CHAPTER XVI
Heart Disease
Edward F. Bland, M.D.
During World War II, the fevers and fluxes of previous warswere largely replaced by the hazards of high altitudes and by the devastation ofblasts and bombs-circumstances where physical fitness assumed specialsignificance. It was, therefore, inevitable that the stability of thecirculation, its diseases and its disorders, should have attracted particularattention and detailed study. The Army Medical Corps, superbly equipped andaugmented manifold by experienced physicians and able investigators fromcivilian life, was presented with an unparalleled opportunity to study diseaseand to acquire new knowledge in far and unfamiliar areas of the world. It iswith the activities and contributions of these men in the field ofcardiovascular disease that this report is concerned.1It is a record of achievement and progress which testifies to their devotion toduty and to the diligence with which they pursued their studies, at times underdifficult and dangerous circumstances.
SELECTION FOR SERVICE
Following the passage of the Selective Training and ServiceAct of 1940, there immediately arose the problem of standards for the newrecruits. With the world again at war and with the contemplated requirements ofthe service, defects and disorders of the cardiovascular system assumed animportant role in the selection of men for the fighting forces. The existingstandards for acceptability as outlined in the early mobilization regulationsbefore 1940, seemed, in the opinion of the Medical Corps of the Army, to warrantrevision, and those pertaining to the heart and circulation were referred to aspecial committee2 on cardiovasculardiseases appointed in 1940 as a subcommittee of the National Research Council.
The range of normal, as always, posed a problem, especiallyin terms of acceptable blood pressure and pulse rates. It was at first suggestedby
1This chapter on the heart has been prepared at the invitation of The Surgeon General, 10 years after the war. The lapse of a decade has been in some respects an advantage in providing a perspective of the contributions of the war years in terms of their later significance.-E. F. B.
2This committee consisted of Dr. Paul D. White (Boston, Mass.), chairman, and Drs. Edgar V. Allen (Rochester, Minn.), E. Cowles Andrus (Baltimore, Md.), Ashton Graybiel (Boston), Robert L. Levy (New York, N.Y.), and William D. Stroud (Philadelphia, Pa.). Later, in 1943, the services of some of the committee members were required in the Armed Forces, and other members were added. (Personal communication from Dr. Paul D. White.)
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this committee that the blood pressure should be determinedin all cases, but it was soon recognized that great difficulties would arise inthe case of healthy young candidates who under the excitement of the occasionmight have temporary elevations above the normal standards. Therefore, the Armywisely decided not to follow this earlier suggestion, and a more practicalcompromise in dealing with this troublesome problem was provided by therecommendation that the blood pressure will be determined only in those cases inwhich it appears indicated. Likewise, considerable leeway was recommended indealing with pulse rates, but special scrutiny was advised of those above 100per minute after a reasonable rest and of those under 50 per minute.3 Theseimportant variants of uncertain significance were subjected later to carefulstudy during the war.
The earlier observations of Lewis4 and his collaborators, inWorld War I, on the soldier's heart and the effort syndrome had emphasized theimportance of determining the response of each recruit to effort rather than ofrelying on instrumental methods of examination. In this connection, it was alsoearly recognized that routine electrocardiograms would be of little or no valuefrom the military standpoint in demonstrating cardiac abnormalities not evidenton physical examination,5 although some useful data in terms of therange of normal were later recorded in electrocardiograms on large numbers ofairmen in the United States6 and in Canada.7
Thus, during the summer of 1940, the simplified and revisedrecommendations8 were completed and incorporated in MR (MobilizationRegulations) 1-9, War Department, "Standards of Physical ExaminationDuring Mobilization," 1 August 1940, and the buildup of the new armyacquired momentum.
It soon became evident from the early tabulation available in1942 that diseases and disorders of the cardiovascular system by these standardshad rendered unacceptable for general military service an alarming proportion ofthe eligible population. A summary of a statistical survey carried out bySelective Service and appearing as Medical Statistics Bulletin No. 1 indicatedthat, of the first 2 million men examined up to 31 May 1941, examining boardsdisqualified for general military service approximately
3White, P. D.: The Soldier and His Heart. War Med. 1: 158-167,March 1941.
4(1) Lewis, Thomas: Report Upon Soldiers Returned as Cases ofDisordered Action of the Heart (D.A.H.) or Valvular Disease of the Heart (V.D.H.). MedicalResearch Committee, National Research Council, Special Report No. 8. London: His Majesty'sStationery Office, 1917. (2) Lewis, Thomas: The Soldier's Heart and the Effort Syndrome, 2d edition.London: Shaw and Sons, Ltd., 1940.
5Wood, F. C., Wolferth, C. C., and Miller, T. G.:Electrocardiography in Military Medicine, With Special Reference to Its Lack ofValue in the Study of Recruits. War Med. 1: 696-709, September 1941.
6Graybiel, A., McFarland, R. A., Gates, D. C., and Webster, F.A.: Analysis of the Electrocardiograms Obtained From 1,000 Young HealthyAviators. Am. Heart J. 27: 524-549, April 1944.
7(1) Hall, G. E., Stewart, C. B., and Manning, G. W.: TheElectrocardiographic Records of 2,000 RCAF Aircrew. Canad. M.A.J. 46: 226-230,March 1942. (2) Stewart, C. B., and Manning, G. W.: A Detailed Analysis of theElectrocardiograms of 500 RCAF Aircrew. Am. Heart J. 27: 502-523, April 1944.
8The procedure for determining the blood pressure only in those cases in which it appears indicated was rescinded in MR 1-9, 15 March 1942, by requiringthat blood pressure be routinely measured. This became standard requirementbeginning with the March 1942 revision of MR 1-9.
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1 million (50 percent). Of these rejectees, 10 percent(96,000) had cardiovascular defects, a figure exceeded only by deficiencies ofthe teeth (188,000) and the eyes (123,000) and by illiteracy (100,000).9 Asubsequent and somewhat more detailed report from the same source10 onthe causes for disqualification for general service in 18- and 19-year-oldregistrants indicated that 23.8 percent of the white youths were sodisqualified, whereas, of Negroes, twice as many (45.5 percent) weredisqualified. Cardiovascular defects were in fourth place for the white groupand in third place for the Negro group. Valvular disease and hypertension inparticular were more prevalent among the Negroes. Experience with the olderregistrants showed a similar distribution.11
These rejection rates during the early phases of the war were disturbing and seemed excessive for the age period covered. Therefore, a conference was called in Washington, D.C., on 27 June 1942, for a discussion of the problem. In attendance were members of the Subcommittee on Cardiovascular Disease of the National Research Council (p. 419), as well as representatives of the Army, Navy, Public Health Service, Selective Service, Veterans' Administration, the National Research Council, and the Committee on Medical Research. As a result of this conference, a letter was sent to Maj. Gen. Lewis B. Hershey, Director, Selective Service System, proposing that in each of five cities special boards of experienced cardiologists reexamine 1,000 registrants rejected for cardiovascular reasons. The project was approved and thus was launched one of the most important and practical cardiovascular studies of the war years-a study which in turn led to further investigations of considerable significance. Boston, Mass., Chicago, Ill., New York, N.Y., Philadelphia, Pa., and San Francisco, Calif., were designated as the five centers; the objectives of the program were (1) to determine the problems in diagnosis that particularly concern the range of the normal cardiovascular system with respect to service, (2) to determine the possible salvage of men for the Army by reclassification as 1A, and (3) to compare the opinions of cardiovascular experts with those of the examiners of local boards and induction stations to determine the desirability of such reexaminations in this or other special medical fields throughout the coun-
9Rowntree, L. G.: Rehabilitation and Prehabilitation. J.A.M.A. 119: 1171-1175, 8 Aug. 1942.
10Rowntree, L. G., McGill, K. H., and Edwards, T. I.: Causes of Rejection and the Incidence of Defects Among 18 and 19 Year Old Selective Service Registrants. J.A.M.A. 123: 181-185, 25 Sept. 1943.
11In view of this high overall rejection rate, it is of interest to recall comparable data from World War I. An official report of the Cardiovascular Section of the Office of the Surgeon General, U.S. Army (Connor, L. A.: Report of Cardiovascular Section. In Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1923, p. 377) indicated that in one million recruits 1.15 percent were rejected for cardiovascular reasons, whereas 0.88 percent with cardiac disorders were accepted for limited service only. The causes of disqualification of the 11,562 rejected were: Valvular disease, 49 percent; other organic diseases, 19 percent; and functional disorders, 23 percent. The belief was expressed that the number rejected for organic heart disease was too high, because of the tendency of the examiners to classify functional conditions, such as irritability of the heart, as instances of organic disease. In the German and British official reports covering World War I, there were no features worthy of special note in this connection (cited by Levy, R. L.: The Stimulus of War to Cardiology. Bull. New York Acad. Med. 22: 237, May 1946).
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try. The results of this study, published in 1943, by Levy,Stroud, and White12 are noteworthy. These are summarized as follows:
Of the total number of 4,994 rejectees examined, there were863 (17.3 percent) resubmitted as 1A and 4,131 (82.7 percent) whose rejection as4F was confirmed. It was suggested that the low salvage rate might have been dueto the already free use of cardiovascular experts in these communities inconnection with doubtful cases, but in any event the wisdom of extending thesereexaminations for the sake of the salvage alone seemed questionable.
The chief cause for rejection was rheumatic heart disease,found in 2,476 (50 percent) of the total 4,994 men.
The second most common cause for final rejection washypertension, found in 1,059 cases (21 percent).
Third in frequency was neurocirculatory asthenia (204 cases,4 percent) and fourth was sinus tachycardia (189 cases, 3.8 percent). Congenitalheart disease was found in 183 cases.
In conclusion, Levy and his associates pointed out that thereremained eight problems of special interest as yet unsettled but concerningwhich tentative opinions were expressed, as follows:
1. The interpretation of apical systolic murmurs-may they,if very slight or even slight, in the absence of any other abnormal or doubtfulfinding be considered inadequate reason for rejection?
2. The upper limits of the normal blood pressure-may thesystolic pressure in very nervous young men be set perhaps as high as 160 mm. ofmercury or even a shade more, provided the diastolic pressure does not exceed 90mm.?
3. The limits of the normal pulse rate at rest-may therenot be a wider range, perhaps 40 to 120 per minute, than that given in thecurrent criteria?
4. The heart size-especially in relation to body build.
5. The electrocardiogram of which the wide range of normalhas not been explored adequately.
6. Neurocirculatory asthenia-difficult to diagnose in milddegree, but probably rejectable even when slight, unless there is an obviouscorrectable cause.
7. Recent rheumatic fever-a hazard even when the heartseems normal.
8. Exercise tests-the usefulness of which in cardiovascularexamination for military service is open to question.
The ensuing 4 years provided ample opportunities to observe the effectiveness of the screening program, and reports from medical officers in the Zone of Interior and from those overseas are available in this connec-
12Levy, R. L., Stroud, W. D., and White, P. D.: Report of Reexamination of 4,994 Men Disqualified for General Military Service Because of the Diagnosis of Cardiovascular Defects. J.A.M.A. 123: 937-944, 11 Dec. 1943; 1029-1035, 18Dec. 1943; Am. Heart J. 27: 435, 1944.
