the Quartermaster Corps, designated as the Trench Foot Control Team, to work in close

cooperation with the representative of the Army Surgeon concerned with the prevention of

trench foot. The duties of this team will be:

(1) To determine periodically the existing frequency of trench foot and of frostbite

in regiments of the command and in separate units.

(2) To determine the factors contributing to excessive numbers of cases in particular units.

(3) To provide information to non-commissioned trench foot control officers as indicated in sub-paragraph 4b, below, in the methods of prevention of injuries resulting from

cold (trench foot and frostbite).

(4) To recommend to unit commanders the necessary measures for improved

control.

(5) To advise the army commander on observed deficiencies, on the existing status

of trench foot in the command, and on the necessary remedial measures.

30 January 1945
532 COLD INJURY, GROUND TYPE

b. Unit commanders at company level, or the equivalent for separate units, will appoint trench foot control non-commissioned officers, selecting men of demonstrated ability and experience in order to insure that the duties outlined below are executed with energy, initiative and originality:

(!) Determination by personal inve, tigation of the extent and satisfactoriness with which foot discipline is practiced in the company, and to encourage improved per- formance through personal instruction and by force of example. (2) Determination of shortages in equipment and supplies essential to the preven- tion of trench foot.

(3) Institution of program of small group discussion and demonstration designed to acquaint all members of the company with the measures which the individual soldier must practice in the prevention of trench foot and in keeping warm in winter weather. By command of General EISENHOWER:

R. B. Lovett, Brigadier General, USA,

Adjutant General.

G-4 (1) C/Surg (2) AC Opnc (i) AG Casualty (i) AG Records (i)

Distribution:

Each addressee (2) Each Army Group (1)

Each Section Commander, Com (1)

Southern Line of Communications. (1)

G-l (1)

G-3 (TR-MST) (1)
533

43S404'— 58 30

APPENDIX II

GENERAL HEADQUARTERS

UNITED STATES ARMY FORCES, PACIFIC

APO 500

AG 353 (18 July 45) GC 18 July 1945

SUBJECT: Wet-Cold Indoctrination Program.

TO: Commanding General, United States Army Forces, Western Pacific, APO 707. Commanding General, United States Army orces, Middle Pacific, APO 958.

Commanding General, Sixth Army, APO 442.

Commanding General, Eighth Army, APO 343.

Commanding General, Far East Air Forces, APO 925.

1. Wet-Cold Indoctrination Program will be established in this theater to acquaint

troops with adequate means of self-protectionagainst winter weather conditions.

2. Troops in this theater have been subject only to tropical climates. For that reason

particular attention will be given to preparing troops for coid weather conditions. Experience in the European theater, where troops were already acclimated to temperate climate,

proved conclusively that unless vigorous emphasis was placed on the dangers inherent to

sustained exposure to winter weather necessary under combat conditions, high casualty

rates invariably resulted.

3. Many troops in this theater are unfamiliar with standard items of cold weather

clothing and equipment. In order to cause such clothing to be utilized with the maximum

benefit it is necessary that strong emphasis be placed on the use of cold weather clothing.

4. The Commanding Generals, United States Army Forces, Western Pacific and United

States Army Forces Middle Pacific are charged with technical and administrative control of

the program as it applies to troops for which each of these commanders is logistically responsible. Tactical commanders are charged with the responsibility of insuring that the

information included in this program is appropriately disseminated to personnel of their

commands. Direct contact between Commanding General, United States Army Forces,

Western Pacific, Commanding General, United States Army Forces, Middle Pacific and

tactical commanders concerned is authorized for the purpose of carrying out the objectives

of the Wet-Cold Indoctrination Program.

By command of General MacARTHUR:

18 July 1945

/S/ H. W. ALLEN

T/ H. W. ALLEN

Colonel, A. G. D.,

Copies to: Asst. Adjutant General.

ASCOM-O

ASCOM-C

535

APPENDIX

HEADQUARTERS

UNITED STATES ARMY FORCES WESTERN PACIFIC

OFFICE OF THE COMMANDING GENERAL

Training Memorandum]

No.

APO 707

August 1945

WET-COLD INDOCTRINATION PROCRAM

1. PURPOSE. This indoctrination program is designed to establish universal appreciation and full recognition of wet-cold weather problems, together with the value of training in the proper use of individual wet-cold weather clothing and equipment.

2. OBJECTIVES:

a. The major requirement is the eventual qualification of every individual in this

command in the correct employment of wet-cold weather procedures and equipment.

b. second requirement is the qualification of appropriate supply personnel as

experts in technical matters of supply and storage, care and maintenance, fitting and issue

and the presentation of clothing and equipment.

c. Incident to the above requirements, further objective to the establishment of

definite command responsibility toward insuring that:

(1) Training in the proper use of wet-cold clothing and equipment is continuing

proposition, to be carried on subsequent to initial indoctrination.

(2) All officers and key enlisted personnel fully comprehend the capabilities and

limitations of clothing and equipment in winter weather so that they may utilize the knowledge in exercising all possible precautions against weather-caused casualties.

3. PRIORITIES OF INSTRUCTION: First priority will be given to combat units

scheduled for earliest staging in any forthcoming operation. Other units will be phased

in accordance with mounting out schedules.

4. COURSES:

a. Indoctrination in Proper Use of Clothing and Equipment. All individuals, officers

and enlisted men, will be given two (2) hours course of instruction to include:

(1) Principles of how to live in wet-cold climates; (2) Demonstration and explanation of fitting, wearing, care and designed purpose

of wet-cold weather clothing;

(3) Training aids and training film to exhibit the dangers of wet-cold weather

combat;

(4) period reserved for answering questions.

b. Supply Course. Unit supply personnel and Quartermaster Class II and IV personnel will be given minimum of one (1) hour additional instruction in the issuing and

proper fitting of each individual article of the uniform.

c. Refresher Training. Constant review of the indoctrination course will be given.

5. INSTRUCTIONS:

a. Wet-Cold Instructional Team. team of officer instructors will be attached to

subordinate commands, as indicated in separate instructions to the commanders concerned.

Full advantage will be taken of the services of these instructors as lecturers to personnel and

for the training of unit instructors for supplementary indoctrination. Particular attention

should be paid to the assistance the officer instructors can render to supply personnel.
536 COLD INJURY, GROUND TYPE

b. Each major unit of this command will utilize the team referred to in subparagraph (a) above to train sufficient instructors within each major unit to centralize supplementary indoctrination.

6. WET-COLD CLOTHING AND EQUIPMENT:

a. Special indoctrination is required to obtain the maximum benefit from wet-cold

clothing. Such individual clothing includes:

(1) Cap, field, cotton, O. D., with visor.

(2) Jacket, field, M-1943.

(3) Hood, jacket, field, M-1943.

(4) Jacket, field, wool, O. D.

(5) Sweater, high-neck.

(6) Trousers, field, cotton, (). D.

(7) Trousers, wool, O. D.

(8) Suspenders, trousers.

(9) Glove-shells, leather.

(10) Glove-inserts, wool.

(11) Shoe pacs, M-1944 with two felt insoles.

(12) Socks, wool ski.

(13) Overshoes, Arctic M-1945.

b. Individual equipment in the wet-cold classification includes:

G) Bag, clothing, waterproof.

(2) Bag, sleeping, wool.

(3) Case, waterrepellant, for bag, sleeping.

c. Special purpose items of clothing and equipment in Class IV category for which

indoctrination will be required are the following;

(1) Parka, wet-weather.

(2) Trousers, wet-weather.

(3) Overcoat, parka type, pile lined.

(4) Boots, knee, wader.

d. Training kits containing sample items of wet-cold clothing and equipment will be

distributed to major commands by the team referred to in paragraph 6a above. Additional

kits will be distributed as required.

7. TRAINING AIDS AND REFERENCES: The following training aids and references will be given limited initial distribution as they become available. Requisitions will

be filled as promptly as possible under limitations of availability. Reproduction of training

aids will be accomplished by the major echelons to the maximum extent possible.

a. Manuals Wet-Cold:

(1) TM 10-275Principles of Cold Weather Clothing.

(2) FM 70-10 Mountain Operations.

b. Manuals, Extreme Cold: (For consideration only; indoctrination in extreme cold

is not part of the program sponsored by this memorandum) TM 70-15 Operations in Snow

and Extreme Cold.

c. Printed Matter:

(1) Letter, Hqs Army Ground Forces, (file 710/111 (20 Jan 45) GXGBI) subject:

“Prevention of Trench Foot and Frostbite.” (To be furnished by WETCO officers.)

(2) WD Circular 312, 1944—Trenchfoot, Cause and Prevention.

(3) AR 850-125—Fitting of Shoes. (4) AR 850-126—Fitting of Clothing.
APPENDIX 537

d. Bulletins on Fitting and Sizing:

(1) SB 10-236 Size Tariffs. (2) SB 10.191 Fitting and Issuing Jacket, field, M-1943.

(3) SB 10-194 and Change —Supplement Tariffs.

(4) TB 10-275 (1) Lengthing of Sleeping Bags, Foot. Measuring and Fitting of

Shoes and Socks. e. Cartoons: (To be prepared for automatic distribution)

(1) How to Use the Sleeping Bag.

(2) How to keep dry.

f. Training Films:

(1) FB 180 Trenchfoot.

(2) Combat FB 30 through 42.

(3) FS 142-3-4—5 Cold Weather Clothing.

g. Special “Wetco Outlines”:

(1) —Wet-Cold Clothing and Equipment Indoctrination Course. (To be furnished by WETCO officers.)

(2) —Supplement for Supply Personnel to Wet-Cold Clothing and Equipment

Indoctrination Course. (3) —Accelerated Acclimatization. (To be furnished by WETCO officers.)

8. REPORTS:

a. Unit Status of Training Report. All USTR submitted to this headquartersprior

to operational commitment will contain statement as to the number of hours of Wet-cold

Indoctrination accomplished per individual and the rating by unit commander as to the

units proficiency in this subject.

b. Classification Card Remark. Hours of indoctrination accomplished per individual

will be entered on Individual AGO Form 20 and Form 66-1 cards, (Example: Wet-Cold

Indoctrination hours on (day) (month) 1945). (GSC 353)

By Command Of Lieutenant General Styler:

Edmond H. Leavey,

Major General, USA, Deputy Commander and Chief of Staff. Official:

S/Leonard S. Carroll,

Lt. Col. A. O. D.,

Asst. Adj. General.

Distribution:

AD

AGGA, AFWESPAC—30

539

APPENDIX

HEADQUARTERS NORTH AFRICAN THEATER OF OPERATIONS

Office of the Surgeon

APO 534

June 1944

710.

SUBJECT: Trench Foot.

TO: Commanding General, NATOUSA. 1. The total cases of trench foot as shown on hospital bed status reports from 12 Nov.

43 to 30 Apr. 44 was 5,670. The total battle casualties for Fifth Army for the same period

was 21,674, giving ratio of trench foot to battle casualties of to 3.8. Trench foot accounted

for 9% of all disease admissions from Fifth Army for the period Nov. to 30 April.

2. Information available indicates that 20% of trench foot cases return to duty in to

weeks, the remaining 80% have prolonged hospitalization period with probable return

to full duty of not over 60%. The remainder must be used in limited assignment or evacuated

to the ZI. Those cases returned to duty are much more susceptible to further injury due

to cold. One battalion surgeon reports that out of 281 cases of trench foot evacuated from

his battalion (Hawaiian) 29% were recurrences.

3. The prevention of trench foot is primarily training problem which must depend

entirely upon the education and discipline of the individual soldier. The problem is complicated during combat by the fact that the most susceptible group, the infantry, has rapid

turnover in personnel. We must teach the recruit how to keep from becoming trench foot

casualty at the most tense moment in his life, namely, when he is about to engage the enemy

in close combat for the first time. To date there is repeated evidence that replacements in

this theater have not received instruction in the prevention of trench foot prior to joining

the combat division.

4. British troops in the beachhead had less trench foot than US troops. This was probably due to:

a. Better foot discipline and training in care of the feet.

b. Heavy wool socks.

c. Shoes large enough so that no constriction of the feet was caused by wearing heavy

wool socks. (US troops tend to fit shoes too small for cold weather when heavy socks or two

pair of light socks must be worn).

d. pair of clean dry socks for each man daily, issued with the ration.

e. More frequent shifting of personnel in the line.

5. It is apparent from the above that trench foot is serious problem. Foot disabilities

experienced in warm weather are not as serious as trench foot but because of their prevalence

they greatly affect troop efficiency. The solution of these problems can be obtained by proper

training and equipment.

6. Studies in equipment requirements have been made and appropriate recommendations

made to the War Dept, radio to AGWAR, ref. No. F53022, 31 May 44:

“Training in care of the feet and foot discipline has not reached the required standard.

It is therefore recommended:

1. All units be issued the NATOUSA pamphlet on care of the feet and that it be used

as basis for unit training.

2. All unit training programs include at least hours instruction in care of the feet.
540 COLD INJURY, GROUND TYPE

3. That special training in care of the feet be given to unit commanders and NCO’s

and thal they be taught the fundamentals of foot inspection by medical officers of the unit.

