CHAPTER III
Historical Note
With the single, and notable, exception of Larrey's1 observations during the Napoleonic Wars, injuries of warfare caused by cold and exposure were not recorded in any great detail until fairly modern times, more particularly until World War I. Numerous brief references, however, indicate that this type of injury was responsible for an important loss of manpower in early military history. Thus, there are references to frostbite in the writings of Hippocrates, Aristotle, and Galen. The armies of Alexander of Macedon experienced casualties from this cause.2 According to Grattan,3 Xenophon, in the Anabasis, mentions cold injury as a significant problem in the Greek armies operating in western Armenia late in the fourth and early in the third centuries B. C.
In more modern times, Thatcher described serious losses from cold injury.4 In 1777, 2,900 of an army of 10,000 men were unfit for duty because of sickness and lack of clothing. By February of the following year, the number of casualties had been increased by nearly a thousand men who, according to General Washington, "had been left to perish by winter cold and nakedness." In January 1780, some 20 percent of 2,500 men sent from Elizabethtown to attack the British on Staten Island also suffered cold injuries. Thatcher writes: "The party passed over on the ice * * * but the enemy having received intelligence of their design returned into their strongworks * * * . The snow was three or four feet deep, the weather extremely cold, and American troops continued on the island for twenty-four hours without cover. About 500 were slightly frozen."
Benjamin Rush,5 who was physician general to the military hospitals of the United States during the Revolutionary War, contributed, perhaps unwittingly, some useful advice in the prevention of cold injury. In a small pamphlet of directions for preserving the health of soldiers, he wrote: "The
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1 Larrey, D. J.: Memoirs of Military Surgery and Campaigns of the French Armies, on the Rhine, in Corsica, Catalonia, Egypt, and Syria; at Boulogne, Ulm, and Austerlitz; in Saxony, Prussia, Poland, Spain, and Austria. Translated by Richard Willmott Hall, with notes by the translator. First American edition from the second Paris edition. Baltimore: Joseph Cushing, 1814, 2: 153-164; 205-224; passim.
2 Ariev, T. V.- Fundamental Outlines of Present Day Knowledge of Frostbite. Medgiz: Moscow, 1943. This is one of a series of 16 papers originally published in Russia from 1939 to 1944 and translated into English and published by Earl R. Hope, in Ottawa, Canada, in 1950 under the title "Frostbite."
3 Grattan, H. W.: Trench Foot. In History of the Great War Based on Official Documents. Medical Services. Surgery of the War. London: His Majesty's Stationery Office, 1922, 1:169-177.
4 Thatcher, James: Military Journal of the American Revolution. Hartford: Hurlburt Williams and Co., 1862, pp. 127, 188.
5 Rush, Benjamin: Directions for Preserving the Health of Soldiers, Addressed to the Officers of the Army of the United States. Published by order of the Board of War, 1777. Pennsylvania Packet, No. 284.
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commanding officer should take the utmost care never to suffer a soldier to sleep, or even to sit down in his tent with wet clothes, nor to lie down in a wet blanket or upon damp straw. The utmost vigilance will be necessary to guard against this fruitful source of diseases among soldiers."
THE NAPOLEONIC WARS
The role of cold as such in the production of injuries to the body tissues was vividly, and for the most part correctly, described by Baron Larrey, surgeon to the French armies in the Napoleonic Wars. His classic description of the part played by frostbite and "congelation" in the defeat of these armies in Poland in 1812 is an accurate and affecting resume of the tactical and clinical effects of injuries caused by cold. It is of sufficient importance, in fact, to be related in considerable detail.
Baron Larrey began his military medical career in the French Navy, serving in waters in which immersion foot might well have been observed. At the end of 2 years, chiefly because of his susceptibility to seasickness, he transferred to the army, in which he became a division surgeon. In this new position, lie quickly perceived that the previously accepted practice of waiting to care for the wounded and dispose of the dead until the battle had moved on was resulting in great, and for the most part unnecessary, loss of life and limb. To remedy the situation, he devised a field medical organization in which light ambulances, together with field stations, brought medical care to the wounded immediately behind the lines. He eventually developed this service to such a point that it was often possible to have all the wounded off the field and cared for by military surgeons within 24 hours after a battle had ended. The development of this effective divisional medical service gained such recognition for Larrey that he was withdrawn from his division and charged with the responsibility of developing a similar system for the whole army. Shortly afterward, he was ordered to join the army commanded by Napoleon, with whom he served for many years, eventually becoming chief surgeon of the Grande Arm?e which was to invade Russia.
The principles and practices of military medicine laid down by Larrey are essentially those used in modern military field medicine. He was, in addition to being an administrative genius, a skillful and accomplished surgeon, and it is not surprising, therefore, that his description of frostbite and of the changes underlying its clinical manifestations comes very close to the present concept of the causation and pathogenicity of injuries of warfare caused by cold.
Causes of cold injury.- Physicians who had previously written on this type of "mortification," Larrey pointed out, believed cold to be the exciting cause of the gangrene. Attention to the time at which the gangrene occurred, however, as well as to its progress and the phenomena which accompanied it, would make it clear that cold was only the predisposing cause. Between the 5th and
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9th of February 1807, before the battle at Eylau, in Prussia, not a single soldier in the French Army complained of frostbite, although the temperature ranged from -10? to -15? R. (Reaumur thermometer) or from 9.5? to -1.8? F. and during this period they had spent all of their days and most of their nights in the snow and in most severe frost. Even the Imperial Guard, which had been on duty for more than 24 hours, in the snow, without much exercise, did not suffer frostbitten feet.
During the night of 9 and 10 February, the temperature suddenly rose to 3?-5? R. (38.8?-43.2? F.). On 10 February, a copious fall of sleet occurred, and the following day a thaw set in and continued for some time. Almost immediately, a number of soldiers of both the guard and the line began to complain of their feet. Their first symptoms were "acute pains in the feet, torpour, heaviness, and a disagreeable pricking in the extremities, which were slightly swelled and of a dark red." In some instances, the base of the toes and the upper surface of the foot were slightly reddened. Sometimes, the toes were without any sensation, heat,, or motion and were black and "in a manner dried."
Without exception, the affected soldiers assured Larrey that they had felt no pain or other untoward sensations during the severe cold in bivouac on 5-9 February and that it was not until 10 February, when the temperature rose by 18? to 20? R. (40.5?-45? F.), that they began to experience "congelation." The first symptoms were not severe. Painful, pricking sensations were succeeded by numbness, stiffness, immobility, and a sense of heaviness as well as of cold. Those men-fortunately the greater number-who followed the advice of Larrey and his colleagues, to rub the affected parts immediately with snow and later with camphorated brandy, did not suffer from gangrene if it. was not already present when treatment was begun. Those able to go into town, like those who approached the fire of the bivouac to warm themselves, were severely affected. Gangrene appeared almost abruptly and progressed rapidly in men who approached the fire. While it was generally limited to the toes and seldom rose above the ankle, in some instances it extended over half of the foot.
This type of "sphacelus of the foot," Larrey emphasized, should not be confused with gangrene of the skin. He had observed casualties in whom, while the skin of the foot was deprived of life to a greater or lesser degree, the vessels, deep-seated nerves, tendons, ligaments, and bones were not affected. The patient experienced pain when the subjacent parts were touched, but the foot retained its internal heat and could be moved. Gangrene of this type, Larrey continued, "* * * is superficial, and cannot be considered as similar to the sphacelus of the foot that deprives it of motion, of sensibility, and of all the phenomena of life. The patient cannot feel that he has a foot and it appears like a foreign body suspended to his leg."
Then followed the important warning that tine nature of the disorder must be carefully ascertained before amputation was resorted to and that general remedies should always precede surgery.