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tion. An early survey of the fate of selectees previouslypassed by their local draft boards revealed, upon later examination at theinduction station at Camp Shelby, Miss., an additional rejection rate of 25percent of which cardiac defects accounted for 1.9 percent-an indication, itwas thought, of the initial confusion and variance in interpretation of theregulations prescribed by the War Department.13 The remarkablesuccess of the overall program is borne out, however, by subsequent experience.Reports from the station and general hospitals at Fort Devens, Mass., covering a1- and 2-year period, respectively,14 indicated an expected highincidence of functional complaints relating to the heart and the circulation anda low incidence of organic disease, with a ratio of approximately 10:1.
A reexamination for aircrew training of 344,134 menpreviously passed by other Army medical facilities and already in the servicesheds some further light on the incidence and nature of the more frequentlymissed cardiovascular defects (fig. 53).15 As a result of this second screening,an additional 2,033 (5.9 per 1,000) were disqualified for cardiovasculardefects. The majority, however, were for defects of conduction and fordisturbances in blood pressure and circulation of psychogenic origin-variantsquite understandably overlooked or considered less significant for generalservice.
In the South Pacific Area, Sprague and McGinn16 undertooka similar study with reference to the cardiovascular system. During the 12months from 1 July 1942 to 1 July 1943, there were 22,085 patients (Army, Navy,and Marine) admitted to two hospital facilities. In that year, 143 patients(0.65 percent) were found to be suffering from valvular disease, degenerativeheart disease, or important functional disorders of the heart. During the sameperiod, 36 patients with rheumatic fever (0.16 percent) were evacuated. Typicaleffort syndrome (neurocirculatory asthenia), although important, appeared to beless common than in World War I, owing in part to this syndrome being absorbedin neuropsychiatric diagnoses without as much emphasis as in the past on thecirculatory system. Sprague and McGinn believed that the elimination of men withheart ailments was being satisfactorily accomplished in enlistment, recruiting,induction, and training areas in the United States.
In concluding this review of the standards employed in theselection of men for service in World War II and of the results in terms oflater reports from the United States and overseas, it is with great admiration
13(1) Saslaw, M. S.: Medical Aspects of the SelectiveService System. War Med. 1: 486-492, July 1941. (2) Saslaw, M. S., and Jundermann, C. S.: MedicalAspects of the Selective Service System; Follow-Up Study. War Med. 2: 99-101,January 1942.
14(1) Brown, M. G.: Cardiac Problems in a Station Hospital. Am. Heart J. 27: 565-567, April 1944. (2) Porter, R. R.: Cardiovascular Experiences in an ArmyGeneral Hospital. Am. Heart J. 27: 559-564, April 1944.
15Leach, J. E.: Diseases and Defects in Aircrew Trainees. I.Cardiovascular System. War Med. 8: 1, 1945.
16Sprague, H. B., and McGinn, S.: Heart Diseases andDisorders as Causes for Evacuation From the South Pacific Combat Area. Am.Heart J. 27: 568-574, April 1944.
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that one contemplates the long hours, the inherentdifficulties, and the extraordinary efforts of our medical colleagues, on theinduction boards, who so conscientiously sought and succeeded in providing theArmed Forces with men remarkably free of defects of the heart and circulation.
INFECTIONS AND DEFICIENCIES
Rheumatic fever and infections likely to injure the heart17received careful study during World War II. In most instances, theobservations served to extend existing knowledge, but occasionally an unusualopportunity was presented to acquire new and detailed information, notably intsutsugamushi fever (scrub typhus), where earlier studies had been scant andsketchy. The availability and full use of electrocardiograms and roentgenogramsin the field and the expert processing and study of the specimens
17In this section, a discussion of these infections isrestricted to those aspects of the various diseases as they relate to thecardiovascular system.
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in laboratories overseas with subsequent assembly andanalysis in the United States provided reliable and revealing data of lastingimportance.
Furthermore, the harassing experiences and consequentdebilitation of U.S. personnel in the prison camps of the Far East and of theinmates of the concentration camps in Germany presented medical officers with akeener insight into the untoward effects of deficiency states upon thecirculation.
Rheumatic Fever and Rheumatic Heart Disease
In the early months of the war, the assemblage of largegroups of men from civilian life in the crowded buildings and barracks of thetraining centers provided a favorable medium for the spread of respiratoryinfections, which at times reached epidemic proportions. This led, inevitably,to the appearance of rheumatic fever cases in considerable number. Thus, earlyin the war, a situation was created which, fortunately, proved far lesstroublesome later in the field, where more rugged but less crowded conditionsprevailed. This early experience served as the basis for a number of importantbacteriological and epidemiological studies concerning the role of thestreptococcus and for the testing of preventive programs of early detection,intelligent isolation, and mass protection with chemotherapy (sulfonamides) andlater with antibiotics (penicillin). It even provided the basis for a new andless conservative approach to the management of rheumatic fever than hadhitherto been recommended, of merit perhaps under such special circumstances,although generally not acceptable in the younger age groups where the heart ismore susceptible.
An extensive study18 of the protective effects of dailysulfadiazine (1.0 gm.) in 250,000 trainees at a large base, between December1943 and April 1944, indicated that sulfadiazine could (1) check a well-advancedstreptococcal epidemic, (2) repel a streptococcal outbreak at its onset, and (3)protect 85 percent of susceptible recruits from implantation with bacterialrespiratory pathogens. Untoward effects were minimal, with evanescent rashes in0.5 percent and dangerous constitutional disturbances in only 0.01 percent. Allthese factors are of special significance in the prevention and control ofrheumatic fever.
Likewise, the Army Air Forces inaugurated a broad program19in the spring of 1943 at 40 of the larger hospitals, representing 25,000beds and 800,000 troops. The posts chosen were in areas where the incidence ofrheumatic fever was high and intermediate, as well as low. At some airbases, therates of incidence for 1943 were in excess of 25 per 1,000 troops, and, duringthe peak of the rheumatic fever season, one
18Coburn, A. F.: The Prevention of Respiratory TractBacterial Infections by Sulfadiazine Prophylaxis in the United States Navy.J.A.M.A. 126: 88-92, 9 Sept. 1944.
19Holbrook, W. P.: The Army Air Forces Rheumatic FeverControl Program. J.A.M.A. 126: 84-85, 9 Sept. 1944.
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large post experienced rates in excess of 100 per 1,000troops. It was concluded from this extensive study that acute rheumatic feveroccurring in high incidence was invariably preceded by a high incidence ofhemolytic streptococcal infection. A 50- to 75-percent reduction wasaccomplished by the use of sulfadiazine prophylaxis (1.0 gm. daily) undercareful conditions on a significantly large troop population. No serious drugreactions occurred, and from these data it appeared that the reduction inrheumatic fever paralleled that in streptococcal respiratory diseases.
The thesis that early physical activity might be of value inthe treatment of rheumatic fever was explored by the Army Air Forces at theRegional Station Hospital, Orlando, Fla.20 The patient's comfortwas employed as the principal determining factor in prescribing strict bed restor in permitting early ambulation. In this program, apparently, the incidence ofanxiety neurosis was considerably lessened, and at the same time satisfactoryclinical results were obtained in 200 patients.21
A survey of the overall problem of preexisting valvulardisease and the prevalence of acute rheumatic fever in the U.S. Army overseaswas made in the Mediterranean (formerly North African) theater from November1942 to the end of hostilities in May 1945.22 These data were obtained largelyfrom the 17 general hospitals in that theater and from those station hospitalsfunctioning in a like capacity. Approximately 1,400 patients were hospitalized,of whom more than one-half had rheumatic fever and the remainder inactive,preexisting rheumatic valvular disease. In addition, a review of the records of1,507 consecutive post mortem examinations at the 15th Medical GeneralLaboratory and from the 2d and 4th Medical Laboratories disclosed only 13instances of healed valvulitis (all unrelated to the cause of death) and 2instances of active carditis-an overall incidence of 9.9 per 1,000. Thisextraordinary low post mortem incidence, in terms of civilian experience, wasthought to be due to careful preinduction screening and to the prompt evacuationto the Zone of Interior of patients with valvular defects or rheumatic activity.
From this study, it was noted also that rheumatic fever andrheumatic heart disease accounted for 3.9 percent of the patients returned tothe Zone of Interior from the medical services of the general hospitals andthat, if those patients with preexisting (and detectable) heart disease andthose who had had recognizable rheumatic fever within 1 year of entry into the
20Robertson, H. F., Schmidt, R. E., and Feiring, W.: TheTherapeutic Value of Early Physical Activity in Rheumatic Fever: Preliminary Report. Am. J.M. Sc. 211: 67-73, January 1946.
21This interesting report is open to the general objection that such a program is contrary to the well-established precepts of the beneficial effects of rest in combating inflammation and more specifically that it lacks clinical and laboratory details, adequate control studies, and followup data. Furthermore, the material concerns acute rheumatic fever in previously healthy young adults, where the duration of the disease is apt to be shorter and injury to the heart less common than in younger age groups. Nevertheless, it was evident that such a program had merit under the special circumstances.-E. F. B.
22Bland, E. F.: Rheumatic Fever and Rheumatic HeartDisease in the North African and Mediterranean Theater of Operations, UnitedStates Army. Am. Heart J. 32: 545-559, November 1946.
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service had been excluded, the problem presented to the Armyoverseas would have been reduced by 37 percent. Nevertheless, a scrutiny of thedetails in individual cases also indicated that the measures then in force toexclude from oversea service individuals with chronic valvular disease and thoseespecially susceptible to rheumatic fever had been, with occasional evidentexceptions, highly effective. Contrary to the earlier experiences in thetraining centers, no frank epidemics were encountered, and no mass protectionwith chemotherapy was undertaken.
Somewhat at variance with the foregoing studies are tworeports from the postwar era which are provocative in their implication in termsof future planning. They concern the fate of known rheumatic fever subjects, inmilitary service during the war, from two well-known series with long-termfollowups.23 In both instances, the recurrence rate was actually less in theservice groups than in their civilian counterparts; furthermore, those withrheumatic heart disease (usually of minor degree) tolerated strenuous activityin basic training and under combat conditions without difficulty or detriment,and some even received decorations for outstanding service. This documentedexperience may well require further consideration should the Nation again befaced with a serious manpower shortage in some future crisis.
Scrub Typhus (Tsutsugamushi Fever)
Involvement of the heart and failure of the circulation inthe course of severe scrub typhus had been recognized but only briefly describedbefore World War II.24 This acute and serious disease was widelyencountered by the Army in the Southwest Pacific Area and in Burma, where over5,000 cases were reported. Three major epidemics occurred in northern Burma andin Netherlands New Guinea in 1944, and, as a direct result of the Armyexperience, ecologic concepts of this rickettsial disease were changed (it wasfound that there were no typical scrub typhus areas), a wider geographicdistribution of the disease became evident, the etiology was confirmed, vectorspecies were proved, strains were isolated, a new complement fixation test wasevolved, and the clinical pattern and pathological features became established.25Among the extensive studies completed during the war were a number ofimportant reports of cardiovascular significance.
23(1) Wilson, M. G., Payson, J. W., and Lubschez, R.:Experience of Rheumatic Patients Who Served in the Armed Forces, 1942-1946. Am. J. Pub. Health 38: 398-405, March 1948. (2) Bland, E. F., and Jones, J.D.: Rheumatic Fever and Rheumatic Heart Disease: A 20 Year Report on 1,000Patients Followed Since Childhood. Circulation 4: 836-843, December 1951.