4. That unit commanders and NCO’s be held responsible for foot casualties. high

incidence of these conditions to be indicative of lack of leadership.

5. That frequent inspections of feet and foot gear be made by the officers of combat

units. That following such inspections immediate action be taken to correct deficiencies

found in training, equipment or physical condition of individual’s feet.

6. That all Replacement Depots conduct school in care of the feet and certify that

all individuals furnished to combat units have completed such course.”

7. Laundry facilities for socks shovdd be provided for combat divisions during cold wet

weather. Under such conditions one pair of dry socks should be furnished each individual

daily with the ration.

8. In addition to the above measures commanders should arrange, during cold weather,

for men in front lines to be released frequently. If this is not done they will lose one man with

trench foot for each to battle casualties.

Morrison C. Stayer,

Major General, USA., Surgeon.
541

APPENDIX

HEADQUARTERS GROUND FORCE REPLACEMENT SYSTEM

European Theater of Operations

No. 55

APO 887

13 December 1944

1. PREVEN TION OF TRENCH FOOT—1. References: War Department Circular

312, 1944; Circular 108, European Theater of Operations, 1944; Medical Bulletin 25; Circular

Letters 126 and 134, Office of Chief Surgeon, European Theater of Operations, 1944.

2. Trench Foot has recently come to the fore-front as major cause of casualties among

combat troops in this Theater. This serious condition is largely preventable, provided the

individual is instructed and takes certain basic measures to prevent it.

3. All members of the Ground Force Replacement System must be made fully aware of

this problem. The Replacement System can and will make material contribution towards

its solution by properly indoctrinating replacements during the time they are under this

command. Each man who is thereby spared the development of this condition is one more fighting man with his unit, and one fewer casualty that requires replacement.

4. It is urgent that each replacement passing through the Ground Force Replacement

System is given adequate instructions to inform him of the individual measures for successfully preventing this disability. Instructions will be concerned with effective measures to

be taken under field conditions and will be presented in such manner as to impress the man

with the seriousness of the condition.

5. Depot Commanders will designate instructors in sufficient numbers to give small

group instruction to replacements under their control. Instruction in this will be included

in the initial orientation given all incoming replacements, and in addition the training

program given all replacements during their stay in the Replacement System will include

minimum of hour each week on this subject.

6. The following points will be stressed:

a. The seriousness of the condition to the individual, both as to immediate dangers

and the permanent injuries that may result therefrom.

b. The seriousness of the problem to the War Effort in this Theater.

c. Factors contributing to its development, with special emphasis on the role of conditions causing impairment of the circulation.

d. The preventable nature of the condition with practical preventative measures, including class demonstrations and practice by each individual. Included will be examinations to see that shoes and socks are properly fitted and the shoes or boots are habitually

laced loosely; massage of the foot; exercise of the toes and ankles, both with and without

shoes on; postural exercises of the foot.

7. The instructors to be used for this will secure the advice and assistance of the unit

medical officers. It is recommended that men designated as instructors visit hospitals in

the vicinity of the depot in company with some of their unit medical officers, and there see

actual cases of Trench Foot so that they may be more conversant with and aware of the

seriousness of this condition
542 COLD INJURY, GROUND TYPI

By command of Brigadier General MATCHETT:

Charles H. Valentine,

Colonel, G. S. C.,

Chief of Staff. Official:

F. G. Garrison,

Major, A. G. D., Adjutant General.

Distribution: “C.” Less Non-GFRS Units.
543 543

Index

Aachen, 407, 418

Acetic acid, in treatment of trenchfoot, 343

Activity index, as predictive test, 361-362

Adak, 89, 96

Adjutant General, The, 193

Admiralty Islands, 221

Africa, 414

Age as factor in—-

chilblains,

cold injury, 378-379

immersion foot, 10-11

shelterleg,

Aird, Ian, 386

Alaska, 47, 83, 91, 92

Alaska Defense Command, 83, 89, 94

cold injury in. See Attn campaign and

Kiska operation.

Alcohol, rubbing, in treatment of trenchfoot, 319

Aleutians, 5, 60, 61, 62, 82, 83-100, 128, 216,

221, 230, 315, 431, 491, 492

cold injury in;

clinical description of, 260-262

clinical manifestations of, 261

statistics on, 260-261

treatment of, 310-315

immersion foot in, studies on, 242

Purple Heart award in, 190

trenchfoot in, 471

complications following, 284-285

sequelae of, 284-285

See also Attu campaign and Kiska operation.

Altitude, as factor in—-

cold injury, 423-424

cold injury, high-altitude, 131

Ambulation, in treatment of cold injury, 335

Amchitka, 96

Ameiican Expeditionary Forces, 47, 51

American Medical Association, 160

Amputation, after

cold injury, 31, 34, 311-312, 315, 343-344

in German armies, 204

frostbite, 37, 38, 39

in German armies, 204

trenchfoot, 47, 272-273, 279, 281-282,

298, 324, 325, 334

Amputation, spontaneous natural, in frostbite, high-altitude, 16

Anesthesia in—-

cold injury, 302

frostbite, high-altitude, 15-16

trenchfoot, 285

Angelucci, R. J., 378, 382

Anoxemia, ir—-

frostbite, 239

frostbite, high-altitude, 13

Anoxia, in frostbite, 13, 238, 239

Antarctic, 159, 232, 416

Antibiotic therapy, in treatment of trenchfoot, 343

Anticoagulants, in treatment of trenchfoot,

326-327

Antwerp, 149

Anzio, 106, 108, 110, 111, 143, 144, 291

Arch supports, in treatment of trenchfoot,

320

Arctics, 416, 495

Ariev, T. V., 34, 39, 42, 235, 240, 303, 390

Ariev’s theory of pathogenesis, 240

Armenia, 29

Armies;

First Canadian Army, 418

First U. S. Army, 138, 139, 140, 142, 147,

149, 151, 165, 166,168, 171, 179, 186. 204,

210, 413, 462, 463, 465, 500-501, 606

Second U. S. Army, 75

Third U. S. Army 136, 138, 139, 140, 141,

142, 147, 149, 154, 166, 168, 179, 185,

192, 203, 210, 308, 382, 383, 413, 420,

439, 448, 463, 464, 500-501, 506

Fifth U. S. Army, 62, 101, 102, 103, 105,

106, 108, 109, 110, 111, 117, 118, 120,

122, 185, 315, 380, 381, 398, 494, 506

Sixth U. S. Army, 213, 224, 228

Seventh U. S. Army, 111, 120, 138, 139,

141, 142, 150, 154, 157, 158, 166, 173,

181, 184, 185, 202, 449, 455, 467, 501

Eighth U. S. Army, 224, 228

Ninth U. S. Army, 138, 139, 140, 142,

156, 166, 168, 169, 467, 501

Fifteenth U. S. Army, 501

Army Committee on Insect and Rodent

Control, 489

Army Epidemiological Board, 488

Army Institute of Pathology, studies on

trenchfoot at, 243-257
544 COLD INJURY, GROUND TYPE

Army Regulations 600-45:

Change No. 4, 1944—190

Change No. 5, 1944—194

Change No. 6, 1945—194

Change No. 7, 1945—195

Arteries, status of, in—-

frostbite, high-altitude, 14

immersion foot, 11

trenchfoot, 293, 300

Arterioles:

status of, in—-

frostbite, high-altitude, 13-14

trenchfoot, 243

thrombosis of, in frostbite, 13

Ashford, B. K., 49, 50, 51, 56

Ashford General Hospital, 78, 259, 333

Asian mainland, 217

Aspirin, in treatment of tenchfoot, 319

Athletes’ foot, 70-71

Atrophy, muscular, in trenchfoot, 294—295

Atteberry, Maj. Roy L., Jr., 98

Attn, 63, 83, 84, 87, 88, 89, 91, 92, 94, 96

99, 225, 242, 261, 284, 310, 311, 312, 381,

492, 493, 507

Attn campaign, 57, 59, 101, 191, 260, 431

clothing in, 89-91

cold injury in, 61, 84-96, 492-493

statistics on, 84, 506

summary of, 99

evacuation in, 88-89

footgear in, 91

medical care in, 88-89

physical status of troops in, 95

tactical situation in, 86-87

trenchfoot in, 175

Aviation protective equipment. See Equipment, aviation protective.

Awards. See Purple Heart.

Azochloramid, in treatment of cold injury,

311

Bacillus proletis, in deep gangrene, 301

Bacillus pyocyaneus, in deep gangrene, 301,

343

Badger, Col. Theodore L., 202

Baines, A. E., 55

Balkan Wars, 41-42

Barnes General Hospital, 89, 311

Barvaux, 464

Basal metabolic rate, 388-389

Bastogne, 463

Bates, Lt. Col. Robert H., Ill, 117

Battle injuries, fatality rates for, 1-2

Battle trauma, general considerations of.

1-6

Bayne-Jones, Brig. Gen. Stanhope, 77.

217, 219

Bazin’s disease,

Bed rest, in treatment of

cold injury, 312

trenchfoot, 318, 324, 334, 335

Beeck, 456

Beffe, 464, 465

Beho, 466

Belgian experience with cold injury in

World War I, 52

Belgium, 43, 200, 291, 407, 421, 426

Belle Isle, 33

Bellican, Col. Charles P., 228

Bendiara, 38

Benzoin, tincture of, in treatment of cold

injury, 311

Berismenil, 464

Berson, R. C., 378, 382

Blackwood, W., 235, 242

Blesse, Brig. Gen. Frederick A., 75, 77, 106

Bliss, Maj. Gen. Raymond W., 67, 69, 72

Blister formation, in—-

chilblains,

cold injury, 240, 259, 292

frostbite, 13

frostbite, high-altitude, 14, 15

immersion foot, 11

trenchfoot, 271, 282

Block, W., 385

Blood flow, 236

Blood vessels:

in trenchfoot, 241

pathologic changes of, in trenchfoot,

244-249

pathologic process of, in—-

cold injury, 241

trenchfoot, 241, 242

Board (proposed) for control of trauma, 488-489

Body structure, changes in, in cold injury,

241

Boland, F. K., 266, 272, 280, 305, 386

Bones, pathologic change in, in trenchfoot,

256

Bonfill, J., 52

Boulogne, 43

Boyd, L. J., 235, 239, 326

Bradley, Gen. Omar N., 142, 148, 167, 168, 210

Briey, 149
INDEX 545

British experience with cold injury, 61, 67,

166, 185, 218, 222, 225

in Crimean War, 34-36

in European theater, 127, 153, 198-202

in Mediterranean theater, 103-106

in World War I, 42-47, 175, 200, 202, 376,

411

British Isles, 200

British Medical Research Council, 160

British 21st Army Group, 199

Brooke General Hospital, 78

Bruneau, J., 255

Buerger’s exercises, 334, 338, 353

Buerger syndrome, 384

Bulgaria, 38

Burch, G. H., 361, 362

Burdenko, N. N., 235

Bureau of Medicine and Surgery, U. S. Navy,

233

Buwi Drome, 213

Byrd, RADM Richard E., 159, 232

Camouflage clothing, 222

Campbell, Sir Colin, 36

Camp Butner, N. C., 78, 79, 80, 194

Camp Carson, Colo., 78, 79, 297, 333, 354

Canada, 54, 175

Canadian experience with cold injury, 98-99

Canadian troops. See British armies.

Capillaries:

Status of, in

frostbite, high-altitude, 14

trenchfoot, 243

thrombosis of, in frostbite, 13

Capillary loops;

damage to endothelium of, 14

in frostbite, 238

Capillary walls:

in frostbite, high-altitude, 14

maintenance of tone in,

permeability of, 239, 240

Capua, 110

Carbamylcholine chloride, in treatment of

trenchfoot, 319

Carter, Col. B. Noland, 58, 59

Case fatality rates. See Fatality rates.

Case histories, of trenchfoot, 263-265,

266-268, 273-275

See also Unit case histories.

Cassino, 101, 108, 110, 291

Castor oil, in treatment of cold injury, 311

Casts, plaster, in treatment of trenchfoot,

319-320

Casualties:

evacuation of, 827

neuropsychiatric, 397-399

Celles, 462

Chemotherapy, in treatment of trenchfoot,

343

Chief Consultant in Surgery, OTSG, 62

Chief Medical Officer, SHAEF, 154

Chief of Staff, SHAEF, 154

Chief Quartermaster, ETOUSA, 144, 145,

146, 151, 164

Chief Surgeon, AFWESPAC, 282

Chief Surgeon, ETOUSA, 184, 145, 160, 168

167, 170, 180, 181, 188, 189

Chilblains:

blister formation in, 7,

chronic form of, 8,

disability caused by, 21-28

etiology of, 8,

lesions in, 8,

manual on, 70

mechanisms of, 287

pain in,

ulceration in,

China, 217, 231

Churchill, Col. Edward D., 101

Circular No. 3, Ground Force Reinforcement Command, ETOUSA, 1945—172

No. 19, 12th Army Group, 1944—467

No. 20, Seventh U. S. Army, 1944—166

No. 55, Ground Force Reinforcement

Command, ETOUSA, 1944—172, 541

No. 76, Third U. S. Army, 1944—167-168

No. 108, Headquarters, ETOUSA, 1944—-

164, 525-528

See also War Department Circulars.

