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Cold Injury, Ground Type

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MEDICAL DEPARTMENT
UNITED STATES ARMY IN WORLD WAR II


Trenchfoot, ground type

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, Jr., MC

Associate Editor
ELIZABETH M. MCFETHRIDGE, M.A.

OFFICE OF THE SURGEON GENERAL
DEPARTMENT OF THE ARMY
WASHINGTON, D. C., 1958


COLD INJURY, GROUND TYPE, IN WORLD WAR II

The Historical Unit, United States Army Medical Service
Colonel JOHN BOARD 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 B. HINE, Chief, Administrative Branch


COLD INJURY, GROUND TYPE

by
Colonel TOM F. WHAYNE, MC, USA (Ret.)
Professor of Preventive Medicine, School of Medicine,
University of 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, A US


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 II:
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


Contents

FOREWORD
PREFACE
ACKNOWLEDGMENTS

Chapter

I General Considerations of Battle Trauma
The Epidemiology of Trauma

II General

Considerations of Cold Injury
Types of Cold Injury
The Spectrum of Cold Injury

III Historical
Note
The Napoleonic Wars
The Crimean War
The War of the Rebellion
Other Wars of the 19th Century
The Russo-Japanese War
The Tibet Expedition of 1903-4
The Balkan Wars
World War I
The Spanish Civil War
Etiologic Considerations
Cold Injury of the Hand

IV Actions
Taken in Zone of Interior
May1942-October 1943
October1943-March 1945
Training Program
Hospitalization of Trenchfoot Casualties
Investigations
Conclusion

V The Aleutians
The Attu Campaign
The Occupation of Kiska
Summary

VI Mediterranean (Formerly North African) Theater of Operations
Incidence
Tactical Situation
Climatic Factors
Clothing and Footgear
Indoctrination and Training
Summary

VII European Theater of Operations
High-Altitude Cold Injury in the Eighth Air Force
Tactical and Environmental Considerations
Incidence
Clothing and Footwear
Development of Trenchfoot-Control Program
Other Considerations of Prevention and Control
Epidemiologic Survey and Control
Conferences
Clinical Investigations
Reporting and Nomenclature
Award of the Purple Heart
Public and Congressional Reactions to the Trenchfoot Situation in Europe
Experiences of Other Armies
Statement by the General Board
The Calculated Risk

VIII The Pacific
PART I. COLD INJURY IN THE TROPICS
Clinical Aspect

PART II. THE WET-COLD PROBLEM
Office of the Surgeon General
Medical Planning in the Pacific
Action by Commanders in Pacific
The Quartermaster Corps
Practical Considerations of the Wet-Cold Indoctrination Program
Indoctrination of Other Services
Summary
IX Pathogenesis and Pathologic Process
Pathogenesis
Pathologic Process

X Clinical Picture and Diagnosis
General Considerations
The Aleutians
The Mediterranean (Formerly North African) Theater
The European Theater
Overseas Complications and Sequelae
Observations in the Zone of Interior
Diagnosis Overseas

XI Therapy and Disposition Overseas
Evacuation and Triage
The Aleutians
Mediterranean Theater of Operations
European Theater
Results of Therapy-Disposition

XII Therapy and Disposition in Zone of Interior
Previous(Overseas) Treatment
Therapy(Medical Phase)
Therapy (Surgical Phase)
Reconditioning
Disposition
Predictive Tests

XIII The Epidemiology of Cold Injury
General Considerations
Analysis of Selected Divisions by Correlation Studies
Epidemiologic Analyses of Agent, Host, and Environmental Factors
Summary

XIV The Cold Injury Record of the 84th Infantry Division
8-28 November 1944
29 November-20 December 1944
21 December 1944-2 January 1945
3-16 January 1945
16-31 January 1945
2 February-5 March 1945
Analysis of the Total Experience

XV The Prevention and Control of Cold Injury
General Considerations
Preventive Principles and Practices
Research on Cold Trauma
A Comprehensive Program for the Prevention and Control of Cold Trauma
Alternative Plans
A Proposed Board for the Control of Trauma

XVI The Military Cost of Cold Injury
The Facts of Cold Injury in Theaters of Operations
An Evaluation of the Costs of Cold Injury
Advance Planning