24(1) Lewthwaite, R.: Pathology of the Tropical Typhus(Rural Type) of the Federated Malay States. J. Path. & Bact. 42: 23-30, January 1936. (2)Kouwenaar, W.: Investigations on Rickettsial Diseases in Sumatra; Pathological Anatomy of Human MiteFever. Geneesk. tijdschr. v. Nederl.-Indie 80: 1119-1140, 30 Apr. 1940.
25Developments in Military Medicine. Bull. U.S. Army M.Dept. 7: 594, July 1947.
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Two early studies at the 1st Evacuation Hospital, New Guinea,based on 200 cases indicated a mortality of nearly 10 percent.26 Asregards the cardiovascular system, it was found that a sustained pulse rateabove 120 per minute was of grave significance and was frequently a precursor ofmyocardial failure. In the severely ill patients (20 percent of the series),abnormalities referable to the circulatory system were noted, as follows: Extrasystoles were numerous; a soft, blowing, apical systolicmurmur was not uncommon; a pronounced accentuation of the pulmonary second soundwas frequent; and cyanosis of the lips, mucous membranes, and nail beds wasoften present without dyspnea or clinical evidence of pulmonary congestion. Inthose with a fulminating form of the disease, one or more of the following werenoted: Cyanosis, severe dyspnea, profound tachycardia, atrial fibrillation,gallop rhythm, pulsus alternans, cardiac dilatation with signs of congestivefailure, harsh pulmonary systolic murmur, thrombophlebitis, and pulmonaryemboli. Subsequent reports by others attested to the severity of the acuteillness.27
Although Kouwenaar28 had earlier demonstrated thatmyocarditis may complicate scrub typhus and be a frequent cause of death, thepathological features of the disease were more definitely described than everbefore by the reports from the 3d Medical Laboratory overseas.29 Thestudy was based on an analysis of 55 fatal cases in American troops in NewGuinea and adjacent islands. In these cases, the heart on inspection exhibitedrelatively mild changes and was usually of normal weight, but the myocardium attimes appeared flabby and in a few instances contained minute, pale,brownish-gray areas of degeneration and, more rarely, small focal hemorrhages.No valvular involvement was demonstrated. Microscopically, however, the heartwas involved more seriously than any other organ of the body, since the dominantlesion in all cases was an acute, nonsuppurative myocarditis, focal as well asdiffuse, varying in severity, patchy in distribution, and usually most severe inthe interventricular septum and the left ventricle. The most marked and constantfinding was a perivascular infiltration of mononuclear cells, chiefly plasmacells with lesser numbers of large mononuclear cells, occasional lymphocytes,and sometimes large multi-nucleated cells with vesicular nuclei and basophiliccytoplasm (fig. 54). The more diffuse type of myocarditis was characterized bycolumns of mononuclear cells, chiefly plasma cells, lying in the connectivetissue interstices between individual muscle fibers and in close relationship tocapillaries (fig.
26Lipman, B. L., Byron, R. A., and Casey, A. V.: ClinicalSurvey of Scrub Typhus Fever. Bull. U.S. Army M. Dept. 72: 63-70, January1944.
27(1) Logue, J. B.: Scrub Typhus: Report of Epidemic in theSouthwest Pacific. U.S. Nav. M. Bull. 43: 645-649, October 1944. (2) Berry, M. G., Johnson, A.S., Jr., and Warshauer, S. E.: Tsutsugamushi Fever: Clinical Observations in One Hundred and Ninety-Five Cases. War Med. 7: 71-75, February 1945. (3) Likoff, W.: Changes in the Cardiovascular System in Scrub Typhus in Early Convalescence. Am. J.M. Sc. 211: 694-700, June 1946.
28See footnote 24 (2), p. 427.
29Settle, E. B., Pinkerton, H., and Corbett, A. J.: APathologic Study of Tsutsugamushi Disease (Scrub Typhus) With Notes onClinicopathologic Correlation. J. Lab. & Clin. Med. 30: 639-661,August 1945.
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55). The capillary endothelium often showed swelling andproliferation. Areas of focal hemorrhage were not unusual where thisinflammatory reaction was severe. Degenerative changes in the cardiac musclefibers varied from cloudy swelling, loss of striation, and fatty degeneration,to actual necrosis.
In summarizing their clinical and pathological correlations,Settle and his coworkers concluded:
Circulatory failure, evidenced by increasing pulse rate andfalling blood pressure, rapid shallow respirations, cyanosis, sweating, and coldclammy skin, generally appears in the second week. This syndrome, usuallydiagnosed clinically as peripheral vascular collapse, closely resembled thatseen in surgical shock. Less frequently circulatory embarrassment occurs whichis referable to acute myocarditis. * * * The myocarditis is difficult toevaluate as a cause of death. We do not believe it is of great importance whenmild. In the more severe cases, however, with degenerative changes in themyocardial fibers, death may be due to myocardial failure.
Clinically, death was ascribed to circulatory failure inabout one-third of the patients, to respiratory failure in about one-third, andto cerebral
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involvement and miscellaneous complications in the remainingthird. Generalized acute vasculitis was a constant finding. Woodward and Bland30have emphasized the importance of myocarditis as a cause of death in typhusfever, and their conclusions may apply equally to tsutsugamushi disease.
The cardiac status during convalescence was the object of aspecial investigation for evidence of residual injury at a general hospital inthe Southwest Pacific Area from July 1942 through February 1944.31Electrocardiograms on 118 patients were normal in 109; striking, thoughtransient abnormalities were noted in 7; and minor changes in 2. From theavailable clinical and laboratory data, Levine concluded:
The evidence for persistent myocardial damage followingtsutsugamushi fever is not convincing. In its effect on the heart, this diseaseis rather like diphtheria. If the patient survives the acute phase of thedisease, his heart eventually shows complete return of function.
30Woodward, T. E., and Bland, E. F.: Clinical Observations inTyphus Fever; With Special Reference to the Cardiovascular System. J.A.M.A. 126:287-293, 30 Sept. 1944.
31Levine, H. D.: Cardiac Complications of TsutsugamushiFever (Scrub Typhus); An Investigation of Their Persistency. War Med. 7: 76-81, February 1945.
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Other Infections
Typhus fever.-In spite of fears to the contrary, and thewide distribution of American troops in many areas where typhus fever wasendemic, this disease was rare in U.S. personnel. Shortly after the landings inNorth Africa and because of the known prevalence of the disease in that area, aspecial project was organized in French Morocco under the auspices of the UnitedStates of America Typhus Commission with the aid of the 6th General Hospital andthe cooperation of the municipal authorities in Casablanca. A ward in the localinfectious disease hospital was made available for the study and treatment ofthe disease in the local population (Arab and European). Later, in 1944, certainphases of the study were extended to the epidemic among civilians in Naples,Italy. Inasmuch as previous descriptions of the disease had emphasizedcirculatory collapse and the possible usefulness of cardiotonic drugs, thecardiovascular system was the object of special consideration and study.32 Fromdetailed observations on patients with severe epidemic typhus, it was concluded,as follows:
The altered physiological state, probably owing to widespreadendothelial damage in severe cases, consists primarily of an inadequatecirculating blood volume, hypoproteinemia (especially the albumin fraction),hypochloremia, hemodilution without blood destruction, or an azotemia.
The circulatory collapse frequently encountered under theseconditions is primarily of peripheral origin.
General supportive measures to increase circulating bloodvolumes are not beneficial.
Cardiac drugs (digitalis and allied preparations) areprobably of benefit only in exceptional cases with clear evidence of congestiveheart failure. This was not encountered in the study.
Further investigation is needed to clarify: (1) The bloodelectrolytes and tissue analysis to determine the fate of chloride, (2) carbondioxide combining power and the general alkali reserve picture, and (3) bloodvolume studies with the use of both whole blood and plasma in support of thereduced volume.
Diphtheria.-During World War II, diphtheria was an important epidemic disease among the civilian population of both Europe and Asia, and numerous cases occurred in the American, British, and German Armies. In 1943, an estimated one million cases occurred among civilians on the European Continent, excluding the U.S.S.R., with a probable fatality rate of at least 5 percent. In 1945, there were 2,079 reported cases with at least 53 deaths among U.S. troops in Europe.33 Myocarditis was a frequent complication; in an analysis of 100 fatal cases in U.S. Army hospitals from 1943 through 1947, abnormal electrocardiograms were reported in 90 per-
32See footnote 30, p. 430.
33Diphtheria in American Troops in Europe. Bull. U.S. Army M. Dept. 5: 504, 1946.
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cent.34 Cutaneous diphtheria also was encountered,in which a 5-percent incidence of myocarditis was reported in 141 cases inAmerican soldiers from a general hospital in the India-Burma theater from Julythrough December 1944. In an additional 5 percent, myocarditis could not bedefinitely excluded. The electrocardiograph proved to be more reliable than theclinical examination in detecting cardiac involvement.35 A report on wounddiphtheria in the German Army indicated myocardial involvement (byelectrocardiogram) in 20 percent.36
Malaria.-It is generally agreed that malaria is the mostwidespread and serious disease in the world, and heavy plasmodial infection(especially Plasmodium falciparum) can cause death from myocardialinflammation or capillary thrombosis. However, in Sprague's experience37basedon several thousand cases occurring in members of the Armed Forces, mostly inthe Southwest Pacific Area, there was no instance of an acute cardiac death orof a proved chronic cardiac disease. Likewise, in another, detailed study of 50cases, including roentgenograms and electrocardiograms, Tumulty and hisassociates38 could detect no cardiac injury. Merkel,39 however,reported two cases of death resembling coronary thrombosis where, at autopsy,there was noted widespread obstruction of the coronary vessels by the parasitesof falciparum malaria.
Dengue.-A large number of cases of dengue occurred amongthe naval and marine personnel in the combat area of the Southwest Pacificduring the summers of 1942 and 1943, and the studies reported by Hyman40 indicatedcertain cardiovascular manifestations of interest. The disease was characterizedby a slow pulse rate, low blood pressure, leukopenia, high temperature, and slowrecovery from extreme physical and mental depression. The slow pulse rate wasfound to be due to a simple sinus bradycardia. Disturbances of conduction werediscovered by electrocardiographic examination; these consisted of a delay inthe P-R interval (up to 0.34 seconds) and a widening of the QRS complexes inthree cases up to 0.12, 0.14, and 0.16 seconds, respectively. There were a fewminor changes in the T waves and the R-T segments of the electrocardiogram.
Irregularities of rhythm were chiefly due to extrasystoles,for the most part ventricular in origin. The heart sounds were of poor quality,and systolic murmurs of varying intensity and localization appeared in manycases
34Edwards, W. M.: Analysis of Fatal Cases ofDiphtheria.U.S. Armed Forces M. J. 2: 217-227, February 1951.
35Kay, C. F., and Livingood, C. S.: Myocardial Complicationsof Cutaneous Diphtheria. Bull. U.S. Army M. Dept. 4: 462-464, October 1945.
36Moser, H.: Wound Diphtheria. Deutsche med. Wchnschr. 70:5, 7 Jan. 1944.
37Sprague, H. B.: The Effects of Malaria on the Heart. Am.Heart J. 31: 426-430, April 1946.