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Larrey's explanation of the progress and development of this gangrene, or, as he preferred to call it, of "the modus operandi of the causes which produce it," follows, in his own words:
Cold acts on the living parts by blunting the sensibility of those organs which are subjected to its immediate impression: the natural heat is absorbed, and a discharge and repercussion of calorick takes place: the pores are closed: the fibres and the capillary vessels fall into a state of contraction: the fluids are condensed, and flow more slowly. At first, the action of the cold is painful: the skin wrinkles and loses its natural colour. Yet, the animal heat and the vital powers resist this sedative and contracting power that opposes the return of the fluids: the capillary system is obstructed more easily when its extreme ramifications are weakened. The skin becomes red, its sensibility is blunted, and if the effects of the cold continue, it gradually becomes extinguished and torpour soon takes place. The parts may remain for a longer or shorter period in this state of asphyxia without losing their life; and if the cold be removed by degrees, or if the person affected by it pass gradually into a more elevated temperature, the equilibrium may be easily reestablished with the functions of the organs, and the disposition that the parts have to fall into gangrene is removed: but if on the contrary, persons who are thus affected by cold pass suddenly from a temperature at the freezing point to one more elevated, an obstruction of the parts affected must of necessity be produced; and if it be considerable, the vessels lose their elasticity altogether, become paralyzed, and sometimes burst, or are torn asunder: and hence follow blisters and cracks, or fissures of the part. The course of the fluids in the vessels is interrupted; there is a redundance of carbon, the parts turn black, and gangrene is abundant. Infection is propagated to all those parts which have been seized on, or affected by the cold. Thus the gangrene advances until it meets with resistance from the vital powers. Now the systaltick motion of the vessels, the irritability of the cellular substance of the membranes and of the skin, which had resisted the action of the cold, resist the principles of the gangrene, and far from absorbing them, the extremities of the capillary vessels which convey blood, and the lymphaticks being irritated by these heterogeneous qualities, become obstructed and inflamed: the gangrene is circumscribed, and a line of separation formed between the dead and the living parts. If the mortification be superficial, the sloughs are generally thrown off between the ninth and thirteenth days: they leave a wound or ulcer which soon heals. If the whole of a limb be deprived of life, nature of herself is not sufficient to remove the dead parts, because she has too many obstacles to surmount; at least she can seldom overcome them. The resistance almost always surpasses her power, and the patient sinks in consequence of the absorption that takes place when the sloughs are detached, and suppuration has opened the mouths of the absorbents. This absorption affects organick life: a slow fever ensues, with colliquative diarrhoea: the gaseous exhalations from the gangerened parts disorder the organs of respiration, and concur with the matter that has been absorbed, in producing a general debility of the functions, and death. After some time, gangrene may pass immediately to the neighbouring parts; but this can never happen before the ninth or tenth day, when the sloughs fall off: the vessels and the cellular tissue are then prepared to absorb, but that does not always take place, and then the disease may remain stationary: it becomes defined, and the dead parts separate from those which retain their vital power and action, and the general functions are not disturbed. The dead parts fall off, the sores which are the consequence, soon heal up, and the patient recovers.
Larrey concluded his description of these phenomena with the assertion that he was quite positive that they never appeared until the temperature was suddenly raised "from a very low to a very high degree above zero." He was convinced that "partial or general death" cannot take place merely from the severity of the weather in persons subjected to the influence of cold for a long
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period, "even until they are seized with asphyxia, unless a second sedative or narcotick cause act internally in concert with it."
Numerous instances were cited to support this theory. Thus, travelers who crossed the Alps and the Pyrenees during intense frosts did not suffer harm as long as the level of cold remained the same. Larrey had had this experience himself. The Polonese chose "the time of the most regular cold" to undertake long and difficult journeys from Siberia but avoided travel when the temperature was variable because, they told Larrey, they feared "the effects of congelation." In May 1788, while Larrey and his companions were in North America, they found at Belle Isle, near Newfoundland, a number of persons who had been shipwrecked and who had passed several days lying under the snow during a period of intense cold. The victims suffered no accidents during this period; but when the temperature changed, on the day of their rescue, two died suddenly and the feet of several others "fell into gangrene."
At the end of the winter of 1795, when Larrey was with the Army of the Eastern Pyrenees, numerous soldiers suffered from frostbite when an extreme degree of cold was succeeded by an elevated temperature. The suffering was most extreme in men whose feet had already been frostbitten at the siege of Roses. During the preceding 15 to 20 days of "rigorous cold" and up until the time the thaw commenced, Larrey had observed no frozen limbs in any of the ambulances over which he presided. Within 24 hours after the change of weather, some of the more advanced sentinels were found dead at their posts.
Larrey also related instances of gangrene caused by "congelation" in. other parts of Europe. During the conquest of Holland, for instance, as lie was informed by M. Paroisse, first surgeon to the King of Spain, a great number of soldiers had their feet frostbitten. The men had long been exposed to snow and ice, but gangrene did not appear until the thaw commenced.
Still another experience concerned the army which left Madrid on 22 December 1808 to cut off the retreat of the English Army on the road to Corunna. The next 2 days were spent crossing the Guadarrama Mountains. It had been snowing for several days, and, at the foot of the mountains, the wind blew directly from the north and the temperature was 9? below zero R. (11.75? F.). As the men ascended the mountains, the cold, already piercing, became still more intense, and thick whirlwinds of hoarfrost and snow made a halt imperative. During the overnight halt, the temperature rose several degrees. When fires were kindled, Larrey continued:
* * * they were more injurious than useful * * *. For all who subjected their hands or feet to the warmth of the fire, were suddenly affected with gangrene from congelation, to a greater or less extent. But this gangrene appeared in no case among those who avoided the fire. One of the soldiers of our ambulance, having had his right hand affected with the cold as he climbed the mountain, suddenly approached the fire of bivouac, and chafed his hand near it. It instantly swelled in a surprising manner, like dough when put into a hot oven. When he rejoined his ambulance some hours after, his hand was entirely sphacelated, and I was obliged to amputate it at the wrist. This fact supports the opinion on which I advanced relative to gangrene from congelation.
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Cold, Larrey concluded in the light of these various experiences, is only the predisposing cause of gangrene, which can be averted by taking care to remain away from heat and to avoid subjecting parts "benumbed by the cold to its sudden action." The exciting cause is heat "* * * suddenly applied to the parts which have been rendered torpid by cold * * *. Let this principle be once established and it will be easy to prevent the effects of congelation."
Data on injuries caused by cold among Russian troops in the campaign of 1812 are scanty. They probably suffered severely, though not as severely as the French, because, according to Ariev, 6 they were already acclimated to the severe weather and they had some knowledge of the elementary rules for combating frostbite. These factors, he thought, exerted a protective influence, although Russian soldiers, like French soldiers, were hungry, tired, and poorly clothed and thus were subject to the very conditions which might predispose to cold injury.
Therapy.- Except for the warning against the sudden application of heat to the affected part, which is still sound advice, Larrey's methods of treating cold injuries are merely of historic interest. First aid consisted of friction with snow or ablutions with water in which ice had been dissolved. If snow or ice could not be procured, cold red wine or vinegar and camphorated brandy were substituted or the parts were immersed in well water. Full details were given for the management of gangrenous limbs, but amputation, it was emphasized, was always a last resort.
THE CRIMEAN WAR
Many of Larrey's observations were made on soldiers who operated under conditions of extreme cold and who were facing, and later experienced, a disastrous defeat. In the course of the defeat and the retreat which followed, a large part of the army was lost as a consequence of cold and intercurrent disease. The military cold injuries next recorded, in the Crimean War of 1854-56, arose on a very different basis, in that the cold in which they were sustained was not extreme and the military circumstances were different.
During the first winter of the war, fighting in the Crimea took the form of dogged trench warfare, with relatively little change in the position of either side. The campaign was fought by inexperienced soldiers, who were handicapped by lack of supplies, clothing, and food. Diarrhea and dysentery were prevalent and were attended with a high mortality, and 1,924 cases of frostbite were reported. Mr. Dumbreck, of the First Regiment, did not find this surprising. "I consider," he observed, "that many of the cases of denominated gelatio, were in reality gangrene from debility, many of the men having been
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6 See footnote 2, P. 29.
7 Medical and Surgical History of the British Army During War Against Russia in Years 1854-56. London: His Majesty's Stationery Office, 1858, vol. 2.
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attacked when the thermometer was between 40? and 50? Fahrenheit." Dr. Longmore shared his views. The frostbite which occurred during 1854 and 1855, he stated, "could not be attributed to the severity of the climate, but was chiefly owing to the exceedingly depressed vital power which characterized the general condition of the soldier at that period."
It seems reasonable to accept the opinion of these observers that the frostbite which occurred in the British Army during the first winter of the Crimean War was not primarily caused by cold. Through October, the weather was rather mild. In January, it is true, snow fell and there was much "frost," but low temperatures, in themselves, did not seem to produce cold injuries. Many, on the contrary, seemed to occur as a direct consequence of exposure to wet, especially when the winds blew from the northeast. Periods of thawing seemed particularly likely to produce cold injuries, which were notably frequent when frost by night alternated with thaw by day. Men in the trenches, especially the most forward trenches, experienced protracted exposure under the most unfavorable possible conditions. They often had to stand knee-deep in mud and water as well as in snow. Their movements were restricted because of the vigilance of the enemy. Often, to protect themselves, they had to seek shelter in the bottom of the trenches, where the bad conditions under which they ordinarily existed were likely to be worse. They sometimes remained in such situations for 12 to 24 hours. In addition, their hands sometimes became gangrenous from handling "wet metallic substances."
The authors of the official history of the Crimean War recorded other deficiencies. The soldiers' boots were defective and quite unsuited for this type of operation. Often, they had been fitted in too small sizes, and the men were afraid to remove them for fear that they would not be able to replace them. Shelter and bedding were equally unsatisfactory. Tents were of single-thickness canvas, with flaps that were difficult to close. The allotment of blankets was one to a man. Straw, hay, reeds, boards, stretchers, and similar makeshifts had to be used for beds. Firewood to be used for the preparation of food was difficult to come by, and the partial inadequacy of nutrition was evidenced by the high incidence of scurvy. The chronic fatigue of the men, as well as the high incidence of diarrhea and dysentery, has already been mentioned.