Circular Letter

No. 12, Office of the Chief Surgeon,

ETOUSA, 1943—135, 160

No. 94, Office of the Chief Surgeon,

ETOUSA, 1944—188

No. 126, Office of the Chief Surgeon,

ETOUSA, 1944—164

No. 134, Office of the Chief Surgeon,

ETOUSA, 1943—188

No. 156, Office of the Chief Surgeon,

ETOUSA, 1943—188

See also War Department Circular Letters.

Circulatory abnormalities, as factor in cold

injury, 387-388

Civil War. See War of the Rebellion.

Claiborne, T. S., 272, 386
546 COLD INJURY. GROUND TYRE

Cleveland, Col. Mather, 188, 204

Climatic Research Laboratory, 79

Closure, wound, in treatment of cold injury,

311

Clothing:

as factor in cold injur3 476

directive on: War Department Field

Manual (FM) 21-100, 1941—69-70

responsibility for, 431

studies of, 431

Clothing, aviation protective, 133

Clothing, camouflage, 222

Clothing, cold-weather:

adequacy of, 430-431

basic items of, 185

blouse, service, wool-serge, 147

cap, cotton, field, olive-drab, with visor,

144, 145

cap, field, 146

conferences on, 159

in European theater, 184-185

directive on, War Department Technical

Manual (TM) 10-275, 1944—70

gloves, leather;

wool insert, 144, 145

wool-lined, 111

in Aleutians, 83

in Attu campaign, 90-91

in British armies, 199, 201

in European theater, 208, 209

planning on, 144-146

priority classification of, 148

requisitions for, 146-150

supply system for, 148-150

summary of, 159-160

tactical situation in, 148-150

in German armies, 205-206

in Mediterranean theater, 111

in Russian armies, 207

jacket, ETO, wool, 144, 145

jacket, field:

Alaskan, 97

arctic, 90

Parsons style, 147

sateen, M-1943—146, 147

with hood, 111

wool, Eisenhower type, 146, 147

wool, olive-drab, 145, 146

jacket, herringbone-tweed, 144

jacket, M-1943, 144, 145

jacket, pile-lined, 111

mackinaw, 145

manual on, 70

Clothing, cold-weather—Continued

mittens:

fabric, woolen insert, III

with insert, 146

muffler, 111

muffler, wool, 145

overcoat:

parka, 90-91

parka, pile-lined, 111

wool, 144, 145, 146, 147

parka, 97

parka, ski, 90-91

rain outfit, 111

raincoat, 146

rainsuit, 90, 97

shirt:

wool, 111

wool, olive-drab, 144

sizing of, 149

sweater, 90, 111

sweater, wool, high-neck, 144, 145, 146, 147

tariffs for, 149

trousers:

cotton, field, 144, 145

cotton, field, olive-drab, 146

field, 111

field, cotton, 111

herringbone-tweed, 144, 145

issue, waterproofed, 90-91

kersey-lined, 90, 97

wool, field, 144

wool, olive-drab, 144

underdrawers, heavy wool, 144, 145

undershirt, heavy wool, 144, 145

underwear:

heavy wool, 144

wool, 111

See also Footgear.

Clothing;

Japanese types of, 91-92

winter. See Clothing, cold-weathei.

assemblies, 430

discipline, in prevention of cold injury,

474-475

supply, as factor in cold injury, 430-432

Cocoa butter, in treatment of cold injury,

311, 312

Codeine, in treatment of trenchfoot, 319

Cold, as factor in cold injury, 376-377

Cold injury:

administrative considerations of, in Zone

of Interior, 57-82

admission rates for, 333, 502-503
INDEX 547

Cold injury—Continued

behavior of, 20

classification of, 188-189, 263, 269-278

clinical description of, in Aleutians, 260-

262

clinical investigations of, in European

theater, 185-186

clinical manifestations of, in Aleutians, 261

clinical picture of, 259-305

clinical progress of, summary of, 259-260

clinical stages of, 263

conferences on, in European theater, 176

control of, 128

advanced planning for, 507

alternative plans for, 487-488

board (proposed) for, 488-489

clothing, as factor in, 476

discipline in, 474-475

elements in, 474-476

general considerations in, 471-473

individual instruction in, 476-478

practices in, 473-478

principles in, 473-478

program for, 479-486

research on, 478

degrees of, 262

diagnosis of, 259-305

differential, 303

general considerations of, 259-260

in forward areas, 302-303

overseas, 302-304

signs considered in, 303

symptoms considered in, 302-303

directives on:

Circular No. 3, Ground Force Reinforcement Command, ETOUSA,

1945—172

Circular No. 55, Ground Force Reinforcement Command, ETOUSA,

1944—172

Circular Letter No. 12, Office of the

Chief Surgeon, NATOUSA, 1943

160

Circular Letter No. 94, Office of the

Chief Surgeon, ETOUSA, 1944—188

Circular Letter No. 134, Office of the

Chief Surgeon, ETOUSA, 1943—188

Circular Letter No. 156, Office of the

Chief Surgeon, ETOUSA, 1943—188

War Department Circular No. 48,

1944—74

War Department Circular No. 312,

1944—122

Cold injury—Continued

directives on—Continued

War Department Field Manual (FM)

31-15, 1941—68

War Department Technical Bulletin

(TB MED) 81, 1944—188, 307, 324,

509-514, 515

War Department Technical Manual

(TM) 1-240, 1942—71

War Department Technical Manual

(TM) 8-220, 1941—70

disability caused by, 260-261

disposition of patients with, 85, 327-331

duration of exposure, as factor in, 291-292

epidemiology of, 127-128, 135-136, 363-

453

etiologic factors in, 96, 135-136, 208

climatic conditions as, 109-110, 208

environment as, 87-88, 96-97, 138

individual susceptibility as, 95-96

immobility as, 208

physical status of troops as, 95

shelter as, 208

tactical situation as, 86-87, 96, 107-109,

136-138

weather as, 87-88, 208

etiology of, 20, 24, 28, 30-36, 39, 53-56,

128

in German armies, 205

evacuation of patients with, 307-310

evacuation system for, 308-310

evaluation of costs of, 497-506

exposure duration, as factor in, 291-292

general considerations of, 7-28

grades of, 278-279

gradients of severity of, 20-21

ground type, importance of,

historical note on, 29-56

hospitalization cost of, 502-504

hyperemic stage of, 269-275

in Aleutians, 492-493

in Attu campaign, 84-96

statistics on, 84

summary of, 99

in Balkan wars, 41-42

in Crimean War, 34-36

in European theater, 127-210, 221

conferences on, 187-184

control program in, 128

environmental considerations in, 138

experiences of other armies in, 198-207

investigation of, 196-198

preparedness for, 128-129
548 COLD INJURY, GROUND TYPE

Cold injury—Continued

in European theater—Continued prevention program for, 128

recurrence of, 150

statistics on, 67-68, 208

study on, 199-202

summary of, 209-210

in Franco-Prussian War, 38

in Kiska operation, 96-100

summary of, 99-100

in Mediterranean theater, 60-62, 101-125,

141-142, 493-495

statistics on, 102, 103, 106

studies on, 278-280

summary of, 125

in Napoleonic Wars, 30-34

in Pacific, 211-234

incidence of, 213

medical planning for, 220-234

planning for prevention of, 216-234

statistics on, 213, 215

summary of, 234

in Revolutionary War, 29

in Russo-Japanese War, 38-39

in Russo-Turkish War, 38

in Spanish Civil War, 52

in Tibet Expedition of 1903-4—39-40

in Tropics, 211-216

in War of the Rebellion, 37-38

in World War I, 42-52, 492

incidence of, 497-498

according to services, 140

by commands and armies, 500-502

in Attu campaign, 61

in British armies, 199

in European theater, 138-142, 208, 455-

469, 500-502

in French Army, 203

in German armies, 203-204

in Kiska operation, 98-99

in Mediterranean theater, 101-106

in reinforcements, 502

in Russian armies, 207

in Zone of Interior, 173

incubation period of, 260

indoctrination program for, in Pacific,

224-234

inflammatory stage of, 269-275

ischemic stage of, 266-269

management of

in Aleutians, 492-493

in European theater, 457-458

in Mediterranean theater, 493-495

planning for, 492

Cold injury—Continued

management of—Continued training for, 492

manpower loss due to, in World War I, 47

medical cost of, 502-504

military cost of, 491-507

nomenclature for, 186-189

occurrence of, with other injuries, 303

pathogenesis of, 235-240

cooling process in, 235-236

immediate reactions in, 238-239

local defense in, 236-237

reactions in, 240

supercooling in, 237

theories of, 235-240

vascular supply in, 239-240

vasoconstriction in, 236-237

vasodilatation in, 236-237

pathologic process in, 7, 63-70

posthyperemic stage of, 66-70

postinflammatory stage of, 66-70

predictive tests for, 361-362

prevention of, 58-59, 73-77, 128, 140, 208-

209

advanced planning for, 507

analysis of, 180

clothing, as factor in, 476

elements in, 474-476

general considerations in, 471-473

in British armies, 199-200, 201

in German armies, 206-207

in European theater, 140-141

in Pacific, 216-234

in Russian armies, 207

individual instruction in, 476-478

practices in, 473-478

principles in, 473-478

program for, 479-486

research on, 478

responsibility for, 60-63, 167, 172, 176,

200, 209, 219, 222, 472, 475

rotation, as factor in, 173-174

shelter, as factor in, 174-175

tentage, as factor in, 174-175

training program for, 68-78, 172-173,

208-209

preventive measures. See Clothing, coldweather; Equipment, protective; Footgear; Training program.

Purple Heart award for:

directive on, 192

recommendations concerning, 191, 193-

195

rate of, 222
INDEX 549

Cold injury—Continued

ratio to battle casualties, 504-506

record of 84th Infantry Division, 455-469

recurrence of, 381

in German armies, 204-205

reporting of, 186-189, 500

residua of, in European theater, 290-291

rotation, as factor in, in British armies, 201-202

shelter, as factor in, in British armies, 201

signs of, 278-280

summary of, 259-260

variations in, 259

spectrum of, 20-28

stages of, 259

statistics on, in European theater, 142

studies on, 79-80, 242-243, 278-280, 425

survey of, in European theater, 176-177

symptoms of, 278-280 summary of, 259-260

variations in, 259

tests used in, 304-305

therapy for, 34, 40, 45-47, 51

Aleutians policy on, 310-315

European theater policy on, 163, 324-

327

in Zone of Interior, 333-357

medical phase of, 334-338

previous overseas treatment in, 333-

334

reconditioning in, 353-357

surgical phase of, 339-353

in Mediterranean theater, 315-324

overseas, 307-331

treatment of, in Aleutians, 310-315

triage of patients with, 307-310

classification system for, 309-310

objective changes in, 308

objective signs in, 308

observation in, 308

policy on, 307-308

principles of, at ports of debarkation,

333

types of. See Chilblains, Frostbite, Immersion foot, Trenchfoot.

variations in incidence of, in European

theater, 140

Cold injury, high-altitude,

causes of, 131-132

etiologic factor in, 131-132

altitude as, 131

position of crew as, 131-132

season as, 131

wind blast as, 131, 132

Cold injury, high-altitude—Continued

European theater policy on, 135

hospitalization after, 135

in Eighth Air Force, 128, 130-136

in European theater:

incidence of, 130-131, 132

statistics on, 130-131

summary of, 135-136, 184-185

See also Frostbite, high-altitude.