38Tumulty, P. A., Nichols, E., Singewald, M. L., and Lidz,T.: An Investigation of the Effects of Recurrent Malaria: An Organic andPsychological Analysis of 50 Soldiers. Medicine 25: 17-75, February 1946.
39Merkel, W. C.: Plasmodium Falciparum Malaria; Coronaryand Myocardial Lesions Observed at Autopsy in 2 Cases of Acute Fulminating P.Falciparum Infection. Arch. Path. 41: 290-298, March 1946.
40Hyman, A. S.: The Heart in Dengue; Some Observations MadeAmong Navy and Marine Combat Units in the South Pacific. War Med. 4: 497-501,November 1943.
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(these all disappeared after convalescence). Roentgenogramsshowed no cardiac dilatation. The blood pressure was consistently low inalmost every case and remained low for some time after the attack. There were nostriking changes in venous pressure.
It was suggested that the slow pulse and other cardiovascularsigns were due to an excessive vagal or autonomic response to viral infection.
Infectious mononucleosis.-A study of an epidemic ofinfectious mononucleosis from the Station Hospital, Fort Bliss, Tex., based on556 cases observed during 15 months included some unusual features.41 Thefinding of electrocardiographic changes in 23 percent of 223 patients in theseries was surprising. There was little else to differentiate this group fromthose with normal electrocardiograms. No cardiac symptoms were encounteredexcept for precordial pain in an occasional patient, and abnormal physicalfindings were scant and unimpressive. All patients recovered.
Amebiasis.-The cardiovascular effects of emetineadministration for amebiasis were studied in the Panama Canal Zone42 andat the Schick General Hospital, Clinton, Iowa.43In the latterseries, cardiovascular manifestations were observed in 83 percent of 93subjects, but in most instances they were mild and transient. A significant fallin blood pressure occurred in 36 percent, precordial pain in 36 percent, dyspnea(of doubtful origin) in 15 percent, and tachycardia (at rest) in 13 percent. Noinstance of heart failure or of residual myocardial injury was observed.
Schistosomiasis.-The effects on the electrocardiogram ofantimony compounds (tartar emetic and Fuadin) used in the treatment ofschistosomiasis were studied at the Harmon General Hospital, Longview, Tex.,44and at the Moore General Hospital, Swannanoa, N. C.45In theformer series, variations from the control records were found in all patientsreceiving tartar emetic and from 57 up to 80 percent in those receiving Fuadin,depending on the dose. The findings in the two series were similar and wereconfined for the most part to alterations in the T waves. The commonest findingwas a decrease in amplitude, but actually negative T waves appeared in from 6 to10 percent following tartar emetic. The S-T segment and other portions of therecord (including cycle length) showed no significant change. In no instance wasthere evidence of cardiac weakness or persistent injury.
41Wechsler, H. F., Rosenblum, A. H., and Sills, C. T.:Infectious Mononucleosis; A Report of an Epidemic in an Army Post.Ann. Int. Med. 25: 113, July 1946; 236, August 1946.
42Dack, S., and Moloshok, R. E.: Cardiac Manifestations ofToxic Action of Emetine Hydrochloride in Amebic Dysentery. Arch. Int. Med. 79: 228-238, February 1947.
43Klatskin, G., and Friedman, H.: Emetine Toxicity in Man. Ann. Int. Med. 28: 892-915, May 1948.
44Tarr, L.: The Effect of Antimony Compounds, Fuadin andTartar Emetic, on the Electrocardiogram of Man. Ann. Int. Med. 27: 970-988,December 1947.
45Schroeder, E. F., Rose, F. A., and Most, H.: The Effect ofAntimony on the Electrocardiogram. Am. J.M. Sc. 212: 697-706, December1946.
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Beriberi and Deficiency States
Deterioration of the cardiovascular system and circulatoryfailure during prolonged starvation and deficiency states was the fate of largenumbers of allied personnel in the prison camps of the Far East. A remarkableand distressing on-the-spot study of beriberi in a Japanese camp by a medicalofficer, himself a prisoner, was reported following his release in 1945.46 Theobservations were made over a period of 34 months on approximately 8,000Americans from Bataan and Corregidor and extended from their surrender on 9April 1942 to their release on 30 January 1945. As Hibbs modestly points out,the study was handicapped by meager laboratory facilities, a complete lack ofcooperation by the Japanese officials, lack of supplies for records, inabilityto maintain followup reports, and the poor state of health of most of themedical officers involved. In spite of these almost insurmountable obstacles,important data were obtained, and the observations and conclusions arenoteworthy. These are summarized as follows:
Beriberi was probably the most important vitamin deficiencydisease encountered for several reasons: (1) Beriberi had the highest incidence-everyone in the camp having some form of beriberi at one time or another; (2)beriberi had the highest morbidity-the disease was chronic in nature,incapacitating a soldier for months; (3) beriberi had complications and sequelaewhich were considered to be permanently disabling; and (4) beriberi was directlyresponsible for more deaths than any other vitamin deficiency disease; it wasobserved with many novel features far removed from the textbook picture.
In conclusion, Hibbs states that (1) enlargement of the heartis not to be expected in the majority of cases of beriberi heart disease, (2)thiamine deficiency may be the cause of almost any type of cardiac arrhythmia,(3) both left and right ventricles are involved in congestive heart failure, (4)digitalis is without benefit in the treatment of beriberi heart failure, and (5)beriberi heart disease is an acute medical emergency which must be treatedenergetically to prevent secondary irreversible damage or death.
Further observations on the released soldiers after theactive phases of their avitaminosis had been relieved were more encouraging thanthe preceding paragraph suggests, since there were relatively few residua of aserious nature.47 However, an occasional instance of otherwiseunexplained cardiac enlargement and chronic congestive failure has beendescribed as a probable aftermath of wartime beriberi.48
46Hibbs, R. E.: Beriberi in a Japanese Prison Camp. Ann. Int.Med. 25: 270-282, August 1946.
47Fischbach, W. M.: Cardiac and Electrocardiographic Observations on American Prisoners of War Repatriated From Japan. U.S. Nav. M. Bull. 48: 69-75, January-February 1948.
48Alleman, R. J., and Stollerman, G. H.: The Course ofBeriberi Heart Disease in American Prisoners-of-War in Japan. Ann. Int. Med. 28: 949-962, May 1948.
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The striking electrocardiographic abnormalities reported fromEurope by Ellis49 on four freed prisoners of war suffering fromsevere and prolonged malnutrition are of interest in this connection. Theseabnormalities consisted of marked prolongation of the Q-T interval, unusuallywell marked but not persistent U waves, and, less constantly, depression of theS-T segment, alterations in T waves, and increase in the P-R and QRSintervals (fig. 56). Although the available data did not permit definiteconclusions on the cause of these changes, they were thought to represent acomposite picture of prolonged protein and carbohydrate starvation andelectrolyte imbalance. There was no evidence in these patients of a significantdegree of anoxia of cardiac muscle or of clinical avitaminosis. Vitamindeficiency, however, could not be entirely ruled out as an etiological factor inspite of the absence of clinical symptoms or signs. That the electrocardiogramsreturned to normal within 2 to 3 weeks after the institution
49Ellis, L. B.: Electrocardiographic Abnormalities inSevere Malnutrition. Brit. Heart J. 8: 53-61, April 1946.
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of an adequate regimen suggests that the changes were due tofunctional and not to structural causes.50
HYPERTENSION
The importance of hypertension in determining fitness foractive military duty is indicated by the fact that in World War II one-fourth ofthose rejected for cardiovascular defects were disqualified for this reason (p.422). As was stressed by Levy and his associates, the range of the normal, bothsystolic and diastolic, was not clearly defined, and critical levels above whichit is unsafe or unwise to accept a candidate had not been established on a soundfactual basis. Transient emotional elevations of blood pressure were recognizedand properly discounted by the Army. The guiding principles employed were setforth in MR 1-9, 15 October 1942, as follows: "If the blood pressureappears to be abnormally high, it will be measured after the subject has restedin the recumbent position." A cause for rejection is: "Persistentblood pressure at rest above 150 mm. systolic or above 90 diastolic, unless inthe opinion of the medical examiner the increased blood pressure is due topsychic reaction and not secondary to renal or other systemic disease."
The high rejection rate led to a series of conferences earlyin the war from which evolved a carefully planned program of study for theprimary purpose of obtaining information useful to the Army, but there was alsoa desire to contribute to the general knowledge of the problems involved. Thisimportant project was conceived and organized in 1942, and the subsequentresults were published between 1944 and 1947.51 Because of the significance ofthe data and of the circumstances involved, certain details of this project, asrecorded by Hillman, Levy, Stroud, and White,52 warrant specialrecognition in this account of World War II events. These details are asfollows:
At a meeting of the Subcommittee on Cardiovascular Diseasesof the National Research Council, held in Washington in June 1942, * * * theadvisability of modifying certain of the existing criteria of physical fitnesswas considered. The urgent need for
50In view of postwar recognition of the profound and similareffects on the electrocardiogram of severe alterations of potassiumconcentration in the blood, this seems, in retrospect, to be the most likelyexplanation.
51(1) Hillman, C. C., Levy, R. L., Stroud, W. D., and White,P. D.: Studies of Blood Pressures in Army Officers; Observations Based onAnalysis of the Medical Records of 22,741 Officers of the United States Army. J.A.M.A. 125: 699-701, 8 July 1944. (2) Levy, R. L., Hillman, C. C., Stroud,W. D., and White, P. D.: Transient Hypertension: Its Significance in Terms of Later Development of Sustained Hypertension and Cardiovascular-RenalDiseases. J.A.M.A. 126: 829-833, 25 Nov. 1944. (3) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Transient Hypertension; The RelativePrognostic Importance of Various Systolic and Diastolic Levels. J.A.M.A. 128:1059-1061, 11 Aug. 1945. (4) Levy, R. L., White, P. D., Stroud, W. D., andHillman, C. C.: Transient Tachycardia; Prognostic Significance Alone and inAssociation With Transient Hypertension. J.A.M.A. 129: 585-588, 27 Oct.1945. (5) Levy, R. L., White, P. D., Stroud, W. D., and Hillman, C. C.:Overweight; Its Prognostic Significance in Relation to Hypertension andCardiovascular-Renal Diseases. J.A.M.A. 131: 951-953, 20 July 1946. (6) Levy,R. L., White, P. D., Stroud, W. D., and Hillman, C. C.: Sustained Hypertension;Predisposing Factors and Causes of Disability and Death. J.A.M.A. 135: 77-80,13 Sept. 1947.
52See footnote 51 (1).
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manpower made it imperative to recruit all eligibles whocould serve with safety to themselves and with advantage to the armed forces.With respect to the upper limits of blood pressure, it was suggested by somethat these might be raised, whereas others claimed that the existing levelswere too high. As a result of the discussion, it became clear that a change ineither direction was not justified on the basis of the evidence at hand; for therewas no large series of observations carried out over long periods of time. Toobtain the lacking information as quickly as possible seemed highly desirable.
