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Chapter XV

Contents

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 I (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 a result, no formal program of prevention and control was instituted. In the Mediterranean Theater of Operations (p.101), it took a bitter experience in the winter of 1943-44 to demonstrate the need for the program which was put into effect, with excellent results, 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 a bitter enemy, quite as capable of causing casualties as is a 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.
       
    A brief experience in the Pacific showed that a 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 a war must be prosecuted in a theater located in a 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


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elsewhere, cold injury was second only to combat casualties as a cause of disability and a 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 a 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 a 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 a 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 a 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 a regimental combat commander who happened to see, in the hospital in which he was a patient for another cause, precisely how serious trenchfoot can be. Another commander of an infantry regiment was wise before the event. An observer for the Army Ground Forces Board, NATOUSA,1 quotes him as saying:

     I wrote a monograph at Benning in 1928-29 on the subject of the care of the feet. 1 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 a non-battle casualty reduces your combat strength just as much as does a battle casualty * * *. The remainder of this regiment [he excluded the Japanese-American component, which for various reasons had a high rate] has consistently had the lowest trench-foot rate among the infantry of the division. This, I am sure, is largely due to the emphasis we have placed on care of the feet. I have personally conducted a school on care of the feet for the junior officers of the regiment. We require every man to go into combat with a 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 a short course on care of the feet. The instructor should be a competent doughboy who has done a lot of marching and knows how to take care of feet in wet, cold weather. I 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
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1 Report on Infantry, Army Ground Forces Board, Army Ground Forces Headquarters, NATOUSA, 27 Mar. 1944.


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promptly have been reduced to a minimum. Soldiers who contracted trench-foot 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 a hospital in Italy: 2
       
    Not a single person I 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, I 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 all right 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 a talk given to soldiers by a medical officer.
       
    Naturally, the talk should emphasize the ill effects of the ailment rather than describe it as a means of getting back to the hospital for a 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 walking) 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 a 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 a cellophane wrapper or canned in something like a ration tin, they would have a better chance of being dry when the change was made.
       
    Back in a bivouac or rest 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 a 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 a 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
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2 Report, Lt. Col. F. A. Simeone, to Surgeon, Fifth U. S. Army, subject: Trench Foot in the Italian Campaign 1943-45,   1945.


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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.366) 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.
       
    Athough it has been recognized since World War I 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 I 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 are properly sized, well fitted, correctly worn, and always readily available; (2) the mainte-


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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 individual soldier 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 lie goes to sleep. He must massage his feet at regular intervals. He must so fully understand the necessity for movement that lie will automatically exercise his feet and legs whenever he can, even if lie 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 lie suspects that lie has sustained a 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 a frontline position to a dugout, a tent, the basement of a 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 a 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 a battalion, a regiment, or some other military unit out of the line into a reserve position in the division area or farther back in the corps or army area. This type of rotation concerns a total military organization, in contrast to individual rotation. Both types should be practiced on a 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 a 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 a program is made an integral part of unit training and discipline, a 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


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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 a role in the success of a 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 unless 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, by 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 a 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 trench-foot which the individual soldier should know:
       
    1. Trenchfoot is produced by standing or sitting about over a 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. They are swollen and


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white except for a 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 a hospital where he can be treated adequately. In the meantime, lie 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 socks 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 are 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 a 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


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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 a 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 a 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 a 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. 3
     
    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 a whole in relation to his environment. Only from such an all-inclusive program can there conic the fullest understanding of the factors involved in cold and other trauma. Whether a research program, and the organization necessary to carry it out, should be set up within the framework of the Armed Forces or under a civilian science foundation is a 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.
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3 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 exposure sustained 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 Department of the Army has evaluated equipment in relation to environment at a post set up in a 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, a research team was sent to Korea to study a program of prevention and control which, for the first time in United States Army history, was planned in advance of the expected cold injuries.


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A COMPREHENSIVE PROGRAM FOR THE PREVENTION AND CONTROL OF COLD TRAUMA 4
 
    A 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 been 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 a 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, a 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 a member of a 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 a 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 be fully effective in time of war, their training and indoctrination with respect to cold injury must be undertaken in time of peace.
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4 The authors of this volume, on the basis of their personal experiences in World War II and after a thorough review of both the good and the bad practices in the control of cold injuries in this war, believe that the preventive principles outlined in the following pages should be adopted.


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    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 a 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 a 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 a part of the training of the individual soldier in the Zone of Interior during peacetime is a 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,


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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 a test, the results would have been satisfactory.

    Cold injury indoctrination in overseas theaters should be 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) A 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 a 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 a 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 a deputy chief of staff serve in this capacity, so that the theater commander may be kept fully cognizant of its findings, decisions, and recommendations.
     
    A 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 effectivness with which the cold injury program is being carried out by the major theater organizations. Other functions of such a hoard 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


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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. A 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 cold-trauma 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 a 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 a 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 a 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


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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 sufficient rank, 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 a 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 a 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


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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 a cold injury indoctrination program in a 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 a 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 a 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 a theater-wide indoctrination program within from 6 to 8 weeks. It should also be possible to accomplish the total instruction required for any given combat unit within a period of from 3 to 6 days if, during this time, arrangements can be made for each component of the unit to receive from 3 to 6 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 has been careful, it is perfectly possible to phase the training program for cold injury within an army in such a 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 a field army rests with the army trenchfoot-control team. This team is made up of a line officer with combat experience and an officer from the Quartermaster Corps. It is not necessary for the team to include a 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 a thorough knowledge of methods of prevention of cold injury, as well as an understanding of


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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 a 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, a 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 a 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 a 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 results.
       
    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 a few corps and in several divisions, and they were occasionally employed at, regimental and battalion levels. Though this is entirely a matter for local command decision, it is somewhat doubtful that the mission of these teams justifies their routine use below the army level. A cold injury control officer would seem sufficient for an organization smaller than an army.


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    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, a control team from an army or a 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 a period of intensely active combat. With correct advance planning, this 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 trenchfoot-control 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 trenchfoot control team system, in conjunction with cold injury control officers, noncommissioned officers, and key enlisted men, requires full 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.


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ALTERNATIVE PLANS
 
    The experience of World War II amply demonstrates that the teani 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 a special organization to accomplish what should be accomplished automatically by ordinary staff and command methods. Furthermore, it might be argued that if a 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 a number of extra organizational 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 a 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 a 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


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this practice. So is the Special Epidemiologic Unit created by the United States Navy in World War II and used with such effectiveness that it was made a part of peacetime naval medical organization. The epidemiologic teams set up by 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.
 
A 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 a 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 a 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 a 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 a part of the total field of trauma, and combat trauma is a constant wartime problem. Trauma from accidents of all kinds is also a 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 board would be 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 a proposal. Both World War I 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, a board for the control of pneumonia performed a 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


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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 a 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 a board for the prevention and control of trauma, including cold trauma, might eventually lead to an even broader concept, the establishment of a board of preventive medicine. Such a board would be composed of command, staff, and service and technical experts. Its function would he 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.