It has already been pointed out that during the winter of 1854-55, in a force of slightly less than 50,000 men, there were 1,924 cases of cold injury, of which 457 (23.75 percent) were fatal. During the winter of 1855-56, there were only 474 reported cases, of which only 6 (1.3 percent) were fatal. Since weather conditions and precipitation were essentially the same in both years, one must look elsewhere for the explanation of the improvement in the second winter of the war. The clue is found in the medical records of the British experience, which describe two distinct types of cold injury. The first, which
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was caused by cold in conjunction with debility, occurred during the first winter of the war. The second, which was caused by cold alone, occurred during the second winter. Furthermore, the high death rate recorded for the first winter was not the result of cold injury alone; it was caused also by enteric diseases and typhus fever, which often developed when the soldiers were hospitalized for their cold injuries.
The authors of the history of the Crimean War supply numerous details which explain the improvement in the second winter of fighting. During the summer, the troops in the Crimea regained most of their physical vigor and "ability to resist the affection." They were no longer the "raw unformed lads" who had made up a large part of the fighting force the previous winter. Instead, they were seasoned, hardened troops. While the type of combat action in the winter of 1855-56 did not differ greatly from the action in the preceding winter, men had to spend less time in the forward trenches. Finally, living conditions were better, food supplies were much more adequate, and the individual soldier had gained some understanding of how to protect himself against the cold.
A number of other perspicacious observations on cold injury are found in the official history of the Crimean War. It was the authors' opinion that even higher rates of injury might have been experienced had the type of warfare been mobile instead of static and had there not been opportunities of "receiving reinforcements from the seaboard." A reconnaissance in force made in the midst of a severe storm from which the men returned very cold and greatly exhausted is described in this history. The authors noted that, if Sir Colin Campbell and the officers of the regiment had permitted the men in this operation to rest and had not taken the precaution of keeping them constantly in motion, many more cases of frostbite might have resulted. British military surgeons were fully cognizant of the effect of alcohol in cold injury and remarked on the high rates in drunken men. They were also aware of the underreporting of cases, some of them mild cases and others more severe gangrenous cases associated with infectious diseases, to which death was likely to be attributed. Finally, the British surgeons noticed that there was a disproportionately larger incidence of cold injury in the Infantry then in the Cavalry and Ordnance. The relative strengths of these arms is not recorded, but the distribution of fatalities is significant-5 in the Cavalry, 27 in the Ordnance, and 431 in the Infantry.
During this same 2-year period (1854-56), according to Sonnenburg and Tschmarke (cited by Ariev), the 309,000 French troops in the Crimea experienced 5,215 cases of frostbite, of which 1,178 (22.6 percent) were fatal. Holmer, Hulke, and Florcken (also cited by Ariev), reported that during 2 consecutive nights in Sevastopol, 2,800 cases of frostbite occurred, of which 900 were fatal.
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THE WAR OF THE REBELLION
The official history of the War of the Rebellion 8 does not describe frostbite as a distinct entity of medicomilitary importance nor are any statistics supplied for the incidence. It is possible, however, to derive some information from notes on amputations for gangrene attributable to frostbite or freezing, as well as from individual case histories under this heading.
A large number of the 15,273 "other accidents and injuries" not caused by combat were instances of frostbite. There were 1,075 fatalities in this group (7.03 percent). In 259 amputations of the leg, in which there were 78 known deaths and 180 known recoveries, 147 of the operations were done for fractures, 44 for frostbite, 17 for gangrene, and the remainder for various other accidents and diseases. Twenty-two of fifty-one amputations of the feet were required for frostbite. One amputation was performed for gangrene caused by wearing tight boots and another for hospital gangrene. In 122 amputations of the toes, there were 6 known deaths and 109 known recoveries. The indications for operation are stated only in the following case:
A 49-year-old hospital steward suffered frostbite of both feet when his tent blew down and his feet were exposed in intensely cold weather. Although he was immediately aware, on awakening, that the foreparts of both feet were frozen, he received no treatment until he was hospitalized a month later. Then, dry gangrene of the toes of both feet was present (fig.17), with destruction of the soft parts. Although the patient was in good spirits and doing well, disarticulation of the toes was regarded as indicated. A year later, he was discharged from service for disability and was pensioned. Twelve years later,
FIGURE 17.- Dry gangrene of toes of both feet, resulting from freezing, and extending on the left side to the metatarsal bones, with destruction of the soft parts.
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8 Medical and Surgical History of the War of the Rebellion. Surgical History. Washington: Government Printing Office, 1883, pt. III, vol. II, pp. 670-679, passim.
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he appeared before an examining board, which certified to his condition as follows:
He has had all the toes of the right foot amputated through the metatarso-phalangeal articulation except the little toe, which is drawn into the cicatrix. The foot is defective in circulation and there are chronic ulcers of the leg extending from the ankle to within four and a half inches below the knee, being very offensive and requiring constant care and attention. This condition no doubt is due to anaesthesia of the foot and leg. The cicatrices extend around the leg and are constantly scaling. There is also varix above to a slight extent. The toes of the left foot were amputated at the tarso-metatarsal articulation, the stump showing a good horny cicatrix; hyperaesthesia of foot or stump; atrophy of leg; stump alleged to be painful during changes of weather.
OTHER WARS OF THE 19TH CENTURY
During the Franco-Prussian War of 1870, there were 1,450 cases of severe frostbite among 92,067 Prussian troops. Pirogov (cited by Ariev) observed 2,632 cases among 16,000 patients in the "gare de perruche" hospital, while in General Burback's military hospitals there were 610 cases in a total of 5,944 casualties.
During the Russo-Turkish War of 1877-78, 4,500 patients suffering from frostbite passed through the evacuation points in Jassy and Bendiara. These casualties represented 1.5 percent of the total Russian expeditionary force of 300,000 troops in Bulgaria and 5.1 percent of the 87,989 evacuated casualties.
THE RUSSO-JAPANESE WAR
The British medical observers attached to the Japanese Army during the Russo-Japanese War made a detailed report on the cold injuries sustained during the battle of Hei-kou-tai from 25 through 29 January 1905. According to MacPherson, 9 300 men from one division and 205 from another were hospitalized for frostbite. Toke 10 stated that 300 men were hospitalized for frostbite and that 173 others, who were not hospitalized, also sustained cold injuries. It was additionally reported that about half of the men hospitalized for other causes during the period of this engagement were likewise suffering "more or less" from frostbite. Total casualties numbered 7,742, which makes the ratio of uncomplicated frostbite to battle wounds about 1: 15. The toes were affected in 67 percent of the cold injury cases and the fingers in 28 percent, but the injury was usually mild and amputation of either fingers or toes was seldom required.
On 23 January, 2 days before the engagement began, the weather suddenly changed. The temperature fell to a low point, the relative humidity in-
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9 MacPherson, W. H. The Russo-Japanese War. Medical and Sanitary Reports from Officers Attached to the Japanese Forces in the Field. London: His Majesty's Stationery Office, 1908, pp. 242, 349.
10 Toke, R. T.: The Effects of Cold During the Battle of Hei-kou-tai, 25-29 January 1905. In the Russo-Japanese War. Medical and Sanitary Reports from Officers Attached to the Japanese Forces in the Field. London: His Majesty's Stationery Office, 1908, p. 201.
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creased, and the wind began to blow from the north. Snow fell on 26 January, the second day of the engagement. The high humidity persisted, and the weather continued bad during the remaining days of the battle. Most of the casualties occurred on 27 and 28 January, and most of them occurred at night. The temperatures for the whole period ranged from a maximum of 17.8? F. (-7.9? C.) on 26 January to a minimum of -11? F. (-24? C.) on 29 January.
The British observers listed as predisposing causes of the cold injuries wet feet resulting from the penetration of melting snow through the stitching of the welts of the boots; constriction of the feet and interference with the circulation as the leather of the boots became hard and frozen; lack of food; the frequent night fighting, with resulting fatigue from lack of sleep; the inability of the men to move from their fixed positions in the snow, so that they had no way of stimulating the circulation in their feet; and their inability to light fires for warmth because of the close proximity of the enemy.
After the unfortunate experience at the battle of Hei-kou-tai, certain preventive measures were instituted and were practiced during the battle of Mukden. This battle was fought from 1 through 10 March 1905, in temperatures varying from a minimum of 0? F. (- 17.8? C.) to a maximum of 53? F. (11.7? C.). The men were given extra socks and gloves, so that they could change them when those they were wearing became wet. Boots were well greased. When there were halts for any period of time, the boots were removed and were replaced by Chinese felt or straw shoes. Finally, each man carried in his pocket an issue of sugar, to eat when he lay in position; this was a measure in which Japanese medical men had great faith. During the whole battle, only 70 patients were admitted to field hospitals for frostbite, and most of these had other wounds. The excessive number of deaths in battle, however, was attributed in part to deaths from cold as the wounded lay on the battlefield before they could be picked up.