It was known that, in the Office of the Surgeon General ofthe Army, there were filed abstracts of the medical records of some 23,000officers, on which were noted the results of annual physical examinations madebetween January 1924 and December 1941. Appended to many of these were thedetailed reports of special examining boards, submitted on the occasion ofpromotion or retirement or of examination incident to hospitalization. Oftenelectrocardiograms and teleroentgenograms were made at such times, and otherlaboratory procedures were employed. In many cases the record began withthe admission of the young man, as a cadet, to West Point. Annual examinationswere discontinued in 1941 owing to the pressure of work essential to the war. Noexaminations were made after an officer had retired unless he applied forreinstatement for active duty. Samples of these records were inspected, andit was at once apparent that here was a valuable storehouse of material.
To supplement the histories in the Surgeon General'sOffice, Col. Albert G. Love, Medical Corps, United States Army, kindly offeredto place at our disposal his notes on the medical records of 5,000 officers whowere in the service on Jan. 1, 1901 and also those commissioned between thattime and Dec. 31, 1916. These had been analyzed in collaboration with ProfessorLowell J. Reed of the Johns Hopkins University, and the results published in1931 and 1932 in a series of papers dealing with "Biometric Studies on U.S.Army Officers."
The availability of this material appeared to offer anunusual opportunity to study variations of blood pressure during the passage ofa number of years and to relate them to various other factors. Of particularimmediate importance was the significance of transient hypertension. Additionaltopics for consideration which at once came to mind were the later course ofthose who developed sustained hypertension, the relationship between body weightand hypertension, and the significance of tachycardia, both transient andsustained. These could all be correlated with disability retirement andmortality rates at various ages, with the causes of retirement and death and, inthose who died, with the findings at necropsy.
* * * * * * *On Sept. 12, 1942 a contract, recommended by the Committee onMedical Research, was made between the Office of Scientific Research andDevelopment and Columbia University, providing funds for this study. Dr. Levywas appointed chairman of the project.
From this study and analysis of the long-term records of22,741 officers of the U.S. Army, the following findings of significance wereestablished:
1. Transient hypertension or transient tachycardia oroverweight, each by itself, increased the probability of the later developmentof sustained hypertension and of retirement or death with cardiovascular-renaldisease. The presence of two of these conditions was of greater importance, inthese respects, than that of any one alone. The presence of all three was ofmajor prognostic importance.
2. In the group in which sustained hypertension developed,the leading causes of retirement because of cardiovascular-renal diseases werehypertension itself, coronary heart disease, and cerebral arteriosclerosis,including
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hemorrhage and thrombosis. These three conditions togetheraccounted for 84 percent of such retirements. Coronary heart disease andcerebral hemorrhage together were responsible for 66 percent of the deaths fromcardiovascular-renal conditions during the period of observation.
It was suggested that, in revising standards for theselection of those physically qualified for military service, factorspredisposing to the later development of sustained hypertension andcardiovascular-renal diseases should be taken into account. When makingdisposition of men in whom sustained hypertension develops while they are inservice, consideration may well be given to the high incidence and disablingnature of the circulatory and renal complications associated with thiscondition. The extent to which the conclusions derived from these studies areapplied can be varied according to the need for manpower.
Furthermore, it seems probable that the facts obtained fromthis analysis hold true also for the general male population of comparablephysical fitness and similar age groups.
Thus ended a unique undertaking, based on the exigencies ofthe war and combining the accumulated experience of the Army and the resourcesof the Government with the services of an expert civilian committee.
CORONARY DISEASE
The stress and strain of the war upon carefully screenedyoung men in service made it possible to study the potential effects of thesefactors upon latent and unsuspected coronary arteriosclerosis. Furthermore, theresults of this study may be, in part, responsible for the existing suspicionthat coronary disease is more prevalent in young men of this generation than inthose of the past.
Relatively early in the war, an analysis was undertaken ofthe clinical and pathological features in 80 fatal cases in soldiers from 20 to36 years of age. This material from the Army Medical Museum, Washington, D.C.,revealed that coronary disease occurred in men of various racial and nationalorigins without predilection for any particular stock.53 The moststriking, and presumably predisposing, factor was overweight, present in 91percent of the cases. Vigorous effort and the activities of early morning choresbrought on the fatal attacks in over 50 percent of the cases. Sudden death orthe onset of the fatal attack occurred during sleep in 10 percent. The basis ofthe occlusion in every case was arteriosclerosis, and a scar of previousinfarction was found in 59 percent.
A subsequent and more extensive study of sudden andunexpected death in young soldiers, based on material received at the ArmyInstitute of Pathology, Washington, D.C., during the 4 years between January1942 and
53French, A. J., and Dock, W.: Fatal CoronaryArteriosclerosis in Young Soldiers. J.A.M.A. 124: 1233-1237, 29 Apr. 1944.
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January 1946, contributed further significant data.54 Amongthe 40,000 autopsy protocols, there were approximately 1,000 which concernedyoung and apparently healthy soldiers whose collapse and death were so suddenand unexpected that there was little or no opportunity to make an ante mortemdiagnosis. The most frequent conditions responsible for death under thesecircumstances were heart disease, intracranial hemorrhage, and meningococcemia.Among these 1,000, there were approximately 350 sudden deaths from previouslyunrecognized heart disease; almost 300 were due to coronary arteriosclerosis.The following additional facts and opinions were derived from a detailedanalysis of the data on 115 who died of coronary disease: There were 8 percentunder 25 years of age, and 22 percent under 30. White and Negro soldiers wererepresented in proportion to their numbers in the Army. The body weights weresignificantly greater than those for healthy inductees; however, this wasequally true of the weights in autopsy protocols of soldiers dead of accidentalinjuries. This important control observation was not considered in the earlierreport by French and Dock (p. 438); its possible significance is weakenedsomewhat, as Moritz and Zamcheck noted, by the fact that the body weights weremostly estimates and hence cannot be used without reservation in appraising therelation of obesity to any given disease.
The frequency with which the onset of the fatal attack ofcoronary insufficiency occurred during a period of strenuous physical exertionsupports the plausible opinion that violent exercise is probably dangerous forpersons with severe coronary disease. Moritz and Zamcheck further suggest,however, that this information would be of little practical value to the Army inthe prevention of such casualties, since none of these soldiers was suspected ofunderlying heart disease before death, and even in retrospect less than 25percent of them had a history of symptoms that might have been of cardiacorigin.
In addition to the two foregoing reports assembled during thewar, a third and important study, based in part upon the material from the ArmedForces Institute of Pathology but expanded during the early postwar years toinclude further data from the Veterans' Administration, has been reported inpapers by Yater and his associates.55 These reports dealt with initiallynonfatal coronary disease in World War II soldiers. The earlier communicationsconcerned the younger men, from 18 to 39 years of age, and the later study theage group over 40. The 1951 report included data
54Moritz, A. R., and Zamcheck, N.: Sudden and UnexpectedDeaths of Young Soldiers; Diseases Responsible for Such Deaths During World WarII. Arch. Path. 42: 459-494, November 1946.
55(1) Yater, W. M., Traum, A. H., Brown, W. G., Fitzgerald,R. P., Geisler, M. A., and Wilcox, B. B.: Coronary Disease in Men Eighteen to Thirty-Nine Years of Age: Report of Eight Hundred Sixty-Six Cases, Four Hundred Fifty With Necropsy Examinations. Am. Heart J. 36: 334-372, September 1948; 481-526, October 1948; 683-722, November 1948. (2) Yater, W. M., Welsh, P. P., Stapleton, J. F., and Clark, M. L.: Comparison of Clinical and Pathologic Aspects of Coronary Artery Disease in Men of Various Age Groups: Study of 950 Autopsied Cases From Armed Forces Institute of Pathology. Ann. Int. Med. 34: 352-392, February 1951.
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on 950 autopsied cases. This formidable undertaking wasapproached as follows:
During 1945-46, a study was made of 866 male patients, ages18 through 39, for whom the principal diagnosis was coronary artery disease.These included 416 who had survived typical attacks of acute myocardialinfarction and whose case histories were obtained from the Veterans'Administration and 450 who died while in the Army and whose autopsy protocolswere in the files of the Armed Forces Institute of Pathology.
Following completion of the study of the younger age group,researchwas begun to determine what similarities or differences might exist in theclinical and pathological aspects of coronary artery disease in oldermen as compared to those under 40 years of age. For this purpose,selection was made of 500 additional autopsy records of men 40 years of age andover.
That the 635 fatalities from coronary artery disease amongWorld War II soldiers in this series do not represent, eithernumerically or percentagewise, the total picture of its incidence among militarypersonnel is shown by the fact that as of 30 June 1948, 6,075World War II veterans were receiving service-connected disabilitypension awards principally because of coronary artery disease.
From these two related studies, it was found that Negroescomprised only 4 percent of the World War II soldiers in the series, althoughthey constituted approximately 10 percent of the Army during that period.
No definite conclusions could be drawn as to the role of armylife in precipitating fatal attacks; however, generally shorter length ofservice of these men as compared with the average in the World War II Armysuggests that they were not in condition to withstand the stress of army life.In contrast to the findings of French and Dock (p. 438) and of Moritz andZamcheck (p. 439), the etiological importance of obesity as a predisposingfactor in coronary disease could not be definitely established in any age group,although a tendency to overweight appeared to accompany advancing age. The onsetof the coronary attack occurred in a higher percentage of the younger men whilethey were engaged in strenuous activity and in a higher percentage of the oldermen while they were in bed. The data also suggested that coronary diseasecarried a more serious prognosis for men under 40 than for those of 40 and over.
The relation of unusual or extreme effort to acute myocardialinfarction is of considerable practical as well as theoretical importance, sincelegal decisions and line-of-duty determinations are often vitally affectedthereby. Blumgart56 cited some striking examples and summarized his Armyexperience in this connection. He discussed the clinical criteria which heconsidered necessary to establish this relation and the pathologicalmechanisms involved.
These extensive data acquired during the war haveemphasized the mounting incidence of coronary disease in otherwise vigorousyoung men and have indicated the need for broader and more basic studies in itscauses and its prevention. In conclusion, a final lesson of the war years
56Blumgart, H. L.: The Relation of Effort to Attacksof Acute Myocardial Infarction. J.A.M.A. 128: 775-778, 14 July 1945.
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should not pass unheeded: Industry, faced with a manpowershortage incident to the war, demonstrated that individuals with healed infarctsand those with lesser degrees of angina, although unsuited for the Armed Forces,are capable of pursuing useful and productive lives under proper training andsupervision without added risk to themselves or to their fellow workers. Theirzeal and energy more than compensate for their physical handicaps. It isunfortunate that with the passing of the emergency the rules and practices ofpeacetime economy often force such useful workers into the ranks of theunemployed. This practical demonstration as a corollary of the war presents achallenge to the medical profession and to the legislators in planning futureprograms for the welfare of the United States and its citizens.
NEUROCIRCULATORY ASTHENIA
(Soldiers' Heart, Effort Syndrome, Shellshock, AnxietyNeurosis)
A wide variety of names had been used to identify thesyndrome which, in 1918, The Surgeon General officially designated as "neurocirculatoryasthenia," a term considered moderately descriptive and yet adequatelynoncommittal.57 In 1871, DaCosta,58an army physician in the CivilWar, proposed the term "irritable heart." Another early Americandescription of the disorder was given by Beard,59 in 1880, using theterms "neurasthenia" and "nervous exhaustion." The name"anxiety neurosis" was substituted later for neurasthenia by Freud.60In World War I, the terms "shellshock" and "effort syndrome"were employed, the latter chiefly by British investigators under Sir ThomasLewis. A group of American workers61 in World War I devised the term"neurocirculatory asthenia," and this term was adopted for use in theAmerican Army and was the title of the report by Brooks62 in theofficial Army history of World War I. Studies of civilians with the disorderwere carried on between World Wars I and II by Craig
57This section on neurocirculatory asthenia has been prepared,at my request, by Dr. Mandel E. Cohen, Boston, Mass., whose long interest andextensive studies qualify him to speak with authority concerning thiscontroversial but important symptom complex, especially troublesome during thestress of war.-E. F. B.