Cold injury control teams, 484-486

Collins, Maj. Gen. J. Lawton, 466

Combat action, as factor in cold injury, 425-

430

Combat Infantryman’s Badge, 390

Command leadership and altitude, as factor

in cold injury, 438-442

Compresses, in treatment of trenchfoot, 343

Conferences on—-

cold injury, 59

in European theater, 176, 178-184

in Pacific, 219, 223-224

exposure to cold, 58-59

medical matters, in Pacific, 220

trenchfoot, 191-192, 303

conclusions of, 183

control teams, 183-184

in European theater, 177-178, 179-184,

186, 434, 457-458

recommendations of, 183

war medicine, 202

Inter-Allied, 178

Connor, F. P., 40

Constantinople, 41

Constitutional factors, inherent, as factor in

cold injury, 384-387

Constriction, as factor in—-

frostbite, 238

immersion foot, 10-11

trenchfoot, 11-12

Consultant in cold injury, Office of the

Chief Surgeon, AFWESPAC, 223

Consultant in dermatology, Office of the

Chief Surgeon, ETOUSA, 161

Consultants in neurosurgery, in Phirope

theater, 134

Consultant in orthopedic surgery, Office of

the Chief Surgeon, ETOUSA, 188

Consultant in surgery:

Norwegian Army, 152

Norwegian Army, in the United Kingdom,

186

Norwegian Forces, in United Kingdom,

161
550 COLD INJURY, GROUND TYPE

Consultant in surgery—Continued

Office of the Chief Surgeon, ETOUSA,

138, 179

Office of the Surgeon, First U. S. Army,

165

Office of the Surgeon, Mediterranean

theater, 101

Office of the Surgeon, Third U. S. Army,

387

Office of the Surgeon, USASOS, SWPA,

221

Office of the Surgeon General, 62

Pacific, 388

Consultants committee, Chief Surgeon,

ETOUSA, 179

Control program, in European theater, 128

Control program (proposed):

for overseas theaters, 480-486

central organization of, 481-483

control teams in, 484-486

indoctrination program in, 483-484

for Zone of Interior, 479-480

Control teams:

cold injury, 484-486

trenchfoot, 484-486

Cooling, in treatment of

cold injury, 311

trenchfoot, 324, 334

Corlett, Maj. Gen. Charles H., 98

Correlation studies of cold injury:

analysis of, 366-376

coefficients applied in, 366-373

interaction of combat action and season,

374-376

results of, 373-374

subjective scoring, 366

variables in, 366

Corunna, 33

Cottonseed oil, in treatment of trenchfoot,

319

Court, A., 416, 417

Crimea, 34, 36

Crimean War, 34-36

Crisler, Col. Joseph A., Jr., 165, 186, 327

Culpin, M., 54

Cutler, Brig. Gen. Elliott C., 138, 161,

162, 165, 166, 181, 186

Cyanosis, in—-

frostbite, 13, 238, 239

trenchfoot, 293

Dardanelles, 44

Davis, Col. Loyal, 13, 14. 131, 135

Davys, C. I. 39, 40, 53

Dawson, J., 241, 242, 411

Death caused bychilblains, 21-23

frostbite, 21-23

immersion foot, 21-23

uremia, 268

Debridement, in treatment of cold injury,

311.

Denit, Maj. Gen. Guy B., 221, 222, 224

Depage’s theory, 41

Dependency, as factor in—-

cold injury, 390-391

immersion foot, 10, 11

traveler’s legs, 10

trenchfoot, 11-12

Deputy Surgeon, ETOUSA, 188

Dermatitis hiemalis,

Dermatophytosis, in trenchfoot, 312

Devantave, 464, 465

Devers, Gen. Jacob L., 78

DeWitt General Hospital, 333

d’HARCOURT, J., 52

Dicumarol, in treatment of trenchfoot, 327

Diet, high-caloric, in treatment of cold injury, 311

Diet, high-protein, in treatment of

cold injury, 313

trenchfoot, 324

Diet, high-vitamin, in treatment of

cold injury, 313

trenchfoot, 324

Dieuze, 420

Dilatation as factor in frostbite, 238

Dillingen, 435

Dinant, 462

Dinez, 464

Director General, British Army Medical

Services, 201.

Disability caused bjr—-

chilblains, 21-23

cold injury, 260, 261

frostbite, 21-23

immersion foot, 21-23

trenchfoot, 278, 279-280

Disarticulation, following gangrene, 344

Discipline, clothing, 474-475

Discipline, foot, 474-475

Disposition of patients:

Alaska Defense Command policy on, 85

considerations governing, 357

enlisted, 357-359

following cold injury, 312, 357-360

followup of, 359

in European theater, 67-68, 208
INDEX 551

Disposition of patients—Continued

in Zone of Interior, 357-360

officer, 359-360

Divisions:

Armored:

2d—462, 463, 464

3d—156. 462, 463

Infantry:

1st—427

2d—426-438

3d—399, 449

4th—92

5th—428

7th—92, 97, 191

8th—395-397

9th—156, 414, 422, 446

26th—420

28th—156, 170

29th—421, 439

30th—140, 407, 456

35th—448

36th—181, 449, 451, 452

45th—445

78th—421-422

83d—392

84th—156, 455-469

87th—439

89th—401

90th—435, 442

92d—380

95th—402, 426, 439

99th—234, 442, 443

102d—156, 437

104th—418, 442

Doriot, Brig. Gen. Georges F., 152

Dorsitlexion, in cold injury, 288-289

Dressings, in treatment of

cold injury, 310, 311, 314, 315

trenchfoot, 316-317, 318-319, 324

Ducuing, J., 52

Dulag, 211, 213

Ears, frostbite, high-altitude, of, 131, 132

Ecchymosis, in cold injury, 259-260

Edema, in—-

cold injury, 239, 240, 259, 292

frostbite, 13

immersion foot, 11

pulmonary emboli, 10

traveler’s legs, 10

trenchfoot, 243, 269-271, 280-281, 285,

291, 294

studies on, 241-242, 244

Edwards, J. C., 263, 288, 319, 322

Eighth AirForce, 128, 130, 132, 133, 135, 189

cold injury, high-altitude, in, 128, 130-

136

Eighth U. S. Army, 224, 228

Electrophoresis, in treatment of trenchfoot, 337-338

Elizabethtown, 29

Elsenborn, 426

Emboli, pulmonary, fatalities caused by, 10

Emerson, Haven,

Endothelium of capillary loops, damage to,

in frostbite, 14

England, 57. 60, 129, 161, 173, 325, 353, 443,

455, 496

Epidemiology of cold injury, 127-128, 363-

453

agent factors:

analysis of, 376-377

cold, 376-377

wet, 377

application of principles to, 364-366

correlation studies on, 366-376

definition of, 363 -364

general considerations of, 363 366

host factors:

age, 378-379

analysis of, 377-404

circulatory abnormalities, 387-388

dependency, 390-391

fatigue, 391-394

infections, preexisting, 387

infectious disease, recent, 390

inherent constitutional factors, 384-387

nutritional status, 394-397

pedal deformities, preexisting, 387-390

physiologic processes, 388-390

posture, 390-391

previous cold-injury experience, 381-384

psychosocial factors, 397-400

race, 397-381

sex, 379

training, 400-404

in European theater, 127

interpretation of experience in, 364-366

interrelationships of, 449-452

physical environmental factors:

altitude, 423-424

analysis of, 404-424

precipitation, 410-413

temperature, 404-410

terrain, 417-423

thawing, 413-416
552 COLD INJURY, GROUND TYPE

Epidemiology of cold injury—Continued

physical environmental factors—Con.

weather, 404

wind, 416-417

socioeconomic environmental factors:

analysis of, 424-452

clothing supply, 430-432

combat action, 425-430

command leadership and altitude, 438-442

experience, 442-444

foot discipline, 444, 446

footgear, 432-434

rotation, 446-448

shelter, 434-437

training, 442-444

summary of, 452-453

Epidermophytosis, in trenchfoot, 288

Epithelium of skin, regeneration of, after

frostbite, high-altitude, 15-16

Equipment, aviation protective;

boots, electrically heated, 132-133

gloves, electrically heated, 132-133

Equipment, protective:

blankets, 149

deficiencies in, 149

directive on, War Department Technical

Manual (TM) 10-275, 1944—70

in Attu campaign, 90-91

in European theater, 148-150

priority classification of, 148

summary of, 159-160

tactical situation in, 148-150

in German armies, 205

manual on, 70

poncho, synthetic-resin, 144, 145, 146

sleeping bag, 90-91, 149

down and feather, 111

wool, with water-repellent case, 144,

145, 146

supply of, in Pacific, 222

tent, half, shelter, 144, 145

toque, 97

See also Clothing, cold-weather; Footgear.

Equipment officers:

assignment of, in Air Force, 133-134

duties of, 133-134

Erythrocyanosis, 8, 237

Eschweiler, 418

ETOUSA. See European theater.

Europe, 9, 23, 44, 47, 48, 69, 80, 99, 127, 128, 130, 131, 132, 136, 138, 142, 146, 155, 173,

180, 183, 216, 221, 225, 227, 374, 381, 424,

432, 433, 434, 447, 495, 496, 499

European theater, 4, 5, 69, 71, 72, 74, 78, 80,

82, 105, 140, 147, 215, 216, 218, 219, 220, 226, 227, 229, 230, 232, 233, 383, 384 ,387,

399, 401, 404, 416, 431, 432, 433, 439, 453,

455, 480, 485, 491, 500, 507

army strength in, 128-129

clothing in, 208

clothing conferences in, 184-185

clothing deficiencies in, 146

climatic conditions in, in—

British armies, 199, 200, 202

French Army, 202

German armies, 203

cold injury in, 127-210, 221, 471

British armies’ experience with, 198-202

clinical investigations of, 185-186

conferences on, 176, 178-184

experiences of other armies with, 198-207

French Army experience with, 202-203 German armies’ experience with, 203 207

incidence of, 138, 140, 500-502

indoctrination program for, 208-209

investigation of, 196-198

preparedness for, 128-129

residua of, 290-291

Russian experience with, 207

statistics on, 67, 99, 138-139, 142, 199,

203, 208

summary of, 209-210

training program for, 76, 208-209

unit case history of, 455-469

cold injury, high-altitude, in, 130-136

incidence of, 130-131, 132

statistics on, 130-132

studies on, 134-135

control program in, 128

environmental conditions in, 138, 208, 209,

456, 457, 464-465

footgear in, 208, 209

frostbite in, 129, 137, 455

incidence of, 139, 465, 466, 467

frostbite, high-altitude, in:

control measures for, 132-134

corrective measures for, 132-134

incidence of, 130-131

preventive measures for, 132-134

manpower loss in, due to

cold injury, 141-142, 208

cold injury, high altitude, 130-131, 132

trenchfoot, 141-142

Medical Department in, strength of, 129

medical liaison with Mediterranean theater, 161
INDEX 553

European theater—Continued medical planning in, 129

physical status of troops in, 208

prevention program in, 128

preventive measures in, 102-164, 208-209

Purple Heart award in, 191-192

requisitions from, 146-148

respiratory disease in, 179

Tactical situation in, 128, 136-138, 208, 209, 456, 459, 461-467

in British armies, 199-200, 202

in French Army, 202

in German armies, 203

training program in, 208-209

for Air Force personnel, 134

trenchfoot in, 129, 137, 138, 216, 455

analysis of, 208-209

classification of, 304-305

complications following, 290-291

conferences on, 179-184, 186

congressional reaction to, 196-198

disposition of patients with, 304-305,

308-310

evacuation system for, 308-309

incidence of, 467

investigation of, 196-198

public reaction to, 196

report on, 208-209

residua of, 290-291

review and evaluation of, 66-68

statistics on, 66, 138-139, 141-142, 203

study of, 304-305

study project on, 280-282

triage for, 308, 309-310

trenchfoot control teams in, 177-178

weather conditions in, 138, 209

Evacuation of casualties, 88-89, 327

Exercise, in treatment of—-

cold injury, 311, 312, 313

trenchfoot, 320-321, 325-326, 334, 335,

338, 344

Experience, as factor in cold injury, 381-384, 442-444

Exposure, duration of—-

as factor in cold injury, 291-292

in correlation with tissue damage, 292

Exudation, in cold injury, 240

Eylau, 31

Face, high-altitude frostbite of, 131-132

Facilities. See Equipment, protective; Hospitals: Supply.

Far East, 130

Far East Air Force, 224

Fatalities, in pulmonary emboli, 10

Fatality rates:

battle vs. nonbattle,

cold injury, in—

Crimean War, 35, 30

Spanish Civil War, 52

War of the Rebellion, 37

World War I, 44

disease vs. battle injury,

before World War II,

frostbite, in World War I, 44

trenchfoot, in World ar I, 44, 52

Fatigue, as factor in cold injury, 391-394

Fearnsides, E. G., 54 Feet;

appearance of, in—-

cold injury, 303

frostbite, 303

immersion foot, tropical, 213-214

trenchfoot, 280-281, 288, 290-291, 293-

290, 303

cleanliness of, in treatment of trenchfoot,

318

cold injury of, 259, 200-201

clinical manifestations of, 201

cooling of, in treatment of trenchfoot, 319

deformity of, 284-285

elevation of, in treatment of

cold injury, 311-314

trenchfoot, 320, 324, 334

examination of, prior to splinting, 303

exposure of, in treatment of trenchfoot,

310, 318, 324, 334

high-altitude frostbite of, 131

Field manuals. See War Department field

manuals.