In contradistinction to the reports of the British observers which have just been cited, Ariev stated that the incidence of frostbite among Japanese troops was "staggering." To support his statement, he cited Lynch's report of between 1,200 and 1,600 amputations in a single month as the result of frostbite. Russian Army medical statistics, according to Ariev, show 1,021 cases of frostbite for the whole Russo-Japanese War; 410 of these were treated in hospital. Statistical tables from the same source record 1,469 cold injuries, of which 856 were severe. It was Ariev's opinion that the Russian incidence must have been higher than these figures indicate, since in the battle of Mukden alone there were well over a thousand casualties from this cause.
THE TIBET EXPEDITION OF 1903-4
Davys,11 in 1904, recorded, without mentioning the exact number of cases, an experience with frostbite sustained during the winter of 1903-4 and during
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11 Davys, G. I. Frost-bite in the Tibet Mission Force. Indian M. Gaz., 39: 245-247, July 1904.
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the following spring, both by men who served with the Tibet Mission Force in the Chumbi Valley and by native inhabitants of the valley. The prime cause of the injury, Davys noted, was a combination of damp clothing and extreme cold. Simple dry cold was se]dom a cause in itself, and the most serious lesions were, as in Larrey's experience, produced not by excessive cold but by carelessly applied heat.
Three degrees of cold injury were recognized: (1) Death of superficial layers of skin; (2) death of the whole thickness of the skin and sometimes of superficial fascia; and (3) death of deeper tissues, such as muscles and tendons. Examination of the patients during the first two (ischemic) stages revealed the affected parts to be cold, white, and painless. The third stage was characterized either by simple dry gangrene, or by moist gangrene, with which emphysema of the tissues was often associated.
Methods of treatment included putting the feet in cold water placed "near but not on a fire"; massage ("friction") to produce slow warming; and, in a few cases, wrapping the affected part very thickly in wool and bandages and placing it in a box of warm sand. All methods of warming, Davys warned, must be applied "very slowly." To prevent gangrene of the deeper tissues, he recommended that superficial dead skin be removed as early as possible; by this means, it was often possible to save fingers and toes which were apparently quite dead.
Connor,12 while working in the Depot Hospital of the 8th Gurkha Rifles at Shillong, treated some of the more severely injured men from the Tibet Mission Force for weeks and in some instances for months after the original injury. Like Davys, he emphasized the importance of extremely conservative surgery because lie too found that dead, blackened skin was often only superficial and that the underlying tissues were viable. Connor also commented on the after-treatment of amputation stumps and recorded such sequelae as loss of tactile sensibility and "persistent stiffness of the adjacent joints."
In this connection, there might be quoted an unscientific but nonetheless significant observation on presumable cold injury in the British Army in India-"in the middle of the Tangi Pass it was"-at the turn of the century. Says Mulvaney, one of Kipling's famed "Soldiers Three":
Our docthor, who knew our business as well as his own, he sez to me * * * "How often have I tould you that a marchin' man is no stronger than his feet-his feet-his feet," he sez. "Now to the hospital you go," he sez, "for three weeks, an expense to your Quane, an' a nuisance to your counthry. Next time," sez he, "perhaps you'll put some av the whiskey you pour down your throat and some av the tallow you put into your hair, into your sock," sez he. Faith, he was just a man!
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12 Connor, F. P.: Notes on Some Cases of Frost-bite. Indian M. Gaz., 39; 365-366, October 1904.
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THE BALKAN WARS
According to Page,13 large numbers of Turkish troops suffered from cold injury in the First Balkan War in the latter part of 1912, particularly near Tchatalja. Precise figures are not available, but it is known that the death rate was high, especially in men with the moist, spreading type of gangrene and in those who also had enteric disease or whose injuries were complicated by tetanus. The gangrene was symmetrical and practically always involved the feet; the fingers alone were seldom affected. The lesions varied from mere discoloration and blister formation of one or two toes to death en masse of the leg to the knee.
The temperature of the area in which the injuries were sustained was usually about 41? F. (5? C.). Page's opinion was that the trauma produced a vasomotor disturbance; but he advanced no explanation which would cover all cases, other than exposure to weather for long periods, frequently in wet trenches, combined with generally insufficient rations. About half of the men had enteritis. Their footgear varied. Some, but by no means all, had been wearing boots and puttees of the European type, and Page granted that in some instances they were tight enough to predispose to gangrene. He was unwilling however, to accept, at least in a universal application, Depage's theory that the pathologic process could be explained by compression from the puttees, which underwent shrinkage as they dried, though Dreyer, who reported on 31 cases observed in the German Hospital in Constantinople, was of Depage's opinion. A valid argument against this theory was that many of the Turkish soldiers who suffered frostbite wore the usual loose native footwear. The theory that gangrene was caused by the eating of infected rye bread could also be dismissed. The affected troops had had very little of this bread, for one thing, and, for another, there was a complete absence of this type of gangrene in the local population before the war, although the suspected rye bread had been a prominent article of diet in the area.
Page was familiar with the history of gangrene following frostbite among British troops in the Crimean War and regarded it as comparable to the gangrene observed in the Balkan war. Apparently, however, he did not consider the two conditions to be the same processes, nor did he seem to realize that, in both, cold and wet were the primary causative factors. This is curious, since both he and Dreyer agreed that in this type of gangrene, just as in frostbite, the arterial circulation of the affected men had been so impaired by starvation and fatigue that a temperature above freezing was able to produce stasis in the peripheral vessels. Page noted, but did not comment on, the fact that frequently soldiers dated the development of gangrene to the time of their arrival in the hospital for treatment for some other injury or disease. Often, the gangrenous process was clearly of much longer duration, and it seems not
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13 Page, C. M.: Gangrene in War. Brit. M. J. 2: 386-388, 30 Aug. 1914.
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unreasonable to postulate an aggravation of the vascular disturbance when a warmer environment was reached.
Ariev cites a number of other observations on the high incidence of frostbite in the Balkan wars of 1912-14: Meyer and Kohlschutter reported on 150 cases, all terminating in gangrene, and Wieting recorded 300 cases. Kosogledova, who reported 400 cases, stated that at one time no less than 2,000 casualties from frostbite were in Sofia and that whole trainloads of other men with this type of injury were en route to base hospitals.
WORLD WAR I
The British Experience
Cold injury is recorded in considerable detail in the official British history of World War I 14 as well as in the large periodical literature of the war years.15 It should be noted again that up to this time, except for the classic description of cold injury by Larrey (p.30) during the Napoleonic Wars and the briefer but equally careful observations of British medical officers during the Crimean War (p.36), there had been no critical appreciation of the military significance of this type of injury.
That the British had not fully profited by their experience in the Crimean War is indicated by the high incidence of cold injuries in their expeditionary forces in the first winter of World War I. At this time, in spite of Larrey's emphasis upon this combination of causes, the role of wet in conjunction with moderate temperatures was not clearly understood, as is evident from the nomenclature employed for cold injuries early in World War I. All through the first months of the war, these injuries were reported as frostbite, water bite, footbite, cold bite, puttee bite, trench bite, N.Y.D. feet, chilled (or cold) feet, effects of exposure, or merely as "feet cases." It was not until after the first winter of fighting that the term "trenchfoot" began to come into general use. Although trench warfare was the exception in World War II, the term was retained in it, partly for lack of a better one and partly because its implications were so generally understood.
In spite of their lack of experience with cold injury, British Army surgeons and nonmedical military officers alike promptly realized the enormous military significance and the potential loss of manpower from trenchfoot, as well as the
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14 (1) General History of the Medical Services. Hygiene of the War. London: His Majesty's Stationery Office, vol. 2, 1931. (2) See footnote 3, p. 29. Except as otherwise indicated, all data concerning the British experience in World War I are derived from Grattan's chapter on trenchfoot in History of the Great War Based on Official Documents.
15 (1) Lawson, C. B.: Frost-Bite. Brit. J. Surg. 2: 703-705, April 1915. (2) Frost, H. M.: Trench-Foot. Boston M. & S. J. 176: 301-304, 1 Mar. 1917. (3) Trench Foot by a Military Observer. Mil. Surgeon 41: 598-609, November 1917. (4) Hughes, B.: The Causes and Prevention of Trench Foot. Brit. M. J. 1: 712-714, 20 May 1916. (5) Delepine, S.: The Prevention of Frost-Bites. Lancet 1: 271-272, 6 Feb. 1915. (6) Johns, F. A.: A Note on the After-Treatment of So-Called "Frostbite." Brit. J. Surg. 4: 336-337, October 1916. (7) Levick, G. M.: Electrical Treatment of Muscles in "Trench Feet." Brit. M. J. 1: 370-371, 30 Mar. 1918. (8) Moynihan, B.: Frostbite (correspondence). Lancet 1: 401, 20 Feb. 1915.