58DaCosta, J. M.: On Irritable Heart; A Clinical Study of aForm of Functional Cardiac Disorder and Its Consequences. Am. J.M. Sc. 61: 17,January 1871.
59Beard, G. B.: A Practical Treatise on Nervous Exhaustion(Neurasthenia): Its Symptoms, Nature, Sequences, Treatment. New York: WilliamWood and Co., 1880.
60Freud, S.: Ueber die Berechtigung von der Neurastheniaeinen Bestimmten Symptomencomplex als "Angstneurose" abzutrenn. Neurol. Centralbl. 14: 50, 1895.
61(1) Oppenheimer, B. S., Levine, S. A., Morison, R. A.,Rothschild, M. A., St. Lawrence, W., and Wilson, F. N. (cited by T. Lewis): Report on Neuro-Circulatory Asthenia and Its Management. Mil. Surg. 42: 409, April 1918. (2) Oppenheimer, B. S., Levine, S. A., Morison, R. A., Rothschild, M. A., St. Lawrence, W., and Wilson, F. N.: Illustrative Cases of Neurocirculatory Asthenia. Mil. Surg. 42: 711, 1918.
62Brooks, Harlow: Neurocirculatory Asthenia. In TheMedical Department of the United States Army in the World War. Washington:U.S. Government Printing Office, 1928, vol. IX.
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and White.63 In World War II, British studiesunder Wood64 were reported as DaCosta's syndrome or effort syndrome.In the American Army, official terminology was shifted somewhat to fit certainetiological and psychological theories, and terms, such as "anxietystate," "somatization reactions," "psychogenicreactions," and "combat fatigue," were introduced. German Armyterminology was even longer, such as "personalities with mixed psychic ** * constitutionally labile * * * organ systems." World War IIinvestigations, however, were mainly reported under the term "neurocirculatoryasthenia" (anxiety neurosis, neurasthenia, effort syndrome, nervousexhaustion) in an effort to reach physicians of various interests andspecialties.
Research During and After World War II
Because of the importance of neurocirculatory asthenia inWorld War I, further organized research was conducted during and after World WarII under the leadership of White and his associates, with Army support.65 Theplan of study was based on applying the best quantitative techniques of the dayto the problem of explaining the symptoms and the other phenomena of thedisorder. For instance, because patients complained of troubles while working,studies in work physiology were done. Because of such symptoms as nervousness,psychological studies were done. Because patients said other members of thefamily had symptoms similar to theirs, genetic studies were done. This is, then,simply the method of scientific investigation in contrast to a method used sooften in fields such as psychology, for instance, of applying the theories andconclusions of a special school or authority to a given problem.
Studies of breathing and dyspnea
Patients with neurocirculatory asthenia commonly complain ofshortness of breath, of inability to draw a satisfactory breath, and ofinability to do hard work because of breathlessness. Such patients sigh, havedifficulty in wearing a gas mask, and find it extremely difficult to run whilewearing the mask. They may complain of difficult breathing during swimming andof shortness of breath for as far back as they can remember.
63Craig, H. R., and White, P. D.: Etiology and Symptomsof Neurocirculatory Asthenia; Analysis of One Hundred Cases, With Comments onPrognosis and Treatment. Arch. Int. Med. 53: 633-648, May 1934.
64Wood, P.: DaCosta's Syndrome (or Effort Syndrome). Brit.M. J. 1: 767-772, 24 May 1941.
65(1) Cohen, M. E., White, P. D., and Johnson, R. E.:Neurocirculatory Asthenia, Anxiety Neurosis or the Effort Syndrome. Arch. Int. Med. 81: 260-281, March 1948. (2) Cohen, M. E., Johnson, R. E., Consolazio,F. C., and White, P. D.: Low Oxygen Consumption and Low VentilatoryEfficiency During Exhausting Work in Patients With Neurocirculatory Asthenia,Effort Syndrome, Anxiety Neurosis. J. Clin. Invest. 25: 920, 1946. (3) Cohen, M.E., Johnson, R. E., Chapman, W. P., Badal, D. W., Cobb, S., and White, P. D.: AStudy of Neurocirculatory Asthenia, Anxiety Neurosis, Effort Syndrome. FinalReport to the Committee of Medical Research, Office of Scientific Research andDevelopment. Washington: National Research Council, 1946.
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Quantitative studies of respiration showed that, whileresting and breathing oxygen, patients with neurocirculatory asthenia have morerapid respiratory rates and more shallow breathing than do healthy controlsubjects. The ventilation index was abnormally high in patients for four speedsof exercise; the more severe the exercise, the greater the discrepancy betweenpatients and controls. This was due to a high ventilation factor and not tovital capacity. (The mean vital capacity for 54 healthy men was 2,387 cc. persquare meter of body surface and for 73 patients with neurocirculatory asthenia,2,362 cc.)
The ventilation index is usually an objective correlate ofthe subjective phenomenon of dyspnea. When the level of ventilation index wasthe same, more patients than healthy controls complained of dyspnea.Furthermore, the degree of dyspnea complained of was greater in patients than inhealthy controls doing the same amount of exercise and with the same ventilationindex.
Drury,66 in 1919, had demonstrated thatintolerant hyperpnea developed in these patients at a lower level ofconcentration of inspired carbon dioxide than in control subjects. It was notedthat patients complained of choking or smothering and had undergone anxietyattacks in crowded places, such as subways, bargain basements, and theaters.This suggested a study in which 43 patients and 27 control subjects firstbreathed oxygen for 12 minutes; then, a second test of 12 minutes of rebreathingwas done in which carbon dioxide had accumulated to about 4 percent of inspiredair. This showed that an increase of sighs to a mean of 7.5 per 12-minute periodtook place in patients as contrasted with 2.8 in comparable controls. It wasconcluded that intolerable hyperpnea, increased sighing, and symptoms of thedisorder identical with anxiety attacks can be produced by rebreathing a mixturecontaining an excess of carbon dioxide. It was not clear, however, that anatural stimulus for the disorder was reproduced experimentally. Nor did thisobservation show whether the entire abnormal response was set off by carbondioxide, by nonspecific discomfort (this seemed unlikely), or by the awarenessof the sensation of disturbed breathing or by something else.
Cardiovascular studies
Cardiovascular studies showed only a few significantdeviations from the normal. The pulse rate at rest, during exercise, and afterexercise was higher than average by 8 to 10 beats per minute as compared withhealthy controls. The size of the heart, as determined by measurements of thediameter and area of the heart in roentgenograms, was not significantlydifferent in the two groups (50 subjects in each group). These findings did notconfirm the conclusion of others that neurocirculatory asthenia is
66Drury, A. N.: The Percentage of Carbon Dioxide in theAlveolar Air, and the Tolerance to Accumulating Carbon Dioxide in Cases ofSo-Called "Irritable Heart of Soldiers." Heart 7: 165, April 1920.
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characterized by the presence of a small heart. Theelectrocardiogram, made with the patient at rest and after mild exercise (Master'stolerance test), was within normal limits.
Other normal findings were related to responses of the bloodpressure and the pulse to changes of posture on a tilt table, resting venouspressure, blood volume, vital capacity, circulation time, and resting cardiacoutput as measured by the acetylene method of Grollman and compared with normalstandards. Measurement of the cardiac output by the direct Fick method,employing catheterization of the right auricle of the heart, gave mean valuesthat were within the limits of those reported for normal subjects with evidenceof anxiety. Patients seemed tense and apprehensive during the procedure. Valuesobtained by the Grollman method were lower than those obtained by the directFick method.
Studies of muscular work
Studies of muscular work were of special interest because (1)patients say they cannot do hard work; (2) the symptoms of the illness have beencompared with the feelings of hard work, this being the basis for the concept ofthe effort syndrome; and (3) patients with this disorder say that they are madeworse by doing hard work.
White,67 in 1920, had described an abnormalperformance of and response to a test which combined work, respiration, anddiscomfort (a 100-meter run, wearing a gas mask) as compared with controlsubjects. Hence, patients and controls were studied during and after muscularwork in the laboratory. Moderate work consisted of walking on a treadmill, andhard work consisted of running on a treadmill, of stepping up and down on a20-inch (50.8 cm.) step, and of stepping up and down with a pack on the back.
In the basal condition, the pulse and respiratory rates areslightly abnormal in neurocirculatory asthenia, but there was no differencebetween patients with neurocirculatory asthenia and controls in regard to oxygenconsumption and the blood lactate concentration while resting. When one comparesgroups of subjects who work hardest and longest with those who work least(women, men in poor training, and patients with neurocirculatory asthenia),differences between the two groups become more apparent as the intensity andduration of the work tests are increased. In other words, the more the work isstepped up, the more clearly does a "poor work group" separate itselffrom a "good work group." When the subjects are at rest, themeasurable differences appear consistently. During a hard-work test which allsubjects perform for a comparable length of time at a fixed pace and grade, allthe differences seen in walking are accentuated. In addition, oxygen consumptionis lowest in groups who do not run well. When subjects run at a fixed pace untilthey reach their stopping point, those who run
67White, P. D.: Observations on Some Tests of PhysicalFitness. Am. J.M. Sc. 159: 866, June 1920.
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longest have higher oxygen consumption, higher pulmonaryventilation, higher blood lactate levels, higher ventilatory efficiency, andlower pulse.
It was concluded that with either moderate or exhaustingmuscular work, during which patients and controls alike perform for the sameduration and at the same rate, there are many measurable abnormalities inpatients with neurocirculatory asthenia. The findings are consistent with thehypothesis that aerobic metabolism is abnormal in these patients. The high bloodlactate concentration suggests reciprocal high oxygen debt. It cannot be statedwhether these findings apply specifically to patients with neurocirculatoryasthenia or whether they are the general signs of poor health, chronic illness,poor runners, or poor state of training.
The results of further studies showed that painful stimulicould produce abnormal responses, also responses at unusually low stimuluslevels in some systems, in patients with neurocirculatory asthenia.68
It was concluded from the studies and the general experiencein World War II that there are fairly definite quantitative abnormalities inneurocirculatory asthenia. The disorder has many recurring symptoms, is nevermonosymptomatic, and can be diagnosed on the basis of symptoms. The laboratoryabnormalities furnish objective evidence related to patients' subjectivecomplaints. It is also clear that several functions seem normal under basalconditions, but under stress, for instance, work or discomfort, measurabledifferences appear between patients and controls.
The question remains, once the diagnosis is made, what is themilitary future of the patient with neurocirculatory asthenia? It was believedthat the automatic rejection or discharge of these patients may not be the rightanswer and that the favorable course of most of the patients in civilian life,and of some in army life, suggests that although neurocirculatory asthenia is ahandicap and difficulty it is not necessarily a disabling disorder.
Finally, it should be pointed out that, as yet, the answersto many of the problems posed by neurocirculatory asthenia are unsettled andthat more scientific investigation is needed.