Fifteenth U. S. Army, 501

Fifth U. S. Army, 02, 101-103, 105-100,

108-111, 117-118, 120, 122, 185, 315,

380-381, 398, 494, 500

Filly, 404

Film Bulletin No. 180-229, 231

Fingers:

cold injury of, 201

frostbite of, 38

high-altitude frostbite of, 14-15

surface temperatures of, in frostbite, highaltitude, 14

First aid measures, directive on, War Department Field Manual (FM) 21-11,

1943—08-09

First Arctic Aeromedical Laboratory, 378

First Canadian Army, 418

First French Army, 202
554 COLD INJURY, GROUND TYPE

First U. S. Army, 138-140, 142, 147, 149,

151, 165-166, 168, 171, 179, 186, 204, 210,

413, 462-463, 465, 500-501, 506

Flanders, 43, 44

Florence, 110

Flossdorf, 455

Folch, A., 52

Foot, sphacelus of, 31

Foot discipline, as factor in cold injury,

444-446

Foot hygiene:

as factor in—-

shoepac foot, 289

trenchfoot, 288

directives on, 63-66, 74, 153

War Department Circular No. 312, 1944—172, 218

War Department Technical Bulletin

(TB MED) 81, 1944—172, 218

War Department Technical Manual

(TM) 8-210, 1942-70-71

European theater policy on, 129, 153, 162,

163-164

film on, 73

in Aleutians, 310

in British armies, 199, 201, 202

in European theater, 140, 169-170

in German armies, 206

in Mediterranean theater, 118-119

in prevention of cold injury, 474-475

manuals on, 68-71

Mediterranean theater policy on, 120

posters on, 123

responsibility for enforcement of, 64,

66, 162, 209

in French Army, 202

Foot powder, boric salicylic, in treatment

of cold injury, 312

Foot soak, potassium permanganate, in

treatment of cold injury, 312

Footgear, 98-99, 208, 209

as factor in cold injury, 432-434

boots, 150-152

blucher, 91, 115

combat, 114-115, 150-152, 209

mountain, ski, 115-116

rubber, 116

construction of, 151

directives on;

War Department Circular No. 312,

1944—152, 158

War Department Field Manual (FM)

21-100, 1941-69-70

Foot hygiene—Continued

Footgear—Continued

directives on—Continued

War Department Technical Bulletin

(TB MED) 81, 1944—153, 158

War Department Technical Manual

(TM) 10-228—71

fitting of, 150

galoshes, 116, 208

improvisations of, in European theater,

159

in Attn campaign, 91

in British armies, 199, 200, 201

in European theater, 150-159, 208, 209,

221

investigation of, 152

summary of, 159-160

in French Army, 202

in German armies, 205-206

in Russian armies, 207

Japanese types of, 91-92

overshoes, 138, 141, 150, 154-157

directive on, 154-155

discarding of, 155

reequipment of, 154-155

sizing of, 155

standardization of, 155

survey of, by War Production Board,

155-156

repair of, 151

replacement of, 151

shoepac, 91, 97, 116-117, 141, 145, 150,

157-159, 164, 185, 208, 222

shoes, 150-152

fitting of, 162, 163

quarter, 335

service, 115, 150-152

sizing of, 116, 118, 149, 151, 152

socks, 113-114, 152-154, 208, 209

exchange system for, 152, 153

fitting of, 152

heavy wool, 145

ski, 113-114

wool, 150, 222

woolen content of, 152, 162, 178

soles, inner, 114

tariffs for, 149, 151

training program on, 117-118

waterproofing of, 152

See also Clothing, cold-weather.

Footwear. See Footgear.

Form 323, Office of Chief Surgeon, ETOUSA,

187
INDEX 555

Formalin, in treatment of trenchfoot, 337-

338

Fort Greely, Alaska, 89

Fort Knox, Ky., 431

Fort Mears, Alaska, 89

Fort Ord, Calif., 92, 93

Fort Richardson, Alaska, 89, 260, 310

Foxhole foot, 188

France, 43-45, 53, 66, 135, 144, 150, 154, 157,

166, 210, 288, 291, 382, 392. 395, 418, 421, 426, 428, 437, 443, 451, 496

Fran co-Prussian War, 38

Frei’s method, 337-338

French experience with cold injury, in—

Crimean War, 36

European theater, 202-203

Napoleonic Wars, 30-34

World War I, 52, 380

Friedman, N. B., 243-257, 295

Frostbite:

article on, 160

classification of, 188-189

classifications used in, 187

designations used in, 187

diagnosis of, 187-188

differential diagnosis of, 303

directives on:

War Department Field Manual (FM):

21-10, 1940—69

21-11, 1943—68-69

31-15, 1941—68

War Department Technical Bulletin

(TB MED) 92, 1944—186

War Department Technical Manual

(TM) 8-210, 1942-70-71

disability caused by, 21-23

etiology of, 12, 13, 20

in European theater, 128, 129, 137, 455

in German armies, 203-204

incidence of, in—

Alaska, 83

Balkan wars, 42

Crimean War, 34, 36

European theater, 139, 465, 466, 467

Fran co-Prussian War, 38

German armies, 204

Russo-Japanese War, 38, 39

Russo-Turkish War, 38

World War I, 43-44, 52

management of, 160

manual on, 70-71

mechanisms of, 237-238

onset of, 303

pathogenesis of, 238-239

rostbite —Continued

pathologic characteristics of, 12-13

pathology of, 255

prevention of:

in German armies, 206-207 training program for, 76

Purple Heart award for, recommendations concerning, 189-190, 190-191, 193

reporting of, 186-189

stages in, 238-239

Frostbite, high-altitude:

amputation, spontaneous, natural, following, 16

control measures for, 132-134

corrective measures for, 132-134

designation of, 187-188

dry type of, 16

epidemiology of, 135-136

etiologic factor in, 13, 135-136

electrical supply failure as, 133

equipment failure as, 132-133

wind blast as, 132-133

incidence of, in Eighth Air Force, 130-131

investigations in, 134-135

pathologic characteristics of, 14-15

pathology of, 13-14

preventive measures for, 132-134

protective clothing for, 133

recovery from, 14

similarity to ground type of cold injury,

135

studies on, in European theater, 134-135

wet type of, 15-16

Frozen feet. See Trenchfoot.

Fungous infections, 387

Gage, Col. M., 386

Galen, 29

Gallipoli, 44

Galoshes. See Footgear.

Gangrene:

amputation for, 37

clinical picture of, 299

deep:

demarcation of areas of, 301

development of, 298

dry type of, 37-38, 301-302

features peculiar to, 299-300

observations on, 298-302

sympathectomy in treatment of, 339-

343

etiology of, 30-34

in cold injury, 40, 41-42, 240

in frostbite, high-altitude, 14
556 COLD INJURY, GROUND TYPE

Gangrene—Continued

in German armies, 204

in immersion foot, 7, 11

in immersion foot, tropical, 215

in trenchfoot, 271, 272, 281-282, 324, 325

superficial:

infection in, 300-301

observations on, 296-298

symptoms of, 300

Geilenkirchen, 455, 456, 467

German experience with cold injury in—

European theater, 203-207

World War I, 52

Germany, 66, 138, 147, 157, 210, 291, 496

General Board, U. S. Forces, ETOUSA, 127,

160, 193, 208, 209

General Orders

No. 11, GHQ, AEF, 1918-48-49, 50

No. 128, ETOUSA, 1945—208

Gilcreest, E. L., 379

Glenn, Lt. Col. Frank, 213

Gohrbandt, E., 385-386

Gold, M. A., 389

Gorby, Col. Alvin L., 167, 172, 191

Gordon, Col. John E., 5, 140, 145, 153, 163,

164, 170, 176, 178, 180, 183 184, 187, 220,

223, 224, 363

Gothic Line, 398

Gouby, 466

Grafts:

split-thickness, 341, 344-347

tube transfer, 339, 341, 347-350

use of, in trenchfoot, 300

Grattan, H. W., 29

Greene, Raymond, 160, 179

Grow, Maj. Gen. Malcolm C., 130, 134

Hagins, Brig. Gen. William A., 221

Hampteau, 462

Hand:

cold injury of, 8,

in World War I, 56

frostbite, high-altitude, of, 13, 131, 132

Harvard Fatigue Laboratory, 431

Harze, 466

Hawaiian Islands, 227

Hawley, Maj. Gen. Paul R., 134, 151, 155,

157, 162, 164, 168, 169, 176, 178, 179,

181, 183, 189, 192

Hawley, Maj. William L., 199, 220, 223,

224

Healing rate, following sympathectomy,

339-341

Heat application, in treatment of trenchfoot

31G, 317-318, 324, 333-334

Heel walking, correction of, 335-330

Heinbecker, P., 255

Hei-kou-tai, 38, 39

Hemorrhage, in cold injury, 240

Heparin therapy, in treatment of trenchfoot

326-327

Herrman, Louis, 313

Hexyl methlamine tablets, 435

High-altitude frostbite See Frostbite, highaltitude

Hillman, Brig. Gen. Charles C., 58, 59

Hogne, 462

Holland, 33, 159, 200, 291, 466

Hollandia, 215

Holst, Col. Johan C., 186

Honshu, 228

Hospitals, general:

named:

Ashford, 78, 259, 333

Barnes, 89, 311

Brooke, 78

DeWitt, 333

Letterman, 78, 95, 96, 260, 262, 284, 313

314, 315

McCaw, 94, 260, 261, 285, 311, 312

McCloskey, 260, 261-262, 312, 313

Mayo, 78, 259, 290, 291, 292, 294, 295

297, 298, 300, 333, 334, 335, 337, 338

339, 343, 354, 356, 359, 360

numbered:

2d—134, 135, 185

th—185

15th—305

23d—142, 319, 382

40 th—181

45th—383

108th—153, 156, 171, 184, 186, 280, 281,

305, 310, 383

114th—325

168th—204

180th—204

189th—204

196th—204

216th—325

Hospitals, regional, 78, 193, 194, 333, 386

Hospitals, station;

110th—185, 326

183d—85, 89, 260, 284, 285, 310

Hospitalization of—-

cold injury casualties, 502-504

cold injury, high-altitude, casualties, 135

trenchfoot casualties, 78-79, 142
INDEX 557

Hospitalization period, after frostbite, highaltitude, 30

Hotton, 462

Houffalize, 463, 464, 466

Hyperemia, in—-

cold injury, 259

frostbite, 13, 239

Hyperesthesia, after trenchfoot, 294

Hyperhidrosis, in trenchfoot, 288, 292, 337-

338

Hyperthermia, in cold injury, 259

Hypesthesia, after

cold injury, 302

frostbite, high-altitude, 15-16

trenchfoot, 285

Icecaps, in treatment of trenchfoot, 319

Icepacks, in treatment of trenchfoot, 334

Immersion foot, 7, 390-391

article on, 160

classification of, directive on, 188

directives on;

Circular Letter No. 12, Office of the

Chief Surgeon, NATOUSA, 1943—

160

Technical Memorandum No. 10, Office

of the Surgeon, USASOS, SWPA,

1943—220

War Department Technical Bulletin

(TB MED) 92, 1944—186

designation of, 187-188

disability caused by, 21-23

etiology of, 10, 11, 20

European theater policy on, 135, 160

in Aleutians, studies on, 242

in European theater, 160

in Mediterranean theater, 161

incidence of, in Alaska, 83

manual on, 70

mechanisms of, 237

pathologic characteristics of, 242

prevention of:

European theater policy on, 162-163

studies on, 175

Purple Heart award for, recommendations

concerning, 189, 190-191

reporting of, 186-189

classifications used in, 187

designations used in, 187

stages of, 11

studies on, in European theater, 135

symptoms of, 11

therapy for, European theater policy on,

163

438404 —58 37

Immersion foot, tropical:

clinical aspects of, 213-210

etiology of, fatigue as factor in, 214

gangrene after, 215

Hospitalization after, 210

In Pacific, 211

statistics on, 213

incidence of, 213

lesions in, 214

lymphangitis in, 214

management of patients with, 215-210

pain in, 215

pulse range in, 215

rainfall, as factor in, 211-213

recovery rate in, 215

recurrence of, 210

temperature range in, 215

therapy for, 215

Immobility, as factor in—-

cold injury, 200

immersion foot, 10-11

trenchfoot, 10-11, 11-12, 174, 188, 240

Incidence rate:

British vs. U. S., 198-199, 199-200

cold injury vs. wounded-in action, 99, 100,

141, 500

cold injury, high-altitude vs. wounded-inaction, 130-131.

trenchfoot vs. wounded-in-action, 102, 100

India, 40

Infection, in—-

gangrene, deep, following trenchfoot, 300

gangrene, superficial, 300-301

Infections, preexisting, as factor in cold injury, 387.

Infectious disease, recent, as factor in cold

injury, 390.

Information and Education Division, Army

Service Forces, 400.

Intelligence, as factor in cold injury, 399

Inter-Allied conference on

cold injury, 179

war medicine, 202

Intima, thickening of, in frostbite, high-altitude, 14.

Ireland, 130, 395, 428

Iron-vitamin therapy, in treatment of cold

injury, 311.

Italian experience with cold injury in World

War I, 52.

Italy, 5, 6, 9, 60, 61, 62, 63, 66, 69, 74, 99,

101, 103, 105, 109, 111, 116, 117, 118, 121, 138, 145, 158, 161, 162, 166, 199, 200, 216, 221, 225, 266, 269, 272, 292, 298, 307, 316,
558 COLD INJURY, GROUND TYPE

Italy—Continued

329, 374, 378, 379, 380, 381, 382, 383, 384,

387, 397, 398, 401, 424, 433, 434, 451, 491,

492, 493, 494, 495, 499, 506, 507.

Iwo Jima, 227

Japan, 6, 83, 129, 216, 217, 218, 223, 224,

225, 227, 228, 231, 232, 507.

Japanese experience with cold injury in

Russo-Japanese War, 38-39.

Japanese types of cold-weather clothing, 91-

92.

Jassy, 38

Johnson Island, 227

Johnston, J. L., 7, 319

Joint tissue. See Tissue, joint.