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strictly financial consideration that these casualties, quite as much as battle casualties, would be entitled to pensions. Three points were generally emphasized in the first reports: (1) The number of men permanently lost to combat from this type of injury; (2) the amount of time lost from service by the men eventually able to return (in mild cases, 2 to 3 weeks and in more severe cases, 5 to 7 weeks or sometimes much more) ; and (3) the possibility of recurrence in men sent back to the same environment in which their original injuries had been sustained.
The high incidence of cold injury and the long duration of the hospital stay, which often reached several months, both proved the intractable nature of injuries caused by cold and their impact upon military campaigns.
Incidence.- Cold injury began insidiously among British troops in France and Belgium in the first months of fighting in World War I. The incidence of frostbite, as it was then termed, rose from 1 case in August 1914, 1 in September, and 11 in October, to 1,555 in November and 4,823 in December. In December, the term "trenchfoot" first appeared in the medical reports, though only eight cases were so listed.
All of the cases reported as frostbite from August through December, inclusive, were cases in which cold injury was the only injury or disease present. Over the same period, frostbite was reported in association with rheumatism (306 cases), myalgia (69 cases), bronchitis (22 cases), and gunshot wounds (170 cases) .
The highest incidence of cold injury was among infantrymen. Officers had a somewhat lower rate of occurrence than enlisted men. Indian troops as well as Europeans were affected.
According to official records 16 the total cases of frostbite and trenchfoot for the whole war, in all theaters of operations and all bases, including the United Kingdom, numbered 115,361. During 1915, when frostbite and trench-foot were differentiated in the returns (as they were not thereafter), there were 30,691 hospital admissions for frostbite and 29,172 for trenchfoot. Total cold injuries treated in hospitals in France and Flanders, practically all of them in the first 2 years of the war, amounted to 97,414 cases. Only 443 cases were shown on hospital records during 1916-18.
Reports of individual observers 17 during the first months of the war are as significant as are the mass statistics. Thus Lawson recorded that, over a 6-week period, 1,131 men with frostbite were admitted to a single hospital in Rouen. Gangrene was present in 24 of 180 cases which lie treated personally. Frost mentioned 120 cases in a convoy of 160 casualties received at the Meerut Stationary Hospital in Boulogne. A military observer wrote in the Military Surgeon for November 1917 that 400 men in a single British battalion, many of whom later required amputation, had been disabled from cold injury in 48 hours.
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16 See footnote 14 (1), p. 42.
17 See footnote 15 (1), (2), and (3), p. 42.
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Weekly divisional records for the First British Army from 12 December 1914 to 28 February 1915 are indicative of what happened as trenchfoot gradually came under control. For the first week of this period, 579 cases were recorded, and 530 cases were recorded for the third week. By the eighth week, the number had fallen to 70 cases, and only 63 were recorded for the last week. The total for the 10-week period was 3,013 cases. While the incidence of trenchfoot was thus decreasing in the First Army coincidently with the institution of "strong disciplinary measures," cold injury continued to occur in large numbers in the Second British Army, which was then fighting in the Ypres salient.
Frostbite case rates per 1,000 strength in France and Flanders were 33.93 for 1914 and 27.50 for 1915.18 Trenchfoot case rates for the same years were, respectively, 33.97 and 38.43. Thereafter, the case rates for cold injury fell progressively to 12.82 in 1916, 11.34 in 1917, and 3.82 in 1918. Death rates per 1,000 in Europe ranged from a maximum of 0.06 in 1914 to zero in 1917 and 1918.
The statistics for cold injury in the British forces in the Middle East are far less reliable than those for the Western Front. Many of the available sources for the winter of 1915 in Gallipoli are diaries, which merely state that "many" or "several" cases were observed. In the Dardanelles,19 for the period April 1915 to January 1916 inclusive, there were 14,584 admissions for cold injury, of which 6,602 were for frostbite and the remainder for trenchfoot. For the 10-month period, the frostbite case rate was 56.39 per 1,000 average strength and the trenchfoot case rate 68.18.
In Macedonia, from October through December 1915, there were 1,014 cases of frostbite and 1,125 cases of trenchfoot. The frostbite rate for this year was 16.65 cases per 1,000 average strength, against a rate of 18.48 cases per 1,000 average strength for trenchfoot. In subsequent years, the trenchfoot rates fell to less than 2 cases per 1,000 average strength. Weekly admissions to medical units were recorded only for the period from 25 March 1916 through 1 June 1918. During this time, there was a total of 43,838 admissions for cold injury, in 38,298 of which (87.36 percent) evacuation to the base was necessary.
Death rates for the campaign in Macedonia are not available. In the Dardanelles in 1915, the death rate for frostbite was 0.58 per 1,000 and for trenchfoot 0.67. These rates are approximately 10 times as high as the highest rates reported from Europe. It is interesting to speculate on the possible role of intercurrent diseases, especially dysentery, in the production of the higher rates in the Middle East.
Diagnosis.- When trenchfoot once began to be carried in mind as a possibility in British troops, its diagnosis seldom presented any difficulty. The circumstances of the injury, the characteristic symptoms of swelling, pain, and disturbances of sensation, and the physical findings, including color changes and edema, seldom left any doubt about the nature of the lesion. The occur-
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18 See footnote 14 (1), p. 42.
19 See footnote 14 (1), p. 42.
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rence of nocturnal pain was extremely significant. More than one observer suggested that if it was suspected that the man might be malingering, a tour of the wards at night would often provide the answer; if the patient was awake, sitting up in bed, and even crying with pain, there was no question about the genuineness of his diurnal complaints.
Prevention.- The methods of prevention employed by the British in World War I 20 were, in their fundamentals, the same as those they employed so successfully in World War II (p.202). Because only a few medical officers had had previous experience with injuries caused by cold, these measures as well as the whole program of control had to be organized hastily, though they were ultimately developed methodically. They consisted, in essence, of (1) the maintenance of the men in as fit condition as possible; (2) the exercise of as wide hygienic control over the troops as was compatible with the conditions of trench warfare; (3) measures to protect the feet and legs from wet and cold and to keep the men as warm, as dry, and as clean as was possible under the circumstances; and (4) measures to improve the condition of the trenches. Provision of hot food for men in the trenches was always an important feature of the program.
Eventually, as the program developed, great emphasis was placed upon the supervision of troops by unit commanders. The records of all units were scrutinized daily and weekly to detect any rise in the incidence of trenchfoot; increases called for an explanation and sometimes for an investigation. Supervision of this kind was found to be indispensable and was strictly enforced when once it was realized (1) that even mild trenchfoot, without blister formation or gangrene, removed the soldier from service for weeks or months, and (2) that men who had sustained one attack of cold injury were much more susceptible to another attack. The solution of the problem was therefore twofold: (1) For the individual soldier to make a fine art of the toilet of the feet, and (2) for his leaders to see that he did so.
In December 1916, the Director General of Medical Services for the Western Front issued instructions that thereafter all patients with trenchfoot should receive tetanus antitoxin, whether or not the skin was broken. The same instructions had been issued the previous winter by the Director of Medical Services in Macedonia.
Therapy.- No really successful method of treatment of trenchfoot was ever developed by British medical officers in World War I. Furthermore, many of the methods used were empirical, particularly at the beginning of the outbreak in 1914 because most medical officers were entirely unfamilar with the condition. Lawson 21 relates what was probably a typical experience. When the first 63 casualties from trenchfoot were suddenly received in a British hospital in France on 23 November 1914, no one had any idea what to do for them. The following day, Lawson himself happened to remember that he had once read in Rose and Carless' Textbook of Surgery that Indians, lumbermen, and pros-
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20 See footnote 14 (1), p. 42.
21 See footnote 15 (1) p. 42.
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pectors in northwest Canada treated cold injury by the liberal use of oil of turpentine. This method was at once applied to these military casualties; when the blebs broke and the pure oil proved too irritating, it was diluted with lanolin. Lawson reported excellent results, stating that when toxemia developed it was almost invariably found that the oil had not been assiduously applied. Nothing else seems to have been written about this special method, and many other equally empirical methods are mentioned only in single reports.
Among the numerous agents used at one time and another for local applications, with or without massage, were alcohol in various strengths; mercuric chloride (0.2 percent) in alcohol; chloral hydrate and camphor; carbolic acid (1:40) and camphorated oil; camphorated oil alone; tincture of iodine; picric acid; oil of wintergreen; evaporating solutions such as lead and opium; and dusting powders containing starch, zinc, boric acid, and salicylic acid. Elaborate methods of massage, radiant heat, and various kinds of electric stimulation were used in the later stages of trenchfoot. 22
In February 1915, Moynihan 23 called attention to the pain inflicted in trenchfoot by the application of various ointments and liniments. Apart from the degree of pain which they caused, he said, there was no appreciable difference between one form of treatment and another. It was his opinion that the pain, which was always the outstanding complaint and which was sometimes so severe as to require morphine for relief, was not caused so much by actual damage to the tissues as by the general practice of wrapping the feet in bandages and wool; the discomfort, in fact, was almost exactly proportionate to the degree of warmth achieved. When the bandages and other wrappings were removed, men who had previously suffered nights of torture had relief within a few hours. Since progress toward recovery was practically always at the same rate, regardless of the method of treatment, it was Moynihan's feeling that relief of pain during healing should be the chief consideration. It therefore became the practice in the Rouen hospitals after this time (February 1915) to elevate the affected feet a few inches on a hard pillow and to cover them only with a thin layer of gauze and a sheet.