APPENDIXES

A War Department Technical Bulletin (TB MED 81)
B. Army Ground Forces Training Directives
C Medical Circular No. 6
D Letter on Trenchfoot, Headquarters, NATOUSA
E Circular 108
F Memorandum on Trenchfoot, Headquarters, Third U. S. Army
G Trenchfoot-Control Officers, ETOUSA
H Wet-Cold Indoctrination Program, AFPAC
I Training Memorandum No. 1
J Letter on Trenchfoot, Headquarters, NATOUSA
K Circular No. 55

INDEX

Illustrations
Figure
1 Photomicrograph of small artery of finger amputated for high-altitude frostbite
2 Capillary bed in normal and frostbitten fingers
3 Blanching of fingers in high-altitude frostbite
4 Wet type of moderately severe high-altitude frostbite
5 Wet type of severe high-altitude frostbite
6 Wet type of moderately severe high-altitude frostbite
7 Wet type of severe high-altitude frostbite
8 Wet type of severe high-altitude frostbite
9 Photomicrograph of skin in high-altitude frostbite
10 Persistent hypesthesia in high-altitude frostbite
11 Dry type of mild high-altitude frostbite
12 Dry type of severe high-altitude frostbite
13 Dry type of severe high-altitude frostbite
14 Dry type of severe high-altitude frostbite
15 Dry type of severe high-altitude frostbite
16 Mixed wet and dry types of severe high-altitude frostbite
17 Dry gangrene of toes of both feet due to freezing
18 Properly equipped and clothed soldier
19 Mired tractor and trailer, Massare Bay, Attu
20 Landing beach in Holtz Bay area, Attu
21 Field hospital on Attu
22 Combat boots worn on Kiska
23 Shoepacs worn during occupation of Kiska
24 Cold-weather uniform
25 Liri-Garigliano Valley, Italy, February 1945
26 Service shoes worn by trenchfoot casualty in Italy
27 United States Army field combat boot
28 Instructional material on prevention of trenchfoot
29 Instructional material on prevention of trenchfoot
30 Instructional material on prevention of trenchfoot
31 Muddy roads in France, November 1944
32 Snow-covered terrain, Battle of Bulge
33 Winter footgear used by German troops in France
34 Tropical environment favorable to skin diseases
35 Phagocytosis of fat in late trenchfoot
36 Oil cyst in late trenchfoot
37 Connective tissue replacement in late trenchfoot
38 Changes in subcutaneous fat lobules in late trenchfoot
39 Thrombosis of posterior tibial vein in early trenchfoot
40 Thrombosis of artery in late trenchfoot
41 Mural angiitis in early trenchfoot
42 Changes in posterior tibial artery in early trenchfoot
43 Change in plantar artery in late trenchfoot
44 Changes in artery in trenchfoot
45 Obliteration of arterial lumen in late trenchfoot
46 Recanalization of artery in trenchfoot
47 Recanalization of artery in late trenchfoot
48 Atrophy of muscle in late trenchfoot
49 Changes in posterior tibial nerve in early trenchfoot
50 Demyelinization of nerve in late trenchfoot
51 Changes in nerve in late trenchfoot
52 Phagocytosis in nerve in late trenchfoot
53 Degeneration of nerve in late trenchfoot
54 Sclerosis of nerves in late trenchfoot
55 Necrosis of bone in late trenchfoot
56 Subsiding inflammatory state of trenchfoot
57 Trenchfoot third day after exposure
58 Trench hands
59 Inflammatory stage of trenchfoot
60 Postinflammatory state of trenchfoot
61 Late inflammatory state of trenchfoot
62 Postinflammatory stage of trenchfoot
63 Early postinflammatory stage of severe trenchfoot
64 Subsiding inflammatory stage of trenchfoot
65 Subsiding inflammatory stage of trenchfoot
66 Late postinflammatory stage of trenchfoot
67 Postinflammatory stage of trenchfoot
68 Late postinflammatory state of trenchfoot
69 Second-and third-degree cold injury
70 Serial changes in trenchfoot
71 Severe flexion contractures of toes after trenchfoot
72 Late postinflammatory stage of trenchfoot
73 Late postinflammatory stage of trenchfoot
74 Late postinflammatory stage of trenchfoot
75 Early postinflammatory stage of trenchfoot
76 Late postinflammatory stage of trenchfoot
77 Typical hyperkaratosis in late trenchfoot
78 Persistent swelling in late trenchfoot
79 Atrophy of muscles in late trenchfoot
80 Atrophy of muscles and periphery neuritis in late trenchfoot
81 Superficial gangrene in late trenchfoot
82 Deep bilateral gangrene in late trenchfoot
83 Management of early trenchfoot in clearing station
84 Management of early trenchfoot in clearing station
85 Effect of sympathectomy in severe trenchfoot
86 Inflammatory stage of trenchfoot after hospitalization
87 Heelwalking in late trenchfoot
88 Correction of heelwalking
89 Management of extensive bilateral gangrene in late trenchfoot
90 Management of extensive bilateral gangrene in late trenchfoot
91 Management of extensive bilateral gangrene in late trenchfoot
92 Management of bilateral gangrene in late trenchfoot
93 Management of bilateral gangrene in late trenchfoot
94 Amputation for gangrene in late trenchfoot
95 Amputation for gangrene in late trenchfoot
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
99 Skin grafting in late trenchfoot
99 Skin grafting in late trenchfoot continued
100 Tube transfer grafts after amputation for gangrene in late trenchfoot
101 Tube transfer grafts after amputation for gangrene in late trenchfoot
102 Tube transfer grafts after amputation for gangrene in late trenchfoot
103 Technique of tube transfer graft in late trenchfoot
104 Technique of plaster immobilization after tube transfer grafts
105 Unsatisfactory stump after loss of toes in trenchfoot