68In a 20-year followup of 173 civilian patients withneurocirculatory asthenia, Wheeler and his associates (see Journal of American MedicalAssociation, vol. 142, 25 Mar. 1950, pp. 878-889) showed the following:
1. Significant amounts of handicap and disability werepresent in 15 percent of the patients, the others reporting that the disorderand its symptoms produced little or no disability.
2. The number of children, divorces, marriages, employmentproblems, adequate income, and reasonably happy lives was not obviouslydifferent from that of the general population.
3. Hospitalizations, surgical operations, the development ofother diseases, and mortality are not excessive in patients over 20 years whencompared with the general population.
4. Although these patients showed "anxiety" as acharacteristic phenomenon, they did not develop to any unusual extent diseasessuch as hypertension, peptic ulcer, asthma, diabetes, which some authors havespeculated are caused by "anxiety."
5. A comparison of the condition of these 173 patients whoreceived only a thorough examination and a simple explanation and reassurancecompared favorably with the published therapeutic results after sanitariumpsychotherapy, out-patient psychotherapy, Freudist psychoanalysis, sanitariumcare, electroshock procedure and frontal lobotomy.
6. Veterans showed more disability as compared with others ofthe followup study.
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WOUNDS AND FOREIGN BODIES
In World War II, it was estimated that the heart andpericardium were injured in 3.3 percent of intrathoracic wounds in casualtiesarriving at the forward installation.69 Occasionally, the heart orlungs were involved secondarily by missiles migrating in the bloodstream fromelsewhere in the thorax or the abdomen. Serious wounds were detected earlier andtreated more effectively than ever before, and from this experience evolved newtechniques and an attitude of confidence which have contributed significantly tothe remarkable success of the operations for acquired valvular disease developedin the postwar decade. This important and inspiring facet in the progress of thewar years is worthy of special consideration here.
In spite of the dramatic and often singular features incidentto wounds of the heart and great vessels, it is well to remember, as pointed outby Barrett70 in his excellent review, that the unique cases recorded duringeach World War usually have had their counterparts in previous conflicts. Thisis well illustrated by three case histories from the early 19th century. Thefirst describes an unusual foreign body (embolic) in the chamber of the rightventricle, reported first by Davis,71 in 1834, and commented uponlater by Bland-Sutton,72 in 1919, as follows:
A boy, aged 10, made a gun of a telescopic toasting fork.To form the breach of the gun he drove a plug of wood three inches long into thehollow handle of the fork and made a touch-hole. When the gunpowder exploded thestick was forced into his chest between the third and fourth costal cartilages,to the right of the sternum. Immediately after the accident the boy walked adistance of 40 yards to his home. He survived the accident thirty-seven days.After death, a piece of wood 3 in. long and as thick as a cedar pencil was foundin the right ventricle of the heart encrusted in a clot. Thomas Davis reportedthese facts in 1834; he found no wound in the pericardium or the heart, andexpressed the opinion that the stick, after wounding the lung, had passed intothe vena cava and was carried by the bloodstream into the right auricle and theninto the right ventricle, where it was found. On reading this report for thefirst time, I was skeptical in regard to the emboli theory that Davis advancedto explain the presence of the stick in the ventricle, for at the date of theaccident surgeons knew nothing of the transport of bloodclot either to or fromthe heart. It was at least a quarter of a century later that the word"embolus" was coined by Virchow, and the dangers underlying themovement of clot began to be understood.
The second case cited by Barrett dates from the NapoleonicWars and demonstrates that a large object may enter the aorta near the heartwithout causing the patient to die of primary hemorrhage:
Mr. Beunton, Assistant Surgeon on board the hospital ship inthe Mediterranean, says that a boat's crew, detached to cut-out a Frenchvessel, met with such determined
69Samson, P. C.: Battle Wounds and Injuries of Heart andPericardium; Experiences in Forward Hospitals. Ann. Surg. 127: 1127-1149, June1948.
70Barrett, N. R.: Foreign Bodies in the CardiovascularSystem. Brit. J. Surg. 37: 416-445, April 1950.
71Davis, T. D.: Cited by Bland-Sutton (see footnote 72) andBarrett (footnote 70). Trans. Prov. Med. Surg. Assoc. 2: 357, 1834.
72Bland-Sutton, J.: A Lecture on Missiles as Emboli. Lancet1: 773, 10 May 1919.
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resistance that several were killed or wounded, andamongst the latter was a seaman who affirmed that a musket-ball, striking hisoar, had run along it and entered his side; he bled a good deal and then, almostcompleting the third day from the injury, he died.
The post-mortem examination showed that the missile enteredthe body between the eighth and ninth ribs, it had wounded the diaphragm andpassed into the pericardium, which was full of blood; a hole in the aorta hadbeen made by the shot, and this had been closed up by a firm coagulum. Muchblood had escaped into the chest and abdomen, not only from the vessels woundedin the course followed by the ball, but from the heart itself. The ball wasfound adhering to the inner side of the aorta, and there it is now. (The ballmeasured 1? inches in diameter.)
A third case of historical interest mentioned by Bland-Suttonconcerns a foreign body which entered the left side of the heart by penetratinga pulmonary vein:
At the storming of the Great Pagoda, Rangoon, 1852, a roundleaden bullet entered the chest of a soldier between the third and fourth ribsnear the anterior fold of the left axilla. Blood and air issued from the woundfor several days, and the surrounding tissues became emphysematous. The man wasattended in the field hospital by Dr. J. Fayrer (the late Sir Joseph Fayrer),the symptoms abated, and the patient came under the care of Dr. W. White. Thesoldier died 72 days after being wounded. An examination of the body revealed apint of pus in the left pleural cavity and a piece of cloth from his jacket. Thelung was solid. The track of the missile ran through the chest to the leftpulmonary veins. The rifle ball lay in the left ventricle of the heart near itsapex. There was no wound of the heart. It appeared from these facts that theball perforated one of the left pulmonary veins, entered the left auricle, andfinally passed into, and settled in, the left ventricle. The heart is preservedin the Museum of the Medical College, Calcutta.73
Others had recognized in the 19th century that patients couldsurvive for years with foreign bodies (usually needles) in their hearts withoutapparent harm, and by 1900, although it was known that the heart could surviveserious wounds and heal well, cases of weak scar with aneurysm formation hadbeen recorded and the risks of sepsis appreciated. Suture of heart wounds wasknown to be possible and was accepted as indicated in certain emergencies.
The experience provided by World War I with heart wounds wasextensive. Numerous operations for the removal of foreign bodies from in andaround the heart were recorded between 1914 and 1918, for which the Frenchsurgeons deserve especial credit. Delorme,74 in 1917, reviewed 13operations (Beaussenat (2), Beloit, Laurent, Bichat, Dujarrior (2), Chauvel,Hallopean, LeFort, Gaudier, Fredet, and Delbet), in France, of which the resultswere known with only 3 deaths. Of special interest were four operations for theremoval of intraventricular (right) foreign bodies, all of which weresuccessful. The following year, LeFort75 reported the first
73White, W.: Case of Lodgment of a Musket Ball in the LeftVentricle of the Heart. Indian Ann. M. Sc. 1: 294, 1853-54. Cited byBland-Sutton (see footnote 72, p. 446) and by Barrett (see footnote 70, p. 446).
74Delorme, E.: Contribution ? l'?tude de laChirurgie Cardiaque. Bull. Acad. de m?d., Paris 78: 243, 18 Sept. 1917.
75LeFort, R.: Extraction d'un Eclat de Grenade de laCavit? du Ventricle Gauche; Gu?rison: Pr?sentation du Malade. Bull. Acad. de m?d., Paris 80: 147, 6 Aug. 1918.
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case in France of a fragment successfully removed from theleft ventricular chamber. He also recorded a consecutive series of ninecardiotomies for the removal of foreign bodies with only one death.
Nonetheless, as Barrett (p. 446) points out, opinion wasstill divided at the start of World War II. An extensive survey by Decker,76in 1939, indicated that the late mortality from foreign bodies in theheart was 20 percent and that the mortality from operations for their removalwas no less, with the probability that many unsuccessful attempts had escapedpublication and that therefore the risk was understated. Likewise, Turner77 atthis time (1941) advised caution, with the admonition: "It would seem to bea good rule to leave the foreign body alone unless the heart continues to rebelagainst its presence."
On the other hand, after World War I, a considerable group ofwell-informed surgeons, including Leriche,78Delorme (p. 447),Tuffier,79 and Sauerbruch,80 advocated the removal of allforeign bodies lodged in the heart. Sauerbruch recorded in 1941 a series of105 patients from whose hearts foreign bodies had been taken to control latecomplications, with a mortality of 8 percent. Further, he concurred withStephens (cited by Barrett), who stated that, although 95 percent of people whosurvive cardiac injuries and who have foreign bodies in their hearts aresymptomless, only 13 percent continue to be well indefinitely.
Since these conflicting opinions were expressed by ableobservers,the experience gained in another war has added to our knowledge. It was theauthor's privilege during World War II to assemble and review on behalf of theMediterranean theater surgeon (and his medical and surgical consultants81) thetotal experience with wounds and injuries of the heart in the North African,Sicilian, and Italian campaigns from November 1942 until the end of hostilitiesin May 1945.82 This material consisted of 94 cases (of which 15 were personallyobserved) and included the cases recorded in the report of the 2d AuxiliarySurgical Group and additional cases encountered by others in the Mediterraneantheater. The pertinent features of the total experience are as follows:
Wounds of the ventricular wall occurred in 53 cases; of theauricular wall, in 5; and of the pericardium alone, in 22. The remaining 14patients presented a variety of conditions, including 3 with retained missilesfor 9,
76Decker, H. R.: Foreign Bodies in the Heart and Pericardium-ShouldThey Be Removed? J. Thoracic Surg. 9: 62-79, October 1939.
77Turner, G. G.: A Bullet in the Heart for Twenty-Three Years.Surgeon 9: 832-852, June 1941.
78Leriche, R.: Sur un Cas d'ablation de CorpsEtranger du Coeur Suivie de Gu?rison. Rev. de chir., Paris 51: 274, 1916.
79Tuffier, T.: Surgery of the Heart. Cinqui?me Congress la Societe International de Chirurgie Rapports Proces-Verbaux etDiscussions. Bruxelles: M. Hayez, 1921, pp. 5-75.
80Sauerbruch, F.: Steckgeschosse in Herz und Lunge.Deutsche Ztschr. f. Chir. 255: 152-170, 1941.
81Col. Perrin H. Long, MC, and Col. Edward D. Churchill, MC,respectively.
82Bland, E. F.: War Wounds of the Heart: A Report of 94 CasesWith a Note on Foreign Body Emboli. [Unpublished data, The Surgeon General'sOffice, U.S. Army, 1945.]
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13, and 20 years, respectively, and 4 others in whom metallicshell fragments migrated in the bloodstream from distant wounds.
Cardiac tamponade occurred in 12 cases. It was relieved byearly surgical intervention in 10 but was an unexpected post mortem finding inthe remaining 2. In an additional eight patients, active hemorrhage of seriousproportions was encountered at operation, but the escape of blood into thepleural cavity through the pericardial laceration prevented the development oftamponade.