Eventually, a plan of treatment along much these general lines became standard practice for British casualties with trenchfoot.24 The injured foot was carefully and thoroughly washed with soap and water, an antiseptic lotion was applied, and the skin was painted with a 1-percent solution of picric acid. In mild cases, additional treatment consisted only of bed rest, with the feet slightly elevated. If the feet were red and hot, they were left exposed, with all dressings omitted. If they were cold and numb, they were wrapped in cotton wool, which was removed at intervals so that they could be rubbed. If blistering was extensive, the bullae were punctured, and the feet were coated with ambrine or some other preparation of paraffin wax. Salicylates were used in large dosages for the control of pain. In the later stages of mild trench-
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22 See footnote 15 (6) and (7), p. 42.
23 See footnote 15 (8), p. 42.
24 See footnote 14, p. 42.
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foot, the application of a high-frequency current together with massage was thought to be beneficial.
Immediate amputation was never considered justified, even when gangrene was evident, since even the early experience showed that in the majority of cases the part could be saved. In the moist type of gangrene, fairly prompt amputation was sometimes required, but, in the dry type, it was the practice to wait for a line of demarcation. Amputation through the leg was seldom necessary, since the Syme operation was usually practiced, even in severe cases.
The United States Army Experience 25
Since the United States Army in World War I had little experience with trench warfare in cold weather, it had a correspondingly limited experience with trenchfoot. Most of the fighting in the trenches occurred at a time of year when exposure to combined cold and wet was not great. Noneffectiveness from this cause was therefore never important in the American Expeditionary Forces.
The majority of cases of trenchfoot occurred during the Meuse-Argonne operation, in October and November 1918, when fighting continued day after day for several weeks until the soldiers were exhausted as well as chilled and wet. It was difficult to bring relief troops forward; and the men, in addition to being without shelter and heat, suffered for lack of dry clothing and proper shoes.
With this exception, the majority of cases of trenchfoot observed in American troops in overseas hospitals arose from conditions not connected with trench warfare and would probably, in the absence of the previous British experience, have been diagnosed as chilblains or frostbite. Most of the lesions diagnosed as trenchfoot actually were instances of frostbite with minor grades of inflammation and with some ulceration and abrasion of the waterlogged skin. The deep sloughing and gangrene characteristic of much of the trenchfoot experienced by British troops in the first winter of the war were seldom observed in American troops.
Incidence.- The official history of the Medical Department of the United States Army in World War I 26 lists a total of 2,061 admissions for trencbfoot, including 27 among officers. Sixty-seven admissions, one an officer, occurred in training camps and other installations in the United States and Alaska. Most of the remaining admissions occurred in Europe.
The peak number of cases, as already mentioned, occurred in the fall of 1918, during the Meuse-Argonne offensive. The hospital-admission rate per 1,000 troops per annum was 0.50 for the whole Army and 1.17 for the troops in Europe, where the rate for officers was 0.35, and for enlisted personnel 1.21.
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25 Weed, Frank W.: Trench-Foot. In the Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XI, pt. 1, pp. 290-293. Except as otherwise indicated, all data concerning the United States Army experience in World War I are derived from this source.
26 Medical Department of the United States Army in the World War. Statistics. Medical and Casualty Statistics. Washington: Government Printing Office, 1925, vol. XV, pt. 2, passim.
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The loss from trenchfoot for all classes of personnel in the United States Army amounted to 97,219 days, an average of 47 days per case. In Europe, the total loss was 92,249 days, an average of 47 days per case. The average loss of time for officers was 29 days; for white enlisted men, 49 days; and for colored enlisted men, 68 days. On the Western Front, the average loss per admission for enlisted men of all races was 48 days.
Prevention.- The United States Army in World War I, partly because of the comparatively favorable circumstances under which it fought and partly because it had the advantage of the previous British experience, did not have to learn by its own experience that trenchfoot can be prevented. In General Orders No. 11, General Headquarters, American Expeditionary Forces, issued on 17 January 1918, the causes were outlined, the prophylactic measures to be employed by American troops were fully described, and organization commanders were charged with responsibility for their implementation.
The predisposing and exciting causes of trenchfoot were grouped in General Orders No. 11 under two headings: Hygienic causes and causes of circulatory interference. Under hygienic causes were listed the existence of systemic disease; insufficient food, particularly the lack of hot food; insufficient sleep and comfort; and too infrequent changes of shoes and socks, which permitted the accumulation of bacteria-laden secretions and the consequent maceration of the skin of the feet. The causes of interference with the circulation were listed as the wearing of tight shoes, socks, leggings, puttees, and breeches; long-continued standing or sitting without exercise and with the feet and legs in strained positions; and prolonged exposure of the feet to the effects of cold and wet.
Commanding officers of all units were held personally responsible for seeing that the following routine was carried out under the personal supervision of commissioned officers:
1. Provision of clean, dry, well-fitting woolen socks, with further provision for replacements and laundry, sufficient to insure each man at least one change daily. The socks were to be pinned to the breeches with safety pins. Garters were prohibited.
2. Provision of not less than one change of shoes or boots for each man. The shoes were to be in serviceable condition, well fitted, thoroughly greased, and large enough for woolen socks to be worn with them.
3. Provision "at all times" of suitable rooms for drying footgear and other clothing.
4. Prohibition of the wearing of rubber boots for longer than a few hours at a time. Neither puttees nor leggings were to be worn under them. The disadvantages of this form of footgear were to be explained to the troops, who were to be shown also how to care for the boots after they were removed.
5. Provision, whenever possible, of a dry environment, even though it amounted only to trench drainage and the use of duckboards.
6. Vigorous rubbing of the feet with animal fat at least once daily.
7. Active foot exercises, supplemented from time to time by removal of shoes and socks so that the feet could be dried and massaged.
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8. Regular inspections of the feet by the officers, to detect corns, ingrown nails, blisters, and inflammations. Men with such lesions were to be referred at once to a medical officer.
9. Inspections by company commanders before troops moved into forward areas, to be certain that all the provisions just listed had been complied with. At this time, the men were also to be warned against winding their puttees too tightly, since it had been found that a shrinkage of 3 percent occurred when dry puttees, which had been applied according to regulations, became wet.
10. Suitable arrangements for provision of hot food and drinks so that all men in forward areas had at least two hot meals daily.
The orders issued on 17 January 1918 also contained information about how to secure the various instructions and equipment necessary for carrying these orders into effect. Plans for improvising and constructing field cookers, kitchens, clothes driers, and other special equipment were to be furnished upon application to headquarters. Foot powders, oils, greases, and ointments were to be furnished by the Medical Department. Supplies for the lubrication of shoes and boots were to be secured from the quartermaster. Responsible officers were directed to prepare the necessary requisitions for these various items without delay.
For the most part, these policies remained unchanged throughout the war. The only important alteration was that whale oil and grease in general came to be looked upon with disfavor, since the coating which lubricants formed held back secretions and encouraged maceration of the skin. It therefore became the practice to use these agents only when gum boots were not available or when they had to be worn for unusually long periods of time.
Ashford 27 provided a significant account of the real value of these measures. In September 1917, shortly before he assumed the duties of commandant of a corps training school for American medical officers, he made a visit of a few hours to the French Sanitary School, and, just before he left, was briefed on trenchfoot by Col. Victor Raymond, of the Service de Sante of the French Army, who also provided him with the brochure he had written on the subject. This, wrote Ashford, "was the first notion I had had of the disease." The remainder of the story seems worth quoting in detail:
A training school for line officers was established in the damp October chill * * *. Our division had arrived in July at their training area, and as most of us had been serving in tropical or subtropical countries we had little idea of the climate of the Haute-Marne. The army was just organizing, and we had little transportation and comparatively little wood for fires. A barrack cantonment for the line school sprang up overnight in a beautiful meadow, which in forty-eight hours became a sea of mud. The temperature ran between zero and 10? C'. There had been no time to construct drying rooms. It rained for forty days and forty nights with persistence, and men and officers were so intent upon learning, that they forgot mud, water, and cold and trudged about all day with wet feet without sufficient means for drying their shoes at night. The result was that every one in a few days had all their foot-wear muddy and soaked through, and were obliged to put on wet shoes in the morning. A battalion on duty at this camp, a half mile from the town, were
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27 Ashford, B. P.: Trench Foot: Its Treatment. War Med. 2: 717-724. December 1918.