Tables
1 Morbidity and mortality data, United States Army, in four major wars,1861-1945
2 Cold injury on Attu
3 Trenchfoot and battle casualties, Fifth U. S. Army, Italy, 1943-44
4 Trenchfoot and battle casualties, Fifth U. S. Army, Italy, 1944-45
5 Trenchfoot and battle casualties, British 10 Corps, Italy, 1943-44
6 Comparative incidence rates for trenchfoot and battle casualties, Fifth U. S. Army, 1944-45
7 High-altitude frostbite, Eighth Air Force, 1942-45
8 Tissue damage in trenchfoot in relation to duration of exposure
9 Residual manifestations of trenchfoot
10 Classification and disposition of trenchfoot cases
11 Scores of 21 infantry divisions, European theater, by cold injury modifying factor, November 1944
11 Scores of 21 infantry divisions, European theater, by cold injuryt modifying factor, November 1944 continued
11 Scores of 21 infantry divisions, European theater, by cold injuryt modifying factor, November 1944 continued
11 Scores of 21 infantry divisions, European theater, by cold injuryt modifying factor, November 1944 continued
11 Scores of 21 infantry divisions, European theater, by cold injuryt modifying factor, November 1944 continued
12 Scores of 21 infantry divisions, European theater, by cold injury modifying factor, December 1944
12 Scores of 21 infantry divisions, European theater, by cold injury modifying factor, December 1944 continued
12 Scores of 21 infantry divisions, European theater, by cold injury modifying factor, December 1944 continued
12 Scores of 21 infantry divisions, European theater, by cold injury modifying factor, December 1944 continued
13 Cases of trenchfoot in 21 infantry divisions, European theater, November-December1944
14 Comparative incidence rates for trenchfoot cases and battle casualties, Italy, October 1944-March 1945
15 Age of 1,018 patients with trenchfoot
16 Combat exposure of 1,018 patients with trenchfoot
17 Cold injury, 83d Infantry Division, European theater, November 1944-January1945
18 Cold injury, 8th Infantry Division, European theater, November 1944-February1945
19 Results of opinion survey on trenchfoot prevention
20 Cold injury, 95th Infantry Division, European theater, November-December1944
21 Mean-temperature, precipitation, and cold injury cases, First U. S. Army, European theater, November 1944-February 1945
22 Mean temperature, precipitation, and cold injury cases, Third U. S. Army, European theater, November 1944-February 1945
23 Cold injury admissions and rates for the First, Third, Seventh, Ninth, and Fifteenth U. S. Armies, European theater, November 1944-April 1945
24 Cold injury, 30th Infantry Division, European theater, November 1944-February 1945,
25 Cold injury, 9th Infantry Division, European theater, November 1944- March1945
26 Cold injury, 104th Infantry Division, European theater, November 1944-January1945
27 Cold injury. 29th Infantry Division, European theater, November-December1944
28 Cold injury, 78th Infantry Division, European theater, December 1944-January1945
29 Cold injury cases in armored divisions, European theater, October 1944-March1945
30 Arm or service of 1,018 patients with trenchfoot
31 Cold injury, 2d Infantry Division, European theater, November 1944-February1945
32 Daily incidence of trenchfoot and frostbite; 2d Infantry Division, European theater, January-February 1945
33 Cold injury, 5th Infantry Division, European theater, 11-24 November, 1944
34 Cold injury, 90th Infantry Division, European theater, November-December1944
35 Cold injury. 102d Infantry Division, European theater, November 1944-February1945
36 Cold injury, 87th Infantry Division, European theater, 11-22 December,1944
37 Cold injury, 346th Regiment, 87th Infantry Division, European theater,11-22 December 1944
38 Cold injury, 99th Infantry Division, European theater, November 1944-March1945
39 Cold injury, 45th Infantry Division European theater, November-December1944
40 Cold injury, 35th Infantry Division, European theater, 8-30 November,1944
41 Mean temperature, precipitation, and cold injury cases, 84th Infantry Division, European theater, November 1944-January 1945
42 Admissions for cold injury, all theaters, 1942-45
43 Incidence of cold injury, all theaters, 1942-45
44 Incidence of cold injury, all theaters, 1942
45 Incidence of cold injury, all theaters, 1943
46 Incidence of cold injury, all theaters, 1944
47 Incidence of cold injury, all theaters, 1945
48 Cold injury, Ground Forces, European theater, 1944-45
49 Cold injury, major commands, European theater, 1944-45
50 Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and prevalence rates, United States forces, Mediterranean theater, 1943-45
50 Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and prevalence rates, United States forces, Mediterranean theater, 1943-45-continued
51 Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and prevalence rates, United States forces, European theater, 1943-45
52 Ratio of cold injuries to battle casualties by United States force or army, Attu and Mediterranean and European theaters-