Pericardial effusion of clinical significance occurred inseven cases. Its delayed appearance from 2 to 6 weeks after injury in one-fourthof those with retained foreign bodies was of special interest. Pneumopericardiumwas a complication in three, and in one additional patient purulent pericarditiswas successfully relieved by surgical drainage.
Intracardiac mural thrombi were found post mortem in threecases, and thrombosis of an injured left coronary artery was noted in anotherfatal case. Peripheral emboli from the heart were not encountered.
Missiles were removed at operation from the myocardium in 11patients, in 1 of whom it extended into the ventricular cavity, and from thepericardium in 3 others. All made good recoveries. In 18 cases, foreign bodiesremained within the heart or pericardium and, in 2 additional cases, against theascending aorta. The subsequent progress of these patients should be followedcarefully in connection with the unsettled question of future hazards fromretained missiles. The intravascular migration of metallic fragments wasrecorded in four cases.
The mortality figure of 24.4 percent for this series, ascontrasted with 45.5 percent for 428 cases collected from the literature in 1934by Ramsdell,83 is noteworthy. Probably three factors were chieflyresponsible for this striking reduction: (1) Early administration of plasma andblood, (2) chemotherapy and antibiotics, and (3) expert surgical interventionclose to the frontlines.
Complete perforation of the heart with survival is unusual.In the Mediterranean theater series, there were four cases with two survivors.In one of these (Samson's case),84 in addition to a diagram of the operativefindings (fig. 57), electrocardiograms were available during the recovery phaseand are reproduced here as a matter of interest (fig. 58).
The migration of metallic fragments in the bloodstream is abizarre complication, not necessarily fatal. The fragments usually enter by wayof the great veins in the thorax, by the hepatic veins from liver wounds, orthrough the inferior vena cava, pass with the bloodstream to the chambers of theright side of the heart and, occasionally, on into the pulmonary circulation tolodge finally in a major pulmonary artery. Thus, a foreign body
83Ramsdell, E. G.: Stab Wounds of the Heart. Ann. Surg. 99:141-151, January 1934.
84Samson, P. C.: Two Unusual Cases of War Wounds of theHeart. Surgery 20: 373-381, July-September 1946.
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at the hilum of the lung is sometimes found at operationimpacted in a pulmonary artery. Harken and Williams85 encountered this in patientsin the European theater, and a striking example of a casualty of the Italiancampaign (in the Mediterranean theater series) is recorded herewith:
On 12 April 1944, an infantryman of the 45th InfantryDivision received multiple severe penetrating wounds of the right thorax,right leg, and both feet. Roentgenogram showed a large metallic body atthe hilum of the left lung. On 28 April, after transfer to a generalhospital, his condition seemed good except for moderate dyspnea. Further X-raystudy confirmed the presence of the foreign body in the left lung (fig. 59). On10 May (4 weeks after injury), dissection of the left hilar region by Maj.Thomas H. Burford, MC (2d Auxiliary Surgical Group), failed to reveal theforeign body, and the chest was closed. Recovery was uneventful. Postoperativeroentgenograms revealed the foreign body now at the right hilum (fig. 60). On9 July (3 months after injury), a right thoracotomy revealed the foreign bodyimpacted in the right pulmonary artery. The circulation to the lungseemed entirely adequate, and a palpable thrill was felt over the artery for ashort distance distal to the foreign body. A complete dissection of the hilarstructure did not mobilize the artery sufficiently to permit an arteriotomy,since the involved segment was directly beneath the superior pulmonary veinanteriorly and rested upon the right
85Harken, D. E., and Williams, A. C.: Foreign BodiesIn, and In Relation To, the Thoracic Blood Vessels and Heart; Migratory ForeignBodies Within the Blood Vascular System. Am. J. Surg. 72: 80-90, July 1946.
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stem bronchus posteriorly. Furthermore, since there was noevidence of aneurysmal dilatation of the artery or of inadequacy of thepulmonary circulation, it was decided not to sacrifice the superior pulmonaryvein. The chest was closed, and convalescence was uneventful except for adisproportionate degree of dyspnea for a few days after operation. On 16 August1944, the patient was transferred to the Zone of Interior, ambulant and ingood condition. A followup letter in October (6 months after the injury)reported no further studies or operative procedures and no symptoms other thandyspnea on fast walking.86
It is of interest that, during a review of this unusual caseshortly after the first thoracotomy, Col. Edward D. Churchill, MC, suggestedthat the fragment had originally entered the superior vena cava and passedthrough the right heart chambers to the left pulmonary artery and later, justbefore or during operation, shifted intravascularly to the right pulmonaryartery. In any event, the absence of infarction and significant impairment ofrespiratory function is remarkable.
A curious and further variant from the usual migration offoreign bodies in the direction of blood flow is represented by the infrequentcase where the metallic fragment arriving in the right auricle passes down theinferior vena cava against the stream to lodge in the cava or in one of its mainbranches, as observed by Cutler87 in World War I and by others88 in World WarII.
In contrast to the Mediterranean theater data where theemphasis was upon the management of cardiac wounds in the forward installationsand
86Burford, T. H.: Personal communication, 1945.
87Cutler, E. C.: Migration of Shell Fragment FromInferior Vena Cava to Right Pulmonary Artery. Mil. Surgeon 53: 264-267,September 1923.
88Davey, W. W., and Parker, G. E.: Surgical Pursuit andRemoval of Metallic Foreign Body From Systemic Venous Circulation. Brit. J.Surg. 34: 392-395, April 1947.
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FIGURE 59.-Roentgenograms showing an embolic shell fragment in the left pulmonary artery.
early protective operations, the extensive experience ofHarken and his collaborators89 at the base center in England has a more directbearing on the problems of later definitive and often elective surgery, inparticular with the much discussed issue of retained foreign bodies. Their threereports cover a series of 134 fragments removed from within or adjacent to theheart and great vessels. The following tabulation shows the distribution of the134 missiles in relation to the pericardium, heart, and great vessels:
| Number of fragments |
Pericardial | 26 |
Involving pericardium, but principally pulmonary | 17 |
Intracardiac | 13 |
On great vessels (and in walls) | 35 |
Intravascular (three embolic) | 7 |
On great vessels, but principally pulmonary | 17 |
Mediastinal, but not directly on great vessels | 19 |
|
| 134 |
There were no deaths in the three cited reports.
In particular, the successful evacuation of 13 missiles from within thecardiac chambers without mishap represents a brilliant extension of the
89(1) See footnote 82, p. 448. (2) Harken, D. E.: Foreign Bodies In, and In Relation To, the Thoracic Blood Vessels and Heart. Techniques for Approaching and Removing Foreign Bodies From the Chambers of the Heart. Surg., Gynec. & Obst. 83: 117-125, July 1946. (3) Harken, D. E., and Zoll, P. M.: Foreign Bodies In, and In Relation To, the Thoracic Blood Vessels and Heart. Indications for the Removal of Intracardiac Foreign Bodies and the Behavior of the Heart During Manipulation. Am. Heart J. 32: 1-19, 1946.
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earlier French experience in World War I. This, together withthe equally favorable outcome in removing fragments from the heart wall, both inthe European theater and in the Mediterranean theater series (11 cases) withouta fatality, represents a real advance in heart surgery. It in turn strengthensthe position of those who believe all foreign bodies had best be removed. Inparticular, Harken and his associates naturally and strongly recommend theirremoval, in order (1) to prevent embolus of the foreign body or associatedthrombus, (2) to reduce the danger of bacterial endocarditis, (3) to preventrecurrent pericardial effusions, and (4) to diminish the incidence of myocardialdamage. The additional factors of pain and cardiac neurosis are occasionalindications.
It seems appropriate to end this discussion with theconclusions of Barrett (p. 446) who, after a thoughtful consideration of bothsides of the issue, observed:
There are three clinical phases in the history of thesepatients in which a decision must be taken. In the emergency the concern isto save life and the presence of a foreign body in the heart is of secondaryimportance. During the period of convalescence and shortly after, the decisionto operate depends upon the belief that late complications can be avoided, orthat limitations of cardiac function can be ameliorated without exposing thepatient to mortal hazard. Patients who have harboured a foreign body in theheart for years without apparent harm will not want it removed, but they maycome to the surgeon when complications occur; some of these late complicationscan still be relieved by removal of the foreign body, but others are by nowbeyond surgical cure.
To the medically minded, and especially to those who havediscovered by chance retained foreign bodies of many years' standing, the sentiments
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attributed to Frank Jeans but quoted in this connection byTurner (p. 448) still have some appeal: "A living problem is better than adead certainty."
SUMMARY
In summarizing this survey of diseases and disorders of theheart in the Second World War, it seems appropriate to commend again the wisdomand foresight of those responsible for the special Subcommittee onCardiovascular Diseases. The wise counsel and sustained activities of this groupthroughout the emergency not only contributed directly to the war effort but,also, in various subtle ways afforded encouragement and aid to many doctors inuniform in their pursuit of useful knowledge. This coordination of militarypersonnel, civilian consultants, and Government resources was of great practicalbenefit and lasting importance, and the lessons learned may serve well anothergeneration should the need arise.
The special attention given to the circulatory system in theselection for service provided an insight into the strength as well as theweakness of our eligible population and, though it proved to be disturbing incertain respects, stimulated the thoughtful planning of special studies in thefields of hypertension and of latent coronary disease. The spread of respiratoryinfections in training centers led to a number of important epidemiologicalstudies and, in turn, to effective programs of control and prevention, not onlyof streptococcal diseases but of rheumatic fever as well.
That traditionally troublesome complex, neurocirculatoryasthenia (including shellshock) at best poorly understood, was again the objectof careful analysis. Its apparent diminished incidence, in comparison withprevious conflicts, was perhaps the result both of its earlier detection and ofa shift in emphasis to its manifestations on other systems. In the overseatheaters, especially in the Southwest Pacific, the opportunity to observe and todelineate more carefully than ever before the cardiac lesions of tsutsugamushifever was a noteworthy event. Elsewhere, our surgical colleagues, with thesupport of modern anesthesia, antibiotics, and blood, pushed forward inbrilliant fashion to remove missiles from within the heart and great vesselsmore effectively than ever before. There still remains, moreover, an equalopportunity and obligation in this connection for the Army Medical Corps and theVeterans' Administration to trace and record the ultimate fate of thatconsiderable number of soldiers who were discharged from the service withretained missiles in the cardiovascular system.
It is unlikely in future crisis of comparable magnitude thatthe United States can afford to write off one-half or even one-quarter of itseligible manpower as unfit for service by the standards of World War II. It nowseems certain that future circumstances will require either broader standards ornew categories whereby those with minor defects may serve with recognition, ifnot in the lines at least on the production front.
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The preparation of this chapter on the heart has been apersonal privilege. It is submitted as a token of gratitude to our patients ofthe war years-the men and women of the Armed Forces who in spite of illnessand injury did all they could to help. For the members of the medical professionwho shared a little in this great effort, the recollection of those eventfulyears has probably been dimmed by other interests and new responsibilities, butto them in quieter moments of reflection the words of that noble Irishchurchman, Jeremy Taylor, written in equally turbulent times three centuries agomay have a special significance: "To preserve a man alive in the midst ofchances and hostilities is as great a miracle as to create him."90
90Taylor, Jeremy (1613-67), cited by Hume, E. E.:Introduction to Military Medicine. Mil. Surgeon 102: 17-24, January 1948.