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engaged in construction and were constantly wet through. From the very first, the commanding officer had been going to great lengths to secure fuel and to prevent the effects of exposure; but before anyone had time to do anything, the camp surgeon, on the first day I was given medical supervision over this camp, called my attention to a prevalent affection of the feet of the men working there, as well as of the student officers. These men had not been in the trenches, but the surgeon stated that the clinical picture resembled what he had seen described somewhere as "trenchfoot", and called me to go over the situation. By that time the battalion was seriously crippled by a large number of men who were actually unable to walk with any degree of comfort. I went over this organization, man by man and found that a good twenty-five percent had what they called "chilblains." One or two men had gone to the hospital with beginning necrosis, and those in quarters at the camp, as well as many still trying to do duty, were in the first or second stage of the affection.
That same day Colonel Raymond's brochure was abstracted, particularly that part relating to prophylaxis and treatment; efforts were redoubled, and this time with success, to provide more fuel; and the condition was reported to the Chief Surgeon with the diagnosis of trenchfoot, one of the first, if not the very first, made in our Army. Telegraphic authority was requested, and promptly obtained, for a good supply of whale oil, camphor, borate of soda, and green soap, secured in open market, and within three or four days the outbreak had declined as suddenly as it had appeared.
I have detailed the conditions under which the affection appeared, because the sudden and severe onset was evidently precipitated by those conditions, and troops who have to live under them here do not have to be in trenches to reap the results of exposure to moderate cold, with constantly wet and muddy footwear. The disease made its appearance under the very conditions considered by Raymond as favoring its development. It was a short lesson, but a striking one, at a propitious time for the American Army, and thanks to the energetic action of the Chief Surgeon of the American E. F. in acquainting the entire Army with its prevention and cure, it has never shown its head since as an important source of invaliding of soldiers.
In the meantime, we had personally followed the cases and had carried into effect the prophylaxis. In all, about 300 cases of some 1,000 strength were treated, all of which were promptly and completely cured without loss of tissue. In fact, not over three men had beginning necrosis, 15 percent blisters, and the rest merely the edematous, or first stage. The most notable result was seen in the rapid return to normal of all treated by the camphor and sodium borate fomentations. In forty-eight hours they were usually free from symptoms and ready for duty.
Ashford then quoted the first circular on the subject issued by the Army School, which contained essentially the same recommendations as those in General Orders No. 11, though in a few instances they were even more specific:
(1) The daily examination of the feet in each squad by squad leaders * * *. (2) The daily massage of the feet with camphorated oil * * *. This was to be done in the presence of the squad leader * * *. (5) Furnishing of well-fitting shoes, presence of officers during issue of same * * *.
When, about this time, a nearby division received orders to go into the trenches for the first time, the men were enjoined to carry out the provisions of the circular just cited and were also given special instructions for prophylaxis in the trenches. Again the instructions were somewhat more specific than those contained in General Orders No. 11. Among other things, the men were warned to exercise their feet and toes from time to time, "and always as often as possible if numbness should be perceived." They were also warned against warming affected feet before the fire.
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These measures, Ashford stated, saved the division from "the fate of the training school," in addition to cutting short the outbreak in the school itself. Practically no cases were reported in the division, "although much worse predisposing conditions prevailed."
Therapy.- The treatment of trenchfoot in the American Expeditionary Forces was based chiefly on methods proposed by Raymond and Parisot of the French Army Medical Service.28 The essentials were set forth in Memorandum No. 4, Army Sanitary School, American Expeditionary Forces, in the fall of 1917. The type of treatment depended upon the stage of the injury at which the patient was seen.
1. During the edematous stage, the feet were first bathed with green soap and water. Hot fomentations of camphor (1 part), sodium borate (15 parts), and boiled water (1,000 parts) were then applied. Finally, gauze compresses were applied, well above the tipper limits of the edema, and were covered with some impermeable material such as oiled silk or oiled paper. Ashford reported that this treatment provided such prompt relief from pain that men previously unable to rest often fell asleep at once. He also recommended potassium iodide, which he said had almost a specific action in relieving the pain of trenchfoot.
2. In the second, or blister stage, treatment began with the excision of all blisters larger than one-half inch in diameter, after which their gelatinous bases were gently wiped with pledgets of sterile cotton. The application of compresses of camphor (30 parts) and ether (1,000 parts) was followed by the use of fomentations, as in the edematous stage. After edema had disappeared, treatment with camphorated ether was continued.
3. Sloughs, which occasionally formed in spite of these measures, were loosened by the application of compresses of camphor and ether and fomentations of alkaline camphor until access to the affected tissues beneath was possible. An acceptable variation was the use of the paraffin footbath, in which the affected feet, wrapped in cotton batting, were immersed for 30 to 60 minutes in a small footbath filled with paraffin heated to 140? F. (60? C.) or higher. When the feet were removed from the bath and exposed to the air, the paraffin taken up by the cotton batting hardened and the patient had what amounted to a pair of paraffin sabots. Treatments were given daily.
Surgery was conservative and limited to hard sloughs. These were incised down to the grumous layer, after which compresses were applied. "Blood letting" was avoided, and the cautery was not used.
Ashford warned that feeding soldiers with trenchfoot was an essential part of treatment, since they were apt to be weak, malnourished, and exhausted. He also warned that trenchfoot predisposes to tetanus and that failure to administer tetanus antitoxin to all patients who had passed beyond the first stage and to repeat the injection every 8 days until the lesion looked healthy, would certainly result in some preventable deaths.
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28 See footnote 25, p. 47.
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Other Experiences in World War I
According to Tuffier (cited by Ariev), the 79,465 cases of trenchfoot in the French Army in World War I accounted for 3.02 percent of all battle casualties. There were 170 fatalities from trenchfoot. According to Mignon (also cited by Ariev), the average number of cases of trenchfoot per year was more than 30,000. Records, however, support this statement only for 1916, when there were 31,051 cases; 17,026 cases were recorded in 1915, and 15,870 in 1917. The French offensive at Verdun, which began on 15 December 1916, is known to have produced more than 3,600 cases; 1,869 cases occurred in a single division, the 38th, which had 1,971 battle casualties. French Senegalese troops fighting on the Aisne sustained 1,225 cold injuries between 15 and 17 April 1917.
The Italian Army, according to Bonomo (cited by Ariev), had almost 38,000 cases of frostbite during 1915-18. The Belgian Army seems to have had few casualties from this cause.
Statistical records of frostbite and other cold injuries are not available for the German Army in World War I, but the scope of the problem may be gathered from the fact that special hospitals were set up for the treatment of these injuries and that staff positions were set up in other hospitals for surgeons who specialized in their treatment. According to Schade (cited by Ariev), there were 12,848 casualties caused by cold injuries in a total of 500,000 sick and wounded in 1914 and 1915.
THE SPANISH CIVIL WAR
Trenchfoot does not seem to have been reported in any of the numerous hostilities which occurred between the close of World War I in 1918 and the outbreak of World War II in 1939. Ducuing, d'Harcourt, Folch, and Bonfill,29 who made an extensive study of cold injuries during the Spanish Civil War, stated that they had seen nothing precisely comparable to the type of trench-foot observed in World War I, although they had observed numerous cases which resembled it at some special time in their evolution. The troops who were chiefly affected were operating on the Sierra Palomera, then covered with snow, and were exposed for several days at a time. About 500 men were treated weekly for cold injuries of the lower extremities in a total exposed force of about 120,000, which gives a weekly rate of approximately 4.16 per 1,000 average strength and an annual rate of 216.32 per 1,000 average strength. This is very high in comparison to United States Army rates in World War II.
During the period covered by their observations, Ducuing and his associates also observed 10 cases of simultaneous freezing of the upper and lower extremities and 5 cases, all fatal, of total freezing.
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29 Ducuing, J., d'Harcourt, .1., Folch, A., and Bonfill, J.: Les Troubles trophiques des Extr?mit?s Produits par le Froid. Sec. en Pathologic de Guerre. J. de Chir. 55: 385-402, May 1940.
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ETIOLOGIC CONSIDERATIONS
Although the theories of etiology advanced to explain cold injuries in the wars prior to 1914 have already been mentioned, it might be well to summarize them briefly. Larrey (p.30) stated unequivocally that cold per se was merely the predisposing, not the exciting, cause; that the condition was not caused by a freezing temperature but occurred during a succeeding period of mild weather or in the course of a thaw; and that heat, suddenly applied, would promptly bring on gangrene from "congelation." Davys (p.39), in recording the experiences of the Tibet Mission Force in 1904, also emphasized that the most serious results of cold injuries could be explained by carelessly applied heat, not by excessive cold. Page (p.41), who compared the Balkan experience with that of the Crimean War, believed that gangrene which followed cold injury was on a vasomotor basis and could be explained by the effect of cold on an arterial circulation already impaired by starvation and fatigue. He pointed out that under these circumstances temperatures above freezing could cause tissue damage. He noted, but did not enlarge upon, the fact that in many instances the first complaints related to the extremities came after the men had been hospitalized. Their pain was very marked during the "period of reaction." Page granted the possible influence of tight boots and puttees in some cases but was unwilling to accept constriction as a universal explanation. Numerous early observers called attention to the possible indirect effects of hunger, exhaustion, and concurrent wounds and illness.
