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Chapter XVI


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 II, 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 a full appreciation is t.o 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.
    A 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 a 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 a 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

that they made almost no impression on the training program in the Zone of Interior, and they were not utilized as a 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 a 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 a 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 a 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 a few United States casualties in World War I, in October, November, and early December 1918, should not have been appreciated as a potential source of heavy casualties in World War II. As a 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 a 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 a 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 Attu (p.84), the experiences of a small and uninitiated task force demonstrated the role of cold and wet as agent factors, and also emphasized the importance of the

TABLE 42.- Admissions for cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1942-45  

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 Attu 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 a 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 a 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 a 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


TABLE 43.- Incidence of cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1942-45

fit so snugly that a heavy wool sock could be worn only by issuing a larger size shoe. Supplies were not adequate for such a 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 a 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 a short time-a matter of days-before trench-foot made its appearance in the theater. In the early winter of 1943-44, a number of command directives relating to the prevention and management of trenchfoot were published and disseminated (appendixes C and D), but they appeared only after the condition had 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 a high incidence of casualties from trench-foot (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

TABLE 44.- Incidence1 of cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1942
    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 a great reduction in the incidence of cold trauma as compared with the previous winter (tables 3 and 4) and a 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 a 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.

TABLE 45.-  Incidence of cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1943
    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 a 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 trench-foot 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 K and G).
    As a 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.

TABLE 46.- Incidence of cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1944
    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 a 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). A program of prevention was finally formulated, but only after a 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.
    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.

TABLE 47.- Incidence of cold injury in the United States Army (including the Army Air Forces) by specific diagnosis and theater, 1945
    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 a 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 ccst of uncontrolled cold injury in World War II was enormous.
    Since it would also be an impracticable task to revise unit data, or even data for armies or total ground forces for a theater, by a 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 a serious problem (that is, the Mediterranean and European theaters) are considered, and if the total cases

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 (lays.
    An average loss of 83 days per case means that there was a 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 man-years. If the loss is considered in terms of a hypothetical field army of 250,000 men, it represents the noneffectiveness of the entire field army for about 1 month. If it is considered in terms of a 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 a 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 lie 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. A 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 3 regiments of 3 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 3 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 5 divisions of 15,000 men each was lost to combat.
    This still, however, does not give a true picture of the situation. Approximately 90 percent of all cold injury casualties were riflemen, of whom about


TABLE 48- Cold injury incidence for the United States Army Ground Forces, European theater ( Continent only), by month, November 1944 through April 1945

4,000 were in each infantry division. The loss of effective fighting strength from cold injury thus could be interpreted as more nearly 16 divisions than as 5 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 II approximated 91,000. The total time lost is estimated as 7,514,000 man-days, or 20,586 man-years, 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 a  


TABLE 49.- Cold injury incidence in major commands, United States Army, European theater(Continent only), by month, November 1944 through April 1945
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 a 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 a 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 a 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 a higher level for a 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

combat effectiveness of some of the smaller units, in fact, was reduced by more than half during some weeks of the November offensive.
    Reinforcements.1- 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. A 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 8 to 15 weeks of basic training before he can be assigned to a 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 a 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 a unit that has experienced high casualties for any cause and that must operate with a 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 a 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 a 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 a hospital bed for periods varying from a 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
1 See footnote 49, p. 171.

6 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 9 February 1945 (table 51). Not all of these men, it is true, occupied hospital beds on any given day, but a 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

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 gas-treatment 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 perations. 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 a sound criterion of the military cost of cold trauma.


TABLE 51.-  Trenchfoot, immersion foot, and frostbite patients remaining in hospitals, and prevalence rates, United States forces, European theater, 1943-45

    In the 22-day operation on Attu in May and June 1943 (table 52), which was a small operation, the ratio of cold injuries to battle casualties was approxi - mately 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 a ratio of only 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 a 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 a 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. Army in Italy for the winter of 1943-44 and the winter of 1944-45.

    Details of the program of prevention and control planned for the invasion of Japan, and planned well in advance of the date 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 a coordinated effort. Training personnel, Quartermaster Corps personnel, and medical specialists and organizations united in a common effort to meet the potential problem. In these endeavors, all the services were fully supported by command. Behind the entire effort was 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 a 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 was to train him in the use of his rifle to protect himself in combat.

    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.