Kenner, Maj. Gen. Albert W., 154, 167,

170.

Kimbrough, Col. James K., 165, 166, 186

Kirk, Maj. Gen. Norman T., 67, 194, 196,

218, 220.

Kiska, 84, 85, 87, 99, 381

Kiska operation;

cold injury in, 96-100

summary of, 99-100

environmental conditions in, 117

tactical situation in, 96

Knight, B. W., 9, 10

Korea, 228, 232

Kramer, M., 389

Kreyberg, Maj. Leiv, 179, 186, 235, 238-

240, 244

Kreyberg’s theory of pathogenesis, 238-240

Kwajalein, 227

Kyushu, 228

Ladd, Col. Mason, 197, 198, 199, 201

Landis, Dr. E. M., 59

Lange, K., 235, 239, 326, 385, 389, 390

Lanolin, in treatment of

cold injury, 311, 313

trenchfoot, 319, 334, 341

La Roche, 463, 464

Larrey, Baron D. J., 29, 30-34, 53, 411

Lawson, C. B., 43, 45, 46

Lear, Gen. Ben, 76

Legal Division, OTSG, 197

Le Havre, 148

Leigh, Maj. Octa C., Jr., 186

Lesions, inchilblains, 8,

cold injury, 213, 259

frostbite, 12, 13

Lesions, in—Continued

frostbite, high-altitude, 14-16

immersion foot, tropical, 214

trenchfoot, 281

Les Tallies, 464

Letterman General Hospital, 78, 95, 96, 260,

262, 284, 313, 314, 315

Lewis, T., 2, 3, 235-238, 384

Lewis’ theory of pathogenesis, 235-238

Lewis' triple-response phenomenon, 237

Leyte, 7, 211, 212, 213, 215, 221

Lindern, 456, 459

Linnich, 455

Liston, Col. David E., 188

Littlejohn, Maj. Gen. Robert M., 145,

147, 150, 158

London, 7, 9, 171, 178, 179

Longridge, C. N., 55

Lubrication, in treatment of trenchfoot, 334-

335

Lumbar sympathetic block, in treatment

of

cold injury, 312, 313, 314

trenchfoot, 324, 334, 336-337

Lumbar sympathectomy, in treatment of

cold injury, 311-312, 339-343

Lupus,

Lutes, Lt. Gen. LbRoy, 218, 219

Luxembourg, 291, 392, 395

Luzon, 213, 221, 227

Lymphangitis, in immersion foot, tropical,

214

McCaw General Hospital, 94, 260, 261,

285, 311, 312

McCloskey General Hospital, 260, 261, 262,

312, 313

McCloy, John J., 66

Macedonia, 44, 45

MacPherson, W. IL, 38

Madrid, 33

Maginot Line, 420

Malmedy, 407, 408

Manhay, 463

Manila, 224

Manpower loss from

cold injury, 499-500

in commands and armies, 500-502

in European theater, 141-142, 208

in Mediterranean theater, 102-103

in reinforcements, 502

cold injury, high-altitude, 130-131, 132

frostbite, 499
INDEX 559

Manpower loss from—Continued

trenchfoot, 499

in Aleutians, 85

in European theater, 141-142

in Mediterranean theater, 61, 102, 162

in World War I, 47

Maps, wind-chill, 416

Marche, 461, 462, 463

Marshall, Gen. George C., 67

Mason, Col. Richard P., 220

Massage, in treatment of trenchfoot, 334-335

Mayo, Col. Charles W., 223

Mayo General Hospital, 78, 259, 290, 291,

292, 294, 295, 297, 298, 300, 333, 334,

335, 337, 338, 339, 343, 354, 356, 359,

360

MI) forms. See War Department MD

forms.

Mead Committee. See Special Committee

for Investigation of the National Defense

Program.

Mecholyl chloride, in treatment of trenchfoot, 338

Medical Consultant, Normandy Base Section, 202

Medical Consultants Divisions, OTSG, 186,

194, 326.

Medical Department, in European theater,

strength of, 129

Medical Department Field Research Laboratory, 390

Medical News Letter No. 1, OTSG, 1943

160

Medical planning, in European theater, 129

Medical Research and Development Board,

389

Medical Research Laboratory, 431

Medical Section Study No. 94 (General

Board)—127

Mediterranean theater, 5, 62, 63, 71, 74, 82, 128, 130, 144, 146, 150, 152, 154, 157,

166, 173, 179, 216, 218, 221, 226, 227,

230, 324, 387, 388, 404, 416, 431, 433,

439, 480, 495, 507

cold injury in, 60-62, 101-125, 471

clinical description of, 263, 280

indoctrination program for, 118-125

investigation of, 328-329

summary of, 125

training program for, 118-125

manpower loss in, due to

cold injury, 162

trenchfoot, 61

Mediterranean theater—Continued

medical liaison with European theater, 161

preventive measures in, 62

Purple Heart award in, 190

statistics on

cold injury in, 99, 102-103

trenchfoot in, 102, 106

tactical situation in, 107-109

training program in, 117-118

trenchfoot in, 143, 145

complications following, 285-290

disposition of patients with, 328-331

incidence of, 101-106, 494-495

observations on, 289-290

sequelae of, 285-290

studies on, 266-268, 381-382

summary of, 125

treatment of, 315-324

weather condition in, 109-110

Memorandum No. 4, Army Sanitary School,

AEF, 1917—51

Memorandum No. 68, Ninth U. S. Army,

1944—166

Menil, 462

Mercurochrome, aqueous, in treatment of

trenchfoot, 343

Merthiolate, tincture of, in treatment of cold

injury, 314

Metycaine hydrochloride, in treatment of

cold injury, 313

Metz, 141, 426, 428, 429, 439

Middle East, 44

Middle Pacific Area, 224

Middleton, Col. William S., 179

Midway, 87

Miller, A. J„ 379, 394

Mindanao, 227

Mineral oil, in treatment of trenchfoot, 334-

335

Mobile Intelligence Training ETnits, 77

Monschau, 415

Morale, as factor in cold injury, 399

Morbidity rate. See incidence rates.

Morphine, in treatment of cold injury, 310

Motivation, as factor in cold injury, 398-399

Moynihan, B., 46

Mukden, 39

Muscle:

pathologic change in, in trenchfoot, 243,

250

pathologic process in, in—-

cold injury, 241

trenchfoot, 241
560 COLD INJURY, GROUND TYPE

Nadrin, 464

Nancy, 420, 448

Naples, 108

Napoleonic Wars, 30-34

Narcotics, in treatment of gangrene, 334

National Research Council, 175

Division of Medical Sciences, 57, 58, 160

Subcommittee on Clothing, 431

Neck, high-altitude frostbite of, 131, 132

Necrosis, in—-

cold injury, 240

frostbite, 239

Nerves:

pathologic change in, in—-

frostbite, 255

trenchfoot, 243, 253-255

pathologic process in, in—-

cold injury, 241

trenchfoot, 241

Neuropsychiatric casualties, 397-399

New Britain, 221

Newburgh, Louis, H., 189, 431

Newfoundland, 33

New Guinea, 213, 215, 221

New York, 146, 147

New York Port of Embarkation 146, 150

Nicotinic acid, in treatment of trenchfoot,

319, 324

Ninth U. S. Army, 138, 139, 140, 142, 156,

166, 168, 169, 455, 467, 501

Nome, 83

Nonbattle injuries, fatality rates of, 1,

Normandy, 210, 392, 414

Norris, G. W., 55

North Africa, 101, 174, 329, 387, 398, 416

North African theater. See Mediterranean

theater.

Northwest Pacific Area, 311

Norwegian experience with cold injury, 165

Novocain, in treatment of trenchfoot, 322,

325

Nutritional status, as factor in cold injury,

394-397

Oahu, 227, 228, 229, 233

Occupational therapy, in treatment of

trenchfoot, 321

Odom, Col. Charles B., 387

Office of Scientific Research and Development, 361

Committee on Medical Research, 58

Office of the Air Surgeon, 431

Office of the Chief Surgeon, ETOUSA, 177, 187, 188, 382, 401

Office of the Surgeon;

First U. S. Army, 165

NATOUSA, 476

United Kingdom Base, 383

Office of the Quartermaster General, 70, 89,

91, 105, 111, 143, 146, 159, 200, 216, 219, 220, 226, 227, 228, 230

Office of the Surgeon General, 57-58, 59-60,

62-63, 67, 71, 72, 73, 76, 77, 79, 80, 81,

160. 172, 190, 194, 216, 217-224, 233, 431,

474, 491, 495

Office of the Surgeon General of the Navy,

431

Oil, in treatment of cold injury, 311

Ointments, policy on use of, in European

theater, 175-176

Okinawa, 227, 234

Operation CORONET, 223, 228

Operation GRENADE, 467

Operation NEPTUNE, 163

Operation OLYMPIC, 223, 228

Operation OVERLORD, 162

Operations Service, OTSG, 67

Opinion survey, of trenchfoot, 400-401

Orthopedic appliances, in treatment of

trenchfoot, 325

Osler, Sir William, 54

Osteomyelitis, after—■ amputation, 344, 350

gangrene, 343

trenchfoot, 301-302

Osteoporosis, in trenchfoot, 284, 296

Overshoes. See Footgear.

Oxygen deficiency, in frostbite, 238, 239-240

Oxygenation, in treatment of trenchfoot, 314

Pacific, 72, 74, 77, 78, 81, 183, 216, 217, 223,

225, 226, 227, 228, 229, 233, 234, 492,

507

cold injury in 211-234, 471

incidence of, 213

statistics on, 213

immersion foot, tropical, in, 127

statistics on, 213

manpower loss due to rainfall in, 211-213

medical planning in 220-224

tactical situation in, 213

trenchfoot in, 211

weather conditions in, 213

wet-cold injury in, 211

wet-cold program in, 216-234

Pacific Islands, 230

Pacific theater, 3, 6, 216

Paddock, F. K., 290, 305
INDEX 561

Page, C. M., 41, 53

Pain, in—-

chilblains,

cold injury, 236-237, 259, 260-261, 271,

275-277, 278, 292, 302-303

frostbite, 12-13, 238

frostbite, high-altitude, 14-15

immersion foot, 11

immersion foot, tropical, 215

trenchfoot, 44-45, 46, 269, 271, 275-277,

280-281, 284, 285-286, 288, 290, 300

recurrence of, 289-290

Palo, 211, 213

Panchenko, D. I., 255

Paravertebral block, in treatment of—-

cold injury, 313

trenchfoot, 322

Paresthesia, in—-

frostbite, high-altitude, 14

trenchfoot, 294

Paris, 142, 147, 171, 179, 180, 183, 184, 187,

280

Paris Conference on Trench Foot, 177, 186,

191, 303, 325, 327, 434

Parisot, J., 55

Parker, F. P., 272, 386

Paroisse, M., 33

Patients:

disposition of. See Disposition of patients,

segregation of, in treatment of trenchfoot,

321

Patterson, R. H., 242

Patton, Gen. George S, 141, 168, 172

Pa vex machines, use of, in treatment of cold

injury, 313

Pearl Harbor, 74

Pedal deformities, preexisting, as factor in

cold injury, 387

Penicillin, in treatment of trenchfoot, 324,

334, 343

Peripheral nerve involvement, in trenchfoot,

294-295

Pernio,

Petrolatum, in treatment of cold injury, 313

Philippine Islands, 7, 211, 215, 223, 224, 230

rainfall in, 211-213

Physical fitness, importance of, 378-379

Physical therapy, in treatment of

cold injury, 312, 313-314

trenchfoot, 319, 335

Physiologic processes, as factor in cold injury, 388-390

Physiotherapy, in treatment of trenchfoot,

320, 325, 344

Pillsbury, Col. Donald M., 161

Pilocarpine, in treatment of trenchfoot, 319

Pirogov, N. I.,

Plasma infusions, in treatment of cold

injury, 310

Plastic revision, in treatment of—-

cold injury, 311, 315, 343

trenchfoot, 344-35)

Poland, 30

Polyvitamin therapy, in treatment of trenchfoot, 319

Pont-it-Mousson, 428

Pontocaine hydrochloride, in treatment of

trenchfoot, 325

Posture, as factor in cold injury, 390-391

Pounder, Lt. Col. William F., Jr., 144, 145,

157, 227, 228

Powder, in treatment of trenchfoot, 316-317

Precipitation, as factor in cold injury, 410-

413

Prevention program, in European theater,

128

Preventive Medicine Division, Office of the

Chief Surgeon, ETOUSA, 189, 199, 382,

425, 433

Preventive Medicine Division, OTSG, 57,

77, 79, 217, 219

Preventive Medicine Section, Office of the

Surgeon, 12th Army Group, 167

Preventive Medicine Section, OTSG, 217,

400

Preventive program (proposed), in—-

overseas theaters, 480-486

central organization of, 481-483

control teams in, 484-486

indoctrination program in, 483-484

Zone of Interior, 479-480

Procaine, in treatment of cold injury, 313

Professional Memorandum No. 5, Office of

the Surgeon, First U. S. Army, 1944—165

Professional Service, OTSG, 58

Professional Services Division, Office of the

Chief Surgeon, ETOUSA, 175, 178

Professional Services Division, OTSG, 175

Protective equipment, aviation. See Plquipment, aviation protective.