The realization that cold injuries could not be explained entirely by cold came early in World War I. In the first months of that war, British troops were obliged to march miles along wet and muddy roads in order to reach the entrance to communications trenches. When they arrived, cold, soaked to the skin, and already fatigued, they had to expend an immense amount of additional energy marching along the wet and muddy trenches to reach the forward trenches. Once they reached their station they were never really warm, dry, and comfortable until they were relieved; and that, in the early winter of 1914, might be a matter of weeks. Meantime, they remained almost immobile, in cold and mud, frequently in the rain, but not in freezing temperatures. The special correspondent in northern France 30 wrote in the British Medical Journal for 26 December 1914:
The temperature so far has never been really low; in fact, there has never been more than a few degrees of frost for a limited number of hours, mainly at night. In all probability the actual temperature of the air at any given moment is only one of several factors in the production of the condition * * *. Apart from actual frost, the factors in question appear to be the soaking of the men's boots and socks either in freezing water or a mixture of mud and slushy snow, the absence of any local output of muscle heat owing to the fact that the men are standing still, and some tightness of their boots owing to the men putting on two or three pairs of socks which are thick even when dry and thicker still when wet. [Cottell 31 had previously made a similar observation about the wearing of extra socks.] With their legs
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30 Frostbite (The War). From a special correspondent in northern France. Brit. M. J. 2: 1115, 26 Dec. 1914.
31 Cottell, A. B.: Frost-bite. Brit. M. J. 2: 992, 5 Dec. 1914.
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thus chilled in advance, and the whole local circulation already reduced to a very low ebb, it is comprehensible that here and there in superficial areas it should be arrested for a time altogether. The usual history of these cases is that a man who has just got into his dugout after standing for an hour or more with his rifle on the deck, has seen his way to a good rest and consequently has taken off his boots. On doing this he has noticed nothing the matter with his feet but subsequently has found that they have become so swollen that, apart from any question of pain, to get his boots on again is quite impossible.
In December 1915, Sir William Osler 32 called attention to another important cause of trenchfoot. The venous stasis which is the anatomic background, he wrote, is not simply the effect of cold, wet, or both. The feet may be aglow after a 10-mile tramp in snowshoes with the thermometer 20? below zero; and men actively at work on big lumber rafts in Canada have cold, wet feet for weeks at a time and yet suffer no injuries. It was not cold or wet, Osler concluded, and not puttees or boots which were doing the damage but the comparative inertia of the muscles of the leg. To keep the trenches dry and to use special kinds of socks might be useful, but the disabling effects of "cold bite" were inevitable in feet attached to legs whose muscles did not have play enough to maintain a circulation hampered by gravity and by cold and wet.
The principal causes of trenchfoot were thus clearly set forth many years before World War II as a combination of conditions and not a single condition. 'These causes included cold, wet, constriction, and immobilization. Cold injury could occur with the temperature above freezing and with frost present for limited periods only if at all. Lack of proper (principally warm) food and the influence of fatigue were other contributing causes. Tullidge,33 who had been first an Austrian medical officer and then a military surgeon with the French Red Cross, advised recruiting physicians to remember that men with circulatory disorders and sluggish circulation were most susceptible to frostbite. If they were enlisted, lie suggested that they be kept out of situations in which these injuries could be sustained.
A few other observers also called attention to a possible individual predisposition to cold injury, or, more correctly, to a possible individual variation in susceptibility, as evidenced by striking differences in the development of trench-foot under the same environmental conditions. It was noted that, as a general rule, symptoms appeared within 3 or 4 days after exposure and that disability became marked within the next day or two. In some instances, however, men would be completely incapacitated within 24 hours after their first tour of duty in the trenches had begun, while others under precisely the same circumstances might not present, symptoms for 5 or 6 days and might not be completely incapacitated for another 5 or 6 days.
A few other theories of the causation of trenchfoot were advanced in World War I in addition to the reasonable and generally accepted explanations just set forth. Fearnsides and Culpin,34 although they agreed with the generally
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32 Osler, W.: Cold-bite+Muscle-inertia=Trench-foot. Lancet 2: 368, 18 Dec. 1915.
33 Tullidge, E. K.: Frozen Limbs and Their Treatment in the Present War. M. Rec. 90: 11-14, 1 July 1916.
34 Fearnsides, E. G., and Culpin, M.: Frost-bite. Brit. M. J. 1: 84, 9 Jan. 1915.
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accepted theories, considered that apprehension acid fear of a new disease were other possible causes.
Longridge's 35 elaborate theory of leakage of electricity from the foot to the earth, because the electrical resistance of the skin is enormously diminished when it, is wet, was based on the researches of one A. E. Baines, who, shortly before the war, had published a book on electropathology. Longridge was so impressed by the concept, that he "ventured to predict" that in the future the name of Baines would appear with those of Lister, Simpson, and Koch as among the benefactors of the human race. Recommendations for prevention based on the electrical theory of trenchfoot began with the wise, if unattainable, order not to get wet. Other advice included soaking the shoes, socks, and puttees in oil and applying dialectric oil (commercially available) directly to the feet. If trenchfoot had developed, the limb, from foot to knees, was to be wrapped in gamgee tissue soaked in dialectric oil. "I have seen enough of this treatment," concluded Longridge, "to justify the assertion that no serious case of trenchfoot necessitating amputation need take place." It would scarcely be necessary to refer to this curious item in a serious account of trenchfoot except that it was printed in the Lancet in January 1917, when the whole problem of cold injury was well under control in the British Army.
The French were in general agreement with the British that the important etiologic factors in trenchfoot were cold, wet, and lack of movement. Almost the only dissenters were Raymond and Parisot,36 who argued that "gelure des pieds" is infectious. They reported in 1916 that they had isolated from the lesions a, fungus identified as Scopulariopsis koming? oudemans, which was found in mud and straw and which came into contact with the feet by way of the mud of the trenches. Under the influence of more or less continuous immersion in cold water, this fungus became pathogenic and readily invaded the body through the macerated epidermis, frequently at the matrices of the nails. Although Raymond and Parisot claimed to have reproduced the lesions of trenchfoot by experimental animal inoculation of pure cultures of the fungus, their work was not generally accepted nor was it ever confirmed.
British theories of the etiology of trenchfoot were generally accepted by medical officers of the United States Army in World War I. The only deviation was a theory advanced by Sweet., Norris, and Wilmer,37 who conducted comparative blood pressure studies on the upper and lower extremities, on the assumption that trenchfoot was analogous to Raynaud's disease and on the further assumption that Raynaud's disease can be explained by vasomotor spasm. While they found pressures in the leg considerably increased over pressures in the arm in casualties with trenchfoot, they were unable to determine whether the increase was the result of an excess of vasoconstrictor substance or
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35 Longridge, C. N.: A Note on the Cause and Prevention of Trench-Foot. Lancet 1: 62-63, 13 Jan. 1917.
36 Raymond, V. V., and Parisot, J.: Etiologie Piophylaxie et Th?rapeutique de I'Affection Dite "Gelure des Pieds." Presse m?d. 24: 199, 4 May 1916.
37 Sweet, J. E., Norris, G. W., and Wilmer, H. P.: The Etiology and Treatment of Trench-Foot. J. A. M. A. 70: 455-458, 16 Feb. 1918.
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of a loss of vasodilator substance in the blood. Like Ashford (p. 49), they found that notable relief of pain could usually be secured (in 29 of their own 31 cases) by the administration of potassium iodide, which they employed as a "blood pressure reducing substance." Had they been able to obtain thyroid extract, they would have preferred to use it on the ground that the clinical picture in trenchfoot is the reverse of that in thyroid disease.
COLD INJURY OF THE HAND
In the great majority of cases of cold injury in World War I, only the feet were affected. Cold injuries of the hand, when they did occur, were seldom of consequence. Walther, however, reported an interesting exception in the experience of P?r? and Boy?, 38 who observed, in 120 cases of "frostbite of the foot," 30 instances of frostbite of the hand (main de tranchees). The explanation was a particular series of circumstances. Because of the violence of the bombardment, the men had to remain crouched in the same position for several hours, without moving at all. Snow fell on their hands as they grasped their rifles, and they could not wipe it off. Many of them were then obliged to move on all fours for a considerable distance, over ground covered with snow and mud. When they had been relieved, they complained of pricking of the fingers and of difficulty in holding their rifles; some could not hold them at all. They also complained of edema of rapid development, which was apparently transient since it was not present when they reached the ambulance. Almost all of the lesions were bilateral and symmetrical. There were eight instances of gangrene, which in advanced cases extended almost to the metacarpophalangeal articulations.
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38 P?r? et Boy? (reported by Charles Walther): Main de Tranchees. Bull. et Mem. Soc. de Chir. de Paris 43: 1483-1485, 4 July 1917.