Charts
1 Cold tolerance of normal and frostbitten hands
2 Gradient (schematic) of cold injury
3 Incidence of trenchfoot in relation to various environmental factors, Fifth U. S. Army, Italy, 1943-44
4 Incidence of trenchfoot in relation to various environmental factors, Fifth, U. S. Army, Italy, 1944-45
5 Evacuation, cold injury casualties, European theater
6 Trenchfoot incidence rates, Italy, October 1944-March 1945
7 Comparison of ratios of trenchfoot to battle casualties, Italy, October, 1944-March 1945
8 Cold injury, 83d Infantry Division, European theater, November 1944-January1945
9 Cold injury, 8th Infantry Division, European theater, November 1944-February1945
10 Cold injury, 95th,Infantry,Division, European theater, November-December1944
11 Cold injury cases, mean temperature, and precipitation, First U. S. Army, European theater, November-December 1944
12 Cold injury cases, mean temperature, and precipitation, First U. S. Army, European theater, January-February 1945
13 Cold injury cases, mean temperature, and precipitation, Third U. S. Army, European theater, November-December 1944
14 Cold injury cases, mean temperature, and precipitation, Third U. S. Army, European theater, January-February 1945
15 Total cold injury incidence rates for the First, Third, Seventh, Ninth, and Fifteenth U. S. Armies, European theater, November 1944-April 1945.
16 Cold injury, 30th Infantry Division, European theater, November 1944- February1945
17 Trenchfoot and frostbite, 9th,Infantry,Division, European theater, November1944-March 1945
18 Cold injury, 104th Infantry Division, European theater, November 1944-January1945
19 Cold injury, 26th Infantry Division, European theater, November-December1944
20 Cold injury, 29th Infantry Division, European theater, November-December1944
21 Cold injury, 78th Infantry Division, European theater, December 1944-January1945
22 Cold injury, 2d Infantry Division, European theater, November 1944-February1945
23 Cold injury, 5th Infantry Division, European theater, 11-24 November,1944
24 Cold injury, 90th Infantry Division, European theater, November-December 1944
25 Cold injury, 102d Infantry Division, European theater, November 1944-February1945
26 Cold injury, 87th Infantry Division, European theater, 11-22 December,1944
27 Cold injury, 346th Regiment, 87th Infantry Division, European theater, 11-22 December 1944
28 Cold injury, 99th Infantry Division, European theater, November 1944-March1945
29 Cold injury, 45th Infantry Division, European theater, November-December1944
30 Cold injury, 35th Infantry Division, European theater, 8-30 November 1944
31 Cold injury in relation to environmental factors, 3d Infantry Division, European theater, January-February 1945
32 Mean temperature, precipitation, and cold injury cases, 84th Infantry Division, European theater, November 1944-January 1945