Prostheses, in treatment of

cold injury, 312

trenchfoot, 335-336, 350-353

Prussia, 31

Psychoneurosis, 358

in trenchfoot, 285

Psychosocial factors in cold injury, 397-400

Public Relations Division, ETOUSA, 170
562 COLD INJURY, GROUND TYPE

Pulmonary emboli, fatalities in, 10

Purple Heart:

award of, 187, 189-195, 303-304

directives on, 192

in Aleutians, 190-191

in Army Air Forces, 189-190

in European theater, 191-192

in Mediterranean theater, 190

morale factor in, 194

directives on:

Army Regulations (AR) 600-45:

Change No. 4, 1944—190

Change No. 5, 1944—194

Change No. 6, 1945—194

Change No. 7, 1945—195

War Department General Orders No.

3, 1932—189

establishment of award of, 189

recommendations concerning, 189-195 revival of award of, 189

Quartermaster Corps, 223, 226-228, 416, 434

Quartermaster General, The, 60, 64-65, 144,

145, 147, 148, 150, 152, 158, 159, 185, 218,

226, 233, 430, 431

Race, as factor in cold injury, 379-381

Ragan, C. A., 288

Rankin, Brig. Gen. Fred W., 62, 63, 67,

194, 219

Raymond, Col. Victor V., 49, 55

Raynaud syndrome, 384

Raynaud’s disease, 11, 55

Reamputation, following cold injury, 315

Reconditioningprogram:

ambulatory patients in, 354-355

bedridden patients in, 354

educational features in, 355

in treatment of trenchfoot, 326, 353, 357

initial phase in, 354-355

outdoor activities in, 355-356

results of, 356-357

second phase of, 355-366

water calisthenics in, 354-355

Reconditioning section in hospitals, value of,

321

Regiments:

Infantry;

2d—430

10th—428, 430

11th—141, 428, 430

17th—96, 99

23d—427

Regiments— Continued

Infantry—Continued

28th—396

47th—171, 415, 416

53d—96

60th—415, 416

101st—420

115th—421

116th—421

121st—396

134th—448

137th—448

157th—445

175th—421

179th—445

180th—445

184th—96, 99

309th—421-422

310th—421-422

311th—421-422

320th—448

328th—141

329th—392

330th—392

331st—392

333d—455, 456-457, 464

334th—455, 456-457, 462, 464, 467

335th—455, 456, 464

338th—420

345th—440

346th—439-442

347th—440

357th—141, 435

358th—435, 437

359th—435, 437

393d—443

395th—443

405th—437

406th—437

407th—437

413th—420

414th—420

415th—420

Mountain Infantry, 87th—96, 99

Rehabilitation, in treatment of—■ cold injury, 313

trenchfoot, 325-326

Rehabilitation section in hospitals, value of,

321

Research and Development Branch, Office

of the Quartermaster General, 151, 152,

160

Research Clothing Board, 79
INDEX 563

Resources and Planning Division, OTSG, 79

Respiration, mechanical, in treatment of

trenchfoot, 314

Respirator, negative-pressure, in treatment

of trenchfoot, 325

Respiratory disease, incidence of, in European theater, 179

Revision

after amputation, 343, 344-350

in treatment of cold injury, 311-312, 315

Revolutionary War, 29, 189

Reynolds, Maj. Gen. Russell B., 190

Ritchie, J., 241, 242, 411

Rochester Desert Laboratory, 431

Rome, 107, 108, 287, 292, 398

Roses, 33

Rotation policy, as factor in—-

cold injury, 173-174, 446-448, 475

in British armies, 202

trenchfoot, 174

in British armies, 200-201

Rotgen, 421

Rotnes, L., 239

Rouen, 43, 46

Royal Air Force, 190, 431

Royal Army Medical College, 202

Royall, Brig. Gen. Kenneth C., 198

Ruffin, J. B., 319

Rush, Benjamin, 29

Russia, 30, 231

Russian experience with cold injury, 165, 175,

191, 222

In European theater, 207

in Russo-Japanese War, 39

in Russo-Turkish War, 38

Russo-Finnish War, 161

Russo-Japanese War, 38-39, 217

Russo-Turkish War, 38

Ryles, Col. C. S., 179, 202

Saareguemines, 439

Saarlautern, 426

Saint-Vith, 408, 426, 466

Saipan, 227

Salerno, 60

Salt solution, hypertonic, in treatment of

trenchfoot, 319

Salt solution, physiologic, in treatment of—-

cold injury, 311

trenchfoot, 319, 343

Salves, use of, in European theater, 175-176

Samaree, 464

Sanders beds, in treatment of trenchfoot, 338

Sanitation, directives on;

War Department Field Manual (FM)

8-40, 1940—69

War Department Field Manual (FM)

21-10, 1940—69

Sasebo, 228

Schecter, A. E., 288

Schools:

American School Center, 173

Medical Field Service School, 173

Schouten Islands, 221

Second U. S. Army, 75

Sedatives, in treatment of trenchfoot, 334

Segregation of patients, in treatment of

trenchfoot, 326

Selye, H., 389

Separations from service, due to cold injury,

312

Service branch, as consideration in diagnosis

of trenchfoot, 302

Seventh U. S. Army, 111, 120, 138, 139, 141,

142, 150, 154, 157, 158, 166, 173, 181, 184,

185, 202, 449, 501

Sevastopol, 36

Sex, as factor in—-

cold injury, 379

shelterleg,

Shanghai, 228

Shapiro, M. S., 319

Shelter:

directive on, Standing Operating Procedure No. 5, ETOUSA, 1944—174

as factor in cold injury, 174-175, 434-437

in British armies, 201

Shelterleg, 7, 390

training manual on, 68-69

etiology of, 9, 10

Shillong, 40

Shrivenham, 173

Shoepac foot, 158

in European theater, 289

in Mediterranean theater, 289

recurrence of, 289

Siberia, 33

Sicily, 101, 414

Silverman, J. J., 388

Simeone, Col. Fiorindo A., 119, 161, 263, 266-267, 316, 318, 322, 381

Simmons, Brig. Gen. James S., 57

Simpson, K., 10

Simpson, Lt. Gen. W. H., 467

Siple, Lt. Col. Paul A., 155, 159, 160, 199,

200, 416, 431-432
564 COLD INJURY, GROUND TYPE

Sixth U. S. Army, 213, 224, 228

Skin:

appearance of, in—-

chilblains,

cold injury, 237, 259-260, 261

frostbite, 12-13, 238-239

frostbite, high-altitude, 15-16

immersion foot, 11

immersion foot, tropical, 213-214

trenchfoot, 269-271, 281, 285-286, 288,

291, 294, 296

cellular permeability of, 214

heat loss of,

inflammation of, 237

pathologic changes of, in trenchfoot, 244

pathologic characteristics of, in—-

cold injury, 236-237

frostbite, high-altitude, 15-16

trenchfoot, 269-271

pathologic process of, 241

regeneration of, after frostbite, highaltitude, 15-16

supercooling property of, 237

temperature of:

after sympathectomy, 341

in cold injury, 236-238

in frostbite, 238

in trenchfoot, 271-272, 281, 292

observations concerning, 361-362

studies on, 305

Skin grafts, 343

in treatment of

cold injury, 315

trenchfoot, 325, 344-350

Smith, J. L., 241, 242, 411

Soaks, in treatment of trenchfoot, 334

Sofia, 42

Somervell, Lt. Gen. Brehon, B., 63, 67

Southwest Pacific, 180, 183

Southwest Pacific Area, 222

Spanish Civil War, 52

Spanish experience with cold injury, in

Spanish Civil War, 52

Special Committee for the Investigation of

the National Defense Program, 196-197, 198

Sphacelus of the foot, 31

Splinting of feet, examination for cold injury

prior to, 303

Splints, in treatment of cold injury, 314

Standing Operating Procedure

No. 5, ETOUSA, 1944—174

No. 15, ETOUSA, 1944—162-163

Stasis, in—-

frostbite, 239

pulmonary emboli, 9, 10

Staten Island, 29

Statistics, on

admissions for cold injury, in Zone of

Interior, 333

amputations, 334

in War of the Rebellion, 37

in Russo-Japanese War, 39

Army strength, in European theater, 128-

129

cold injury, 498-499, 500

in Aleutians, 260-261

in Attu campaign, 84, 85, 95-96

in British armies, 199

in Crimean War, 35

in European theater, 67-68, 127, 138-

139, 142, 208, 383, 502-503

in French Army, 203

in Kiska operation, 98-99, 100

in Mediterranean theater, 105-106

in Pacific, 213, 215

in Revolutionary War, 29

in Russo-Japanese War, 39

in Spanish Civil War, 52

in World War I, 43-44, 52

cold injury, high-altitude, 130-131, 131-

132

disposition of patients, 85, 208, 329-331,

357-359

frostbite, in—

Balkan wars, 42

Crimean War, 34, 36

European theater, 498-499

Franco-Prussian War, 38

Mediterranean theater, 498-499

Russo-Japanese War, 38, 39

Russo-Turkish War, 38

World War I, 43-44, 52

immersion foot, tropical, in Pacific, 213

trenchfoot, in—

Attu campaign, 94

European theater, 66, 138-139, 139-142,

153-154, 156-157, 171, 498-499

French Army, 203

Kiska operations, 98-99

Mediterranean theater, 102-103, 106,

498-499

World War I, 43-44, 47-48, 52

See also Fatality rates, Incidence rates.

Stayer, Maj. Gen. Morrison C., 495

Stefansson, Vilhjalmxjr, 57
INDEX 565

Streptococcic sore throat, with trenchfoot,

325

Stress, as factor in cold injury, 389-390

Structure. See Body structure.

Sulfadiazine, in treatment of trenchfoot, 343

Sulfanilamide, in treatment of cold injury,

310

Sulfanilamide powder, in treatment of

trenchfoot, 318

Sulfathiazole powder, in treatment of cold

injury, 314

Sulfonamides, in treatment of trenchfoot,

324, 334

Supply of—-

clothing:

aviation protective, in European theater, 133

cold-weather, in—

Aleutians, 90-91

European theater, 128, 143-160, 208

Mediterranean theater, 111

equipment:

aviation protective, in European thea

ter, 132-133

cold-weather, in—

European theater, 128

Pacific, 222

for prisoners of war, 150

protective, in—

Aleutians, 90-91

Pluropean theater, 143-160

tentage, in European theater, 174-175

footgear, in—

Aleutians, 91

European theater, 128, 138, 141, 143-

164, 179, 208

Mediterranean theater, 113-117

Pacific, 222

Supreme Headquarters, Allied Expeditionary

Force, 147, 154, 167, 170.

Surgeon

Alaska Defense Command, 57

Eighth Air Force, 130, 133

Fifth U. S. Army, 122

45th Infantry Division, 382

NATOUSA, 101

2d Infantry Division, 382

Sixth U. S. Army, 221

12th U. S. Army Group, 167, 172, 191

Surgeon General of the Army, 64-65, 66, 67,

68, 79, 81, 82, 171, 178, 188, 193, 194.

Surgery, overseas, necessitated by cold injury, 334.

Surgery Division, OTSG, 62

Surgical Consultant, Office of the Surgeon,

Hq., Sixth U. S. Army, 213.

Surgical Consultants Division, OTSG, 63, 67, 80, 81, 186, 190, 216, 217, 313, 326.

Surgical Division, OTSG, 57, 58

Survey on—•

cold injury, in European theater, 176-177

trenchfoot, in European theater, 176-177, 179-180.

Sweet, J. E., 55

Syme’s operation, 47, 344

Sympathetic activity, in trenchfoot, 294-295

Sympathetic block, in treatment of trenchfoot, 321-322, 325

Sympathectomy:

in patients with

cold sensitivity, 342

deep gangrene, 339-342

pain on weight bearing, 342

in treatment of trenchfoot, 322, 325, 336-

337.

value of, 342-343

with amputation, 343

Tacloban, 211,213

Tchatalja, 41

Technical Bulletins. See War Department

Technical Bulletins.

Technical Manuals. See War Department

Technical Manuals. Technical Memorandum No. 10, Office of the

Surgeon USASOS, SWPA, 1943—220.

Telford, E. D., 322

Temperature, as factor in cold injury, 404-

410.

Temperature, surface, in high-altitude frostbite, 14.

Temperature ranges, in cold injury, 7, 11,

12, 13, 31, 32-33, 34, 35, 38, 39, 41, 88, 109,

110, 131, 138, 157, 188, 211, 266, 303, 405-

406, 409, 444, 459, 469.

Tenosynovitis, 91

Tentage, 174-175

Terrain, as factor in cold injury, 417, 423

Tetanus antitoxin, in treatment of cold injury, 45, 51.

Tetanus toxoid, in treatment of cold injury,

310.

Textile Foundation, 431

Thawing, as factor in cold injury, 413-416

Thermal injuries,

Thiamine chloride, in treatment of trenchfoot, 319, 338
566 COLD INJURY, GROUND TYPE

Third U. S. Army, 136, 138, 139, 140, 141,

142, 147, 149, 154, 166, 168, 179, 185, 192,

203, 210, 308, 382, 383, 413, 420, 439, 448,

464, 500-501, 506

Thrombosis, in—-

frostbite, 13

frostbite, high-altitude, 13-14

pulmonary emboli, 9, 10

trenchfoot, 243-244

studies on, 244-247

Thatcher, James, 29

Tibet Expedition of 1903-4—39-30

Tibet Mission Force, 40

Tinian, 227

Tissue:

pathologic process of, in cold injury, 241

pathologic change in, in trenchfoot, 243

joint, changes in, 241

subcutaneous, pathologic changes in, in

trenchfoot, 244

Tissue damage:

causative agent of, 7,

exposure duration, as factor in, 292

in frostbite, 12-13, 238-239

in frostbite, high-altitude, 14-15

in trenchfoot, 239, 240

spontaneous separation of, 298

Toes:

amputation of, 31, 37, 38, 272, 279, 281-

282, 311, 315, 334, 343-344

extensor contracture of, 344

flexion contracture of, 285, 344

frostbite of, 38

gangrene of, 37-38

Tore, R. T., 38

Tokyo, 228

Training—-

as factor in cold injury, 400-404, 442-444

in European theater, 208-209

in Mediterranean theater, 118-125

Training Division, OTSG, 58, 72, 73, 77

Training Film 180, 223

Training Memorandum No. 11, USAF.

PGA, 227

Training program, 68, 78, 492

brochures used in, 170-171

charts used in, 134

editorials used in, 170

feature notes used in, 170

films used in, 79-82, 171

in Attu campaign, 92-95

in British armies, 201

in European theater, 181

for Air Force personnel, 133-134

Training program—Continued

in French Army, 202

in German armies, 206

in Kiska operation, 97-98

in Mediterranean theater, 117-118

in Reinforcement Command, 171-172

in Zone of Interior, 172-173, 491-492

indoctrination in, 74-78

manuals used in, 68-72

news articles used in, 170

opinion survey of, 400-401

photographs used in, 134

posters used in, 72-73, 170

radio publicity used in, 170

Transfusion, in treatment of cold injury, 311

Trauma;

battle, general considerations of, 1-6

cold. See cold injury,

cold injury as component of, 363

control of, board (proposed) for, 488-489

epidemiology of, 2-6

Traveler’s legs, 10

Trenchfoot:

admissions for, in Zone of Interior, 333

amputation after, 281-282

awareness of, 266

British experience with, 374-376

in World War I, 175, 202

case histories of, 263-265, 266-268, 273-

275

classification of, 188-189

directive on, 188

in European theater, 304-305

clinical classification of, 280-281

clinical degrees of, 280-281

clinical picture of, 278-280

clinical progression of, 266, 278-279

in hyperemic stage, 269

in posthyperemic stage, 275-278

clinical stages of, 266-268

clinicopathologic groups of, 262

complications following, 284-302

Aleutians experience, 284-285

European theater experience, 290-291

Mediterranean theater experience, 285-

290

conferences on, 303, 433-434

congressional reaction to, 196-198

control teams, in European theater, 177-

178

control of, individual instruction in,

476-478

degrees of, 129

designation of, 187-188
INDEX 567

Trenchfoot—Continued

diagnosis of, 187-188

history as consideration in, 302

in World War I, 44-45, 47

ischemic-pain test in, 305

malingering as factor in, 302

neuropsychiatric consulation in, 302

objective findings in, 302

objective tests in, 302

service branch as consideration in, 302

skin temperature studies in, 305

differential diagnosis of, 303

directives on;

Circular No. 19, Hq. 12th U. S. Army

Group, 1944—167

Circular No. 108, Hq., ETOUSA,

1944—164

Circular Letter No. 126, Office of the

Chief Surgeon, ETOUSA, 1944—164,

166

General Orders No. 11, GHQ, AEF,

1918-48-49, 50

Memorandum, unnumbered, Hq. Third

U. S. Army, 21 Nov. 1944—168

Memorandum No. 4, Army Sanitary

School, AEF, 1917—51

Standing Operating Procedure 15,

ETOUSA, 1944-162-163

War Department Circular No. 48,

1944—74

War Department Circular No. 312,

1944—63-64, 65, 66, 164, 172, 221

War Department Technical Bulletin

(TB MED) 81, 1944-65-66, 164,

172, 315, 509-514, 515

War Department Technical Bulletin

(TB MED) 92, 1944—186

disability caused by, 278

disposition of patients with, 327-328

in Aleutians, 260-261

in Attu campaign, 85

in European theater, 304-305

etiologic factor in, 208

tactical situation as, 202

etiology of, 11-12, 20

evacuation system for, in European

theater, 308-309

experience with, in World War I, 379

French experience with, in World War I,

4,

German experience with, 203

grades of, 278-279

hospitalization after, 78-79

hyperemic stage of, 269

Trenchfoot —Continued

in European theater, 128, 129, 137, 138,

155, 160-173, 196-198, 216, 455

conferences on, 179-184, 186

report by General Board on, 127 report on, 208-209

review and evaluation of, 66-68

special experiences in, 181-183

in Mediterranean theater, 101-125, 145,

161

report on, 161

studies on, 266-268

summary of, 125

in World War I, 4, 5, 12, 42-52

experimental observations on, 241-242

pathologic studies on, 241, 242

incidence of

in European theater, 66, 138, 141, 171,

457-458, 459, 463, 467

in French Army, 202

in German armies, 203-204

in Kiska operation, 98-99

in Mediterranean theater, 101-106,

110, 374, 380

in Pacific, 211

in World War I, 47-48, 52

overshoe supply as factor in, 156-157

sock supply as factor in, 153-154

inflammatory stage of, 269

management of, 79, 307, 327

manpower loss due to, in—

Aleutians, 85

Mediterranean theater, 102

World War I, 48

mechanisms of, 237

nomenclature of, during World War I, 42

observations on, in—

Mediterranean theater, 269-271, 289-

290

Zone of Interior, 291-302, 378

occurrence of, with other injuries, 303

onset of, 303

opinion survey of, 400-401

pathogenesis of, 239-240

pathologic changes in, studies on, 241-242

pathologic characteristics of, 12, 266, 268

pathology of, 243-257

posthyperemic stage of, 275-278

postinflammatory stage of, 275-278

predictive tests for, 361-362

prevention of:

analysis of, 180

directives on, 65-66, 74

European theater policy on, 162-163
568 COLD INJURY, GROUND TYPE

Trenchfoot—Continued

prevention of—Continued

European theater program for, 160-173

factors in, 184

foot powder used in, 175

in Attu campaign, 175

in British armies, 201, 202

in German armies, 206-207

in reinforcements, 171-172

individual instruction in, 169-171, 476-

478

indoctrination in, 169-171

Mediterranean theater policy on, 120

ointments used in, 175-176

responsibility for, 63-64, 66, 81, 121-

125, 134, 168, 169, 183, 458

rotation, as factor in, 174

salves used in, 175-176

training program for, 76, 118-125

preventive measures in, in European

theater, 167-169, 458-459

psychogenic factor in, 315-316

public reaction to, 196

Purple Heart award for, recommendations

concerning, 190-192, 193-195

reactions in, 239

recurrence of, 103, 287-288

in Aleutians, 85

in European theater, 138, 141, 166, 171,

382

See also Epidemiology of.

rehabilitation after, 307

rehospitalization for, 329-330

reporting of, 186-189

classifications used in, 187

designations used in, 187

security classification of, 187

report on, by General Board, U. S. Forces,

ETOUSA, 159

residua of, 289-290, 307

in European theater, 290-291

residual manifestations of, categories of,

292-295

rotation as factor in, in British armies,

200-201

seasonal effect on, 374-376

sequelae of, 284-302, 307

Aleutians experience with, 284-285

Mediterranean theater expeiience with,

285-290

signs of, 278-280

variations in, 260

Treuchfoot—Continued

statistics on, in European theater, 139-

140, 141-142

studies on, 272-275

in European theater, 304-305

in Mediterranean theater, 278-280

study project on, in European theater,

280-282

survey of, in European theater, 176-177, 179^ sympathetic activity in, as residual manifestation, 292-294

symptoms of, 266, 278-280

classification of, 292-295

disappearance of, 281

variations in, 260

therapeutic observations on, 242

therapy for, in—

European theater, 163, 324-327

Mediterranean theater, 119, 315-324

World War I, 45-47, 51

Zone of Interior, 333-357

training film on, 73

training program for, in Zone of Interior,

172-173

treatment of, 307

considerations in, 315-316

general measures in, 343

in inflammatory stage, 318-320

in postinflammatory stage, 278-280

in preinflammatory stage, 316-318

morale, as factor in, 321

triage for, in European theater, 308, 309-

310

vascular changes in, in—-

inflammatory stage, 280

ischemic stage, 280

postinflammatory stage, 280

Trenchfoot control teams, 484-486

conferences on, 183-184

evaluation of, 184

functions of, 177

implementation of, 177

in European theater, 140, 177-178

recommendation for, 183

Trichophytosis, in trenchfoot, 288

Trimble, Col. I. Ridgeway, 221, 222, 223, 388.

Tropical immersion foot. See Immersion

foot, tropical.

Tube transfer grafts, following sympathectomy, 339

Turner, Lt. Col. Roy H., 194
INDEX 569

Tullidge, E. K., 54

Tuttle, Maj. Arnold D., 70

Typhoid vaccine, in treatment of trenchfoot,

294, 337

Typhus Commission, 488

Ubach, 437

Ulceration, in—-

chilblains,

immersion foot, 11

Ungley, C. C., 10, 11, 242

Unit case histories, 392, 395-397, 402, 407-

408, 414-415, 418, 402, 421-422, 426-427,

435-437, 439-442, 443-444, 445, 448, 449,

451-452, 455-469

United Kingdom, 43, 129, 148, 149, 150, 152,

171, 185

Vasoconstriction:

in cold injury, 236-237

peripheral, in frostbite, 13

Vasodilation, reflex, in treatment of trenchfoot, 318

Vasodilatator agents, in treatment of trenchfoot, 325

Vasoneuropathy, peripheral, 10

Vasospasm, in trenchfoot, 285

Venafro, 291

Venules, 236

Verdenne, 462

Verdun, 52

Veterans’ Administration, 307

Visayan Islands, 213, 215

Vitamin therapy;

in treatment of trenchfoot, 324

supplemental, in treatment of cold injury,

313

Walther, C., 56

War Department Circular

No. 32, 1944—152

No. 48, 1944—74

No. 312, 1944-63-64, 65, 66, 122, 158,

164, 166, 167, 172, 218

War Department Decorations Board, 195

War Department Field Manual (FM)

8-40, 1940—69

21-10, 1940-69

21-11, 1943—68-69

21-100, 1940-69-70

31-15, 1941—68

War Department Film (FB) 108—171

War Department General Orders No. 3, 1932—189

War Department MD Form

52—186

86ab—186, 187

War Department Pamphlet 8-9—71

War Department Technical Bulletin (TB

MED)—

81, 1944—65-66, 153, 158, 164, 172, 188,

218, 307, 324, 509-514, 515

92, 1944—186

War Department Technical Manual (TM)

1-240, 1942—71

8-210, 1942—70-71

8-220, 1941—70

10-275, 1944—70

War of the Rebellion, 37-38

War of the Revolution. See Revolutionary

War.

War Production Board, 153

survey of footgearby, in European theater,

155-156

Warren, S., 242

Washington, Gen. George, 29, 189

Water calisthenics, in reconditioning program, 354-355

Waubach, 466, 467

Weather, as factor in cold injury, 404

Webster, D. R., 7, 160, 319

Weed, Dr. Lewis H., 57

Weiner, D., 389

Western Pacific Area, 224

Wet, as factor in cold injury, 377

Wet-cold injury, in Pacific, 211

Whayne, Col. Tom F., 183

Whisky, in treatment of trenchfoot, 318, 325

White, J. C., 242

Wilmer, H. B., 55

Wind, as factor in cold injury, 416-417

Wind-chill maps, 416

Wind-chill value tables, 416

Winter clothing. See Clothing, cold-weather.

Wood, Brig. Gen. Sterling A., 180, 181-183

Woolhouse, F. M., 7, 319

World War I, 42-52

Wlirm, 456

X-ray therapy, in treatment of trenchfoot,

314-315

Yokohama, 228

Zinc oxide, in treatment of trenchfoot, 343

Zinc oxide ointment, in treatment of cold

injury, 311
570 COLD INJURY, GROUND TYPE

Zinc peroxide emulsions, in treatment of cold

injury, 311

Zone of Interior, 57-82, 117-118, 143, 149,

151, 154, 171, 173, 185, 198, 220, 229, 284, 290, 291, 301, 305, 327, 378, 383, 384, 434, 492, 502

Zone of Interior—Continued disposition of patients to, 67-68

Alaska Defense Command policy on, 85

evacuation of casualties to, 89

criteria for, 328

Purple Heart award in, 193-195